Women often have one of two reactions to being told they have cervical cancer. If they have been having Pap smears, they may feel confused: "But I had a normal Pap smear last time! How did this happen?" And if they haven't had a Pap smear in a while, they may feel guilty: "I should have seen the doctor sooner." Either way, the diagnosis can be devastating. Cervical cancer may be difficult for women to discuss because it involves the cervix (the opening of the womb), which is not a part of the body women usually talk about. Also cervical cancer is caused by a sexually transmitted virus, and women might feel embarrassed. Let's deal with these issues first.
The anatomy of the female pelvis is not necessarily a familiar area. Many important parts are located in the pelvis and it may be helpful to review the anatomy before moving forward.
The reproductive organs include the uterus (the womb), the cervix, the fallopian tubes, and the ovaries. The uterus sits in the middle of the pelvis and the fallopian tubes and ovaries are located to the right and the left. The cervix is the opening to the uterus and is the part that dilates when a woman goes into labor. The cervix is divided into two parts. The ectocervix is the outside portion of the cervix and is lined by squamous cells. The endocervix is the inside portion of the cervix. It is the tunnel that leads to the inside of the uterus and is lined by glandular cells. The labia (lips) are the part of the female genitalia that you see on the outside and are sometimes referred to as the vulva or genitalia. The vagina (birth canal) connects the cervix to the vulva, and as the name implies, this is the tunnel that babies travel through when they are born (unless a cesarean section is performed). The rectum and sigmoid colon (where bowel movement is stored) are located behind the uterus and cervix. The bladder (where urine is stored) is located in front of the uterus and cervix. Figure 1-1 has been included for easy reference.
When you go to the gynecologist's office for a routine exam, the doctor will evaluate all these organs. The gynecologist first looks at the outside to make sure there are no abnormal areas. He or she then inserts an instrument called a speculum to look at the cervix and vagina. The bimanual exam is the part of the exam where the doctor uses his or her hands to feel for abnormalities of the uterus, cervix, tubes, and ovaries. A rectal exam is often performed to better evaluate the pelvis.
Urinary bladder Pubic bone Urethra Mons pubis Clitoris Labium majora Labium
Ovarian ligament Body of
Ovarian ligament Body of
If there is a suspicion of cervical cancer or if cervical cancer has been diagnosed, surgery may be recommended. These procedures will be discussed in detail in later chapters, but a short introduction will be helpful as we proceed forward. Knowledge of the anatomy is essential for an understanding of the surgery. A cold knife cone and a loop electrosurgical excisional procedure (LEEP) involve removal of part of the cervix. They are often performed to make a diagnosis, but can sometimes be sufficient to cure the disease. A trach-electomy refers to removal of the cervix without removal of the uterus. This procedure preserves fertility. A total hysterectomy involves removal of the uterus and cervix. The type
of hysterectomy just refers to how the uterus is removed. If the tubes and ovaries are removed, this is referred to as a salpingo-oophorectomy, and can involve both the right and left or just one side.
WHAT CAUSES CERVICAL CANCER?
Cervical cancer and the precancerous entity dysplasia are caused by a virus called human papillomavirus (called HPV for short). There are many different types of HPV, some of which cause warts and some of which can cause cervical dysplasia and cancer.
HPV is sexually transmitted, and may be likened to a sexually transmitted common cold. Of women who are sexually active, 85% will be infected with HPV within the first 3 years of having sex. So pretty much everyone gets HPV. Usually the virus infects and irritates the cells on the cervix. Most of the time our bodies fight off the infection, and it goes away without causing any problems. Sometimes, either because our immune system isn't working as well as it should or for reasons we still don't understand, our body doesn't fight off the virus. Smoking can also interfere with your immune system's ability to remove the virus. If your body doesn't get rid of the HPV infection, you can develop cervical dysplasia, which, if left untreated for years, can become a cervical cancer.
HOW DO WE PREVENT CERVICAL CANCER?
Papanicolaou (Pap) smears are designed to find evidence of persistent HPV infection (an infection that won't go away) on your cervix. Usually, Pap smears allow doctors to find precancers (cervical dysplasia) before they develop into cancer. If cell changes are noted early, doctors often simply watch to make sure your cervix is doing its job of fighting off the infection. If these changes are more advanced, doctors often intervene to eliminate the abnormal cells.
