A Study of Cervical Cancer

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Cervical Cancer


Cervical cancer is the cancer of the narrowed entry to the uterus (cervix). It is categorized into stages 0 through IV. Stage 0 cancer is limited to only the cells on the surface layer of the cervix while stage IV refers to cancer that has spread beyond the pelvis. (6)

Worldwide, cervical cancer is the third most common type of cancer in women. (7) Patients will experience abnormal vaginal bleeding, increased vaginal discharge, pelvic pain, pain during urination and also bleeding between regular menstrual periods, after sexual intercourse, douching, or pelvic exam. However, these symptoms usually go unnoticed as they are similar to many other ailments. (8)

Studies revealed that a number of factors are associated with increase in the risk of cervical cancer. The main cause of cervical cancer is infection with human papillomavirus (HPV). The risk is even higher when other risk factors such as smoking, use of birth control pills and having multiple sexual partners are part of a person's lifestyle. (9)

Fig.1 Cancerous cervix Fig.2 Normal cervix

(http://www.cecaphil.org/images/FAQ_img/cancerous_cervix.jpg), downloaded 10 April 2010.

(http://www.cecaphil.org/images/FAQ_img/normal_cervix.jpg), downloaded 10 April 2010.

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A possible solution - Pap Smear Test

I strongly feel that there is an importance in going for regular Pap smear test as it is very effective in screening for cervical cancer. Pap smear is a procedure in which a sample of cells from a woman's cervix is collected before being spread on a microscope slide to be examined under a microscope to look for pre-malignant or malignant changes. (10)

Fig.3 Pap smear test

(http://health.allrefer.com/health/pap-smear-and-treatment-the-pap-smear.html), downloaded 10 April 2010

The frequency of Pap smear testing depends on age and sexual activity. In 2009, the American College of Obstetricians and Gynecologists (ACOG) revised their guidelines, recommending screening with Pap smears begin no earlier than age 21 and performed every two years until age 29. , A Pap smear may not be required more than once every three years when a woman reaches 30 years old and has done three consecutive normal Pap smears. (11)

A woman who is menstruating should not have a Pap smear. She should not use douche or spermicidal foams, creams, or jellies or vaginal medicines unless directed by a physician for about two days before testing as these agents may wash away or prevent abnormal cervical cells from being seen. This test can be conducted in doctor's office, a clinic, or a hospital by either a physician or other trained health care professional.

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First of all, the clinician will examine the outside of the patient's genital and rectal areas, including the urethra to make sure that they look normal. Then, a speculum which is an instrument that enable the vagina and the cervix to be viewed and examined is inserted into that vaginal area. A sample of cells is collected by inserting cervical brush into the opening of the cervix and twirling around it. This sample is known as endocervical sample as it comes from inside the cervix. A second sample known as ectocervical sample are also collected by scraping the area surrounding. Both samples are smeared on glass slide and a fixative is used to prepare cells for laboratory evaluation. (12)

Fig. 4 Possible result from Pap smear test

(http://www.labtestsonline.org/understanding/analytes/pap/test.html), downloaded 8 June 2010

When the cells appear to be normal or there is no infection is identified, a "negative" Pap smear is obtained. Sometimes, the conventional Pap smear may be "unsatisfactory" for evaluation, possibly caused by inadequate cell collection or that cells could not be clearly identified. (11)

The final Pap smear diagnosis is decided by three factors, namely the patient's history, sample adequacy and the presence of absence of cellular abnormalities. (13)

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Fig .5 Mortality from cervical cancer in Australia.

*Age-standardised death rate (Australian Standard Population 1991).

