Cervical cancer

Summary

• Cancer of the cervix is a very common malignant disease in South African women.
• This cancer can mostly be prevented by the early detection of cancer precursors using regular screening (Pap smear) and gynaecological check-ups.
• A vaccine that guards against the human papillomavirus (that is the main cause of cervical cancer) also help prevent cervical cancer.
• Cancer of the cervix is most often associated with the human papillomavirus (HPV) which is a common sexually transmitted infection.
• The most common symptom of cancer of the cervix is abnormal vaginal bleeding.

What is cancer of the cervix?

The cervix, also called the neck of the womb, is the lower, narrow part of the uterus (womb). The uterus, a hollow, pear-shaped organ, is located in the pelvis between the bladder and the rectum. The cervix has a canal which is part of the passage connecting the vagina to the uterine cavity and the fallopian tubes.

Like all other organs of the body, the cervix is made up of different tissues. The outer surface of the cervix is covered with an epithelium consisting of a layer of cells like the skin covering the body. The epithelium is constantly replaced by new, young cells forming at the basement membrane (bottom layer) which, while maturing and getting older, move to the surface where they shed and where they can be picked up with a Pap smear. Both the development of new cells by cell division and the maturation are according to a pre-programmed pattern laid down in the genetic code of the chromosomes.

When cancer-producing agents disturb the genetic coding, abnormal cells develop that, after some time, can form a malignant tumour (cancerous growth). If abnormal cells are found only within the epithelium, the condition is called a pre-cancerous lesion. Once malignant cells penetrate through the basement membrane into the deeper tissue, the condition is called cervical cancer because it may then spread to the rest of the body.

Cervical cancer cells can invade and damage organs near the original tumour, for example, the rectum and/or the bladder. Furthermore, cells from any cancer can break away and enter the lymphatic system or the bloodstream. This is also how cancer of the cervix can spread to other parts of the body, such as nearby lymph nodes, the bones of the spine, and the lungs. The new tumour which forms in a distant organ is called a metastasis and once cancer has spread from its original location, one speaks of a metastatic disease.

When a metastasis develops in another part of the body, the new tumour has the same kind of abnormal cells and the same name as the original (primary) cancer. For example, if cervical cancer spreads to the bones, the cancer cells in the bones are cervical cancer cells. The disease is called a bone metastasis of cervical cancer (it is not bone cancer).

Most cervical cancers are squamous cell carcinomas. Squamous cells are thin, flat cells that form the epithelial surface of the cervix. These cells look like flat paving stones. When cancer develops from the endocervical canal which is lined with columnar cells, the condition is called adenocarcinoma of the cervix. Squamous cell cancers of the cervix are far more common than adenocarcinomas of the cervix.

What causes cancer of the cervix?

The development of cervical cancer precursors and later cancer is linked to infection of the cervix with high-risk types of the human papillomavirus (HPV).

The most common means of acquiring HPV infection is through sexual intercourse. Human papillomavirus is also transmitted vertically – that is, from mother to child as the child passes through the birth canal and becomes infected from cells in the vagina and cervix that harbour HPV.

Smoking increases the risk to develop cancer cells in the cervix. The risk is dose related; the more smoking the higher the risk.

Conditions that lower immunity like Aids or certain medicines for transplant patients also increase the risk for cervical cancer.

Cell changes that can lead to cancer

Scientists know that abnormal changes in cells on the cervix are the first step in a series of slow changes that can lead to cancer years later. That is, some changes are pre-cancerous; they may become cancerous with time. However, not all cellular abnormalities will automatically turn into cancer.

Over the years, doctors have used different terms to refer to pre-cancerous changes in the epithelial cells. One term now used in cytological screening of Pap smears is "squamous intraepithelial lesion" (SIL). (The word "lesion" refers to an area of abnormal cells; "intraepithelial" means that the abnormal cells are present only in the epithelial layer covering the cervix.) Changes in these cells can be divided into two categories:

• Low-grade SIL refers to early changes in the size, shape and number of cells. Some low-grade lesions go away on their own. However others may, with time, become more abnormal, forming a high-grade lesion. Pre-cancerous low-grade lesions also may be called mild dysplasia or cervical intraepithelial neoplasia grade 1 (CIN 1). On a biopsy specimen taken from the cervix, these dysplastic cells would only be present in the lower third of the epithelial thickness which covers the cervical surface. It is usually not necessary to treat or investigate further when LSIL is present on a Pap smear. This is however an indication that the smear should be repeated a few months later and if the LSIL is still present on the repeat smear it will need further investigation.
• High-grade SIL means there are a larger number of pre-cancerous cells. On a biopsy specimen, dysplastic cells would be present in the lower and middle third of the epithelial thickness (representing cervical intraepithelial neoplasia: CIN 2) or in the lower, middle and upper third (representing CIN 3). In the past, these lesions were referred to as moderate or severe dysplasia, or carcinoma in situ. When HSIL is found on a Pap smear, a further test like a colposcopy or Lletz is necessary.

