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Cervical cancer: anatomy, causes, symptoms, therapy

by Josephine Andrews
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On average, women develop cervical cancer (cervical carcinoma) at the age of 53. The trigger is usually a specific viral infection (HPV) in the genital area. In the early stages, cervical cancer is almost always curable. As the tumor spreads, the chances of recovery decrease. Read everything you need to know about the causes, symptoms, diagnosis, treatment, prognosis and prevention of cervical cancer here!

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

C53 C57

quick overview

  • What is cervical cancer? A malignant cell growth in the area of ​​the cervix.
  • Frequency: Approximately 4,300 new cases of cervical cancer are expected in Germany in 2018. This incidence rate has been largely stable since the late 1990s. The median age at diagnosis is 53 years. Women who develop a preliminary stage of cervical cancer (in situ carcinoma) are on average 34 years old.
  • Causes: primarily an infection with the sexually transmitted human papilloma virus ( HPV ). Other risk factors include smoking, frequently changing sexual partners, many births, poor genital hygiene and long-term use of the ” pill “.
  • Symptoms: usually only in advanced stages of cancer, eg bleeding after sexual intercourse or after menopause, heavy menstrual bleeding, bleeding between periods or spotting, discharge (often foul-smelling or bloody), pain in the lower abdomen, etc.
  • Therapy: surgery, radiotherapy and/or chemotherapy , targeted therapy (antibody therapy)
  • Prognosis: The earlier cervical cancer is detected and treated, the higher the chances of recovery.

Cervical Cancer: Anatomy

The neck of the womb (cervix) forms the transition between the body of the womb (uterus) and the vagina (vagina). It allows sperm to get out of the vagina and into the uterine cavity inside the uterus during sexual intercourse.

The opening of the cervix into the vagina is called the external os . The opening to the body of the uterus is called the internal os .

The inside of the cervix is ​​lined with a mucous membrane : It consists of a cover tissue (squamous epithelium) and mucous glands embedded in it. If the mucous membrane of the cervix changes malignantly, one speaks of cervical cancer (cervical carcinoma) . In most cases, it starts from the squamous epithelium and is then one of the so-called squamous cell carcinomas . Rarely, cervical carcinoma develops from the glandular tissue of the mucous membrane. Then it is an adenocarcinoma

In most patients, cervical cancer develops in the area of ​​the external os.

Anatomy of the internal female genital organs
The cervix is ​​the narrow, lowest part of the uterus where it meets the vagina.

Cervical cancer should not be confused with cancer of the womb (cancer of the womb). The latter is also called “uterine carcinoma”, endometrial carcinoma” or “corpus carcinoma” in medical terminology.

Cervical Cancer: Causes & Risk Factors

Cervical carcinoma is usually caused by a chronic infection with the human papilloma virus (HPV). There are about 200 different types of this virus. Some of these are considered particularly aggressive and dangerous and are therefore called “high risk” types. These include HPV 16, 18, 31, 45, 51 and 52. Types 16 and 18 alone are responsible for more than 70 percent of all cervical cancers.

The “low risk” HPV types are not involved in the development of cervical cancer. However, they can cause warts on both male and female genitals.

HPV is transmitted almost exclusively through sexual intercourse. Even condoms are not sufficient protection against the human papilloma virus. The pathogens can be transmitted through skin contact in the intimate area.

Almost everyone comes into contact with HPV at least once in their life. In most cases, the immune system can deal with the virus , even if it is a “high risk” type of virus. Less than 1 in 100 women who are infected with a high-risk HPV type will actually develop cervical cancer.

Cervical cancer: other risk factors

Another major risk factor for cervical cancer is smoking. Certain toxins from tobacco are deposited specifically in the tissue of the cervix. This makes the tissue more vulnerable to viruses such as HPV.

