Bartholin Abscess

Cancer of the Cervix

What is cancer of the cervix?
Cancer is not a single disease but a change in behaviour of many different tissues of the body.  In essence, the normal control mechanism, which balances new cell production with cell death and limits the growth of the tissue, is switched off.  This allows the tissue to grow, break out of its normal limits and even spread around the body.  Some cancers are extremely slow growing and present little danger to life.  Others are very aggressive.  Even within one tissue, the cancers which develop can behave in quite different ways.
The cervix is the neck of the womb.  Cancers here tend to spread locally before there is any spread around the body.  There are two main types of cervical cancer: squamous cell carcinoma (SCC) and adenocarcinoma.  90 -95% are SCC. 
In 2007, 2,828 women in the UK were diagnosed with cervical cancer.  957 women in the UK died from cervical cancer in 2008
In the USA, it is estimated that more than 12,000 women will be diagnosed with cervical cancer and 4,000 die from it.  American Cancer Society (2011). Cancer Facts and Figures 2011. Atlanta, GA: American Cancer Society. Retrieved August 25, 2011.

Is there a recognisable pre-cancerous stage?
Yes, there is.  It is called Cervical Intra-epithelial Neoplasia (CIN), meaning “new growth confined to the epithelium or surface layer of the cervix”.  This is recognised by scraping some cells from the cervix, staining them and examining them under a microscope for abnormal cells. An abnormality of the nucleus of a cell is called dyskaryosis.  A cervical smear, Papanicolau smear or just Pap smear.
The degree of abnormality and the number of affected cells allow the description of three stages (CIN1, CIN2, CIN3) of worsening CIN.   
Whilst it is at the stage of CIN, there is no spread and it may be cut out (Cone Biopsy, Large Loop Excision, LLETZ) or destroyed with heat (cautery) or cold (cryocautery).  This cures the woman of the CIN but not of the cause so further surveillance with regular cervical smears is essential.  Both will, of course, be cured if a (total) hysterectomy is performed.

Who gets cancer of the cervix?
In the nineteen seventies, we knew that cancer of the cervix (cervical carcinoma) exhibited all the characteristics of a sexually transmitted disease.  We just did not have a clue about the actual germ.  We knew that it was associated with:

•  Multiple sexual partners
• The contraction of other STDs
• Starting sexual intercourse at a young age
•  Being the wife of someone who worked away from home e.g. long distance lorry drivers or merchant seamen
•  Low socio-economic class
•  Smoking
•  Use of oral contraceptives (not condoms)

During the next twenty or thirty years many proposals were made as we learned how to identify new germs.  It was even suggested at one time that sperm DNA might be the cause.
Only recently have new techniques of DNA hybridisation allowed us to find the true culprit.

How is it caused?
We now believe that infection with human Papilloma Virus (hPV, HPV) is the cause.  There are over 140 different papilloma viruses.  Some cause warts (papillomata), some cause cancerous change and some seem to do nothing at all.  Approximately 40 are sexually transmitted and, of these, types 16 and 18 are associated with the highest risk of CIN (though up to 15 subtypes seem to confer some risk).  Most HPV infection of the cervix does not lead to CIN. 
HPV subtypes 6 and 11 cause genital warts (condylomata acuminate)

How is it diagnosed?
The original technique for a Pap smear involves “fixing” the cells and staining them.  Signs of viral infection may be seen and the degree of CIN estimated.  But it cannot diagnose cancer nor can it recognise “High Risk HPV”. 
In the UK, we have generally changed to “Liquid Based Cytology” (LBC).  This involves a similar sampling technique but the cells are suspended in a liquid to preserve them.  In the laboratory, some cells can be stained as before.  The technique also permits DNA hybridisation to be used to identify HPV DNA and actually identify the subtype.  This test is not generally available on the NHS (but can be arranged privately by Women’s Health UK). 
If a woman is in a stable monogamous relationship and does not exhibit High Risk HPV, it might be reasonable to reduce the frequency of cervical smears.  But if High Risk subtypes are present, more frequent surveillance might be recommended.
If CIN 2 or 3 is suggested, the next step is colposcopy.  In this procedure, the cervix is examined minutely with a special microscope (a colposcope) and the affected part of the cervix identified.  A tiny biopsy of this is taken and examined in the laboratory to give a definitive diagnosis.

How can I prevent it?
The surest way to eliminate risk for genital HPV infection is to refrain from any genital contact with another individual.  For those who are sexually active, a long-term, mutually monogamous relationship with an uninfected partner is the strategy most likely to prevent HPV infection.  However, it is difficult to determine whether a partner who has been sexually active in the past is currently infected.
Research has shown that correct and consistent condom use can reduce the transmission of HPV between sexual partners .  

Winer RL, Hughes JP, Feng Q, et al. Condom use and the risk of genital human papillomavirus infection in young women. New England Journal of Medicine 2006; 354(25):2645–2654. [PubMed Abstract]

However, because areas not covered by a condom can be infected by the virus, condoms are unlikely to provide complete protection against transmission of infection.
In the UK, the Department of Health has instituted a programme of vaccination of young women.  Since September 2008 there has been a national programme to vaccinate girls aged 12 to 13 against the human papilloma virus (HPV). This age-group is usually in year 8 at schools in England.
From September 2008 a three-year "catch-up" campaign was started, to offer the HPV vaccine, also known as the cervical cancer jab, to older girls aged 14–17. Most primary care trusts are aiming to complete the catch-up programme within two years.
The programme is delivered largely through secondary schools and consists of three injections that should ideally be given over a period of six months, although they can all be given over a period of 12 months.
In the UK, from September 2008 to July 2010, at least four million doses of Cervarix (the HPV vaccine used in the UK programme) were given.  Source: NHS Choices

Two vaccines are available, Gardasil® and Cervarix® that are highly effective in preventing persistent infections with the two HPV types that cause most cervical and anal cancers. Gardasil also prevents infection with the two HPV types that cause most genital warts.

What if I am over seventeen?
Providing that we have done an HPV DNA hybridisation test and found no high risk HPV subtypes, Women’s health UK can arrange a course of immunisation for you.  It must be remembered that the long term protection is not yet known and so cannot be guaranteed.  Also, the immunisation only affects the two (or four) viruses and cervical cancer might be caused by infection with a rarer subtype.  It is not yet known how much “cross reaction” there might be.

Summary Points

•Human papillomaviruses (HPVs) are a group of more than 150 related viruses, of which more than 40 can be sexually transmitted. Some sexually transmitted HPVs cause genital warts, whereas others, called high-risk or oncogenic HPVs, can cause cancer.

• Genital HPV infections are very common, but most occur without any symptoms and go away without any treatment over the course of a few years.

• Sometimes, HPV infections can persist for many years. Persistent infections with high-risk HPVs are the primary cause of cervical cancer and anal cancer. HPV infections also cause some cancers of the vulva, vagina, penis, and oropharynx.

• The US Food and Drug Administration has approved two vaccines, Gardasil® and Cervarix®, which are highly effective in preventing persistent infections with the two HPV types that cause most cervical and anal cancers. Gardasil also prevents infection with the two HPV types that cause most genital warts.

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