Alright, let’s talk about something super important for women’s health: cervical cancer. While it might not be the most thrilling topic, understanding this disease is absolutely crucial. Think of it as a silent guest that can arrive unnoticed in its early days. The good news? We’ve made incredible progress in figuring out how to prevent, spot, and treat it!

The Global Picture: Where Are We Now?

Globally, cervical cancer is a big deal, often ranking as the third most common cancer for women worldwide, usually right after breast and colorectal cancers. But here’s the twist: this global number hides a huge difference between countries. In many developing nations, where getting screened isn’t easy, it remains a tragically common and often deadly problem. On the flip side, countries with awesome screening programs that lots of women use have seen their rates of cervical cancer drop dramatically [2, 3]. This just screams how powerful early detection and prevention truly are!

We typically see the highest number of cases in women aged 30 to 40. There’s also a smaller bump in cases later in life, around 80 years old [1].

The Usual Suspect: It’s Often Viral!

For ages, the exact cause of cervical cancer was a bit of a mystery. But now? The picture is crystal clear! The vast majority of cervical cancers are caused by a persistent infection with certain high-risk types of the Human Papillomavirus (HPV) [4]. Many HPV infections are just short-term visitors and clear up on their own. But some decide to stick around, leading to changes in cells that can eventually turn into cancer over time.

Other risk factors pop up too, like having many children (high parity), multiple sexual partners, starting intercourse at a young age, and smoking [1]. But honestly, these risks often lead to an increased chance of getting an HPV infection. They can also make it harder for your body to clear the virus. Globally, HPV types 16 and 18 are the main culprits, with HPV 16 being the most common worldwide, though HPV 18 can be more prevalent in specific regions like Indonesia [1, 4].

Here’s the fantastic news: we have vaccines now! These target the most common high-risk HPV types. They are a super powerful way to prevent infection. In turn, they significantly lower the risk of cervical cancer, especially when given before someone becomes sexually active [3, 4].

How It Spreads: A Local Journey

Cervical cancer usually starts in a specific spot on the cervix called the transformation zone. This area is a bit dynamic and is where HPV loves to hang out and cause changes [1].

The cancer tends to spread in a pretty predictable way, mostly by sneaking into the lymph and blood vessels [1]. From the cervix, it can move downwards into the vagina or sideways into the tissue surrounding the uterus (the parametrium). Once in the parametrium, it can reach the pelvic sidewalls, potentially affecting nearby structures like the tubes that carry urine (ureters) and blood vessels. Spreading to the pelvic lymph nodes is common as the disease gets more advanced, and from there, it can travel up to the lymph nodes near the aorta (para-aortic lymph nodes). While it can spread through the bloodstream to distant parts of the body, it’s less common. Local and lymphatic spread are more typical [1]. Interestingly, if it spreads upwards into the main body of the uterus (the corpus), that doesn’t actually change the stage of the disease.

Finding Our Uninvited Guest: Diagnosing Cervical Cancer

Catching cervical cancer can happen in a couple of ways. The ideal scenario is finding it really early, even before it’s fully cancer, through routine cervical screening programs [2, 3]. This usually involves a Pap smear (cytology) to check for abnormal cells. More and more, HPV testing is also being used, sometimes alongside or even as the first step in screening [3, 4].

Sometimes, women come to the doctor because they’re experiencing symptoms. This often means the disease is a bit more advanced. Symptoms can include unusual vaginal bleeding (especially after sex), strange vaginal discharge, or pelvic pain [1, 5]. During a check-up, a healthcare professional might see a visible lesion on the cervix [1].

Confirming the Diagnosis: The Biopsy Step

If something looks suspicious, the next crucial step is taking a small tissue sample (a biopsy) to look at under a microscope. This is the definitive way to confirm if it’s cancer and figure out exactly what type of cervical carcinoma it is [1, 5].

Understanding the Different Types of Cervical Cancer

Most cervical cancers – about 85% – are called squamous cell carcinomas [1, 5]. These come from the cells covering the outer part of the cervix. There are a few types of squamous cell carcinomas, including large cell keratinizing, small cell, and large cell non-keratinizing types. A smaller group, around 15%, are adenocarcinomas, which start in the glandular cells inside the cervix [1, 5]. You can also get adenosquamous carcinomas, which are a mix of both. Knowing the specific type is helpful because it can sometimes affect treatment plans and how well treatment works [1].

Staging Cervical Cancer: How Far Has It Spread?

Once we know it’s cervical cancer, the absolute most important step is staging the disease. Staging tells us how far the cancer has spread, and this information is the main guide for deciding on the best treatment [1, 5]. The most commonly used system is the FIGO (International Federation of Gynecology and Obstetrics) staging system, which looks at the extent of the disease based on physical exams and imaging results [4, 5].