Other risk factors for cervical cancer are:

  • Large number of sex partners: The more sex partners a woman has in her life, the higher her risk of cervical cancer.
  • Early start of sexual activity: Girls who have sexual intercourse before the age of 14 have an increased risk of HPV infection – and thus also of the development of cervical cancer (or its precursors).
  • Poor genital hygiene: It makes you more susceptible to HPV infection and many other sexually transmitted diseases. For example, the HPV infection rate is lower in circumcised men than in uncircumcised men.
  • low socioeconomic status: People with low income are more likely to be infected with HPV than people from higher social classes.
  • many pregnancies and births: Every pregnancy that lasts at least five to six months or every birth increases the risk of HPV infection and thus cervical cancer. This is either due to tissue changes during pregnancy or because women with a low socioeconomic status in particular become pregnant more than once.
  • Long-term use of oral contraceptives (“the pill”): Women who are infected with a high-risk HPV type and have been taking an estrogen-progestogen contraceptive pill for five years or more have a slightly increased risk of cervical cancer.
  • Other STDs: In women infected with HPV, an additional STD (such as genital herpes or chlamydia) can also contribute to the development of cervical cancer.
  • Weakened immune system: A weakened immune system can either be caused by an illness (such as AIDS) or by drugs that suppress the immune system (administered, for example, after transplantations). In any case, a weakened immune system is unlikely to be able to fight off an HPV infection effectively.

According to the current state of knowledge, genetic factors play only a minor role in the development of cervical cancer.

Cervical Cancer: Symptoms

Cervical cancer usually does not cause any symptoms in the early stages . Cervical cancer precursors also go unnoticed for a long time.

Only over time do the malignant cell changes become noticeable with symptoms such as vaginal discharge (vaginal discharge) – it can be bloody or foul smelling. Bleeding after sex can also be a sign of cervical cancer. The same applies to bleeding after exertion such as cycling, horseback riding or hard bowel movements.

In women over the age of 35, heavy menstrual bleeding, intermenstrual bleeding or spotting are also considered to be suspected of being cancerous. Bleeding after menopause can also be a symptom of cervical cancer.

The symptoms mentioned are not clear signs of cervical cancer! They can also have other causes. To be on the safe side, however, you should have them checked out by a doctor.

Some patients also report pain in the lower abdomen . Unexplained weight loss is also common in women with cervical cancer.

In advanced stages of the cancer, there are signs that other organs are also affected. Some examples:

  • Lymphedema (swelling of the legs with moist, swollen skin ) develops when the lymphatic system is extensively affected.
  • Red urine can occur when cancer cells have invaded the urinary tract and bladder, causing bleeding into the bladder.
  • Deep back pain , which often radiates into the pelvis, is a possible sign of pelvic and spinal cancer.
  • Severe abdominal pain with paralysis of bowel movements is possible if the abdominal viscera are affected by cancer. If the intestines are affected, bowel movements can also be disturbed.

In the final stage, the tumor spreads throughout the body. Many vital organs then fail , ultimately leading to death.

Cervical Cancer: Examinations and Diagnosis

The most important examination is the regular check-up at the gynecologist (early cancer detection) . This also applies to women who have been vaccinated against the most important HP viruses: Vaccination does not replace preventive care, it only complements the preventive program.

In Germany, every woman over the age of 20 can have a check-up/early detection examination carried out by a gynecologist once a year. All cash registers cover the costs for this. You can ask any gynecologist for more information.

Women should definitely take advantage of the free cancer screening test! The earlier malignant cell changes are discovered and treated, the better the prognosis.

The routine screening for early detection of cervical cancer is the same as the screening that is done when there is a definite suspicion of cervical cancer (due to symptoms such as irregular bleeding):

anamnesis interview

First, the doctor will talk to the woman about her medical history ( anamnesis ). He asks, for example, how regular and heavy the menstrual bleeding is and whether there are occasional bleeding between periods or spotting. He also inquires about any symptoms and previous illnesses as well as the use of contraceptives.

Gynecological examination & PAP test

The consultation is followed by the gynecological examination: the gynecologist first examines the external genitalia, such as the labia , for any abnormalities. Then he spreads the vagina open with the help of a metal spatula (speculum). So he can take a look at the vaginal walls and the external cervix.

He will also use a small brush or cotton swab to take a sample of cells from the surface of the lining of the cervix and cervical canal. It is examined more closely under the microscope. In this way, the doctor can see whether there are altered cell forms under the mucosal cells. This examination is called a cervical smear or cervical smear ( PAP test ).

