Dr Olumide Ofinran is a consultant gynaecologist, sub-specialist in gynaecological oncology and advanced laparoscopic and robotic surgeon. The specialist in colposcopy who is with the National Health Service, United Kingdom, talks about cervical cancer in this interview with ALEXANDER OKERE
What is cervical cancer?
Cervical cancer is the abnormal growth of cells from the cervix (neck of the womb) that have the ability to invade tissues or spread to other parts of the body.
What are the causes and risks of cervical cancer?
The main cause of cervical cancer is the presence of the human papillomavirus infection. HPV is a common viral infection, which is transmitted through sexual contact, including skin-to-skin contact. However, most women who have HPV infection do not develop cervical cancer. There are over 100 different types of HPV, and while some cause warts, others can cause different types of cancer (cancers of the cervix, vagina, vulva, anus, penis and back of the throat).
Over 80 per cent of sexually active people would have had HPV infection at some time in their life but majority will get rid of it via their body’s immune system. Persons with persistent HPV infection have an increased chance of acquiring precancerous cell abnormalities and subsequently developing cancers if left untreated.
Vaccines can help protect against the strains of HPV most likely to cause genital warts or cervical cancer. Other risk factors act together with HPV to increase the risk for cervical cancer. These include cigarette smoking, having sex from an early age, having multiple sexual partners, having children early and having a lot of children; weak immune system, low income or education and taking the contraceptive pill. Cervical cancer typically develops over 10 to 20 years. Also, there is an increased risk of cervical cancer if other women in the immediate family (mother, sister or daughter) have had cervical cancer. Research is ongoing to find out if this is because of faulty genes or other reasons.
How is it different from other forms of cancer?
Cervical cancer is one of the cancers considered to be preventable because there is a precancerous stage, which is a stage of abnormality that exists before the development of the cancer. This stage can be detected early and treated through screening, lifestyle changes and vaccination against HPV. Other cancers that fall into this category include breast, colorectal, anal, vulval, vaginal and testicular cancers.
What are the symptoms of the disease?
Cervical cancer in its early stage may not cause any symptoms but, if present, may include abnormal vaginal bleeding, bleeding after sexual intercourse or unusual discharge, back or pelvic pain, tiredness, weight loss or loss of appetite. More severe symptoms may appear in advanced stages.
How can it be detected?
Cervical cancer can be detected early through screening (Pap smear, a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix) or diagnosed clinically by a physical pelvic examination and colposcopy.
Colposcopy is a procedure in which a colposcope (a lighted, low-power microscope) is used to magnify and check the vagina and cervix for abnormal areas. Confirmation of diagnosis is made by taking a biopsy of the cervix. A biopsy is a small sample of tissue taken from the body so that it can be examined more closely under a microscope. Once a diagnosis of cervical cancer is made, other tests such as chest X-ray, MRI or CT scan, can be done to help in determining if the cancer has spread to other parts of the body. Examination of the bladder (cystoscopy) or rectum (proctoscopy) may be necessary.
How prevalent is it in Nigeria? Is there any statistical data?
Cervical cancer is the most common gynaecological cancer in sub-Saharan Africa. In Nigeria, it is the second most common cancer in women and the second most common cause of death from cancer in women after breast cancer. Over 570,000 new cases were reported worldwide in 2018 and about 90 per cent of deaths from cervical cancer occur in developing countries.
How do contraceptives put a woman at risk of cervical cancer?
Research has shown that prolonged use of the oral contraceptive pills (for more than five years) increased the risk of cervical cancer by up to four times, but only in women with the human papillomavirus infection. The increased risk reduces as soon as the pill is stopped; and after 10 years of stopping it, the risk is the same as if the pill was never used.
Though prolonged use of the pill can also slightly increase the risk of breast cancer, it is important to note that the overall chance of getting cervical cancer is low. The benefits of using oral contraception outweigh the risks for the majority of women and using the pill can help reduce the risk of uterine and ovarian cancers.
Is it true that women may live with cervical cancer for years without knowing?
