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Cervical Cancer

Cervical cancer is the second most common cancer among women, and it is caused by HPV (Human Papillomavirus) in about 98% of cases. It is known that at least 2 out of every 100 women will develop cervical cancer at some point in their lives. However, preventive measures against cervical cancer significantly reduce the likelihood of women encountering cancer throughout their lives. Uniqacare's Department of Gynecologic Oncology provided information about cervical cancer.

What is cervical cancer?


Cervical cancer is more common in developing and less developed countries. Every year, 500,000 new cases of cervical cancer are diagnosed worldwide. While cervical cancer typically appears around the age of 50, it has also started to be observed in younger women in recent years.


HPV (Human Papillomavirus) is responsible for almost all cervical cancers. This virus does not often show symptoms and is highly contagious. Most women can overcome the HPV virus they encounter at some point in their lives with the help of their own immune system. However, some HPV viruses can evade this immune system and lead to cervical cancer. Taking preventive measures to protect against the HPV virus and getting regular health check-ups and screenings can help detect the disease in its early stages or before it even develops, increasing the chances of successful treatment.


What is cervix?


The cervix, also known as the uterine cervix, is the lower part of the uterus that connects the uterus to the vagina. It plays a crucial role in allowing the passage of fluids between the uterus and the vagina. Additionally, during childbirth, the cervix enables the baby to pass through the vagina and exit the uterus.


What are the causes of cervical cancer?


Like many cancers, the exact cause of cervical cancer is not known. However, certain factors can increase the risk and accelerate the development of cervical cancer. In general, the risk factors for cervical cancer include:

  1. Having multiple sexual partners.

  2. Initiating sexual activity before the age of 20.

  3. Smoking.

  4. Weakened immune system.

  5. Frequent occurrences of viral and bacterial infections in the genital organs.

  6. Giving birth to a large number of children.

  7. Low socioeconomic status.

  8. Deficiency in vitamin C and vitamin A.


What are the types of cervical cancer?


Adenocarcinoma


There are different types of cervical cancer, and one of them is adenocarcinoma. In addition to invasive cancers like squamous cell carcinoma, there are many different types of cervical cancer. Adenocarcinoma is a relatively aggressive type of cancer that is less common and can be more difficult to detect among cervical cancers. Adenocarcinomas typically form in the inner canal of the cervix rather than on the outer surface, which is where smear tests collect cell samples. Therefore, when adenocarcinoma is diagnosed, the cancer has often reached an advanced stage. Adenocarcinoma is more frequently associated with HPV types known to cause cancer, such as 16, 18, 45, and 31.


What are the symptoms of cervical cancer?


Cervical cancer symptoms may not manifest in the early stages of the disease. Even during a gynecological examination, problems in the cervix may not be visible. Changes can be noticed with instruments called "colposcopes," which magnify the cervix, following a positive result in high-risk HPV screening tests or the detection of abnormalities in a vaginal smear test. The definitive diagnosis can be made through a biopsy taken from the suspicious area.

The symptoms of cervical cancer become more apparent in the advanced stages of the disease. Symptoms of cervical cancer include bloody discharge, bleeding after sexual intercourse, and irregular menstrual bleeding. In advanced cases, a tumor can even be detected during an examination. As cervical cancer progresses, urinary problems, difficulty with bowel movements, and leg pain may occur.


One of the symptoms of cervical cancer is "postcoital bleeding," which refers to unexpected bleeding that occurs immediately or the day after sexual intercourse. Postcoital bleeding is an important finding and can be an early sign of cervical cancer.


Genital warts caused by HPV are not considered a symptom of cervical cancer. This is because some types of HPV can cause genital warts, while others can cause changes in cervical cells. However, due to the possibility of high-risk HPV types being present if genital warts are detected, a thorough examination and HPV typing should be performed. To determine if someone has an HPV infection, cervical swabs are taken. Depending on the test results, it can be determined whether there is an HPV infection and, if so, which type.


If cervical cancer has progressed to advanced stages, its symptoms can be summarized as follows:

  • Urinary and fecal incontinence

  • Back pain

  • Leg pain

  • Loss of appetite

  • Pelvic pain

  • Swollen feet

  • Weight loss

  • Fatigue

  • Bone pain and fractures


What are the risk factors of cervical cancer?


The causes of cervical cancer include factors such as giving birth to many children, engaging in sexual intercourse at an early age, having multiple sexual partners, and smoking. HPV infection has been detected in 98% of cervical cancer patients. HPV, which is typically transmitted through sexual intercourse, has more than a hundred types. Specifically, types 16 and 18 are known to cause cervical cancer, while types 6 and 11 lead to genital warts.


