Health matter Cervical cancer and the health of women

General Overview

Cervical cancer is simply defined as an abnormal and uncontrolled overgrowth of the cells of the cervix, which annually accounts for about 370,000 new cases with 50% mortality (deaths) rate in developing countries.

Cancer of the cervix is the 2nd most common cancer-related morbidity and mortality in women with an average age of 51 years in developing nations. The World Health Organization (WHO) statistics have given an estimated 1.5 million deaths from cervical cancer annually, in which 86% are women living in developing countries, the Gambia inclusive.

Aetiology/Causes:
Like other cancers, the exact cause of cervical cancer remains unknown but it is strongly related to Human Papilloma Virus infection. This is because more than 90% of women suspected of cervical cancer test positive to HPV by pap smear.

But it must be noted that that HPV alone cannot actively function in cervical cancer development, hence needs other factors called co-carcinogens (contributors to cancer development) like smoking, oral contraceptives, herpes simplex virus type II, etc to carry out its dysplastic (abnormal cell growth) function.

Risk Factors (Predisposing Factors)
* Sex at an early age; particularly before 17 years, a time at which the anatomy (structure & function) of the female genitalia isn’t fully developed yet hence sex at that age can lead to dysplasia and thus facilitating HPV activity together with that of other co-carcinogens.

* Multiparity (high number of pregnancies after 24 weeks gestation); it has been documented that women that had 10 or more pregnancies have higher chance of developing the disease than those that have less due to the chance of developing dysplastic cells in the course of the pregnancies.

Multiple Sexual Partners; prostitutes have 65% chance of developing cervical cancer later in their lives due to the high risk of transmission from intercourse with different partners..

Promiscuous Male Partner; women with male partners that have more than one female partner also serves as a reservoir of risk factors for the development of cancer of the cervix.

Smoking; facilitates HPV function and thus predisposes to cervical cancer development. Reports have shown that high amount of nicotine from cigarette smoking have been found in the cervical mucous of about 60% of women smokers with cervical cancer which qualifies it as a chemical carcinogen

Obesity; this can be enhanced by the steroid from oral contraceptives in long term users which increases the chance of cancerous cell development because more cells are produced in obese people.

Oral contraceptives use; researches have found out that long term oral contraceptive use can lead to dysplasia and subsequently metaplasia (change of type of surface lining) which serves as a terrain for cervical cancer development in the 3rd or 4th decades of life due to the effect of estrogen to the surface lining of the cervix.

This can also lead to the uprooting of other risk factors or complications like obesity, myocardial infarction (death of heart muscle) with increase in age, heart attack and even secondary amenorrhea (absence of menses) & infertility in prolong use can occur. And the more the number of sex partners a woman has whiles on oral contraceptives ( for 5 or more years), the high the risk of cervical cancer development as a result of dysplasia.

 STIs (sexually transmitted infections); infections like gonorrhea, syphilis, HIV, etc can provide fertile grounds for the action of the HPV and can also pose a great risk in cases of pregnancy due to their effects on the baby particularly during delivery through the birth canal.

 Immunosuppression (decrease immunity due to other diseases); reduction in the immunologic strength seen in diseases like AIDS cause a serious dilemma on the immunologic response to HPV and other accompanying diseases or infections.

However, it has to be noted that polygamy is/can be a risk factor simply because the man marrying more than one wife has a high probability of being exposed to HPV infection which can be easily transmitted to the other wives compared to those with lesser number of wives. For example a man of four wives whom is away on a mission only back for a leave after a year while the wives are all young ladies at their reproductive ages.

With this situation and in cases of long distant lorry drivers, the probability of all the wives being faithful (i.e. abstaining from sex) would be very low and in the course, one can get infected and at the end transmit it to the husband which can serve as a source of infection to the others. The same can apply to that marrying one wife but the point of emphasis here lies not on the number of wives married but the faithfulness of the wife (wives) to the husband and vice versa.

Clinical Features (symptoms and signs)
Patients with early stage cervical cancer are mostly asymptomatic (symptoms less) which has accounted for the late diagnosis and progressive development of the disease due to lateness in seeking medical intervention.
However, some of the late symptoms include:

 Postcoital bleeding (bleeding after intercourse)
* Abnormal vaginal bleeding
*  Postmenopausal bleeding (bleeding  after age  of menstruation that is around 45years and above)
* Malodorous vaginal discharge
* Nonpruritic (non-itching) vaginal discomfort

And at onset of complications, the patients would experience symptoms like dysuria (pain in urinating), frequency of urination, pelvic pain, diarrhea, tenesmus (pain in defecation), weakness, weight loss, anaemia (low blood hemoglobin level), urine & faeces dribbling from the vagina due to abnormal communications between the vagina & bladder and vagina & rectum respectively, etc.

Therefore regular screening for early detection is very important in the prevention of onset of symptoms and successful treatment of the disease. Researches have concluded that about 60% of pre-invasive (early stage) cancers are successfully treated. This is because at the early stage, the cancer would not have gone beyond the basement membrane (thin layer under the covering) of the cervix thus making it’s treatment easier than as in invasive (after spreading by passing the basement membrane)

Disease development and types:
Cervical cancer development is said to begin at a point where the upper layer of the uterine cervix (columnar epithelium) meets with that of the vagina & cervix (squamous epithelium) called the transformation zone. The condition further proceeds by abnormal growth of cells at that point which has high tendency of malignant cells development (cancerous cells).

