Detecting, treating cervical cancer

The Baltimore Sun

Each year, about 11,000 new cases of cervical cancer are diagnosed in the United States, according to the National Cancer Institute. This cancer is relatively slow-growing and may not cause any symptoms, but it can be detected with regular tests called Pap smears. If detected early enough, the cure rate - or five-year-survival rate - is about 80 percent, says Robert E. Bristow, director of the Kelly Gynecologic Oncology Service and the Ovarian Cancer Center of Excellence at Johns Hopkins Hospital.

What is cervical cancer?

Cervical cancer is a malignancy in the cervix [lower part] of the uterus that usually starts with precancerous changes or dysplasia that is detectable with a Pap smear [in which cells scraped from the cervix are examined under a microscope]. Cervical cancer is caused by human papillomavirus (HPV), which is usually spread through sexual contact. A recently developed vaccine for young women can protect them against the more common types of HPV that are most often associated with cervical cancer.

What is the incidence of cervical cancer in the United States?

The incidence is about 11,000 cases a year in the United States, with about 3,000 deaths from cervical cancer. Worldwide, cervical cancer is one of the top two causes of death due to cancer among women, second to breast cancer. There are about 500,000 cases diagnosed in the world annually, largely because many women in developing countries don't have access to the necessary medical care and cervical cancer screening practices.

How is it diagnosed?

The standard screening test for cervical cancer and pre-cancer is the Pap smear. It is pretty low-tech, as it were. It is a way to look at the changes in the cells of the cervix, and it does have a 20 percent false negative rate - so it is not a perfect test. That is why it is recommended that women get tested every year. It takes a relatively long time for a pre-cancer to become cancer: About 10 to 20 years in most cases. Ideally, the Pap smear would detect an early pre-cancer change of the cervix and it would be successfully treated before it ever had the chance to develop into an actual cervical cancer.

Then why not recommend that women get tested every five years?

Because of that 20 percent false negative. You don't want to take the chance of getting a false negative and then waiting five years to discover that. Also, not all cancers take 10 years to develop, and you don't want to take that chance either.

What is the treatment?

For cervical cancer, there are two primary options: surgery and radiation. The best candidates for surgical treatment have early-stage disease and are healthy enough to undergo a major surgical operation. For women with very-early-stage lesions, a simple cone biopsy of the cervix (less than complete removal of the cervix) may be adequate therapy. For most other women with early-stage disease, however, the standard surgical treatment is a radical hysterectomy, which includes removal of the uterus and tissues around it and the lymph nodes in the pelvis. In premenopausal women undergoing radical hysterectomy, the ovaries can usually be preserved, so that hormone replacement therapy is not needed.

For young women with early-stage cervical cancer who have not completed their childbearing, we also can perform a surgery called a trachelectomy. In this, we remove the cervix and surrounding tissue and lymph nodes and leave the top part of the uterus (as well as the fallopian tubes and ovaries) in place and reattach it to the top of the vagina. For example, if a patient is a 26-year-old with no children, we can preserve the child-bearing capacity of the woman using this approach. (The child would be delivered by Caesarean method.) This is not the standard approach, however, and patients must be carefully selected to ensure successful treatment of the cancer, which is the top priority.

If a woman is not a good candidate for surgery, for example because of more-advanced-stage disease, extensive prior surgery, or serious medical conditions that would make surgery unsafe, she can be treated with radiation combined with low doses of chemotherapy. We call this approach chemo-radiation. If the disease is a stage-3 or beyond, if the cancer has spread to the liver or lungs, then these patients would be treated with chemotherapy alone, with the hope that it would shrink or eradicate the tumors.

How are these surgeries performed?

Traditionally, a radical hysterectomy is performed by making an incision (usually 10-12 inches) in the abdomen with a scalpel. But, about 10 years ago, a minimally invasive approach was developed called laparoscopic surgery. This consists of making four or five incisions no more than a half-inch in size, and the surgeon operates through these small incisions with long instruments [that are] about 18 inches in length. In the U.S., about 75 percent of radical hysterectomies are performed using the traditional open approach, and about 25 percent are done using minimally invasive approaches (laparoscopy).

More recently, computer-assisted laparoscopy (or robotic surgery) was developed. In this case, the advantage is that the surgeon has much more accurate and precise motions with the surgical instruments, making the procedure safer and faster. With conventional laparoscopy, you are working in reverse motions, but with computer-assisted robotic laparoscopy, the robotic instruments allow a much wider range of motions that mimic the hand motions exactly. The surgeon also has the advantage of three-dimensional vision with robotic surgery, which is also a big advantage over the two-dimensional view provided by conventional laparoscopy. We have been performing these robotic-assisted surgeries for the past two years and currently do about 75 percent of all hysterectomies using this technology. This is probably a higher percentage than in most centers across the country.

The robotic surgery approach is minimally invasive, speeds recovery and the patient can go back to work in a couple of weeks. I had a patient a few weeks ago who was out of the hospital on the next day and back to work in the next week.

Are there other new developments in cervical cancer prevention or treatment?

Yes, I mentioned the combination chemo-radiation treatment and robotic surgery. There also is a relatively new primary prevention method: HPV vaccines, or vaccines for human papillomavirus (as mentioned earlier).

The HPV vaccine holds great promise for reducing the rate of cervical cancer and pre-cancer by perhaps 50 percent to 70 percent. The question the medical community now struggles with is: Who gets the vaccine? Currently, it is recommended that girls from the ages of 8 to 14 get the vaccine - before sexual activity. No one is issuing a blanket statement about who should get the vaccine or when: That is something parents would want to talk to their pediatrician and primary-care doctors [about]. Another question is whether or not to vaccinate males.

Is cervical cancer treatable?

Absolutely, particularly for early-stage cancer. The cure, or five-year survival rate, is about 80 percent for stage-1 disease. This drops to about 60 percent for stage-2 and 40 percent for patients with stage-3 disease.

Holly Selby is a former reporter for The Baltimore Sun.

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