Risk factors for cervical cancer include having multiple sexual partners, starting sexual activity before the age of 20, smoking, having a weakened immune system, frequent viral and bacterial infections in the genital area, giving birth to many children, having a low socioeconomic status, and deficiencies in vitamins C and A.


What are the preventive measures for cervical cancer?


Preventive measures for cervical cancer include:

  1. Regular Medical Check-ups: Attend regular gynecological check-ups and screenings, including Pap smears and HPV tests, as recommended by your healthcare provider.

  2. HPV Vaccination: Consider getting vaccinated against HPV. HPV vaccines are available to protect against the most common high-risk HPV types that can lead to cervical cancer.

  3. Avoid Smoking and Tobacco Products: Stay away from smoking and the use of tobacco products, as they increase the risk of cervical cancer.

  4. Boost Your Immune System: Maintain a healthy lifestyle to boost your immune system. A strong immune system can help your body fight off HPV infections and reduce the risk of cervical cancer.

  5. Practice Safe Sex: Use protection (condoms) during sexual intercourse and limit your number of sexual partners to reduce the risk of contracting HPV and other sexually transmitted infections.

  6. Healthy Diet: Consume a balanced and nutritious diet rich in fruits and vegetables, as certain nutrients like vitamins C and A may help reduce the risk of cervical cancer.

  7. Manage Obesity: Take measures to maintain a healthy body weight, as obesity is associated with an increased risk of cervical cancer.


Remember that early detection through regular screenings is crucial for the early diagnosis and successful treatment of cervical cancer. Always consult with your healthcare provider for personalized advice and recommendations based on your individual risk factors and health history.


What are the stages of cervical cancer?


The progression of cervical cancer typically involves the stages of CIN 1, CIN 2, CIN 3, and eventually leads to cervical cancer. In the initial stage, CIN 1, there is a 70-90% chance of spontaneous regression, while in CIN 2, it's around 40-45%, and in CIN 3, it's approximately 30-35%. Without any treatment, the transformation to advanced-stage cancer can take several years. In the early stages, complete healing can often be achieved without the need for a hysterectomy, through procedures like LEEP or conization, where a part of the cervix is removed. Patients who undergo these treatments can still become pregnant and have children.


The stages of cervical cancer are as follows:


Stage 0: Abnormal cells are found in the innermost layer of the cervix. This stage is also known as carcinoma in situ (CIS).

Stage I: Cancer cells are present only in the cervix. The tumor size can vary between 3 mm and 4 cm.

Stage II A: Cancer has spread beyond the cervix into the upper two-thirds of the vagina but has not spread to nearby tissues around the cervix.

Stage II B: Cancer has spread beyond the cervix into the upper two-thirds of the vagina and to nearby tissues around the cervix.

Stage III A: Cancer has spread to the lower third of the vagina but has not reached the pelvic wall.

Stage III B: Cancer has extended to the pelvic wall or blocked the flow of urine by involving the tubes that connect the kidneys to the bladder (ureters), causing dilation of the kidneys.

Stage IV: Cancer has spread beyond the cervix to areas such as the bladder, rectum, or other parts of the body.


CERVICAL CANCER VACCINE


Sexually transmitted HPV can lead to cervical cancer. To protect against HPV, it is recommended that girls and boys aged 9 to 26, as well as adults, receive the cervical cancer vaccine. In the United States, three vaccines (9-valent, 4-valent, and 2-valent) have received FDA approval and are in use, but the 9-valent vaccine has not yet arrived in our country. The 2-valent vaccine contains virus-like particles of HPV types 16 and 18, which are the most common culprits for cervical tumors, providing immunity against these types. The 4-valent vaccine, in addition to these types, also includes virus-like particles of HPV types 6 and 11, which cause warts, providing protection against warts as well. The most recent vaccine, the 9-valent vaccine, includes virus-like particles of HPV types 31, 33, 45, 52, and 58, in addition to the types found in the 4-valent vaccine (6, 11, 16, 18), providing greater protection against a wider range of HPV types that can cause cervical cancer. These vaccines also provide some level of cross-protection against other HPV types.


For children aged 9 to 15, 2 doses of the vaccine are sufficient. The first and second doses should be administered 6-12 months apart. For individuals aged 15 to 26, a 3-dose vaccination is recommended at 0, 1, and 6 months. After the age of 26, vaccination is generally not recommended due to the likelihood of prior exposure to HPV, but it can be considered in appropriate cases after discussing with a healthcare provider. The HPV vaccine is administered intramuscularly and can be given in the shoulder or buttock.