Cervical cancer is one of the cancers that we know how it behaves and progresses. Typically, it develops slowly over several years. Women may have the precancerous cells, which don’t cause any symptoms in their cervix for years before development of cancer. That is why cervical screening is very important for early detection and treatment of this abnormality before it develops into cancer.
Is it also true that girls who have sex before the age of 16 or within a year of beginning their menstrual cycles are at a high risk of developing cervical cancer?
Having sex at an early age can double the risk of developing cervical cancer; it exposes the woman to the HPV infection more than women who get the infection later in life.
What are the stages of treatment and how are they different?
Cervical cancer can be described in terms of its stage, type and grade. Once diagnosed, the next step is to determine the stage. The stage of a cancer tells you how big the cancer is, whether it has spread and how far it has spread in the body. This is known as metastasis. There are four stages of cervical cancer. Stage one is when the cancer is still restricted to the body of the cervix.
Stage two is when the cancer has spread outside the cervix into surrounding tissues. Stage three is when the cancer has spread even further to involve the lower part of the vagina and the walls of the pelvis and may even block the tubes (ureters) that carry urine from the kidneys to the bladder.
Stage four is when the cancer has spread to the bladder, rectum or beyond. There are different types of cervical cancer; the most common of which is the squamous cell cervical cancer. The grade means how abnormal the cells look under the microscope and how aggressive they are.
When are surgery and radiotherapy necessary?
Treatment of cervical cancer depends on different factors but mainly on the stage when it was diagnosed. Other factors include age, health and fitness of the woman, fertility plans, treatment preference and availability of treatment options. Treatment options include surgery and radiotherapy. For surgery, radical hysterectomy and pelvic lymphadenectomy are the most common treatment (options) for early stage cervical cancer. This is an operation to remove the uterus, cervix, upper vagina, surrounding connective tissues (parametrium) and lymph nodes in the pelvis. Removal of the lymph nodes allows us to check for the spread of the disease. Unfortunately, in young women with cervical cancer, it means they can’t get pregnant again.
The earliest stage of cervical cancer, however, can be treated with cervical conisation or loop diathermy excision of the cervix, which removes only the cancer from the cervix and can allow for preservation of fertility, or a simple hysterectomy, which removes the uterus and cervix alone. A less aggressive fertility preserving operation, called radical trachelectomy, can be performed in the very early stage of cervical cancer. This removes the cervix and upper vagina leaving the uterus. In all these procedures, there’s no need to remove the ovaries.
Radiotherapy, which uses high-energy X-rays to kill the cancer cells and is usually given internally or externally in combination with chemotherapy, can be given after surgery if the tissues removed show high risk factors for the cancer coming back; this is called adjuvant treatment, or as an alternative to surgery if the cancer is at an advanced stage or if the patient is not fit for surgery or chooses this option.
What are the risks involved in these types of treatment?
The risks of having an operation include wound infection, bladder infection, wound and nerve pain, slow wound healing, wound breakdown, clots in the legs and lungs, and bleeding needing blood transfusion. Others are damage to the bowel, bladder, ureters or major blood vessels, bladder or bowel problems, or swelling in the abdomen or legs. Loss of fertility also occurs following hysterectomy. The side effects of radiotherapy and chemotherapy are similar. Most are temporary and start to go away once treatment ends, and they affect about one in 10 women.
Radiotherapy side effects depend on the dose of radiation used and whether it was internal or external. Chemotherapy side effects, which are more likely to affect the whole body, depend on the type of drug used, the dosage and a woman’s overall health. These side effects include nausea, vomiting, constipation, diarrhoea, tiredness, headache, muscle ache, mouth sores, skin irritation, hair loss, and bone marrow suppression/infection/low blood count and nerve damage.
What are the habits that can keep the cervix healthy?
Having regular cervical screening, avoiding smoking, vaccination against HPV, and safer sex (use of a condom) can reduce the risk of cervical cancer. The use of a condom will reduce the HPV infection. However, it can be transmitted during any type of sexual contact, including oral sex, anal sex, use of sex toys and skin-to-skin contact between genitals.