Unfortunately, Pap smears are not perfect; they only find changes, if there are any, about 60% of the time. That's why we have to do Pap smears so often. Since it usually takes at least 5-10 years for irritation from an H PV infection to cause cancer, this system works pretty well. However, Pap smears sometimes don't pick up the changes until after cancer has already developed. This delayed detection happens most often when the HPV infection affects the cervical canal rather than the outside of the cervix. Even in these situations, the cancer is still identified at an early stage.
If you haven't had a Pap smear in a while, you may be feeling guilty. There are lots of reasons why women don't get Pap smears, and beating yourself up over it will take your energy away from fighting your cancer.
Once again, it's important to note that smoking increases the risk of developing cervical cancer and dysplasia and worsens the outcome for women who have developed cervical cancer. Therefore, smoking cessation is a great idea both for women who are at risk for cervical cancer or dysplasia and for women who have already developed cervical disease. As a cancer patient or survivor, sharing your thoughts with a friend or family member may be enough to stop someone from smoking and can make a tremendous difference in someone's health.
WHAT ABOUT VACCINES?
Vaccines are medicines that result in immunity against infections. They teach your immune system how to fight a particular virus or bacteria. Vaccines can be either prophylactic or therapeutic. A prophylactic vaccine prevents an infection from occurring. It doesn't work in someone who has already been infected. A therapeutic vaccine treats a patient after she has already been infected with the disease.
A prophylactic vaccine that prevents genital warts and the majority of cervical cancers is currently available. The vaccine prevents infection by HPV 6 and 11, which cause warts, and HPV 16 and 18, which cause two-thirds of cervical cancers. Unfortunately, the vaccine does not work in women who have already been infected. The vaccine is recommended in girls ages 11-12, with catch-up vaccination recommended for females ages 13-26. Even if a patient is vaccinated, she still needs to get Pap smears as recommended. Although women with dysplasia have been infected with at least one HPV type, it is extremely unlikely for anyone to be infected with all four HPV types covered by the vaccine. Therefore, patients with dysplasia are still eligible for the vaccine. In these cases, the vaccine will not make the dysplasia go away, but can prevent infection by other HPV types. The vaccine is not recommended for patients with cervical cancer.
Clinical trials will continue to investigate therapeutic vaccines for HPV. However, these trials are in their early stages and there are no commercially available therapeutic HPV vaccines. Unfortunately, current vaccines are not helpful for women already diagnosed with cervical cancer.
As a cervical cancer patient or survivor, you are uniquely positioned to educate your friends and family about the HPV vaccine. You may be the difference between someone getting or not getting the vaccine. Although the vaccine won't prevent your cervical cancer, you could play a vital role in preventing someone else from getting cervical cancer.
OK, so now that we've covered some basics, let's talk about getting your treatment started.
SELECTING AN ONCOLOGIST/MEDICAL CENTER
Women with cervical cancer should be treated by a gynecologic oncologist. Gynecologic oncologists are doctors who have received specialty training to operate and give chemotherapy for cancers that only women can develop (such as cervical, ovarian, and uterine cancers). Gynecologic oncologists are certified by the American Board of Obstetrics and Gynecology. You should make sure that your physician is either board certified or board eligible. Studies have shown that women who contract these types of cancers and are treated by gynecologic oncologists typically receive better care, have a lower recurrence rate, and have a higher survival rate. The easiest way to find out if your doctor is board certified is to ask her or him directly.
After the diagnosis of cervical cancer has been made, your gynecologist will usually give a referral to a gynecologic oncologist. This is a good first step. As with any significant health care decision, a second opinion can be appropriate. There are many sources for a second opinion. A friend or family member may have required treatment by a gynecologic oncologist. The Internet can also be a good resource. Patients can search for gynecologic oncologists in their area on Web sites such as the Women's Cancer Network (http://www.wcn.org/).
Gynecologic oncologists can practice in an academic center or in a community hospital. Both systems provide excellent care, but have several differences. Some patients prefer academic centers, while others prefer community hospitals. Additionally, some medical centers are hybrids ofboth systems.
Gynecologic oncologists are experts who help you survive and cope with what is happening to you. Always make sure your doctor is someone you feel comfortable with and that he or she is willing to explain the procedures you are about to have. Remember, your doctor is there for you!
In addition to choosing your physician, you have a choice of facilities in which to receive care. There are certain features that are considered valuable characteristics in a cancer center. Does the facility provide easy access with timely appointments? Is the facility committed to having the patient as an active participant in treatment planning? Are there resources available for patient and family education? Is there a multidisciplinary conference to review patient treatment recommendations? Can all your treatment (surgery, chemotherapy, and radiation) be performed within the cancer center?
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