The progression in growth is through local invasion then by lymphatic (transport system in the body) spread and sometimes by use of blood vessels at advanced stages of the disease. Therefore, the more the extent of local invasion, the greater the involvement of lymph nodes and the higher the likelihood of involvement of other organs like kidneys, bladder, brain, intestines and the liver & lungs are affected by blood-borne spread.

When untreated or fails to respond to treatment, cancer of the cervix can lead to severe complications like sepsis (disseminated infection) from kidney infections like pyelonephritis, bleeding from tumour invasion into blood vessels, vesicovaginal & rectovaginal fistulae, intestinal obstruction and even to the death of the patient.

The typing of cancers and cervical cancer spegeocific depends on the origin of the cancerous cells which can be well differentiated or poorly differentiated in other cases as well. Therefore the commonest and most severe of all the types is the squamous carcinoma which account for about 70%, adenosquamous and adenocarcinoioma accounts for 25% and 5% is for others like sarcoma, small cell carcinoma, lymphoma and transition cell carcinoma.

Investigations:
The most important and routinely used investigation is the Pap smear which is highly effective in the detection of the DNA of the HPV, key to cervical cancer diagnosis. Other forms of investigation include cytology for cell typing to know the type of cancer cells and histopathology to determine the stage and extent of the disease.

But culture of samples collected from the cervix can also be done to help in isolating other organisms that might be present thus facilitating their treatment. The rest of the investigations would be directed towards the complications which involves complete blood count, serum chemistry, colposcopy (visualization of the cervix), scanning (abdomen & pelvis) and imaging (magnetic resonance imaging & computed tomography).

Treatment:
The treatment of cervical cancer is directed to the stage of the cancer in relation to the wish of the patients regarding the retention of fertility particularly in young patients. The treatment include both medical and surgical interventions in which the later is the treatment of choice in the early stage of the cancer including simple surgical removal of the lesion, hysterectomy (removal of the uterus) which can be radical or complete.

In advance stages of the disease, radiation with/without chemotherapy is of great benefit to the patients but in severe cases total pelvic exenteration (removal of almost all organs of the pelvis) can be done.

Pregnancy and Cervical Cancer:
Cervical cancer is easily diagnosed during pregnancy due to cytology screening done at the first prenatal period. This makes the detection of abnormal cytology smear in pregnancy very high.

Colposcopy and biopsy (histological examinations of samples from the cervix) are also used but biopsy is less commonly done in pregnancy except in patients with suggestive signs of carcinoma in situ or invasive cancer. Colposcopy may be challenging because of the occurrence of cervical epithelial changes which mimics dysplasia during pregnancy.

When diagnosed, cervical cancer treatment is delayed till 24 weeks for fetal maturity and then surgical removal of the fetus by cesarean section this is because of the effects of radiation to the fetus when initiated during early pregnancy.

This period is accompanied by a three monthly colposcopic examination and cervical cytology for follow up of disease progression. But in advance stages of the cancer during pregnancy, conization (removal of a conical portion of the tissue involved) can be done which can lead to abortion, bleeding, infections and incompetent cervix.

Prognosis (Likely outcomes):
The outcome of the disease in relation to the treatment solely depends on the stage in which the higher the stage of the disease, the lower the chance of patients living a period of five years after treatment. And the stages are divided into four with subgroups.

Preventions:
* Regular screening; is essential for the early diagnosis, prompt and successful treatment of cervical cancer for it being treatable at its early stage.
* Sexual abstinence; this is the most effective means of prevention from HPV infection and from other STIs.
* Barrier protection; although not very effective because HPV can be transmitted from the genital surface of the male to the female by contact during intercourse however it can still be used in the form of condoms to prevent the risk of other infections.
* Vaccination against HPV; this is to prevent HPV infection

How can we surmount the problem posed by cervical cancer on the health of our women?
In overcoming such a menace in our society, several modalities have to be put in place so as to prevent and at the same time decrease the incidence of the disease. This will as such play a vital role in the early diagnosis and successful treatment of cervical cancer which has long been “headache” to women of developing countries in which the Gambia isn’t an exception. Thus:

∑ Mass community-based campaign by health professionals particularly community health workers on the importance of regular screening (pap smear) by all women of the age 35-45 years including all sexually active ladies, to facilitate in the early diagnosis and prompt & successful treatment of cervical cancer since most of the patients come to the hospital at the late stages of the disease. And it has been noted that the incidence of cervical cancer has dramatically been reduced by more than 75% in western countries due to mass population based screening methods.

* All media stations in the country should provide the enabling environment for students at the health schools (i.e. public health, nursing & medical) to carryout educative programs on issues like risk factors, clinical features, preventive measures and when & where to seek for medical intervention for the different diseases common in the Gambia including cervical cancer in order to raise the awareness of the community.

* The screening centres including resources needed, have to be distributed countrywide to reduce the burden related to transportation particularly for those living in the rural areas.