January is National Cervical Cancer Awareness Month, a month set aside to educate the public about cervical cancer health risks. Healthcare Professionals, NGOs and those with interest or passion for the condition are encouraged to organize health promotion events, campaign, and rally people together to spread awareness and show support for not only those living with the health condition but their loved ones as well. National Health Awareness months, weeks and days have become one of the best practices in disease prevention and health promotion. I believe we can learn from the practice as well. it is an opportunity for us to review this condition and see what we can do individually or collectively to reduce the burden of cervical cancer in our community. Developed countries, such as the USA, have achieved significant decreases in cervical cancer burden since the introduction of Pap smear-based and public awareness programs (ACS, 2018). However, many countries in sub-Saharan Africa (SSA) have been unable to attain such reductions (WHO, 2018). I believe this is an opportunity for us to rise up to the challenge of cervical cancer prevention.
Before we get into how we can help, let’s first review some information about cervical cancer.
• What is cervical cancer?
• How common is cervical cancer?
• What causes cervical cancer?
• What are the risk factors?
• Can cervical cancer be prevented?
• What are the ACS Guidelines for the Prevention and Early Detection of Cervical Cancer?
• What are the signs and symptoms cervical cancer?
• What are the stages of cervical cancer?
• What's New in Cervical Cancer Research and Treatment?
• How can you get involved?
Some of you are very familiar with this topic already. However, the focus of the review is on the primary and secondary prevention measures as increasing the level of awareness and health education on cervical cancer and making screening services available, accessible, and affordable, can positively influence the uptake of cervical cancer screening among women (Best practice) (Ferlay et al., 2018).
What is cervical cancer?
Cancer as you know is the growth of abnormal cells. The cells can invade and damage normal tissue. Cervical cancer is a type of cancer that occurs in the cells of the cervix — the lower part of the uterus that connects to the vagina. Most cervical cancers start in the cells lining the cervix.
These cells do not suddenly change into cancer. Instead, the normal cells of the cervix first gradually develop pre-cancerous changes that may turn into cancer. These changes can be detected by the Pap test and treated to prevent cancer from developing (ACS, 2018) – this is why the awareness month is very important (early detection).
Types of cervical cancer
There are two main types of cervical cancer: the squamous cell carcinoma and adenocarcinoma. Each one is distinguished by the appearance of cells under a microscope.
• Squamous cell carcinomas begin in the thin, flat cells that line the bottom of the cervix. This type of cervical cancer accounts for 80 to 90 percent of cervical cancers.
• Adenocarcinomas develop in the glandular cells that line the upper portion of the cervix. These cancers make up 10 to 20 percent of cervical cancers. Sometimes, both types of cells are involved in cervical cancer. Other types of cancer can develop in the cervix, but these are rare.
• Metastatic cervical cancer is cancer that has spread to other parts of the body.
-(ACS, 2018; CDC, 2018)
How common is cervical cancer?
Cervical cancer tends to occur in midlife and is most frequently diagnosed in women between the ages of 35 and 44. It rarely develops in women younger than 20. Many older women do not realize that the risk of developing cervical cancer is still present as they age. More than 15% of cases of cervical cancer are found in women over 65. According to World Health Organization (WHO), cervical cancer is the fourth most frequent cancer in women with an estimated 570,000 new cases in 2018 representing 6.6% of all female cancers. Sadly, approximately 90% of deaths from cervical cancer occurred in low- and middle-income countries.
Nigeria has a population of 50.33 million women ages 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 14943 women are diagnosed with cervical cancer and 10403 die from the disease in Nigeria. Cervical cancer ranks as the 2nd most frequent cancer among women in Nigeria.- (CDC, 2018, WHO, 2018, HPV Information Centre, 2018)
What causes cervical cancer?
More than 90 percent of cervical cancers today are caused by infection with the human papillomavirus (HPV), a virus so common that more than two-thirds of sexually active women are infected with it at some point. The majority of cervical cancer and pre-cancerous lesions are caused by two specific types of HPV; HPV-16 and HPV-18. These two types account for 70 percent of all cervical cancers.-(ACS, 2018; CDC, 2018)
What are the risk factors?
