Expert Care for Cervical Cancer

Cervical cancer develops when abnormal cells grow uncontrollably in the cervix—the lower part of the uterus that connects to the vagina.

Most cervical cancers are caused by a persistent infection with high-risk types of human papillomavirus (HPV). HPV infection is common and usually clears naturally. In a small proportion of people, a persistent high-risk infection can cause precancerous cervical-cell changes that may eventually develop into cancer.

Cervical cancer is one of the most preventable cancers through HPV vaccination, regular screening and appropriate treatment of precancerous changes. It is also highly treatable when detected early.

At AIROC Hospitals, Kondapur, Hyderabad, patients with suspected or confirmed cervical cancer receive coordinated evaluation, personalised treatment planning and supportive care from a multidisciplinary cancer-care team.

Overview and Types

Squamous-Cell Carcinoma

Squamous-cell carcinoma begins in the thin, flat cells lining the outer part of the cervix. It is the most common type of cervical cancer.

Most squamous-cell cancers develop in the transformation zone, where the outer and inner parts of the cervix meet.

Adenocarcinoma

Adenocarcinoma develops in the mucus-producing glandular cells lining the cervical canal.

Although less common than squamous-cell carcinoma, the proportion of cervical cancers diagnosed as adenocarcinoma has increased in some populations.

Adenosquamous Carcinoma

Adenosquamous carcinoma contains features of both squamous-cell carcinoma and adenocarcinoma. It is less common and may require treatment based on its stage and individual pathological characteristics.

Rare Cervical Cancers

Less-common cervical cancers include:

• Small-cell neuroendocrine carcinoma
• Large-cell neuroendocrine carcinoma
• Clear-cell carcinoma
• Serous carcinoma
• Sarcoma
• Lymphoma involving the cervix

These rare cancers may behave differently and require specialised treatment planning.

Cervical Precancer

Cervical precancer is not invasive cancer. It refers to abnormal cells that may develop into cancer if they are not monitored or treated appropriately.

Precancerous changes may be described as:

• Cervical intraepithelial neoplasia
• CIN 1, CIN 2 or CIN 3
• Low-grade squamous intraepithelial lesion
• High-grade squamous intraepithelial lesion
• Adenocarcinoma in situ

Many low-grade abnormalities resolve naturally, but high-grade changes require careful assessment and may need treatment.

Symptoms and Causes

Early cervical cancer and precancerous changes often cause no noticeable symptoms. This is why screening remains important even when a person feels healthy.

Possible symptoms include:

• Vaginal bleeding after sexual intercourse
• Bleeding between menstrual periods
• Menstrual bleeding that is heavier or lasts longer than usual
• Vaginal bleeding after menopause
• Unusual watery, bloody or foul-smelling vaginal discharge
• Pelvic or lower-abdominal pain
• Pain during sexual intercourse
• Persistent lower-back pain
• Tiredness or weakness
• Unexplained weight loss or reduced appetite

Advanced cervical cancer may cause:

• Leg pain or swelling
• Difficulty passing urine
• Painful urination
• Blood in the urine
• Difficulty passing stool
• Rectal bleeding
• Flank or kidney-area pain
• Severe pelvic or back pain

These symptoms can also be caused by infections, fibroids, hormonal changes and other non-cancerous conditions. However, unusual vaginal bleeding—particularly bleeding after intercourse or after menopause—should be medically evaluated promptly.

What Causes Cervical Cancer?

Almost all cervical cancers are associated with persistent infection by high-risk HPV types.

HPV is transmitted mainly through intimate skin-to-skin and sexual contact. Most sexually active people are exposed to HPV at some point, often without knowing because the infection usually causes no symptoms.

An HPV infection:

• Does not mean that a person has cancer
• May remain undetected for many years
• Does not necessarily indicate recent exposure
• Usually clears naturally without treatment
• Can occasionally persist and cause precancerous changes

Cervical cancer develops slowly in many patients, often progressing from persistent HPV infection to precancer and then invasive cancer over several years.

Diagnosis and Treatment

Diagnostic Evaluation

Evaluation may include:

• Review of symptoms and medical history
• Pelvic examination
• Speculum examination of the cervix
• HPV testing
• Pap test or cervical cytology
• Colposcopy
• Cervical punch biopsy
• Endocervical curettage
• Cone biopsy
• Histopathology examination
• Blood tests
• MRI of the pelvis
• CT scan
• PET-CT when clinically appropriate
• Cystoscopy or proctoscopy in selected advanced cases

An abnormal HPV or Pap-test result does not automatically mean that cancer is present. Colposcopy and biopsy may be needed to determine whether there are precancerous or cancerous changes.

Colposcopy and Biopsy

A colposcopy uses a magnifying instrument to examine the cervix closely. A specialist may apply a mild solution to highlight abnormal areas and collect small tissue samples.

A biopsy can establish:

• Whether abnormal cells are precancerous or cancerous
• Cancer type
• Tumour grade
• Depth of invasion
• Other pathological characteristics

Cervical Cancer Staging

Staging determines how far the cancer has developed. Assessment considers:

• Tumour size
• Depth of invasion
• Involvement of the vagina or tissues beside the cervix
• Pelvic or para-aortic lymph-node involvement
• Spread to the bladder or rectum
• Spread to distant organs

Cervical cancer is generally classified from stage I to stage IV. Treatment selection depends heavily on the stage.

Treatment Options

Treatment depends on the cancer type, stage, tumour size, lymph-node involvement, overall health and whether the patient wishes to preserve fertility.