Receiving the cervical cancer vaccine before any exposure to HPV can prevent the majority of cervical cancer cases. It also provides protection against vaginal and vulvar cancers. The 4-valent and 9-valent vaccines can prevent genital warts and anal cancers in both females and males. Since certain HPV types are linked to cancers of the mouth and throat, these vaccines also offer protection against these cancers. The Centers for Disease Control and Prevention (CDC) recommends routine HPV vaccination for girls and boys starting at age 9. The ideal time for cervical cancer vaccination is before sexual activity begins, before any exposure to the HPV virus. The vaccine may not be as effective if administered after HPV exposure has already occurred.


How is cervical cancer diagnosed?


The diagnosis of cervical cancer is based on the stage of the disease. In advanced stages, it can be diagnosed through a gynecological examination, while in early stages, screening tests like high-risk HPV DNA testing showing positivity or the detection of abnormalities in a smear test can lead to further examination using colposcopy and biopsies. Biopsy is crucial in diagnosing the disease accurately and planning the appropriate treatment for cervical cancer. When caught in the early stages and treated, cervical cancer has a success rate of 80-85%.

The staging of cervical cancer is determined based on the extent of the cancer's spread within the body. Staging relies on pelvic and rectal examinations, in addition to radiological studies and other diagnostic tests as needed.


In addition to smear tests and biopsies, the following tests are used in the diagnosis of cervical cancer:


What is a smear test?


A smear test, also known as a Pap test, is a very simple and painless cancer screening method. It's highly important for women to have smear tests to protect against cervical cancer. There are two methods for conducting a smear test. In the classical method, a sample of discharge is spread onto a glass slide, then it is sprayed with a special solution and sent to a laboratory for examination. In the second method, the sample is placed in a liquid inside a container and sent to the laboratory for examination after going through specific processes.


All women aged 21 and older who have started active sexual activity should have smear tests. If active sexual activity began before this age, it is recommended to have the first smear test within three years from the start. For women with normal smear test results and no other risk factors, having a test every three years is sufficient. Testing should not be neglected during menopause. After the age of 65, if a woman has had at least three normal smear test results, she can discontinue smear tests with her doctor's knowledge. Additionally, if a suspicious condition is detected in a smear test, more frequent testing or further examinations may be recommended.


Colposcopy: This involves examining the cervix by enlarging the epithelium lining it using a specialized instrument similar to a microscope. Cervical cancer is not an event that happens overnight; it starts with cell abnormalities and progresses over time. With colposcopy, it is possible to observe these changes in the epithelium lining the cervix. When colposcopy is performed in conjunction with smear tests, the margin of error decreases significantly.


These tests are also used in the diagnosis and staging of cervical cancer:


Rectovaginal examination: In this test, the rectal and vaginal areas are examined simultaneously. It is a simple pelvic examination that can be performed in a doctor's office. It helps determine whether the cancer has spread beyond the cervix.


CT scan (Computed Tomography scan): A CT scan begins with the injection of a radiopaque substance into the bloodstream. This substance enhances the visibility of internal organs in X-rays.


MRI (Magnetic Resonance Imaging) scan: This test uses magnetic radio waves and a computer to create images of internal organs and tissues.


PET (Positron Emission Tomography) scan: Radioactive glucose is injected into the bloodstream, and a PET scan identifies areas of the body where glucose is used at a high rate. Cancer cells are more active and use more glucose than normal cells, making them appear brighter in this test.


Additionally, to determine if cancer has spread to the breasts or lungs, a chest X-ray and blood count may be recommended.


What are the treatment methods of cervical cancer?


HPV virus infection can lead to the development of genital warts, which can be treated by various methods including burning, freezing, surgery, or topical creams. However, the disappearance of warts after treatment does not necessarily mean they won't recur. Some individuals may experience recurrent warts after treatment, while others may not. When new warts appear, treatment should be repeated. The risk of genital warts recurring is linked to the strength of the person's immune system. It's known that in HPV virus infections, the body can sometimes clear the virus on its own without treatment.


In the treatment of cervical cancer, surgical intervention, radiation therapy, and chemotherapy methods are used either alone or in combination. If the precancerous lesion (CIN 2-3) has not penetrated deeply into the cervical tissue, the affected area can be identified by colposcopy. Surgical removal of the affected area can eliminate the region where cancer could develop, leading to a high rate of cure. A simple surgical procedure can allow the patient to be discharged on the same day. If the cancer has become invasive, meaning it has penetrated deep into the tissue, there are two treatment options. In this case, a radical hysterectomy, a complex and lengthy surgery, is performed to remove the cancerous tissue. Additionally, lymph nodes in the pelvic area may also be removed because cancer cells can affect them. An alternative is chemoradiotherapy, where chemotherapy drugs make the cancer cells in that area more sensitive to radiation, followed by radiation therapy and ongoing monitoring. If the cancer is in an advanced stage, chemotherapy is administered, but the chances of recovery in such cases are considerably lower.