Risk factors are anything that can increase or decrease a person’s chance of getting a disease, such as cancer. There are several known risk factors for cervical cancer.
In addition to infection with the HPV virus, factors that increase the risk for cervical cancer include:
• Not getting screened – this is the main risk factor
• Smoking – women who smoke are about twice as likely as non-smokers to get cervical cancer. (it is believed that cigarettes produce chemicals that can damage cervical cells)
• Weak immune system
- Due to human immunodeficiency virus (HIV), the virus that causes AIDS
- Due to treatment with drugs to suppress the immune response, such as when treated for an autoimmune disease or after organ transplant
• Having first sexual intercourse at an early age
• Having many sexual partners
• Giving birth to three or more children
• Birth control pills (oral contraceptives) used over the long term.
-(ACS, 2018; CDC, 2018)
Can cervical cancer be prevented?
Cervical cancer is one of the most treatable and preventable cancers.
The best prevention is early detection. Routine screenings should begin as early as possible. This is a key factor in disease prevention. Because cervical cancer tends to grow so slowly, there are numbers of measures that a woman can take to prevent it from spreading,
1. Regular Pap tests that screen for cervical cancer helps detect abnormal cells
2. Use of condoms to protect against HPV.
3. HPV vaccination
-(ACS, 2018; CDC, 2018)
Cervical cancer screening/Tests
Screening is testing to find cancer, or other diseases, early in people who have no symptoms. Screening can help find cancers when they are small and have not spread – when they have a better chance of being cured. Screening can also find pre-cancerous changes that can be treated to prevent cancer from developing.
The most frequent method for cervical cancer screening is cytology, and there are alternative methods such as HPV DNA tests and visual inspection with acetic acid (VIA). VIA is an alternative to cytology-based screening in low-resource settings (the ’see and treat’ approach). HPV DNA testing is being introduced into some countries as an adjunct to cytology screening (’co-testing’) or as the primary screening test to be followed by a secondary more specific test such as cytology.- (ACS, 2018; CDC, 2018)
Pap smear or liquid-based cytology test can be used to screen for cervical dysplasia (precancer) and cervical cancer.
(a). Pap Smear
A typical Pap smear involves four steps:
1. The doctor inserts a lubricated instrument into your vagina to enlarge the opening.
2. He or she takes a sample of mucus and cells by gently scraping the cervix.
3. The Healthcare Provider sends the tissue samples to a lab for analysis.
4. If any irregularities are found, the Healthcare Provider will suggest next steps.
A Pap smear test is usually not painful, although some women experience minor discomfort. Getting regular Pap smears helps Healthcare Provider detect any changes in the cells of the cervix, including the presence of the HPV virus. Early detection can affect treatment options if cancerous changes are detected in the cervix.
Some institutions strongly recommend that even women who have been vaccinated against HPV get regular Pap smears.
(b). Liquid-Based Cytology
Liquid-based cytology (for example, ThinPrep®) can detect changes in the cervix as well as testing for HPV. If the Pap smear reveals that there are atypical squamous cells of undetermined significance (ASCUS), liquid-based cytology can give a more complete picture of what’s going on. The first part of liquid-based cytology is similar to a Pap smear. The Healthcare Provider inserts a lubricated instrument into the vagina and gently removes a tissue sample. The key difference from a Pap smear is that the tissue sample that gets sent to the lab is of a higher quality because it has been placed in a special liquid, processed in a machine, and then placed on a slide for examination.
(c). Colposcopy and biopsy
If a Pap smear or liquid-based cytology test shows an abnormality, The Healthcare Provider may perform a colposcopy, in which a lighted magnifying instrument attached to magnifying binoculars (a colposcope) is used to examine the cervix. The Healthcare Provider may also perform a biopsy at the same time, removing a tiny section of the surface of the cervix to examine under the microscope. A trained pathologist will examine the sample to see whether it contains abnormal or cancerous cells.