If intraepithelial neoplastic cells break through the base membrane, which is the border between the epithelial layer and the deeper tissue of the cervix, the disease is called cervical cancer, or invasive cervical cancer. It occurs most often in women over the age of 40.

Who gets cancer of the cervix and who is at risk?

Cervical cancer is the second most common cancer in women, comprising 16.6% of all cancers in South Africa.

The incidence of cervical cancer in South Africa is high when compared to women in western countries and appears at a younger age. This is because the majority of women in South Africa have not undergone Pap smears to detect precancerous lesions.

It is important to realise that cervical cancer is a largely preventable disease. If the precancerous lesions are detected and removed, they will not be able to develop into cervical cancer in the future. In South Africa, it is unscreened women who are at greatest risk of developing cancer of the cervix and it is estimated that approximately 1 in 26 black South African women will develop cervical cancer.

There are over 100 different types of human papillomaviruses. Some of them (type 6 and 11), which are also sexually transmitted, cause genital warts (condylomata acuminata). Other HPV types (like 16 and 18) are called high-risk viruses because of their increased association with cervical cancer.

Fortunately, most women who are infected with HPV do not develop cervical cancer. For this reason, scientists believe that other factors act together with HPVs. For example, other genital microbes also may play a role. Further research is needed to learn the exact role of viruses and other micro-organisms and how they act together with other factors in the development of cervical cancer.

Smoking increases the risk of cancer of the cervix. Cancer causing chemicals called carcinogens are taken up into the bloodstream and is then concentrated in cervical mucous. These carcinogens act together with other factors like HPV to cause genetic faults in epithelial cells of the cervix. The risk appears to increase with the number of cigarettes a woman smokes each day and with the number of years she has smoked.

Several reports suggest that women whose immune systems are weakened, are more likely than others to develop cervical cancer. For example, women who have the human immunodeficiency virus (HIV), which causes Aids, are at increased risk. Also, organ transplant patients, who receive drugs that suppress the immune system to prevent rejection of the new organ, are more likely than others to develop pre-cancerous lesions and cancer.

What are the symptoms and signs of cancer of the cervix?

Pre-cancerous changes of the cervix usually do not cause any symptoms at all and are not detected unless a woman has a Pap smear.

Symptoms usually do not appear until abnormal cervical cells become cancerous and invade the tissue below the epithelial surface. When this happens, the most common symptom is abnormal bleeding.

Bleeding may start and stop between regular menstrual periods, or it may occur after sexual intercourse, douching, or during a gynaecological examination. Menstrual bleeding may last longer and be heavier than usual. Bleeding after menopause also may be an indicator of cervical cancer. This symptom may also point to cancer from the endometrium (inner lining of the womb). Increased vaginal discharge can be another symptom of cervical cancer. The discharge typically will have a strong, unpleasant odour.

These symptoms may point to cancer or to other health problems. Only a doctor can tell for sure. It is important for a woman to see her doctor if she is having any of these symptoms.

How is a woman examined for cervical cancer and its precursors?

By performing a gynaecological examination and taking a Pap smear, the doctor with the help of the laboratory can detect abnormal changes at the cervix. If these examinations show that an infection is present, the doctor treats the infection and then repeats the Pap smear. If the Pap test suggests something other than an infection, the doctor may repeat the Pap smear and do other tests to find out what the problem is.

If all women had gynaecological examinations and Pap smears regularly, most pre-cancerous conditions would be detected and treated before cancer develops. That way, most invasive cancers could be prevented. Any invasive cancer that does occur, would be found at an early stage with a much better chance for cure compared to advanced cancer.

During a gynaecological examination, the doctor checks the vagina, cervix, uterus, fallopian tubes, ovaries, and the bladder and rectum. The doctor feels these organs for any abnormality in their shape or size. A speculum is used to open the vagina so that the doctor can see the vaginal walls and the visible part of the cervix.