(http://www.mja.com.au/public/issues/178_12_160603/far10748_fm.html), downloaded 1 June 2010

"Cervical screening in Australia is one of the great public health success stories"

(http://www.mja.com.au/public/issues/178_12_160603/far10748_fm.html), downloaded 1 June 2010

Since the 1960s, cervical screening has been available for Australian women but the organized approach to cervical screening only commenced at 1991. There has been a drop in incidence of and mortality from cervical cancer since the 1960s when cervical screening was introduced. From 1991 onwards, there is a continuing dramatic fall in the incidence of carcinoma of the cervix and mortality from this disease. Thus, this evidence strongly proves that Pap smear is an effective screening tool which can reduce the mortality rates by diagnosing cervical cancer early. (14)

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Similar successes are also observed in The Scandinavian countries, namely Iceland, Denmark and Norway. In Iceland where the program covered most extensively, 80% of decrease in mortality rates was observed between 1965 and 1982, making it the country with greatest decrease in mortality rates. In Denmark and Norway where the screening program covered 40% and 25% of the population respectively, the mortality rates decreased by 25% in Denmark and 10% in Norway.

In Canada, United Kingdom (UK), other European countries and New Zealand, the introduction of organized population screening led to a marked decrease in the incidence and mortality from cervical cancer. For an example, the incidence and mortality decreased by about half when a national call-recall system introduced in the UK in 1988. In other words, the incidence of invasive cervical cancer dropped from 14-16 per 100,000 women in 1971 to 10 per 100,000 in 1995 and to eight per 100,000 women in 2005. Number of deaths from cervical cancer also decreased from 2000 in 1988 to 921 in 2006.

In general, the participation of a woman aged between 35 and 64 in the UK cervical screening program reduces her cervical cancer risk in the future five years by 60-80%. The risk of advanced cancer is reduced by approximately 90%. (15)

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One economical issue that I encountered while conducting this research is that the women in developing countries have higher rates of cervical cancer but are deprived of screening programs causing 80% to 85% of deaths caused by cervical cancer occurring in developing countries. (16)

Fig. 6 (http://www.rho.org/about-cervical-cancer.htm), downloaded 3 June 2010

Barriers to screening in developing countries include limited human resources, finance resources and poorly developed healthcare services.

"Malawi which has a cervical cancer incidence rate of 47 per 10,000 women, has one pathologist, one colposcope and no cytotechnicians." (http://www.who.int/immunization/sage/Dennycervical_cancer.pdf), downloaded 15 June 2010

The governments have to financially independent to cervical screening to the people. I hope that international community will lend a hand to developing countries to set up own screening program.

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In my opinion, a social issue is also implicated here: awareness of cervical cancer is less among women in developing countries due to lack of education.

"In 1996, Pap smear coverage in Malaysia which is a developing country is reported to be merely 26% according to the National Health and Morbidity Survey II." (http://smj.sma.org.sg/5001/5001a6.pdf), downloaded 2 August 2010

This shows that awareness of the importance of regular screening is still below satisfactory level in developing countries. (18) This lack of awareness may be attributed to low level of education and less exposure to basic medical information. Possible approaches to increase awareness among women include reaching women through local women's or community groups. (19) The society also needs to be educated to deal with the mindsets of some women who feel shy to do Pap smear test.

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Benefits and Risks

In my opinion, Pap smear is beneficial as can detect cancerous or precancerous conditions of the cervix. (20) In most cases, the test does identify minor cellular abnormalities before those cells have had a chance to turn cancerous and at the time where the condition is most easily treatable. Other than that, it is simple, quick, and relatively painless. Pap smear cannot detect other forms of cancer such as those of the ovary, vagina or uterus but cancer of those organs can be discovered during pelvic exam which is conducted at the same time as Pap smear. (10)

No test is perfect, so does the Pap smear test. Its specificity which means it ability to differentiate normal smear and abnormal is considered very good but it is not perfect. The same goes to its sensitivity which means its ability to detect every single cancerous cell. Thus, "false negative" results (presence of abnormalities are not detected by the test) will occur, resulting in few women developing cervical cancer despite being screened regularly using Pap smear. (10, 16) Therefore, patients are encouraged to make repeat screening as single screening results in high rate of false-negatives.