(d). Cone Biopsy (Conization)
If abnormal cells are found or if a diagnosis is not clear after a colposcopy, it may be necessary to have minor surgery to remove a slightly larger piece of tissue from the cervix. This procedure is called a cone biopsy, or conization. In addition to helping to confirm a diagnosis, a cone biopsy can serve as an initial treatment, to simultaneously remove any precancerous or cancerous cells.
The Healthcare Provider may also order a chest x-ray, CT scan of the abdomen and pelvis, and/or an MRI scan if there is reason to believe that the cancer has spread, or metastasized, beyond the cervix to other parts of the body. Cervical cancer used to be one of the most common causes of cancer death for women in the United States. However, the rate has decreased by more than 50 percent over the past 30 years due to regular screening tests that detect abnormalities before cancer develops (Best practice) - (ACS, 2018; CDC, 2018; Ferlay et al., 2018)
What are ACS Guidelines for the Prevention and Early Detection of Cervical Cancer?
The American Cancer Society recommends that women follow these guidelines to help find cervical cancer early. Following these guidelines can also find pre-cancers, which can be treated to keep cervical cancer from forming.
• All women should begin cervical cancer testing (screening) at age 21. Women aged 21 to 29, should have a Pap test every 3 years. HPV testing should not be used for screening in this age group (it may be used as a part of follow-up for an abnormal Pap test).
• Beginning at age 30, the preferred way to screen is with a Pap test combined with an HPV test every 5 years. This is called co-testing and should continue until age 65.
• Another reasonable option for women 30 to 65 is to get tested every 3 years with just the Pap test.
• Women who are at high risk of cervical cancer because of a suppressed immune system (for example from HIV infection, organ transplant, or long-term steroid use) or because they were exposed to Diethylstilbestrol (DES) in utero may need to be screened more often. They should follow the recommendations of their health care team.
• Women over 65 years of age who have had regular screening in the previous 10 years should stop cervical cancer screening as long as they haven’t had any serious pre-cancers (like CIN2 or CIN3) found in the last 20 years (CIN stands for cervical intraepithelial neoplasia. Women with a history of CIN2 or CIN3 should continue to have testing for at least 20 years after the abnormality was found.
• Women who have had a total hysterectomy (removal of the uterus and cervix) should stop screening (such as Pap tests and HPV tests), unless the hysterectomy was done as a treatment for cervical pre-cancer (or cancer). Women who have had a hysterectomy without removal of the cervix (called a supra-cervical hysterectomy) should continue cervical cancer screening according to the guidelines above.
• Women of any age should NOT be screened every year by any screening method.
• Women who have been vaccinated against HPV should still follow these guidelines.
• Although annual (every year) screening should not be done, women who have abnormal screening results may need to have a follow-up Pap test (sometimes with a HPV test) done in 6 months or a year.
The American Cancer Society guidelines for early detection of cervical cancer do not apply to women who have been diagnosed with cervical cancer, cervical pre-cancer, or HIV infection. These women should have follow-up testing and cervical cancer screening as recommended by their health care team (ACS, 2018).
Preventing HPV with Condoms
As discussed above, human papillomavirus (HPV) is the main cause of cervical cancer. HPV is a common virus that is passed from one person to another during sex. Other than the presence of genital warts, there is no way of knowing whether a sexual partner is infected with HPV. While condoms do not provide complete protection — HPV can spread through physical contact with infected areas of the mouth, genitalia, and anus — the American Cancer Society reports that using condoms can reduce the rate of HPV infection by about 70 percent. Using condoms regularly also protects against various other sexually transmitted diseases (ACS, 2018).
