Women face a lot of specific health problems, hence a separate stream of medicine—gynecology and obstetrics—is required. A woman is predisposed to a lot of problems. Reproductive tract diseases like pelvic inflammatory diseases, urinary tract infections, pregnancy-related complications, pelvic organ prolapse, menopausal symptoms, carcinoma (cancer) of reproductive tracts, namely cervical cancer, vaginal cancer, and endometrial cancer are common. Breasts tumors in bimodal age (young as well as older age groups) are also common. Systemic diseases like thyroid disorders and autoimmune diseases are also not uncommon in females. These are a few of the many health issues that females are prone to.In our part of the globe, particularly in developing countries, infective and inflammatory diseases and carcinomas (cancer) are common. Carcinoma of the cervix is the most common carcinoma in females from developing countries where screening facilities are often inadequate.
Statistically speaking, as of 2018, Nepal has a population of 10.16 million women aged 15 and above who are at risk of developing cervical cancer. Current estimates indicate that every year, 2,942 women are diagnosed with cervical cancer and unfortunately, 1,928 die from this disease. Cervical cancer is the most frequent cancer among women between 15-44 years of age. Out of them, 80.3 to 99 percent of invasive cancers can be attributed to the Human Papilloma Virus strain 16 or 18. However, only 2-5 percent of these HPV cases will lead to cancer, according to data from ICO/IARC information centre on HPV and Cervical cancer, Nepal factsheet 2018.
Cervical carcinoma is a slow-growing condition where there is an abnormal and uncontrolled reproduction of cervical cells, which can then invade nearby or distant normal cells. Statistics show a deadly picture of the disease with its mortality data, but that’s not the entire picture. In fact, cancer of the cervix is a long course of the disease. The most surprising fact, which many people are unaware of, is that it is almost 100 percent preventable and curable to some extent, depending on the stage of the disease. The carcinoma follows a course before turning into cancer, where there are atypical, low-grade and high-grade stages before developing into carcinoma in situ (a pre-cancerous state) which can completely revert to normal spontaneously (within 8-10 years) if detected and treated early. These stages last for many years before turning to cancer.
HPV, which is the most common cause, can be cleared by the patient’s’ own defense mechanism. Other risk factors are multiple sexual partners, early sexual intercourse (<16 years), sexually transmitted diseases, too many and too frequent births, low socio-economic status, lack of education about genital hygiene, smoking, and even oral contraceptive pills.
The main factor for the development of the cancer and its lack of early detection is that the symptoms of cancers appear late. It remains asymptomatic for a long period of time. The ignorance of patients can result in the ‘three delays’—delay in identifying symptoms, delay in seeking medical help, and delay in receiving medical treatment due to various confounding factors like accessibility of health facility, socioeconomic status, and expenses.
The primary symptoms of cervical carcinoma are slight painless bleeding from the vagina, post-coital bleeding, significant loss of weight, foul smelling vaginal discharge, pelvic pain and other constitutional symptoms like loss of appetite and opportunistic infections. However, the symptoms can be ambiguous and misleading. The disease can spread to nearby structures like the urinary bladder—leading to symptoms like frequency of urination, blood in urine—the intestines—leading to bowel problems like diarrhea, constipation or blood in stool. It can also spread to distant structures like the lungs, lymph nodes, liver, and bones.
The mainstay of the treatment is early diagnosis of the disease and prompt treatment. Early diagnosis is basically a screening test that is known as a papanicolau stain (colloquially known as a pap smear), where cells from the cervix are examined for cancerous growth and classified accordingly.
Other methods are ace to white staining technique, Schillers test, and liquid based cytology. It is astounding that pap smear screening tests, by identifying the carcinoma early for prompt management, can help reduce the incidence of cancer by 80 percent and reduce deaths by 70 percent. A pap smear screening test is recommended for all women starting from 21 years of age or after three years of first vaginal sexual intercourse, without an upper age limit.
Similarly, screening with cervical cytology should be conducted yearly or every three years till the age of 30. Thereafter, from ages 30-65 years, it should be done in an interval of every three years after three consecutive yearly negative smears. Woman after 65 years require no screening after adequate prior negative smears. However, high-risk groups should get tested with HPV detection tests (hrHPV) and get tested every five years. Other modalities of diagnosis are colposcopy, ultrasonography, imaging like CT scans, MRI and PET scans to discover the advancement of the disease, which can then result in a biopsy from the suspected area.
When it comes to treatment, the most important determining factor is prevention. If detected early, also known as downstaging of cancer, the carcinoma can be fully prevented and treated. It first requires identification of high-risk females. i.e., females with high-risk factors. Second, prophylactic vaccines against the HPV virus, like Cervarix and Gardasil, are quite effective. Effective for about 7.5 years, these vaccines are given to girls between 12-18 years of age. But continuous screening should still be done. Third, the use of barrier methods for contraception like condoms, which not only have contraceptive benefits but also protect from sexually transmitted diseases. Fourth, education about genital hygiene for both males and females is important. And finally, reducing or quitting smoking can help reduce the risk of carcinomas.
The definitive treatment of precancerous lesions can just be a local excision of the lesion. The treatment for invasive cancers depends on the grading of the severity of the disease, the age of the patient, and completion of the family. Invasive cancers can be treated surgically by removing the whole uterus, cervix, ovaries, and lymph nodes. Chemotherapy and radiotherapy are also other treatment modalities. The earlier the diagnosis, the better the patient outcome. Constant follow-ups with medical experts is a must to rule out other complications and even a recurrence of the cancer.
In conclusion, cancer of the cervix is the most common malignant tumour in females in the developing world. It is a slow growing cancer that is completely preventable. So, it is a great sorrow and a sign of a failing health delivery system if women are dying from cervical cancer, which is also curable with the help of modern diagnostic modalities. The primary aim of prevention is early diagnosis through a pap smear. If detected early, the outcome for the patient can be good. Nepal should work towards an increasing rate of early diagnosis and treatment and declining rates in incidence and deaths by this preventable cancer among females.