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Surgery is an option for women with Stage I or II cervical cancer. The surgeon removes tissue that may contain cancer cells by radical hysterectomy or total hysterectomy. (21)

Radical hysterectomy

The cervix, parametrium, surrounding lymph nodes, and upper 2 cm of the vagina will be removed by surgeon before the uterus being attached to the remaining vagina. In order to allow the patient to carry a pregnancy, a cerclage (a minor surgical procedure in which the opening to the uterus (the cervix) is stitched closed in order to prevent a miscarriage or premature birth) is performed. (22)

Fig. 7 Extent of Resection for Invasive Cervical Cancer (http://www2.mdanderson.org/depts/oncolog/articles/08/6-jun/6-08-2.html), downloaded 8 February 2010

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Total hysterectomy A total hysterectomy involves the removing the cancerous part, the cervix and the uterus. Simple hysterectomy is typically an option only when the cancer is very early stage - invasion is less than 3 millimeters (mm) into the cervix. (23)

Fig.8 Total hysterectomy removes the entire uterus, including the cervix. (http://www.fibroidsecondopinion.com/hysterectomy-for-fibroids), downloaded 10 February 2010

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Radiotherapy works by delivering high energy radiation or X-rays to a specific part of the body with cancer. (24) Cancer cells will be killed at greater rate compared to normal cells as they are more sensitive to radiotherapy. Normal cells that are affected during the treatment will recover or repair themselves in a short time. (5)

There are two types or radiotherapy: external radiotherapy and internal radiotherapy. (21)

External radiotherapy

At first visit, patient will have to lie under a large machine known as simulator. By using information from simulator, doctor can work out where to give the treatment to maximize the killing of cancer cells and minimize the loss of healthy body tissue. During external radiotherapy treatment, high energy x-rays are directed from a machine at the area of the cancer. (25)

Fig.9 Simulators use X-rays or CT scans to plan the treatment (http://www.cancerhelp.org.uk/type/cervical-cancer/treatment/radiotherapy/about-cervical-cancer-radiotherapy), downloaded 5 May 2010

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Fig. 10 The radiographer will help position patient on the couch and make sure that she is comfortable. (http://www.cancerhelp.org.uk/type/cervical-cancer/treatment/radiotherapy/about-cervical-cancer-radiotherapy), downloaded 5 May 2010

Internal radiotherapy Internal radiotherapy uses radioactive needles or seeds to place radiation source inside the body as near the tumor as possible to kill cancer cells. When it comes to cervical cancer, the source is put into the vagina, through the cervix up into the womb. (26)

Fig. 10 This diagram shows the positioning of radioactive sources in the cervix and womb (http://www.womens-health-concern.org/help/factsheets/fs_cervicalcancer.html), downloaded 12 May 2010 1787 words

Source Evaluation

Pap smear is an effective tool to reduce the incidence and mortality caused by cervical cancer, from reference [http://www.medicinenet.com/pap_smear/article.htm#toca] This source is reliable since it also agrees with many other sources such as [http://www.labtestsonline.org/understanding/analytes/pap/test.html ] with the extract "The Pap smear, when performed routinely, has been a great help in the detection and treatment of areas of pre-cancer, which helps prevent cervical cancer from developing." Labtestsonline.org is produced by American Association for Clinical Chemistry (AACC) and other professional societies representing the laboratory community. The site adheres to the principles espoused by the Health on the Net Foundation to make sure that the site is accepted as a reliable source for medical information.

The statistics showing the effectiveness of the cervical cancer screening programs in Scandinavian countries, Canada, United Kingdom (UK), other European countries and New Zealand were taken from an article entitled Cervical Cancer Prevention from theStar newspaper dated 22th November 2009. It seems to be a very reliable source as the author is a professional in this field and also a well-known figure in the local medical scene. The article is written by Dr Milton Lum who is a consultant obstetrician and gynecologist. Other than that, Dr Milton was the president for Malaysian Medical Association for the year 1997.

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