Taking a Pap smear is a simple, painless procedure to detect abnormal cells, which may be present on the cervical surface or inside the cervical canal. A woman should have this test when she is not menstruating; the best time is between 10 and 20 days after the first day of her menstrual period. However, if bleeding is prolonged or abnormal a Pap smear should be taken regardless of bleeding. The abnormal bleeding may be a sign of cervical cancer. For about two days before a Pap smear, she should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a medical practitioner), which may interfere or mask the detection of any abnormal cells.

A Pap smear can be done in a doctor's office or at a health clinic. A wooden scraper (spatula) and/or a small brush is used to collect a sample of cells from the cervix, cervical canal and back wall of the vagina. The cells are placed on a glass slide, fixed with a fixative spray and sent to a laboratory to be examined for abnormal changes.

The way of describing Pap test results has changed over the years. The present method is called the Bethesda System, where changes are classified as low-grade or high-grade SIL. Many doctors believe that the Bethesda System provides more useful information than older classifications. Women should ask their doctor to explain the classification system used for their Pap smear interpretation.

If the smear is abnormal, a method called colposcopy is used to examine the cervix in detail. The doctor applies a vinegar-like solution to the cervix and then uses a magnifying instrument much like a microscope (called a colposcope) to look closely at the cervix. The vinegar solution (acetic acid) causes abnormal surface cells to turn white, which helps in the localisation of abnormal areas from which small pieces (biopsies) need to be taken. The doctor may also apply an iodine solution to the cervix (a procedure called the Schiller test). Healthy squamous epithelial cells turn brown; abnormal cells remain unchanged or may turn yellow. These procedures can all be done in the doctor's office.

The doctor may remove a small amount of cervical tissue (this procedure is called a biopsy) to be sent and examined by a pathologist. If the doctor can identify an abnormal lesion colposcopically, he uses an instrument to pinch off small pieces of cervical tissue. The biopsy is about the size of a normal freckle and may be slightly uncomfortable. Another method used to take a larger biopsy is called large loop excision of the transformation zone (LLETZ), or in America: loop electrosurgical excision procedure (LEEP). In this procedure, the doctor uses an electrical wire loop to slice off a larger piece of tissue. These types of biopsies may be done in the doctor's office using local anaesthesia.

These procedures for removing tissue may cause some bleeding or other discharge. It is advised to abstain from sexual intercourse until the cervix has healed. Women also often experience some pain similar to menstrual cramping, which can be relieved with simple pain killers like paracetemol.

Sometimes, colposcopically guided biopsies or electrical loop tests may not be feasible, for example due to anatomical or technical reasons. Or the tests may not show for sure whether the abnormal cells are present only on the surface of the cervix. Under these circumstances, the doctor will then remove a larger, cone-shaped sample of tissue by means of surgical excision. This procedure is called conisation or cone biopsy. It requires either local or general anaesthesia and is usually done in hospital. The obtained specimen allows the pathologist to see whether the abnormal cells have invaded the tissue beneath the surface of the cervix. Conisation may also be used as treatment for a pre-cancerous lesion. It is important to inform your doctor if you may be pregnant at the time of a biopsy. The biopsy should be delayed until after the delivery.

In a few cases it may not be clear whether an abnormal Pap smear or a woman's symptoms are caused by changes of the cervix or of the endometrium (the lining of the uterus). In this situation, the doctor may look inside the uterus (hysteroscopy). The doctor stretches the cervical opening and uses a special endoscope (a thin long camera lens) to assess the uterine cavity. The doctor can then take biopsies from any visibly abnormal area or use a curette to scrape tissue from the lining of the uterus (endometrium) as well as from the cervical canal. Like conisation, this procedure requires local or general anaesthesia and may be done in the doctor's office or in the hospital.

If facilities for hysteroscopy is not available a dilatation and curettage (D&C) may be done. The doctor stretches the cervical opening and uses a special instrument to scrape tissue from the lining of the uterus which is called the endometrium. This tissue is then sent for examinitation by a pathologist.

Can cancer of the cervix be prevented?

Regular gynaecological check-ups including a Pap smear, can prevent most cancers of the cervix. Women should have regular check-ups, including a gynaecological examination and a Pap smear, if they are or have been sexually active or if they are age 18 or older.

