Cervical cancer is a slow growing disease and therefore usually not noticeable on visual examination. The use of the Papanicolaou (Pap) test has allowed for early detection of microscopic cellular changes leading to earlier management and treatments that can prevent cervical cancer from developing.
Abnormal Discharge and/or Bleeding
There may be no symptoms of a very early cervical cancer, therefore routine screening with the Pap test is recommended as per current guidelines. Early cervical cancers can be associated with intermittent spotting, watery discharge, or bleeding after intercourse. Anyone with any of these symptoms should be evaluated as this could signal the presence of the disease. Abnormal discharge, as a sign of cancer, can occur when the malignant tissue outgrows its oxygenated blood supply. Some of the cells then die, the tissue can become infected leading to a watery or foul-smelling discharge. If you’ve been treated for a vaginal infection that does not go away, this could also be a symptom.
Bladder and/or Kidney Blockage
As cervical cancer increases in size, it usually grows laterally into the parametria (space next to the cervix) towards and sometimes into the pelvic sidewalls. The ureters (tubes draining urine from the kidney into the bladder) can become obstructed if cervical cancer is able to reach the pelvic sidewall. Obstruction of the ureters can lead to severe consequences including kidney (renal) failure.
When cancer of the cervix grows into the pelvic sidewall, it can press on the nerves that come from the spinal cord and go to the leg causing constant leg pain. In addition, this cancer can spread by way of the lymphatic system. The lymphatic vessels drain from the cervix to clusters of lymph glands along the pelvic wall. If the pelvic lymph nodes on one side of the pelvis become obstructed with cancer, swelling can occur in the in the leg. Both of these leg issues (pain and swelling) can be signs of advanced cervical cancer.
Cervical cancers are easier to diagnose because of the ability to access the cervix for evaluation in the office setting. The Pap test can detect pre-invasive cellular changes leading to cervical cancer (dysplasia) and invasive cervical cancer. An abnormal Pap test is usually followed by a biopsy or cervical cone biopsy (conization) to evaluate for microinvasive or invasive disease. Endocervical curettage (ECC) is performed to evaluate the cells of the inner portion of the cervix known as the endocervical canal.
Doctors should not rely on a Pap test alone to rule out cancer in a woman who has symptoms or findings that could be due to a cancer. Cancer can only be excluded by the proper biopsies. Approximately 10% of women with an obvious cancer of the cervix will have a Pap test that is essentially normal. This is because there is so much inflammation and dead cell debris that it masks the cancer cells. Very rarely, the cervix may be too small or inaccessible to proper biopsy. In these situations, a hysterectomy may be the best treatment and lead to a definitive diagnosis.
In the U.S., more resources are available; therefore, someone with suspected advanced disease may be further evaluated for metastases with kidney and liver function blood tests, cystoscopy (evaluation of the bladder), proctosigmoidoscopy (evaluation of the rectum and sigmoid colon), and additional imaging via Computed tomography (CT) scan or Positron emission tomography (PET) – CT scan. Magnetic Resonance Imaging (MRI) may be useful to evaluate the extent of early disease in patients who are candidates for fertility sparing surgical intervention (radical trachelectomy – removal of the cervix).
Your doctor will consider which treatment options are recommended for you based on your clinical staging (size of the tumor at diagnosis, invasion to sidewalls and/or causing changes in other organs or distant metastases.) Many cervical cancers can be treated with surgery, if diagnosed in the earliest stages. If the tumor is large and/or more advanced, a combination of chemotherapy and radiation may be the best course of action.
Radiation therapy usually requires a treatment each day, five days a week, for about five weeks. Each treatment takes about 30 minutes. This is called external beam radiation therapy (EBRT) or teletherapy. The entire pelvic area is carefully mapped with imaging by a Radiation Oncologist and irradiated by an x-ray beam usually generated by a linear accelerator. Everything in the pelvis is irradiated, bladder, rectum, large intestine, small intestine, bone and skin. Following this treatment, a radioactive source is placed inside the cervix and vagina and left in place a few minutes or several days. This is called an implant, radium implant, intracavitary implant or any of several other names. A more accurate term is brachytherapy, which means slow therapy. Again, carefully mapping with imaging allows for specific treatment dosing to maximize radiation to the tumor and minimize radiation to neighboring vital structures (bowel, bladder, vessels, nerves) when they are not involved.
