Cervix Cancer  Anti-Cancer Foundation (South Australia)

INTRODUCTION
Cervix cancer may take many years to develop and is most often found in women between 30 and 70 years of age. Currently cervix cancer is the twelfth most common cancer among Australian women. In 1987 the South Australian Cancer , Registry recorded 102 new cases of cervix cancer compared with 62 in 1999. The Registry also recorded the lowest number of deaths from cervix cancer in the state's history in 1998 and 1999.

Cervix cancer can be prevented through the early detection of abnormalities in cells lining the cervix. The decreases noted in incidence and mortality can be attributed to the extensive work of SA Cervix Screening Program since 1990. It is estimated that 90% of cases of cervix cancer are preventable with two yearly Pap smears.

STRUCTURE AND FUNCTION OF THE CERVIX
The cervix is part of the female reproductive system, located at the junction of the vagina and the uterus (womb).

The cervix surrounds a passageway, or canal, that connects the uterus to the vagina. Menstrual tissue from the uterus uses this passageway as it leaves the body; sperm also pass through this canal as they travel from the vagina upward to the unfertilised egg to achieve conception.

The part of the cervix projecting into the vagina is covered by a "skin". Seen under a microscope, this "skin" is made up of many layers of cells, which when seen under a microscope have a pattern which resembles a brick wall. The surface layer of cells is continually being worn away, but the "brick wall" is maintained at its same thickness. As the surface layer is being worn away a new deeper layer of cells is developing, pushing the cell layers in between one step towards the surface. Eventually, cells from the bottom will reach the surface, and examination of cells from the surface will therefore give a clue to what is happening in the deeper layers.

CANCER OF THE CERVIX
Cervix cancer is like other cancers in that it is a disease of uncontrolled growth of cells. All cells reproduce themselves by dividing in an orderly system ensuring normal growth. When cell division loses its orderly mechanism this results in abnormal growth of tissue. This abnormal growth is called a tumour. Tumours may be benign or malignant. A malignant tumour is a cancer. Malignant tumour cells are able to break away and move around the body causing secondary growths.

Cancer of the cervix may take years to become established and is almost always preceded by early changes in the cervix. The usual method of detecting these changes is the Pap smear which was developed by and named after Dr George Papanicolaou. Fortunately we can detect these changes before they become cancerous.

The cervix changes are graded into three stages of severity. These are low grade, high grade and invasive or serious lesions. Other terminology that is used to describe cervix changes is Cervical Intraepithelial Neoplasia or CIN. These grades are C IN 1 or low grade, CIN 11 or high grade and CIN 111 or invasive or serious lesions.

Cervix changes do not always develop into cancer but unless detected and treated some may become invasive cancer. Current literature suggests that even for CIN 111, only about a third progress to invasive cancer if not treated. Invasive cancer means that the abnormal cells have broken through the outer layer of the cervix to invade the deeper cervix tissue.

If cancer of the cervix is not detected at an early stage it can spread by local extension as well as through the lymphatic system, rather than the bloodstream. When invasive cancer of the cervix is diagnosed, treatment by a gynaecological oncologist [specialist in women's cancer] is recommended.

CAUSES OF CERVIX CANCER
Our current level of knowledge suggests that there are many factors that cause precancerous and cancerous lesions of the cervix.

Age is no barrier to the development of cervix cancer, therefore it is imperative that all women maintain their vigilance and continue to have two yearly Pap smears.

There has been some publicity about cancer of the cervix and its links with sexual intercourse. Cancer of the cervix is related to- sexual intercourse. Women who started sexual activity at a young age and have multiple partners are at a greater risk.

Infection by the human papilloma virus [wart virus] is associated with a majority of cervix cancers. As this virus is sexually transmitted, the risk of picking up the virus increases with the number of partners either you, or your partner, has had. Note: Human Papilloma Virus is detected in the majority of all cervix cancers and usually transmission is by sexual intercourse. This link between cancer of the cervix and sexual activity is one of a number associated with cancer of the cervix. There is evidence that barrier methods of contraception, such as the condom, act as a protection against the spread of the wart viruses.

The relationship between using the contraceptive pill and the risk of developing cervix changes is unproven.  Women who smoke or are exposed to passive smoke are known to be at a greater risk of developing cancer of the cervix than non-smokers. There is a three times increase in cervix abnormalities in smokers compared to non smokers.