The recommendation for HPV vaccine varies, according to published literature. There are two types of vaccines available: Cervarix to prevent cervical pre-cancer for HPV types 16 and 18 and the Quadrivallent HPV vaccine (Gardasil). The vaccine specifically targets HPV types 16 and 18, which cause about 70 percent of cervical cancer cases, and types 6 and 11, which cause approximately 90 percent of cases of genital warts. The vaccine can only be used to prevent an HPV infection; it is not meant for women who already are infected. The pre-exposure vaccination is recommended for females 9 to12 years of age and a catch-up vaccination recommended for girls aged 13 to 26 years of age. Gardasil vaccine can be administered to males aged 9 to 26 years to prevent genital warts. The vaccine is also recommended for gay and bisexual men (or any man who has sex with a man) through age 26. It is also recommended for men and women with compromised immune systems (including those living with HIV/AIDS) through age 26, if they did not get fully vaccinated when they were younger.
CDC recommends 11 to 12 year olds get two doses of HPV at least 6 months apart. Teens and young adults who start the series later, at ages 15 through 26 years, will need three doses of HPV vaccine to protect against cancer-causing HPV infection. For more information on the recommendations, please see: https://www.cdc.gov/vaccines/vpd/hpv/public/index.html & https://www.cdc.gov/std/hpv/stdfact-hpv.htm
What are the signs and symptoms cervical cancer?
1. No Symptoms
One of the scariest things about this silent killer of women is just that—it’s a serious disease that often presents with no symptoms at all in its early stages, hence the need for regular checkups and screenings for the preliminary signs of the disease. Although screening methods are not 100 percent accurate, these tests are often an effective method for detecting cervical cancer in the early stages when it is still highly treatable.
When present, common symptoms of cervical cancer may include:
. Vaginal bleeding: One of the most common warning signs of cervical cancer is abnormal bleeding outside of the normal menstrual cycle. Of course, this varies from woman to woman; some women experience light spotting, while others may develop heavy bleeding that seems to come and go with no explanation. This includes bleeding between periods, after sexual intercourse or post-menopausal bleeding. However, vaginal bleeding can indicate a number of other conditions, or it may have an entirely benign root cause.
. Unusual vaginal discharge: Abnormal vaginal discharges can indicate cervical cancer. The type of discharge associated with cervical cancer has several definitive characteristics, including unusual textures, colors and odors. These discharges contain high concentrations of mucus, which contribute to their thickness and foul, pungent odor. A watery, pink or foul-smelling discharge is common.
. Pelvic pain: Pain during intercourse or at other times may be a sign of abnormal changes to the cervix, or less serious conditions.
. Urinary abnormalities: Pain when urinating can indicate a problem with the cervix, but like many other symptoms of cervical cancer, it can also indicate a number of other problems.
Signs of advanced stages of cervical cancer
Cervical cancer may spread (metastasize) within the pelvis, to the lymph nodes or elsewhere in the body. Signs of advanced cervical cancer include:
• Weight loss
• Back pain
• Leg pain or swelling
• Leakage of urine or feces from the vagina
• Bone fractures
What are the stages of cervical cancer?
According to the National Cancer Institute (2018), cervical cancer is classified into several stages:
1. Carcinoma In Situ/Precancers (Stage 0) — The first stage of cervical cancer is carcinoma in situ (also known as precancer or severe dysplasia), in which a group of abnormal cells has started to grow but has not yet spread to nearby tissues. Because stage 0 “precancers” are likely to eventually spread deeper into the tissue and become cancerous, they should be treated.
2. Early Cervical Cancer (Stages I–IIA) — although more extensive than stage 0, these cancers are still limited to the cervix.
3. Advanced Cervical Cancer (Stages IIB–IVA) — cervical cancer that has spread beyond the cervix and invaded the surrounding pelvic tissues in the vagina, rectum, or bladder is known as locally advanced cervical cancer.
4. Stage IVB and Recurrent Cervical Cancer — Cervical cancer that has spread beyond the pelvis (into the lungs or liver, for example), or has returned following initial therapy, is placed in this category.
Treatment for early and advanced-stage cervical cancer
Early-stage cervical cancer can often be treated with surgery. The key to treating early-stage cancers or precancers is early detection. For advanced cervical cancers that may spread or have begun to metastasize, a combination of surgery, radiation therapy, or chemotherapy may be used.
