Rising risk of cervical cancer in adolescents and younger women
Cancer cervix has been the culprit for a large number of deaths in women. The incidence of cancer cervix is high in several parts of the world, especially in low- & middle-income countries. In several countries the incidence is receding, however, it is still a major health concern. Prof Zur Hausen (German virologist) showed a strong association between HPV (Human Papilloma Virus) infection and the cancer cervix. HPV is considered a sexually transmitted virus.
Globally Cervical and Breast cancer are frequently diagnosed cancers and a leading cause of death among women. These are also most common in Indian women and contributes approximately 40 % of all cancers in India in 2020. The age-adjusted rate (AAR) for cervical cancer is high in the northern region followed by Bengaluru and Barshi rural areas in Maharashtra, ranging close to 28 per 100,000 population. There has been a sharp increase in Cervical cancer rates in the age over 25 years in all Population-Based Cancer Registries (PBCR) in India from 1985 and later declined. It has been noticed that in the younger population cervical cancer is either static or increasing. In England, cervical cancer is more common under the age of 35 years and in this population, the cervical screening program has been very effective in diagnosing early disease.
Cervical cancer is associated with lower socio-economic status and HPV prevalence. Also, the early age of first intercourse, multiparity and tobacco consumption increases the risk of cervical cancer. The studies have indicated the implication for cervical screening, HPV vaccination and other public health intervention such as health education and tobacco control, needed to target young people. The ICMR recommends cervical screening between 30 and 59 years and WHO recommends HPV DNA detection in screen and treat approach for women starting at age 30 years with regular screening every 5 to 10 years.
Early diagnosis of cervical cancer is key in controlling and curing cancer. Cervical cancer is a highly curable disease. The disease is amenable for radical surgery, especially in the early stages. Radiation therapy with a combination of external beam radiation therapy (EBRT) and brachytherapy provide equal results in the early stages and is a treatment of choice in late stages. Several recent studies proved the use of concurrent chemotherapy with radiation therapy improves the control rates.
In the early stages, fertility-preserving surgery (trachelectomy) has an option provided the disease is limited. Those women (especially young adults) who wish to continue childbearing may consult a Gynaecological Oncologist for needful. Patients with early disease, amenable for surgery should be operated on by the experienced gynaecological oncologist to avoid further adjuvant treatment. Radical surgery (Wertheim’s surgery) provides excellent long-term outcomes in early disease.
Radical radiation therapy is a very important modality of treatment for cervical cancers. In the majority of patients both EBRT and brachytherapy is mandatory. External beam radiation therapy covers all areas of disease including the lymph nodes which may be involved by cancer. The rectum and urinary bladder cannot tolerate high doses of radiation and can give rise to debilitating complications. Therefore, EBRT is given up to the tolerance of these organs, however, the cervix can tolerate high doses and the tumour will be sterilised with a high dose of radiation. Therefore, the brachytherapy is given as an additional dose to the tumour while limiting the dose to sensitive organs.
Chemotherapy along with radiation therapy has proven beneficial in several studies. The schedule used is concurrent chemotherapy. These are generally single-agent chemotherapy given prior to radiation therapy fraction maybe once a week. These enhance the beneficial effect of radiation therapy. Occasionally, chemotherapy may be given after or prior to the definitive treatment.
There are few side effects of the treatment, and these are generally short-lived, and the patient’s quality of life is maintained well. Patients need to maintain nutritional status and may take the help of a dietitian. Once the treatment is concluded, it is important that the patient should remain on follow-up with the treating doctor. During follow-up, if any side effects are encountered, will be treated. A small percentage of patients where the recurrence may occur can be treated efficiently if detected early, therefore regular follow-up is very important.
In certain circumstances, where the disease is not controlled, will require palliative care. The effects related to the advanced disease need to be treated symptomatically and, in many situations, morphine will be required. All these patients are treated on an individual basis depending on the severity of symptoms.
In conclusion, awareness of cervical cancer is essential for all, especially for younger women. The screening for cervical cancer through a simple test at a regular interval is useful in detecting in early-stage and treating successfully. The vaccine is now available, and several countries are adopting it with the aim to reduce the burden of cervical cancer. The treatment of cervical cancer in the early stages is curative in the majority of patients.
With inputs from Dr Shyam Kishore Shrivastava, Director- Radiation Oncology, HCG Cancer Centre- Mumbai