Cervical Cancer and Juanita's Story: The Power of the Pap

Juanita HISTORY
Juanita was a 48 year old Hispanic who noticed vaginal bleeding after she and her husband had had sex. This symptom had occurred off and on for about 6 weeks when he decided to be evaluated in the clinic of the local health department. Juanita had not had a gynecological examination and Pap smear in the last 5 years. She had been pregnant 5 times, children 3 and 2 miscarriages. He had a history of hypertension, but was in good health. ItsExamination revealed a 3 cm mass in the cervix. The gynecologist has obtained a biopsy of the mass revealed squamous cell carcinoma, cancer of the cervix.

After her diagnosis, Juanita had a CT scan of the pelvis showed no clearly visible disease in their lymph nodes or elsewhere outside of the cervix. A chest radiograph was negative. Gynecologic oncologist, Juanita made a radical hysterectomy, which revealed a squamous cell carcinoma of the cervix withoutevidence of spread to surrounding tissues, and negative surgical margins. However, there is microscopic cancer cells in 6 of 8 lymph nodes were removed from the left side of the basin. He also had over cancer cells invade the lymphatic system and blood vessels near the cervix. Juanita has been subjected to a radiation oncologist recommended postoperative radiotherapy and chemotherapy together (chemoRT). Received 5.5 weeks of radiation treatment that uses intensity modulatedtherapy (IMRT), in order to minimize the dose of radiation absorbed by the small bowel and bladder neighbors. Concomitant chemotherapy with cisplatin was delivered by weekly gynecological oncologist. He had a difficult time in your chemoRT due to fatigue and severe diarrhea. It had to be hospitalized for three days towards the end of treatment to receive intravenous fluids because of dehydration. However, within a month after finishing chemoRT, Juanita had fully recovered from the effects of treatment.Four years after the completion of its chemoRT, disease-free or long-term side effects.

FUNDAMENTALS
Cervical cancer is the most common cause of death among gynecologic cancers in women during much of the world. However, deaths from cervical cancer are less common in the U.S. thanks to widespread use of Pap tests. According to the latest NCI's SEER Cancer Statistics Review, survival at 5 years after diagnosiscervical cancer for all stages combined is 70%. If the disease is localized, the 5-year survival is 91%.

CAUSES AND RISK
The human papillomavirus (HPV) are present in almost all squamous cell cancers of the cervix. HPV infection is the major risk factor for developing cervical cancer. Two strains of HPV, types 16 and 18 are most often associated with cervical cancer. The two vaccines that were created forprevent cervical cancer are designed to protect against strains of HPV. The vaccine is approved in the United States to women ages 9 to 26 (and now the kids!). Available vaccines do not eliminate the HPV infection in a woman who is already infected. Most women who develop an HPV infection is cleared by themselves within 1-2 years and do not develop cervical cancer. Activities that put women at risk of HPV infection (such as having multiple partners sex)Also put them at risk for cervical cancer. To the surprise of many young women, including snuff smoke has been clearly linked with increased risk of developing cervical cancer. Therefore, most (but not all) Risk factors for cervical cancer can be modified or changed by women who make the effort to protect themselves.

Signs and symptoms
The classic symptoms of cervical cancer arevaginal bleeding, most notably following intercourse, called post-coital bleeding. Some women may visit their gynecologist with complaints of pelvic pain without bleeding. Those patients who present with significant symptoms and are found to have more advanced cancer, usually haven't had routine gynecological exams including Pap testing. The Pap test is an extremely effective screening tool for the prevention and/or early detection of cervical cancer.

DIAGNOSIS
Most women are diagnosed with cervical cancer following examination and biopsy of the cervix by their gynecologist. Patients should then be referred to a gynecologic oncologist, a surgeon specializing in the care of patients with gynecologic cancers. Roughly 80% of cervical cancers are squamous cell carcinomas.

STAGING
Historically, the primary staging system for cervical and other gynecologic cancers was based on the FIGO system. Patients with very early stage disease have smaller cancers limited to the cervix. Locally advanced disease includes large cervical tumors that invade into the nearby tissues within the pelvis, as well as those that involve pelvic lymph nodes.

TREATMENT
Patients with early stage cervical cancer should be treated surgically by a gynecologic oncologist. The standard surgical procedure is called a radical hysterectomy, which differs from what most people think of as a hysterectomy. In addition to the uterus, the fallopian tubes, ovaries, parametria (tissue on the sides of the cervix), ligaments and tissues that support the uterus, and upper portion of the vagina are all surgically removed by the gynecologic oncologist. Cure rates exceed 80% overall. Potential acute side effects of radical hysterectomy include bleeding, infection, urinary or bowel injury, sexual dysfunction, and rarely life-threatening blood clots to the lungs.

Certain patients will benefit from post-operative radiation therapy (RT) to their pelvis. These groups include patients with cancer cells at the edge of where the surgeon removed the tumor (positive margins), involvement of lymph nodes, parametria, or within lymphatic and vascular channels. Post-operative concurrent chemoRT improves survival over RT alone and is the standard of care for these patients at high risk of cancer returning within the pelvis.

Locally advanced cervical cancer is fortunately becoming much less common throughout most of the U.S. due to the widespread use of Pap testing. The standard treatment for these patients is concurrent chemoRT. This regimen usually includes both external and internal RT. External RT is delivered over roughly 5 weeks of daily treatment. The internal RT may be delivered in the hospital over 2-3 consecutive days usually after completion of external RT, or as an outpatient once per week beginning midway through the treatment course. Medications are given to minimize discomfort.

The most frequent acute side effects of RT to the pelvis include irritation of bladder and bowel causing frequency and/or discomfort with urination or bowel movements. Fatigue and decreased blood counts are also common side effects of chemoRT in this setting. Approximately 5-10% of women will have chronic bladder or bowel problems that affect their quality of life long-term. Rarely, RT may cause permanent bowel or bladder injury requiring surgery to repair. There is also a small but real risk of vaginal stenosis, scarring at the top of the vagina, that may cause pain. The risk of this scarring can be minimized by using a medical dilator to keep the tissue healthy.

Cisplatin is the chemotherapy drug most commonly delivered during RT, usually in low doses once per week. The common acute side effects include decreased blood counts, poor appetite, fatigue, and nausea and vomiting (which are usually very well controlled on current anti-nausea medicines). Uncommon but serious long-term risks of cisplatin include possibility of damage to the kidneys and nerves, as well as loss of high frequency hearing.