Those who are at increased risk of developing cancer of the cervix should be especially careful to follow their doctor's advice about check-ups. Women who have had a hysterectomy (surgical removal of the uterus, including the cervix) should ask their doctor's advice about having gynaecological examinations and Pap smears of the vaginal vault. It is not always necessary to have a smear every year. Ask your doctor for advice.

In South Africa, it is not possible for all women who fall under state health care to have regular Pap smears and gynaecological check-ups for economic reasons. Research has shown that a national screening programme using a Pap smear three times in a woman’s lifetime (at about 30, 40 and 50 years) and with an 80% coverage will reduce the incidence of this cancer by more than half. All women in South Africa are entitled to three free Pap tests, one at 30 years and repeated at 40 and 50. The first smear is by far the most important.

A new tool in the prevention of cervical cancer is a vaccine that protection against the human papillomavirus - which is responsible for up to 80% of all cervical cancers. It is advised that girls and young women be vaccinated before their first sexual encounter. The vaccine is currently available only in the private  health sector in South Africa.

How are precursors of cervical cancer treated?

Treatment for a precancerous lesion of the cervix depends on a number of factors. These factors include whether the lesion is of low or high grade, whether the woman wants to have children in the future, the woman's age and general health, and the preference of the woman and her doctor.

A woman with a low-grade lesion as confirmed by biopsy and histology may not need further treatment. She should have regular gynaecological examinations and Pap smears. When a high-grade lesion is present, it should be destroyed. For this, the doctor may use laser surgery, electrocauterisation methods (also called diathermy) such as LLETZ/LOOP or surgical conisation. Sometimes, cryosurgery (freezing) is also used to destroy the abnormal area. Treatment for precancerous lesions may sometimes cause cramping or other pain, bleeding, or a watery discharge.

In a number of cases, women will undergo a standard total hysterectomy, particularly if abnormal cells occur again after previous treatment of HSIL. Total hysterectomy means that the womb is removed together with the cervix, but not the fallopian tubes and the ovaries. This surgery can be performed abdominally (through an incision in the abdomen below the navel) or vaginally (through the vagina without an abdominal incision). Hysterectomy is more likely to be done when there is no further wish to have children in the future.

Treatment for invasive cancer

Once cancer cells have been identified to invade the tissue beneath the epithelial surface lining of the cervix, the condition is not anymore a precursor but called invasive cancer.

The choice of treatment for cervical cancer depends on the exact place and size of the tumour, the stage (extent) of the disease, the woman's age and general health, and other factors.

Staging
Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Blood and urine tests usually are done. The doctor will do a thorough gynaecological assessment. Other examinations, the doctor may do include procedures called cystoscopy and proctosigmoidoscopy. In cystoscopy, the doctor looks inside the bladder with a thin, endoscopic instrument. Proctosigmoidoscopy is a procedure in which a similar instrument with a light source is used to check the rectum and the lower part of the large intestine.

Because cervical cancer may spread to the bladder, rectum, lymph nodes, or lungs, the doctor also may order x-rays or other tests to check these areas. The woman may first have a sonar examination of her kidneys to see whether the kidney pipes (ureters) are obstructed by the tumour. If this is abnormal it may be followed by a series of x-rays of the kidneys and bladder, called an intravenous pyelogram. To look for lymph nodes that may be enlarged because they contain cancer cells, the doctor may order a CT or CAT scan, which is a series of x-rays put together by a computer to make detailed pictures of areas inside the body. Another rather expensive procedure that may be used to check organs inside the body is magnetic resonance imaging (MRI).

Preparing for treatment

Most women with cervical cancer want to learn all they can about their disease and treatment choices so they can take an active part in decisions about their medical care. The specialist oncologist and others on the medical team can help inform women.

When a woman is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the medical team. Often it helps to make a list of questions. To help remember what was said, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the medical team - to take part in the discussion, to take notes, or just to listen.

Patients should not feel they need to ask all their questions or remember all the answers at one time. They will have more opportunities to ask the doctor to explain things and to get more information.

Here are some questions a woman with cervical cancer may want to ask the doctor before her treatment begins:

• What is the stage (extent) of my disease?
• What are my treatment choices? Which do you recommend for me? Why?
• What are the chances that the treatment will be successful?
• What are the risks and possible side-effects of each treatment?
• How long will the treatment last?
• Will it affect my normal activities?
• What is the treatment likely to cost?
• What is likely to happen without treatment?
• How often will I need to have check-ups?

