The neck of the womb or the uterus is known as the cervix. It is the narrow portion where the body of the uterus joins the vagina. Cancer is a disease caused by the abnormal growth and division of cells. Cervical cancer begins in the cells on the surface of the cervix. Cancer cervix is the third most common cancer in Indian women. Approximately 97 thousand women are diagnosed with cervical cancer and 60 thousand women die of cervical cancer in India every year.
Certain types of HPV predominantly cause cervical cancer. 99.7% of women with cervical cancer have HPV infection. HPV has two types—high risk (types 16, 18, 31, 33, 35, 45, 58 etc) and low risk (types 6, 11, etc). Low risk HPV types 6 and 11 cause genital warts in 90% women.
Two vaccines—bivalent and quadrivalent are available for preventing HPV infection. They should ideally be used before sexual exposure. They can be given between ages 9-26 years. This vaccine does not treat existing HPV infection. Nonavalent HPV vaccines are available in the U.S. which give protection against 9 HPV strains.
Pap Smear and HPV DNA are screening tests for cancer cervix. Pap smear can detect cancerous cells or changes in the cells of the cervix that may lead to cancer. While examination in the outpatient clinic cells from the cervix are collected using a wooden spatula and brush. These cells are either spread on a slide (conventional Pap smear) or sent in a liquid (Liquid based cytology/ Liquid Pap) to the laboratory.
Pap tests should begin after age 21 years and three years after initiation of sexual activity. Women younger than 30 years should have a Pap test every 2 years. HPV infection is very common in younger women, but it usually goes away on its own. A positive HPV test result in a young woman is most likely become negative without any treatment. Hence, routine HPV testing in young women less than 30 years is not recommended. Women aged 30 years and older should have a Pap test every 3 years after three normal annual Pap test results in a row. If the uterus has been removed, need of doing a Pap smear must be discussed with a gynecologist. Pap smear results may not always be accurate. The results if indicate abnormality, should not trigger panic button—the opinion of a gynecologist must be sought immediately. For women 30 years or older, cancer-causing types of HPV can be detected at the same time the Pap test is performed using liquid based method. If the results of both HPV test and Pap test are normal, no further testing is required for another 3 years.
Confirmatory diagnosis of cervical cancer is obtained by performing a biopsy from cervix under colposcopic guidance. The biopsy can be obtained from the abnormal appearing area or growth on the cervix using a punch forceps or by cutting a conical piece of the cervix using knife (conization) or by using an electrical wire known as loop electro-excision procedure (LEEP) of the cervix.
A team of Gynae Oncologists, Radiation Oncologists and Medical Oncologists manages cervical Cancer. The woman is assessed and after confirming the diagnosis of cervical cancer, the case is discussed in the Tumor Board. Based on international evidence based guidelines, a plan of action is formulated. The options of management offered are surgery, radiotherapy, chemotherapy or a combination of all the above modalities. The treatment decided depends on the clinical staging of cancer. Surgery to remove cervical cancer may be an option when the cancer is confined to the cervix.