Cervical cancer

What is cervical cancer?

Cervical cancer is the second most common cancer among Indian women (As per Globocan 2018). Cervical cancer develops in a woman’s cervix (the entrance to the womb from the vagina). It mainly affects sexually active women aged between 30 and 45.
The best way to protect yourself from cervical cancer is by attending regular cervical screening (previously known as a “smear test”) and follow up. Unfortunately, most women in India are not aware about the screening.

Burden of the disease

More women in India die from cervical cancer than in any other country.

• New cases of cervical cancer detected in India: 96,322 every year
• Deaths due to cervical cancer in India: 60,078/year

Risk factors?

Persistent infection of cervix with a virus called Human Papillomavirus (HPV)

• Having many sexual partners
• Husband having multiple sexual partners
• Having first sexual intercourse at a younger age
• Giving birth to many children
• Smoking

Other diseases such as HIV/AIDS, immunosuppressive drugs, renal transplant etc.
These risk factors does not imply that you will definitely acquire cancer. However, if you have one or more of these risk factors, it is advisable to consult the doctor.

Can it be prevented​?

Cervical screening tests

Screening tests are performed  in apparently healthy women to detect abnormal changes in the cells of the cervix which are pre-cancerous and could possibly develop into cervical cancer in the future.  Available screening tests for cervical cancer include Pap smear test, VIA (visual inspection with acetic acid), VILI (visual inspection with Lugol’s iodine) and HPV DNA test.

Women aged 25 to 49 are invited for screening every 3 years. Women aged 50 to 64 are invited every 5 years. For women who are 65 or over, only those who have not been screened since they were 50, have had recent abnormal tests or have never been screened before are still eligible for screening.

It’s important to attend your cervical screening tests, even if you’ve been vaccinated for HPV, because the vaccine does not guarantee protection against cervical cancer.

If you’ve been treated for abnormal cervical cell changes, you may be invited for screening more frequently for several years after treatment. How regularly you need to go will depend on how severe the cell changes are.

Although it can identify most abnormal cell changes in the cervix, cervical screening is not 100% accurate. This means you should report any symptoms, such as unusual vaginal bleeding, to your GP, even if you’ve recently had screening.

HPV vaccination:  vaccines for cervical cancer target HPV 16 and 18, the most common oncogenic types of HPV responsible for cervical cancer. HPV vaccination is not effective against all oncogenic HPV types. Currently two vaccines, licensed globally are available in India; a quadrivalent vaccine (against HPV genotypes 6, 11, 16, 18) and a bivalent vaccine (against HPV genotypes 16, 18). . The recommended age for initiation of vaccination is 9–14 years. Catch-up vaccination is permitted up to the age of 26 years.
Females who have not been exposed to the HPV infection are likely to benefit more from the vaccine.

Indian Academy of Pediatrics (IAP) recommendations on HPV vaccination[4]:

Only 2 doses of either of the two HPV vaccines for girls aged 9-14 years: doses at interval of 6 months

For girls 15 years and older, and those with HIV/AIDS on chemotherapy or after organ transplant: dose at 0, 1-2 and 6 months.

Please Note:

Although the HPV vaccine can significantly reduce the risk of cervical cancer, it does not guarantee complete protection against cervical cancer. You should still attend cervical screening tests, even if you’ve had the vaccine.

VACCINATION IS NOT A REPLACEMENT FOR CERVICAL CANCER SCREENING

SAFER SEX

Most cases of cervical cancer are linked to an infection with certain types of human papilloma virus (HPV). HPV can be spread through unprotected sex, so using a condom can reduce your risk of developing the infection. Following safe sex practices (avoid multiple sexual partners) and timely treatment of reproductive tract infections can protect from cervical cancer

Avoid smoking

You can reduce your chances of getting cervical cancer by not smoking. People who smoke are less able to get rid of the HPV infection from the body, which can develop into cancer.

When to consult a doctor?

• Abnormal vaginal bleeding: Bleeding and spotting between periods, unusually longer or heavier periods,
• Bleeding aftermenopause
• Unusual or excessive vaginal discharge with foul smell
• Vaginal bleeding after having sexual intercourse
• Pain in the lower abdomen or pelvic pain
• Pain during sexual intercourse

If you have one or more of these, it is advisable to consult the doctor.

Cervical Cancer Screening Test

The Pap smear is a simple test that is done to collect a few cells from the cervix and and checked under a microscope for abnormalities. It also aids in diagnosing infections of the lower reproductive tract.

Who should get the Pap test done?

As per the International recommendations, women above the age of 21 years can get the pap test.

If you are 30 years and above Pap test should be done once in every 3 years till you turn 65 years of age. If this test is combined with HPV test, then the test may be repeated every 5 years.

Women who do not routinely require Pap test

Women aged less than 21 years and above 65 years

Women who had their womb removed for non-cancerous conditions

What is the right time for a Pap test?

The Pap test yields optimum results if scheduled between 10 to 20 days from the first day of menstrual period. The woman should not be menstruating at the time of test.

Preparation for Pap smear

You should avoid the following for 48 hours before the Pap test:

• Intercourse
• Douching of vagina
• Vaginal medications
• Vaginal contraceptives like creams/ jellies

Procedure

An instrument called a speculum is gently introduced into the vagina . This holds the walls of the vagina open so the cervix can be seen.There may be some discomfort or cramping during the procedure, but it is usually not painful.

A small soft brush will be used to gently collect some cells from the surface of your cervix. and then sent off to a laboratory for analysis and you should receive the result within 2 days.

Results of Pap test

A Pap test result may be reported as normal or abnormal.

Normal Pap test

If the test report is normal, this means  no abnormal cell changes have been found in the smear taken. A normal test result means  No action is needed and you don’t need another cervical screening test until it’s routinely due.

Inadequate

If the test report is inadequate , then you need to have a repeat test because the first one couldn’t be read properly.

This may be because:

• not enough cells were collected
• the cellscouldn’t be seen clearly enough
• an infection was present

another sample of cells should be  taken, usually after about 3 months.

Abnormal Pap tests

If the report is abnormal , it can be either of the two:

• borderline or low-grade changes (dyskaryosis)
• moderate or severe (high-grade) dyskaryosis

If the result is low-grade, it means that although there are some abnormal cell changes, they’re very close to being normal and may disappear without treatment.

In this case, the  sample will be tested for HPV DNA. If HPV isn’t found , the risk of  developing cervical cancer before the  next screening test is very low.

Depending on the woman’s age ,  routine screening is done in  3 to 5 years

If HPV is found, then  examination called colposcopy, which looks at the cervix more closely is done

Abnormal Pap test results do not mean that the woman has cancer.It just means that some of the cells are abnormal, and if they’re not treated they may develop into cervical cancer.

If the test findings suggest more severe abnormality like  high-grade dyskaryosis, your sample won’t be tested for HPV, but you’ll be offered colposcopy to check the changes in the cervical cells, it is then confirmed by further diagnostic procedures:

Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas.

Biopsy: A sample of tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of cancer. A biopsy that removes only a small amount of tissue (punch biopsy) is usually done in the OPD.