Methods of treatment

Treatment for cervical cancer can involve surgery, radiation therapy and chemotherapy. Patients are often treated by a team of specialists. The team may include gynaecological oncologists, radiotherapy oncologists and chemotherapists. The doctors may decide to use one treatment method or a combination of methods. Some patients take part in a clinical trial (research study) using new treatment methods. Such studies are designed to improve cancer treatment.

Surgery
Surgical removal of cervical cancer depends on the stage of the disease. If the cancer is still at a very early invasive stage and has not invaded deeper layers of the cervix, the doctor may perform an operation to remove the tumour by means of a large conisation but leave the uterus, tubes and ovaries.

In most other early stage cases, however, the patient may need to have a radical hysterectomy with removal of the tissue next to the cervix and uterus (parametrium) to offer the best therapeutic chance for long-term survival. In this procedure, the surgical team not only performs a total hysterectomy (uterus and cervix), but also removes the upper third of the vagina, the ovaries and fallopian tubes. In addition, the nearby lymph nodes are removed to learn whether the cancer has spread.

Radiation therapy and chemotherapy
The decision whether to perform surgery or radiation therapy with chemotherapy depends on the stage of the disease. Radiation therapy (also called radiotherapy) uses high-energy rays to destroy cancer cells and stop them from growing. The radiation may come from a large machine (external radiation) or from radioactive materials placed directly into the cervix (implant radiation). Some patients receive both types of radiation therapy in succession.

A woman receiving external radiation therapy is hospitalised or goes to the hospital each day for treatment. Usually, treatments are given five days a week for five to six weeks.

For internal or implant radiation, a capsule containing radioactive material is placed directly in the cervical canal. The implant radiates cancer-killing rays close to the tumour while sparing most of the healthy tissue around it. A special type of cannula with a long pipe is first placed into the cervical canal through which the radioactive material is moved from a safe container into the cervix and back by remote control. This is repeated several times while the patient stays in hospital.

The effect of radiotherapy is enhanced by simultaneous administration of chemotherapy (drugs to kill cancer cells). Radiotherapy and chemotherapy are used when cervical cancer is not localised to the cervix and has spread to other parts of the body or if the tumour is very large. The doctor may use just one drug or a combination of drugs. Chemotherapy for the treatment of cervical cancer is usually given by injection into a vein. This is also referred to as systemic treatment meaning that the drugs flow through the body via the bloodstream.

Side-effects of treatment
It is difficult to limit the effects of therapy so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes unpleasant side-effects.

The side-effects of cancer treatment depend mainly on the type and extent of the treatment. Also, each patient reacts differently. Doctors and nurses can explain the possible side-effects of treatment, and they can help relieve symptoms that may occur during and after treatment. It is important to let the doctor know if any side-effects occur.

Side-effects of surgery
Radical hysterectomy entails the removal of the womb and the cervix together with the additional removal of adjacent tissues, tubes, lymph nodes and sometimes also the ovaries. For a few days after the operation, the woman may have pain in her lower abdomen. Medicine to control the pain is very effective. A woman may have difficulty emptying her bladder and may need to have a catheter inserted into the bladder to drain the urine for a few days after surgery. Sometimes the bladder problems may even be permanent. She may also have trouble having normal bowel movements. For a period of time after the surgery, the woman's activities should be limited to allow healing to take place. Normal activities, including sexual intercourse, can usually be resumed in four to eight weeks.

Women who have had their uterus removed (total hysterectomy for precursors, radical hysterectomy for invasive cancer) no longer have menstrual periods. Sexual desire and the ability to have intercourse are usually not affected by total hysterectomy but may be affected by radical hysterectomy. After surgery, a woman's view of her own sexuality may change, and she may feel an emotional loss. An understanding partner is important at this time. Women may want to discuss these issues with their doctor, nurse, medical social worker, or member of the clergy.

Side-effects of radiotherapy and chemotherapy
Patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

With external radiation, it is common to lose hair in the treated area and for the skin to become red, dry, tender and itchy. There may be permanent darkening or "bronzing" of the skin in the treated area. This area should be exposed to the air when possible but protected from the sun, and patients should avoid wearing tight clothes to prevent friction at the treated area. Patients will be shown how to keep the area clean. They should not use any lotion or cream on their skin without the doctor's advice.

Usually, women are told not to have intercourse during radiation therapy. However, most women can have sexual relations within a few weeks after treatment ends. Sometimes, after radiation treatment, the vagina becomes narrower and less flexible, and intercourse may be painful. This may also occur after surgery if a portion of the upper vagina has been removed together with the cervix and uterus. Patients may be taught how to use a dilator as well as a water-based lubricant to help minimise these problems.