Treatment of Precancerous Changes

Precancerous cervical lesions may be managed through observation or treatment, depending on their severity, HPV findings, age and pregnancy plans.

Treatment options may include:

• Loop electrosurgical excision procedure
• Large-loop excision of the transformation zone
• Cone biopsy
• Cryotherapy
• Thermal ablation
• Laser treatment

Regular follow-up testing remains important after treatment.

Surgery

Surgery may be recommended for selected early-stage cervical cancers.

Options include:

• Cone biopsy: Removal of a cone-shaped section of cervical tissue.
• Simple hysterectomy: Removal of the uterus and cervix.
• Radical hysterectomy: Removal of the uterus, cervix, surrounding tissue and part of the upper vagina.
• Lymph-node assessment: Evaluation or removal of pelvic lymph nodes.
• Radical trachelectomy: Removal of the cervix and nearby tissue while preserving the uterus in carefully selected patients who wish to retain fertility.

The ovaries may sometimes be preserved in younger patients when medically appropriate.

Radiation Therapy

Radiation therapy is an important treatment for locally advanced cervical cancer and selected early-stage or recurrent cancers.

It may include:

• External-beam radiation therapy
• Image-guided radiation therapy
• Intensity-modulated radiation therapy
• Intracavitary brachytherapy
• Interstitial brachytherapy

Brachytherapy places a radiation source inside or close to the cervix and is an essential component of definitive radiation treatment for many patients.

Chemotherapy

Chemotherapy may be:

• Given concurrently with radiation therapy
• Used before or after selected treatments
• Recommended for recurrent cancer
• Used to treat metastatic disease
• Provided to relieve symptoms and control disease progression

Concurrent cisplatin-based chemotherapy and radiation therapy are commonly used for locally advanced cervical cancer.

Targeted Therapy

Targeted medicines may be considered for selected persistent, recurrent or metastatic cervical cancers. Eligibility depends on previous treatment, tumour characteristics and the patient’s overall condition.

Immunotherapy

Immunotherapy may be recommended for selected patients with advanced, recurrent or metastatic cervical cancer based on biomarkers, previous treatment and clinical circumstances.

Treatment can involve surgery, radiation therapy, chemotherapy, targeted therapy or immunotherapy, used individually or in combination.

Fertility and Sexual-Health Support

Cervical-cancer treatment can affect fertility, hormonal health and sexual function. Before treatment, eligible patients may discuss:

• Fertility-preserving surgery
• Egg or embryo freezing
• Ovarian-preservation procedures
• Pregnancy planning
• Menopause management
• Vaginal-health support
• Sexual counselling

Supportive and Palliative Care

Supportive care may include:

• Pain and symptom management
• Nutritional support
• Management of anaemia
• Psychological counselling
• Treatment of lymphoedema
• Bladder and bowel rehabilitation
• Sexual-health support
• Palliative care

Prevention and Risk Factors

Cervical cancer is largely preventable through HPV vaccination, regular screening and appropriate treatment of precancerous lesions.

Possible Risk Factors

• Persistent infection with a high-risk HPV type
• Not receiving HPV vaccination
• Infrequent or absent cervical screening
• Smoking or tobacco use
• A weakened immune system
• HIV infection
• Long-term use of immune-suppressing medicines
• Previous cervical precancer
• Multiple full-term pregnancies
• Younger age at first full-term pregnancy
• Long-term use of oral contraceptives
• Exposure to diethylstilbestrol before birth
• Limited access to screening and follow-up care

Having a risk factor does not mean that cervical cancer will develop. Persistent high-risk HPV infection is the principal cause, but additional factors can influence whether the infection progresses.

HPV Vaccination

HPV vaccination protects against HPV types responsible for most cervical cancers. It is most effective when given before exposure to HPV, but vaccination may also benefit some older adolescents and adults depending on national recommendations and individual circumstances.

Vaccination:

• Helps prevent cervical cancer
• Also reduces the risk of several other HPV-related cancers
• Does not treat an existing HPV infection
• Does not replace cervical screening
• May still be recommended after treatment for certain cervical abnormalities

Vaccination schedules vary according to age, immune status and national guidelines. A qualified healthcare professional can recommend the appropriate schedule.

Cervical Cancer Screening

Screening can detect high-risk HPV infection or abnormal cervical cells before cancer develops.

Screening methods include:

• Primary HPV testing: Detects high-risk HPV types associated with cervical cancer.
• Pap test: Examines cervical cells for precancerous or cancerous changes.
• HPV and Pap co-testing: Uses both tests when recommended.
• Visual inspection with acetic acid: Used in certain organised screening settings.

The HPV test looks for high-risk viral infection, while the Pap test looks for abnormal cervical-cell changes.

The appropriate test, starting age and screening interval depend on:

• Age
• Previous screening results
• HPV history
• Immune status
• Previous treatment for cervical precancer
• Whether the cervix is still present
• National screening guidelines

People who have received the HPV vaccine should still follow recommended cervical-screening schedules.

Risk-Reduction Measures

Helpful measures include:

• Receive HPV vaccination when eligible
• Attend recommended cervical screening
• Complete follow-up after an abnormal screening result
• Treat high-grade precancerous lesions promptly
• Avoid smoking and tobacco
• Use condoms to reduce—but not completely eliminate—HPV transmission
• Limit exposure to sexually transmitted infections
• Seek HIV testing and treatment when appropriate
• Attend ongoing surveillance after previous cervical precancer or cancer

Nearly all cervical cancers could be prevented through HPV vaccination, routine screening and appropriate follow-up treatment.