Sometimes the external cervical os and its surroundings cannot be adequately assessed with the naked eye. Then a vaginal reflection ( colposcopy ) is necessary: ​​​​The gynecologist examines the inside of the vagina and the cervix with the help of a lighted magnifying glass. He can also dab the tissue on the cervix with an iodine solution: healthy and diseased tissue then show a different coloration. The gynecologist can then take a tissue sample from suspicious areas ( biopsy ). Tests in the laboratory show whether it is actually cervical cancer.

conization

If the suspicious tissue change is only small, the gynecologist usually carries out a so-called conization : A cone is cut out of the tissue, consisting of the pathologically changed cells and a border of healthy cells all around. The latter is to ensure that no altered cells remain. The removed tissue can be examined in the laboratory for cancer cells.

The purpose of conization is not only to remove suspicious tissue so that it can be examined in detail in the laboratory. It can also be considered as a treatment option: A small, isolated tumor can be completely removed by conization (see below).

HPV test

A test for human papilloma viruses ( HPV test ) can also be useful in clarifying a possible cervical cancer disease : A swab from the cervix is ​​examined for the presence of HP viruses (more precisely: for their genetic material).

The HPV test can be used as a routine supplement to screening for cervical cancer in women over the age of 30. Women have to bear the costs themselves.

The HPV test makes no sense for younger women because HPV is often found in them, but the infection usually goes away on its own.

Regardless of the woman’s age, an HPV test is indicated if the Pap smear gives an unclear result. The costs for the test are then covered by the health insurance companies.

Further investigations

If the diagnosis of cervical cancer is confirmed, further tests are necessary. They are intended to show whether the tumor has already spread to the surrounding tissue and whether secondary tumors (metastases) have formed in more distant places. An ultrasound examination , for example, is suitable for this : On the one hand, the doctor performs a transvaginal ultrasound by inserting the ultrasound probe into the vagina. On the other hand, the kidneys are assessed for noticeable changes with a “normal” ultrasound examination (from the outside).

Sometimes the doctor also orders computed tomography ( CT ) and/or magnetic resonance imaging (magnetic resonance imaging, MRI ). This can be used to detect metastases in the pelvis, abdomen or chest. An X-ray examination of the chest ( X-ray chest ) can also reveal metastases in the chest.

If there is a suspicion that the cervical cancer has spread to the bladder or rectum, a cystoscopyor rectoscopy is necessary . This can be used to detect a possible cancer.

A so-called surgical staging may also be carried out for cervical cancer : During an operation, the doctor takes a look at the organs in the pelvis and lower abdomen in order to be able to better assess the possible spread of the tumor. He can take tissue samples from various organs and lymph nodes to have them examined in the laboratory for cancer cells.

Sometimes the operative staging follows the treatment. During the examination, the doctor can decide to cut out the cancerous tumor (usually with the entire uterus). Of course, the patient must have given their consent beforehand.

staging

Depending on how far the cervical cancer has already spread at the time of diagnosis, doctors differentiate between different cancer stages. This is important for therapy planning. In addition, the doctor can better assess the course and prognosis of the cancer based on the stage.

Cervical cancer: treatment

The type of treatment for cervical cancer depends mainly on how far advanced the disease is. However, other factors also influence therapy planning, for example the general condition of the patient and whether she still wants to have children or is already going through the menopause. Possible side effects and consequences of the individual therapy methods are also taken into account.

In principle, there are three treatment options for cervical cancer. They can be used individually or in combination:

  • surgery
  • Radiation ( radiotherapy )
  • drug treatment (chemotherapy and targeted therapies)

Some women only have a preliminary stage of cervical cancer (dysplasia). If these cell changes are only slight, people usually wait and see because they often go away on their own. The doctor can check this during regular check-ups.

Cervical Cancer: Surgery

In the early stages of cervical cancer, surgery is the treatment of choice. The goal is to completely excise the tumor, along with a margin of healthy tissue to be on the safe side. The total amount of tissue that needs to be removed depends on the size and extent of the cancer.