Patients who receive external or internal radiation therapy also may have diarrhoea and frequent, uncomfortable urination. The doctor can make suggestions to control these problems.

The side-effects of chemotherapy depend mainly on the drugs and the doses the patient receives. In addition, as with other types of treatment, side-effects vary from person to person. Generally, anticancer drugs affect cells that divide rapidly. These include blood cells that fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, patients are more likely to get infections, may bruise or bleed easily, and may have less energy.

Cells in hair roots and cells that line the digestive tract also divide rapidly. When chemotherapy affects these cells, patients may lose their hair and may have other side-effects, such as poor appetite, nausea, vomiting, or mouth sores. The doctor may be able to give medicine to help with side-effects. Side-effects gradually go away during the recovery periods between treatments or after treatment is over.

Follow-up care
Regular follow-up examinations - including a gynaecological examination, a Pap smear and other laboratory tests - are very important for any woman who has been treated for pre-cancerous lesions or for cancer of the cervix. The doctor will do these tests and examinations at regular intervals for several years to check for any signs that the condition has returned.

Cancer treatment may cause side-effects many years later. For this reason, patients should continue to have regular check-ups and should report any health problems that appear.

Support for cancer patients
Living with a serious disease is not easy. Cancer patients and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful information and support services.

Patients with cancer may worry about holding their job, caring for their family, keeping up with daily activities, or starting a new relationship. Worries about tests, treatments, hospital stays, and medical bills are common. Doctors, nurses and other members of the health care team can answer questions about treatment, working or other activities. Also, meeting with a social worker, counsellor or member of the clergy can be helpful to patients who want to talk about their feelings or discuss their concerns. Friends and relatives can be very supportive.

It helps many patients to discuss their concerns with others who have cancer. Cancer patients often get together in support groups, where they can share what they have learnt about coping with cancer and the effects of treatment. It is important to keep in mind, however, that each patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another - even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

The Hospice Society of South Africa and CANSA (Cancer Association of SA) are two of the well-known organisations that work with cancer patients and their families. One of these organisations is usually represented in a town or district. The contact telephone numbers should be in the local telephone directory.

What is the outcome of cancer of the cervix?

The outlook for women with pre-cancerous changes of the cervix or very early cancer of the cervix is excellent; nearly all patients with these conditions can be cured.

Researchers continue to look for new and better ways to treat invasive cervical cancer.

Patients and their families are naturally concerned about what the future holds. Sometimes patients use statistics to try to calculate their chances of being cured. It is important to remember, however, that statistics are averages based on large numbers of patients. They cannot be used to predict what will happen to a particular individual because no two people are alike; treatments and responses vary greatly. The doctor who takes care of the patient and knows her medical history is in the best position to talk with her about her chance of recovery (prognosis).

Doctors often talk about surviving cancer, or they may use the term remission rather than cure. Although many women with cervical cancer recover completely, doctors use these terms because the disease can recur. (The return of cancer is called a recurrence.)

When to see a doctor

For the early detection of cancer precursors, women should see their doctor to have a Pap smear at regular intervals.

The doctor should be consulted if any of the following symptoms develop:

• Bleeding which starts and stops between regular menstrual periods
• Bleeding after sexual intercourse or douching
• Bleeding after menopause
• Increased vaginal discharge

What can we hope for in the future?

The Pap test is an excellent tool to detect cervical cancer early. It is however not perfect and some cancers and pre-cancers may be missed despite regular testing. Newer techniques of preparing and interpreting a Pap smear e.g. liquid based cytology are available to increase the accuracy of the test.

Another tool that can be used to help in the detection of the group of individuals that may have a high risk for cervical cancer is a test for HPV infection. There are blood and fluid tests available that can detect the presence of cancer causing HPV, but at the moment there is disagreement among doctors about the exact use for the test.

Cervical cancer is a major problem in South Africa and in many countries of the world where screening programmes are not well developed. A potential solution may be population-based immunisation against the most common types of cancer-causing Human Pappiloma Viruses. Immunisation strategies are being developed and tested and may be available in the next decade.

Reviewed by Professor Lynette Denny, Gynaecology Oncology Unit, Department Obstetrics & Gynaecology, University of Cape Town/Groote Schuur Hospital

Last updated 19/08/2008