The incidence of cervical cancer in NZ has declined dramatically in the last two decades due to effective screening programs with Pap smears. The Pap smear (also called ‘cervical smear’) is designed to detect pre-cancerous changes of the cervix which can be treated before it becomes a cancer

Symptoms

There are rarely any symptoms for early changes in cervical cells. Symptoms include;

  • Abnormal bleeding – longer and heavier period, bleeding between periods, bleeding after menopause, bleeding after sexual intercourse
  • Pain during sexual intercourse
  • Unusual vaginal discharge
  • Lower back pain, leg pain and or swelling

Diagnosis

After a diagnosis has been established by biopsy, the extent of disease needs to be explored. A MRI of the pelvis and abdomen and a PET/CT will determine if the extent of the cancer and whether there is has local spread or if it has gone anywhere else.

Treatment and Surgery

There have also been dramatic advances in its treatment that may include a combination of surgery, radiotherapy and chemotherapy. Selection of which treatment modality to employ is dependent on the stage of the cancer at presentation.

Small lesions that are limited to the cervix (stage 1) can be treated with surgery, whereas larger tumours or those extending beyond the cervix (stage 2 or higher) require a combination of radiotherapy with chemotherapy.

Surgical options need to include the primary tumour (cervix) plus the regional lymph nodes to which the cancer can spread.  A negative PET/CT is only 85% accurate. Removal of lymph nodes increases the accuracy to 100%.

Early stages of disease

Surgery may include the following procedures:

  • A cone biopsy to remove the cervix is sufficient for very small lesions (a few mm small). This procedure can be performed with or without surgical exploration of the pelvic lymph nodes (depending on other factors).
  • A radical trachelectomy which involves removal of the cervix and the tissue next to the cervix (parametria). This procedure is mostly done in combination with a removal of pelvic lymph nodes. It can be performed for small (< 3 cm) lesions and its aim is to retain fertility.
  • A radical hysterectomy is another option if fertility is not desired. (removal of uterus, cervix and tissue around the cervix) and pelvic lymph node dissection. This requires more complex surgery and may have more side effects than a simple hysterectomy, but it is required in order to obtain an adequate normal tissue (margins) around the cancer and achieve a cure. Performing a radical hysterectomy in early stage disease is preferable to radiation and chemotherapy as it offers the same cure rates but with less side effects.

The ovaries, which produce the hormones (oestrogen, progesterone, androgens) can be removed or preserved, depending on the situation. This is traditionally performed with a laparotomy (traditional open abdominal surgery) via a large incision in the abdomen.

The surgical procedure of radical hysterectomy via a laparoscopic approach has not been widely adopted because it is technically more difficult to perform and requires additional training. As a result, it is not yet classified as standard treatment for cervical cancer, which currently stands at a radical hysterectomy via laparotomy. This will be further discussed with the patient during consultation.

Chemotherapy and / or Radiation Therapy

After the hysterectomy, a pathologist will examine the tissue to determine the characteristics of the cancer. If there are high-risk features found, radiation therapy and / or chemotherapy may be recommended to minimize the risk of the cancer recurring after surgery. This decision will be made after discussion at the multidisciplinary meeting.

More advanced disease is usually treated with radiation therapy and chemotherapy without surgery. This is not because the disease is not curable. This is often a difficult concept for patients to understand as they may worry that surgery is not being performed to remove their cancer. The reason is that radiation therapy and chemotherapy are more effective than surgery to achieve a cure in these cases. Performing hysterectomy prior to chemotherapy and radiation does not improve cure rates, and it may delay commencement of radiation therapy and chemotherapy.

 Follow up

There is no data to show that follow up increases the survival. However, it helps allay anxiety for women. The NZ Gynaecology Cancer Group has set guidelines for follow up that is followed though it will be individualized to fit the patient. This usually involves a pelvic examination at each visit and smears if appropriate.

It is particularly important to be alert of any new symptoms rather than just relying on follow-up visits so any recurrence is detected early which allows for fast, effective treatment of the recurrence. 80% of women who recurred presented with symptoms

For patients living outside Auckland, arrangements can be made for on-going follow-up with their local general practitioner or gynaecologist.

If the patient has had chemotherapy or radiation after surgery, follow-up may be shared between me, the medical oncologist or radiation oncologist.

Outcomes

Cancers of all types and stages may recur. Recurrence may be local (vaginal), in the pelvis or at distant sites (abdomen, lungs). Treatment of recurrent cancer depends on the initial stage of the cancer (stages 1 to 4), the cell type of the cancer, the patient’s medical fitness and her wishes.

Survival rates for cervical cancer depend on its initial stage. Survival for stage 1 ranges between 75% and 95% at five years.