There are several techniques available for surgery for cervical cancer. There are also various access routes to remove the diseased tissue (via the vagina, an abdominal incision or a laparoscopy = laparoscopy ).

Conization: The conization mentioned above can be used for small tumors that can be clearly distinguished from healthy tissue. Here, the diseased cells are cut out in a cone shape together with the surrounding healthy tissue. Pregnancy is then still possible, but with an increased risk of premature birth. The cervix is ​​more or less unstable after the procedure – depending on how much tissue had to be removed. To be on the safe side, women should wait a while before having children after a conization (the doctor treating you will give you more detailed information on this).

Trachelectomy: Sometimes conization cannot remove all of the cancerous tissue—a larger operation is needed. However, if the patient still wants to have children, a so-called trachelectomy: The surgeon removes part of the cervix (up to two thirds) and the inner ligaments of the uterus. However, the inner cervix and the body of the uterus remain intact (the inner cervix is ​​connected to the vagina).

Pregnancy after a trachelectomy is associated with an increased risk of complications (such as preterm birth ). In addition, the child must be delivered by caesarean section . As soon as the woman has completed her family planning, the entire uterus is subsequently removed ( hysterectomy ).

Hysterectomy: When a woman with cervical cancer no longer wants children, the entire uterus is often removed. The intervention is also necessary when the tumor has already grown deeper into the tissue. After this operation, the woman is no longer able to become pregnant.

If the procedure involves removing the uterus alone, it is called a simple hysterectomy . If surrounding tissue also has to be excised (neighboring lymph nodes, the upper part of the vagina, etc.), it is a radical hysterectomy . In cervical cancer patients after the menopause, the two ovaries and fallopian tubes are usually removed as well. In younger women, this is avoided if possible to preserve hormone production in the ovaries.

The bladder and rectum also need to be removed if cervical cancer has already spread to these organs.

Cervical cancer: radiation therapy

If extensive surgery is not possible (eg if the patient is in poor general condition) or if the woman refuses, the cervical cancer can be treated with radiation or a combination of radiation and chemotherapy ( radiochemotherapy ) as an alternative. Radiation therapy is also sometimes given after surgery to kill any remaining cancer cells. Then physicians speak of adjuvant radiation .

Two methods are possible in radiotherapy: either the tumor is irradiated through the skin ( percutaneous irradiation ). Or the doctor brings the radiation source through the vagina to the tumor. This radiation therapy from the inside is called brachytherapy .

Radiation for cervical cancer can cause acute side effects. These include, for example, painful irritation of the mucous membranes in the vagina, bladder or intestines as well as diarrhea and infections. Such symptoms disappear again within a few weeks after the radiation. In addition, the treatment months or years later can cause long-term effects, some of which remain permanent, such as impaired bladder function, loss of control when emptying stools, inflammation of the mucous membranes with bleeding or a narrow, dry vagina.

Cervical cancer: chemotherapy

During chemotherapy , the patient receives infusions of drugs at regular intervals to stop the cervical cancer from growing. Because these chemotherapeutic agents (cytostatics) work throughout the body, they are also referred to as systemic treatment.

The rapidly dividing cancer cells are particularly sensitive to these drugs. However, the proliferation of rapidly growing healthy cells is also impaired, such as hair root cells, mucous membrane cells and blood-forming cells. This explains the possible side effects of chemotherapy such as hair loss , nausea and vomiting as well as changes in the blood count with increased susceptibility to infection .

Chemotherapy for cervical cancer (as mentioned above) is usually combined with radiation therapy. Sometimes, however, it is used alone, for example in the event of a recurrence or secondary tumors far away from the primary tumor in the cervix (distant metastases).

Cervical cancer: targeted therapy

Sometimes a cervical carcinoma is treated with an artificially produced antibody ( bevacizumab ) that specifically fights the tumor: as soon as the cancerous tumor has reached a certain size, it needs its own newly formed blood vessels to ensure the supply of oxygen and nutrients. The antibody bevacizumab inhibits a specific growth factor and thus the formation of new blood vessels. As a result, the tumor cannot grow any further.