What's New in Cervical Cancer Research and Treatment?
New ways to prevent and treat cancer of the cervix are being researched. Memorial Sloan Kettering Cancer Center provided information about some promising new developments that include:
Sentinel lymph node biopsy (SLNB)
During surgery for cervical cancer, lymph nodes in the pelvis may be removed to check for cancer spread. Instead of removing many lymph nodes, a technique called sentinel lymph node biopsy can be used to target just the few lymph nodes most likely to contain cancer. In this technique a blue dye containing a radioactive tracer is injected into the cancer and allowed to drain into lymph nodes. Then, during surgery, the lymph nodes that contain radiation and the blue dye can be identified and removed. These are the lymph nodes most likely to contain cancer if it has spread. If these lymph nodes don’t contain cancer, the other lymph nodes don’t need to be removed. Removing fewer lymph nodes may lower the risk of later problems, such as lymphedema of the legs.
A clinical trial is looking at a different way of doing a sentinel node biopsy procedure. It maps the lymph nodes using with robotic (laparoscopic) assisted near infrared imaging after injecting indocyanine green (ICG) dye into the cervix.
SLNB is not a standard procedure for cervical cancer at this time. Available studies suggest that SLNB may be helpful in early-stage cervical cancer, but more studies are planned to see if this procedure should routinely become part of the treatment.
In cancer, the immune system cannot control the fast growth of tumor cells. Recently, new drugs called immune checkpoint inhibitors have been developed that “reset” the immune system. They have been found to be active in treating a number of types of cancer. Their helpfulness in cervical cancer treatment is not yet known, but clinical trials are underway. You may want to read more about this type of treatment - Cancer Immunotherapy.
As researchers have learned more about the gene changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. These targeted drugs work differently from standard chemotherapy drugs. They often have different (and less severe) side effects. These drugs may be used alone or with more traditional chemotherapy. Pazopanib is a type of targeted drug that blocks certain growth factors that help cancer cells grow. It has shown to be helpful in some early studies of patients with advanced cervical cancer. This drug continues to be studied.
Some research indicates that adding hyperthermia to radiation may help keep the cancer from coming back and help patients live longer. Hyperthermia is a treatment that raises the temperature in the area where the tumor is, most often by using radiofrequency antennae placed around the patient. Many organizations cannot do what they do without volunteers and donors. Become a volunteer or participate in a fundraising event to help save lives. According to Abiodun et al. (2013), the most important barrier to reduction of cervical cancer burden is lack of awareness about the disease and its preventive measures.
In addition, the research findings indicated that the implementation of cervical cancer prevention and treatment programs in Nigeria are mostly located at the tertiary and secondary health facilities. The Primary Health Care centers which are closest to where the women live and work are yet to provide cervical cancer screening services. Lack of information, proximity to screen centers, cost of screening services and absence of cervical cancer prevention programs at PHCs negatively influence cervical cancer screening uptake.
Now, how can you get involved?
Assignment for every member of this forum:
. What can you do to bring awareness about cervical cancer to your community?
. How can we increase the number of facilities that provide screening in our communities?
Before the end of this month (January, 2019),
1. Visit your local government and identify at least one facility that provides cervical screening for the community, who pays for the services and how much does it cost?
2. Organize health education on cervical cancer to either JSS/SSS students or for people at your place of worship
3. Get the information out through social media about cervical cancer
4. Post some of your activities on this forum.
Thank you for having me.
About the Author:
Grace Ogiehor-Enoma, DHA, MSN, MPH, NE-BC, RN is the current Executive Director and a founding member of the National Association of Nigerian Nurses in North America (NANNNA), she is also an Administrative Nursing Supervisor at New York Presbyterian Hospital Queens and an Adjunct Associate Professor at Hunter-Bellevue School of Nursing, New York).
Send comments or questions to firstname.lastname@example.org
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U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on November 2017 submission data (1999–2015): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; (June, 2018) Accessed at www.cdc.gov/cancer/dataviz, on January 6, 2019
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