Cervix Cancer

Epidemiology
Cancer cervix is one of the most common malignancy in Indian women. In the rural cancer registry of Barshi and the cancer registries of Banglore, Bhopal, Chennai it is the commonest malignancy in female.

Common Cancers in among Women in India
Rank	Bangalore	Bhopal	Chennai	Delhi	Mumbai	Barshi
1	Cervix	Cervix	Cervix	Breast	Breast	Cervix
	30.8	24.9	41.9	29.0	27.1	27.7
2	Breast	Breast	Breast	Cervix	Cervix	Breast
	21.4	22.2	22.4	29.0	19.5	8.0

Anatomy

Cervix is the opening of uterus into the upper part of Vagina.  Squamocolumnar junction is located on the cervix and as it is a transition zone it is most susceptible to malignant process.
Anatomical illustration is given below.

  Risk factors for carcinoma cervix are :-

1. HPV infection
2. Giving birth to many children.
3. Having many sexual partners.
4. Having first sexual intercourse at a young age.
5. Smoking cigarettes.
6. Oral contraceptive use.
7. Weakened immune system.

Screening of Carcinoma Cervix is possible with the help of PAP smear.  This is a simple technique in which cells are collected from the cervical canal and nearby area of cervix and are examined under microscope.  If there are any suspicious changes then further investigations are required.  PAP smear examination should begin at age 18 years or with the beginning of sexual activity whichever is first.
Once a woman is diagnosed with Carcinoma Cervix she is required to undergo further tests:-
Routine blood investigations
X-ray chest
CECT abdomen & pelvis
Thorough clinical examination (Examination under anesthesia)
Cystoscopy or colposcopy (if required)


On the basis of these investigations & clinical examination stage of the disease is determined.  A broad overview of staging is given below :-
Carcinoma Cervix FIGO Staging
Stage 0: The cancer cells are present superficially (only affecting the outer surface) and they have not invaded into the deeper tissues of the cervix. Stage 0 is also called as carcinoma in situ (CIS) or cervical intraepithelial neoplasis (CIN) grade III.
Stage I: Cancer has invaded the cervix, but it has not spread beyond the cervix.
Stage IA: This is the initial form of stage I which can only be seen under a microscope.

• Stage IA1: Dimensions of invasion is less than 3 mm deep and less than 7 mm wide.

• Stage IA2: Dimensions of invasion is between 3 mm and 5 mm deep and less than 7 mm wide.

Stage IB: This stage includes cancer greater than Stage IA2 and cancers that can be seen without a microscope.

• Stage IB1: More than Stage IA2 or the cancer can be seen but it is not larger than 4 cm.

• Stage IB2: The cancer is larger than 4 cm.

Stage II: Cancer has spread beyond the cervix but not reached the pelvic wall or lower third of vagina.

• Stage IIA: Cancer is limited to upper part of vagina and has not spread to the tissues present next to the cervix.(These tissues are called parametria).

• Stage IIB: The cancer has spread into the parametria.

Stage III: Cancer has grown into the lower third of vagina or upto the lateral pelvic wall. Cancer may be blocking the tubes that carry urine from the kidneys to the bladder. These tubes are called ureter.

• Stage IIIA: The cancer has grown into the lower third of the vagina but not to the pelvic wall.

• Stage IIIB: The cancer has grown into the pelvic wall. If the tumor has blocked the ureters (a condition called hydronephrosis) it is also a stage IIIB.

Note: In another staging system by the American Joint Committee on Cancer, if cancer has spread to lymph nodes in the pelvis it is called as stage IIIB.
Stage IV: Cancer has grown locally to involve the adjacent organs or has involved the other organs of the body.

• Stage IVA: The cancer has spread to the bladder or rectum, which are organs close to the cervix.

• Stage IVB: The cancer has spread to distant organs beyond the pelvic area, such as the lungs.

Five-year survival rates by stage (As quoted by American cancer society)
Stage wise chances of 5 year survival are given below. These figures also include women who die of other causes.

Stage	5-Year Survival Rate
IA	Above 95%
IB1	Around 90%
IB2	Around 80%-85%
IIA/B	Around 75%-78%
IIIA/B	Around 47%-50%
IV	Around 20%-30%

Treatment recommendation as per the stage are:-

Stage	Recommending Body	Recommendation
Stage 0	National cancer institute USA	Loop electrosurgical excision procedure (LEEP). Laser surgery. Conization. Cryosurgery. Total hysterectomy for women who cannot or no longer want to have children. Internal radiation therapy for women who cannot have surgery.
Stage 1A	National cancer institute USA	Total hysterectomy with or without bilateral salpingo-oophorectomy. Conization. Modified radical hysterectomy and removal of lymph nodes. Internal radiation therapy.
Stage 1B	National cancer institute USA	A combination of internal radiation therapy and external radiation therapy. Radical hysterectomy and removal of lymph nodes. Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy. Radiation therapy plus chemotherapy.
Stage 2A	National cancer institute USA	A combination of internal radiation therapy and external radiation therapy plus chemotherapy. Radical hysterectomy and removal of lymph nodes. Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
Stage 2B	National cancer institute USA	Treatment of stage IIB cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Stage 3	National cancer institute USA	Treatment of stage III cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Stage 4A	National cancer institute USA	Treatment of stage IVA cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Stage 4B	National cancer institute USA	Radiation therapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life. Chemotherapy. Clinical trials of new anticancer drugs or drug combinations.