What is HPV and how is it transmitted?


HPV is a sexually transmitted virus that can lead to cervical cancer. HPV (Human Papillomavirus) is a virus that infects the genital area and is transmitted through contact, and it is found in over 95% of women diagnosed with cervical cancer. It can cause warts in the genital area, as well as cervical, external genital, and reproductive tract cancers, especially in women. HPV is a rather insidious virus that can continue to spread for months without showing any symptoms. Cases where symptoms of the virus are detected several months or years after transmission are referred to as "silent infections."


HPV can cause genital warts in both men and women, and in women, it can lead to cervical cancer. HPV is a serious infection that can be controlled by the immune system in some individuals. It's important to note that a virus that cannot be eliminated by the immune system can persist in the body for years without causing any symptoms. This situation not only does not prevent the disease from spreading but also allows the virus to continue to be transmitted during sexual activity.


HPV virus types are categorized into risk groups based on their likelihood of causing cervical cancer. Types that are more likely to cause warts belong to the low-risk group for cervical cancer. Therefore, it's not the case that every genital wart will turn into cervical cancer.


Treatment of genital warts


Warts that result from HPV virus infection can be treated by burning, freezing, surgery, or topical creams. The disappearance of genital warts after this treatment does not necessarily mean they will not reappear. While some individuals may not experience a recurrence of genital warts after treatment, others may observe the formation of genital warts at frequent intervals. It is necessary to repeat the treatment with each new occurrence of genital warts. It is known that in HPV virus infections, the virus can be naturally eliminated by the body without treatment.


After the cervical cancer treatment


Depending on the stage of cancer and the method of treatment, cervical cancer may not disappear or may reoccur after treatment. A new cancer may also appear elsewhere in the body. Therefore, routine check-ups and smear tests are important even after treatment has concluded. Your doctor may recommend more frequent smear tests in the first few years after treatment to ensure that all cancer cells have been eliminated. Additional tests and procedures may also be necessary. Your doctor will work with you to plan the necessary follow-up appointments even after treatment has concluded.


FREQUENTLY ASKED QUESTIONS ABOUT CERVICAL CANCER

Is Cervical Cancer Contagious?


The biggest factor causing cervical cancer is HPV. This virus has been detected in 99.7% of patients. Cervical cancer itself is not contagious, but HPV is the most common sexually transmitted virus. Individuals with genital warts in the genital area have a high transmission rate, around 60%, following sexual contact.


HPV is primarily transmitted sexually, but it can also be transmitted to a very low extent through manual contact, toilets, and personal hygiene items. Having multiple sexual partners poses a high-risk factor for HPV transmission.


What Are the Early Symptoms of Cervical Cancer?


The initial symptoms of cervical cancer can include bloody discharge, post-coital bleeding (bleeding after sexual intercourse), and irregular menstrual bleeding.


Where Does Uterine Cancer Pain Occur?


Uterine cervical cancer can manifest with symptoms such as back pain, leg pain, pelvic pain, and bone pain. Additionally, lower abdominal pain and pressure during sexual intercourse, as well as weight loss, can also be observed.


Can Cervical Cancer Be Felt by Hand?


During a manual examination, the doctor places two fingers inside the vagina and the other hand on the lower abdomen. This way, they can feel for any organs or masses that might be present.


At What Stage Does Cervical Cancer Show Symptoms?


The symptoms of cervical cancer typically appear in the advanced stages of the disease. In advanced stages, a tumor can be seen during an examination. As cervical cancer progresses, urinary problems, difficulty with defecation (bowel movements), and leg pain can also occur.


At What Age Does Cervical Cancer Begin?


Cervical cancer, which usually appears around the age of 50 during menopause, has been increasingly observed in younger women in recent times. While breast cancer holds the top position in the ranking of cancers most commonly seen in women, cervical cancer can surpass breast cancer due to its life-threatening nature.


What Does a Smear Test Reveal? Can It Detect Cervical Cancer?


A smear test is conducted to detect any changes that might occur in the vagina before they turn into cancer. This allows for early treatment options before a woman progresses to a cancer stage. Women may need to undergo routine smear tests as determined by specialists in gynecology.

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