Stage IA1 cancers that invade less than 3mm deep and are less than 7mm length in horizontal spread, can sometimes be treated by simple hysterectomy or even in special cases by a cervical cone biopsy. All other Stage I cancers may require radical surgery, radiation therapy or a combination of radiation and chemotherapy. Very rarely some patients who are stage IA2 (3-5mm depth of invasion with 7mm or less horizontal spread) or early 1B1 (clinically visible tumor confined to the cervix no greater than 4cm), usually less than 2cm size tumor, may be candidates for fertility sparing surgery.
Some stage IIA cancers can also be considered for surgery. Surgery for stage IB and some IIA cancers requires a radical hysterectomy and removal of the pelvic and sometimes para-aortic lymph nodes. Sentinel lymph node (SLN) mapping (injection of special dye into the cervix, illuminating the most draining lymph node that has highest risk of tumor spread) may be utilized following a specific algorithm to decrease pelvic lymphadenectomy is specific cases, usually patients with tumors less than 2cm in greatest dimension. Although the risk is low, pelvic lymphadenectomy can carry some risks of lymphedema (lower leg swelling), lymphocele (fluid collection where lymph fluid leaks causing a cyst like area) and neuralgia (nerve pain). When appropriate SLN mapping is utilized to aide in detection of tumor spread while minimizing co-morbidity from complete pelvic lymphadenectomy.
A regular or simple (extrafascial) hysterectomy removes the uterus with cervix by staying as close to it as possible and is used in early disease only. Radical hysterectomy means that the uterus with cervix is removed, taking the parametrial tissue (tissue next to the cervix) to achieve negative margins (edges of tissue without cancer.) Some patients may require some variation between called a modified radical hysterectomy.
Otherwise, all patients with advanced stage II, III and IV cancers, or those who are not good surgical candidates, are treated with chemoradiation. Chemoradiation can be EBRT with Brachytherapy and a small dose of chemotherapy once per week during the EBRT to help the radiation work more effectively (radiosensitization). Systemic chemotherapy (usually a multidrug regimen) may be needed with or without radiation therapy depending on the extent of disease, distant metastases and need for local control.
Cervical cancer surgery requires that the cancer be removed with as good a margin of uninvolved tissue as can safely be taken. The radical hysterectomy technique removes all the supporting ligaments to the cervix, which means the dissection can be very close to the bladder and to the rectum. The ureters have to be carefully dissected around and the tissue surrounding them is removed. A radical hysterectomy with removal of the lymph nodes takes approximately 3 hours to perform. A simple hysterectomy takes only about 1 hour. The ovaries are rarely involved in earlier cervical cancers and can be left in place in young patients for cardiovascular and bone health. If, after surgery, the pathology indicates that there are positive lymph nodes or that the surgical margins are close, then pelvic radiation with or without chemotherapy may be advised.
A total pelvic exenteration is an ultra-radical pelvic surgery for persistent or recurrent cervical cancer that is only in the pelvic organs and no known metastases outside the pelvis are noted on imaging. This type of surgery can be curative if negative margins can be achieved. This procedure includes removal of uterus and cervix, vagina, bladder and rectum. This can require creation of a colostomy and ileo-conduit (making a bladder out of a piece of the small intestine and connecting the ureters). Sometimes a vagina can be reconstructed. If the rectum can be reattached then there may be no need for a colostomy. Sometimes a continent urinary reservoir can be constructed. Otherwise a bag will have to be placed for the urine to drain through an ostomy in the abdominal wall.
Radiosensitizing chemotherapy is usually given weekly during the EBRT, which helps the radiation work more effectively. Systemic chemotherapy (usually a multidrug regimen) may be needed with or without radiation therapy depending on the extent of disease, distant metastases and need for local control. Neoadjuvant chemotherapy is utilized in very rare cases to shrink the tumor prior to surgery. Chemotherapy may also be initiated in stage IV cases.