A clinical exam is sometimes done under anesthesia. It helps doctors determine the local spread of cancer, such as into the parametrium. They can also assess if it has reached the pelvic sidewalls [1, 5]. Imaging like MRI and CT scans are super helpful for getting a clearer picture of tumor size, how much it has invaded, and if it has reached the pelvic and para-aortic lymph nodes [1, 5]. PET scans can also help spot if the cancer has spread to distant parts of the body [1].

The FIGO system divides cervical cancer into stages I through IV, with smaller subdivisions within each stage. Here’s a simplified look at the stages (consider linking to an external resource like the FIGO website or a reputable cancer organization’s staging guide here):

• Stage I: The cancer is only in the cervix.
• Stage II: It has spread beyond the cervix. However, it hasn’t reached the lower third of the vagina or the pelvic sidewall.
• Stage III: It has spread to the lower third of the vagina, the pelvic sidewall, or is causing kidney issues because it’s blocking the ureters. This stage also includes cases where cancer is found in the pelvic or para-aortic lymph nodes, regardless of the tumor size or local spread [4].
  • Interestingly, in Stage III, about 30% of cases involve the para-aortic lymph nodes.
• Stage IV: The cancer has spread to the bladder or rectum, or to distant organs (metastasis).
  • In Stage IV, about 40% of cases involve the para-aortic lymph nodes.

The presence of cancer in the lymph nodes significantly impacts the outlook, no matter how big the main tumor is [4]. For very early stages (like 1A1), the chance of lymph node involvement is almost zero. In Stage 1B, about 5% of pelvic lymph nodes might be involved. As the stage increases, the likelihood of finding cancer in both pelvic and para-aortic lymph nodes goes up.

FIGO Classification and Corresponding Treatment Options

FIGO Stage	Description	Typical Treatment Options
Stage I	Carcinoma strictly confined to the cervix (extension to the corpus is disregarded)
IA	Invasive carcinoma diagnosed only by microscopy with maximum depth of invasion \le 5 mm	Cone biopsy (fertility sparing), Simple Hysterectomy
IA1	Measured stromal invasion \le 3 mm in depth and \le 7 mm in horizontal spread	Cone biopsy, Simple Hysterectomy
IA2	Measured stromal invasion > 3 mm and \le 5 mm in depth, and \le 7 mm in horizontal spread	Modified Radical Hysterectomy + Pelvic Lymphadenectomy, Radical Trachelectomy + Pelvic Lymphadenectomy (fertility sparing), Brachytherapy (if surgery not possible)
IB	Invasive carcinoma with measured deepest invasion > 5 mm; lesion limited to the cervix uteri with size measured by maximum tumor diameter
IB1	Invasive carcinoma > 5 mm depth of stromal invasion and \le 2 cm in greatest dimension	Radical Hysterectomy + Pelvic Lymphadenectomy, Radical Trachelectomy + Pelvic Lymphadenectomy (fertility sparing), Chemoradiation
IB2	Invasive carcinoma > 2 cm and \le 4 cm in greatest dimension	Radical Hysterectomy + Pelvic Lymphadenectomy, Chemoradiation
IB3	Invasive carcinoma > 4 cm in greatest dimension	Chemoradiation
Stage II	Cervical carcinoma invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall
IIA	Involvement limited to the upper two-thirds of the vagina without parametrial invasion
IIA1	Invasive carcinoma \le 4 cm in greatest dimension	Radical Hysterectomy + Pelvic Lymphadenectomy, Chemoradiation
IIA2	Invasive carcinoma > 4 cm in greatest dimension	Chemoradiation
IIB	With parametrial invasion but not up to the pelvic wall	Chemoradiation
Stage III	The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes	Chemoradiation
IIIA	Carcinoma involves lower third of the vagina, with no extension to the pelvic wall	Chemoradiation
IIIB	Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney (unless known to be due to another cause)	Chemoradiation
IIIC	Involvement of pelvic and/or para-aortic lymph nodes (including micrometastases), irrespective of tumour size and extent (with r and p notations)	Chemoradiation
IIIC1	Pelvic lymph node metastasis only	Chemoradiation
IIIC2	Para-aortic lymph node metastasis	Chemoradiation
Stage IV	Carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum; or distant metastasis
IVA	Spread of the growth to adjacent organs (bladder and/or rectum)	Chemoradiation
IVB	Spread to distant organs (including peritoneal dissemination, involvement of supraclavicular or more distant lymph nodes, lungs, liver, or bone)	Palliative care, Systemic Chemotherapy, Targeted Therapy, Immunotherapy, Radiation for symptom control