Bevacizumab is given as an infusion . However, targeted therapy is only an option in certain cases , namely when the cervical cancer:

  • has already formed metastases
  • cannot be suppressed with other therapies or
  • returns after an initially successful therapy (relapse).

Complementary Treatments

Malignant tumors such as cervical cancer can sometimes cause severe pain. Those affected then receive individually tailored pain therapy .

Many patients develop anaemia , either from the cancer itself or from treatment (such as chemotherapy) The affected women may receive blood transfusions .

Other side effects of cervical cancer therapy are also treated in a targeted manner if necessary. A few examples: Nausea and vomiting, which often occur with chemotherapy, can be relieved with medication. Diarrhea as a result of chemotherapy or radiation therapy can also be stopped with a suitable medication. Radiation therapy for cervical cancer can lead to a dry, constricted vagina: Lubricants help against uncomfortable dryness during sexual intercourse. A narrowing can be prevented by regularly stretching the vagina for a few minutes with aids.

Diagnosing and treating cervical cancer (or any other cancer) can be very psychologically draining. Therefore, patients should receive psycho-oncological care . Psycho-oncologists are specially trained doctors, psychologists or social workers who provide emotional support to cancer patients and their families in dealing with the disease.

Cervical cancer: rehabilitation and aftercare

Rehabilitation after cervical cancer (or any other type of cancer) aims to enable patients to return to their social and professional lives Various therapists and counselors (doctors, psychologists, physiotherapists, etc.) help the affected women to cope with the possible consequences of the illness or treatment and to regain physical fitness. Patients receive all important information about rehabilitation from their doctor and the social services in the clinic.

Cervical cancer treatment is followed by aftercare : it includes regular check-ups. These serve to check the success of the treatment and to identify any relapses at an early stage. The women also receive help in dealing with the consequences of illness or therapy. Experts recommend the following schedule for follow-up visits:

  • For the first three years after treatment, women should have follow-up visits every three months.
  • In the 4th and 5th year after completion of treatment, a follow-up examination every six months is recommended.
  • From the 6th year , women should go for a follow-up examination once a year.

The follow-up examination should consist of the following parts:

  • conversation and advice
  • physical examination of the genitals with palpation of the lymph nodes
  • PAP test

In addition, an HPV test, an ultrasound examination of the vagina and kidneys and a magnifying glass examination (colposcopy) can be carried out at certain intervals.

Cervical cancer: course and prognosis

The chances of a cure for cervical cancer are better the earlier the tumor is discovered and treated:

Early stages can usually be cured. If the tumor is a little more advanced, but can be completely surgically removed, the prognosis is also good. In very advanced stages of cervical cancer and in the event of a recurrence, healing is much more difficult, but still possible. If the cervical carcinoma has already formed secondary tumors (metastases) in other organs, the treatment usually only aims to alleviate the patient’s symptoms and to extend the lifespan as far as possible.

A therapy aimed at healing is called curative. If the treatment only serves to make the remaining life of the patient as symptom-free as possible, it is palliative treatment.

In recent decades, the chances of a cure for cervical cancer have improved significantly: Today, around 1,540 women in Germany die of cervical cancer each year. 30 years ago there were more than twice as many.

Cervical Cancer: Prevention

Vaccination against human papilloma virus (HPV) can reduce the risk of cervical cancer – after all, these viruses are responsible for most cases of the disease. The Standing Committee on Vaccination (STIKO) at the Robert Koch Institute recommends vaccination for all girls between the ages of 9 and 14 before their first sexual intercourse. The costs for this are covered by the health insurance companies.

Experts advise boys should also be vaccinated against HPV. If they are not infected, they cannot infect their sexual partners either – this protects them from cervical cancer. In addition, vaccination offers the boys themselves protection against genital warts and cell changes that can potentially lead to cancer (such as penile cancer).

You can read everything important about the procedure, effects and side effects of the vaccination in the article HPV vaccination .

HPV infection can also be prevented to a certain extent by “safer sex”: The use of condoms can prevent infection in about half of all cases. Apart from that, condoms also protect against other sexually transmitted diseases such as HIV or chlamydia.

Proper genital hygiene and not smoking also help prevent cervical cancer.

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