Cervical Cancer Algorithm

flowchart TD A1[“Suspected Cervical Abnormality or Symptoms”] –> B1[“Screening or Clinical Exam”] B1 –> C1[“Biopsy and Histology”] C1 –> D1[“Diagnosis: Cervical Cancer Confirmed”] D1 –> E1[“Staging – FIGO”] E1 –> F1[“Stage I”] F1 –> G1{“Consider Fertility Preservation?”} G1 — Yes –> H1[“Radical Trachelectomy + Pelvic Lymphadenectomy”] G1 — No –> I1[“Hysterectomy or Radical Hysterectomy + Pelvic Lymphadenectomy”] F1 –> J1[“Cone Biopsy – very early IA”] E1 –> K1[“Stage IIA”] K1 –> L1{“Tumor Size < 4cm?”} L1 — Yes –> I1 L1 — No –> M1[“Chemoradiation”] E1 –> N1[“Stage IIB, III, IVA”] N1 –> M1 E1 –> O1[“Stage IVB or Recurrent”] O1 –> P1[“Palliative Care”] J1 –> Q1{“Resection Margins Clear?”} Q1 — Yes –> R1[“Observation or Follow-up”] Q1 — No –> S1{“Further Treatment Needed?”} S1 — Yes –> I1 S1 — No –> R1 H1 –> T1[“Post-treatment Follow-up”] I1 –> T1 M1 –> T1 T1 –> V1[“Long-term Surveillance”] P1 –> U1[“Supportive Care”]

Planning the Counter-Attack: Treating Cervical Cancer

Treating cervical cancer requires a collaborative team approach. It usually involves gynecological oncologists, who are specialists in female reproductive cancers, as well as radiation oncologists and medical oncologists [1, 5]. The treatment plan is highly personalized and depends heavily on the stage of the disease, as well as the patient’s overall health and what they prefer [5].

For early-stage disease (Stage I and some Stage IIA), surgery is often the go-to treatment and can be curative [1, 5]. This could be a cone biopsy for very tiny, early lesions. Another option is a simple hysterectomy, which involves removing the uterus. For slightly more advanced early stages, doctors may perform a radical hysterectomy. This procedure involves removing the uterus, surrounding tissues, and pelvic lymph nodes [1, 5]. For younger women with early-stage disease who want to have children, a radical trachelectomy might be an option. This procedure involves removing the cervix but leaving the uterus [5].

For more advanced stages (Stage IIB and beyond), or if surgery isn’t the best option, chemoradiation is the main treatment [1, 5]. This combines external radiation to the pelvis with chemotherapy (usually a platinum-based drug like cisplatin) given at the same time. Often, this is followed by internal radiation (brachytherapy) [1, 5]. The chemotherapy helps the radiation work better.

If the cancer has spread to distant parts of the body (Stage IVB), treatment usually focuses on managing symptoms and improving quality of life (palliative care) [1, 5]. This can involve chemotherapy, targeted therapies, or immunotherapy [1, 5].

The prognosis (the likely outcome) is strongly tied to the stage at diagnosis – the earlier it’s caught, the better the outlook [1, 5]. Other factors like tumor size, how deep it has invaded, whether it’s in the lymphovascular spaces, the specific type of cancer, and if lymph nodes are involved also play a role [1].

The Future is Bright: Towards Elimination!

The journey with a cervical cancer diagnosis and treatment can be tough, no doubt. But knowing more about what causes it and having awesome screening and prevention tools gives us immense hope! Getting vaccinated against HPV and participating in cervical screening programs are powerful steps women can take to protect themselves. Catching it early truly saves lives and often means less intense, more effective treatment options are available.

In places like Sri Lanka, we have skilled gynecological oncologists who handle these cancers. However, getting the overall rates down significantly really depends on having widespread, comprehensive screening programs available for all eligible women, typically aged 25 to 65. While funding for such a large-scale program can be a challenge, the hope is that one day we will reach that goal.

With effective HPV vaccination, strong screening programs, and good access to treatment, eliminating cervical cancer as a major public health issue isn’t just a dream – it’s something we can actually achieve [3, 4]! You might add a link to an internal article about cervical cancer prevention. Alternatively, link to a relevant external resource like the WHO’s cervical cancer elimination initiative.

Try the quiz on Cervical carcinoma and CIN to revise what you Learned in this article

References

[1] Information aligned with principles from “Obstetrics by Ten Teachers.”

[2] Principles aligned with Royal College of Obstetricians and Gynaecologists (RCOG) guidelines.

[3] Principles aligned with National Institute for Health and Care Excellence (NICE) guidelines.

[4] International Federation of Gynecology and Obstetrics (FIGO). FIGO staging for cervical cancer.

[5] Additional information on diagnosis and treatment aligning with standard clinical practice as outlined in sources like RCOG and NICE guidelines and common obstetrics and gynecology textbooks.