Research has shown potential links to diet, exposure to immunosuppressive therapy and antenatal exposure to dietlylstilboestrol [DES].

However, having one or more of these risk factors does not mean that a woman is certain to develop cervix cancer.

PREVENTION OF CERVIX CANCER
Screening is the regular examination of healthy people to detect early disease before there are any symptoms. Cervix screening [The Pap smear] can detect early changes in the cervix. Detection and treament of these changes can prevent cervix cancer from developing. Since the introduction of screening, studies have shown that the rate of new cases of cervix cancer has fallen in those countries which have adopted organised cervix screening programmes.

While no screening test is 100% effective, a Pap smear is the best test available to detect changes in the cells of the cervix at an early stage. If all women who needed to, had regular Pap smears, then over 90% of cervix cancers could be prevented by early appropriate treatment. The Pap smear is a way of detecting a pre-cancerous change in the cervix.

Named after it's inventor, Dr George Papanicolaou, the Pap smear is a simple procedure which can be done during a pelvic examination. The Pap smear takes less than five minutes. It can be slightly uncomfortable but is not painful. Even though this procedure is not painful, some women find that it is distressing having this area of the body examined.

The Pap smear is collected in the following manner:

Once the woman is lying comfortably on the couch the doctor will gently insert an instrument called a speculum into the vagina to hold the vaginal walls open. A small spatula is then used to take a sample of loose cells from the cervix. To collect some cells from the opening of the cervix a very thin brush is introduced and gently rotated. These cells are spread onto a glass slide and sent to the laboratory for examination under a microscope by a cytologist, a specialist in cell examination.

Abnormal cells are identified on the slide and graded according to the grade of change [abnormal looking cells], malignancy or other categories. If abnormal cells are detected they can be treated to prevent cervix cancer from developing. But remember, most Pap smears are normal.

It is recommended that all women commence Pap smears one or two years after they become sexually active. They should continue to have a Pap smear every two years for continuing protection against cancer of the cervix. Women who have never had sexual intercourse or women who have had a hysterectomy should check with their doctor about the need for Pap smears. But always remember that the most important thing is to have regular two yearly Pap smears throughout your life.

Listed below are some of the places women can arrange to have a Pap smear:

· General Practitioner [GP].

· SHine SA [formerly Family Planning Association of South Australia] Female practitioners are available to take the Pap smear test. Phone [08] 8431 5177 for address and telephone number of your local clinic.

· Women's Community Health Centres.

· Referral to Gynaecology Clinics in Public Hospitals.

· Migrant Health Service. Bicultural female practitioners are available to take the Pap smear test. Phone (08) 8200 3939.

SYMPTOMS OF CERVIX CANCER

The most common symptom of cervix cancer is irregular bleeding between periods. Post menopausal bleeding, bleeding after intercourse, or increased vaginal discharge may be other symptoms. These symptoms are not sure signs of cancer but they are important signals to see a doctor for examination. There are no symptoms with very early cervix changes known as dysplasia. These changes are detected by the Pap smear.

DIAGNOSIS AND TREATMENT OF CERVIX CANCER

Cancer of the cervix can be detected via a routine Pap smear. However, cervix cancer will need to be confirmed by taking a very small piece of the cervix tissue [a biopsy]. This is done during a procedure called a colposcopy. An instrument called a colposcope, which is like a microscope, is used to take a close, detailed look at the cervix. If cancer of the cervix is found the doctor will refer the woman to a gynaecologist who specialises in cancer treatments.

Cervix cancer may be treated in the following ways. The usual treatment is surgery involving an operation known as a hysterectomy [removal of the uterus or womb]. More extensive surgery may be necessary involving removal of the uterus, cervix, a small portion of the vagina, both ovaries and the lymph glands on the side wall of the pelvis.

Radiation therapy is also an effective method of treating cervix cancer. It may be used in combination with surgery or alone. A radiotherapist would become involved and prescribe the treatment. This treatment may be delivered in one of two ways. External radiation to the pelvic area or the temporary insertion of radioactive material through the vagina to the cervix and uterus.

In the more advanced stages of cervix cancer, anticancer drugs [chemotherapy] may be used. The use of chemotherapy, and its effects will be explained by the specialist.

Effective treatment for invasive cancer results in a complete cure for many women. Some women may find that the threat of cancer and fear of its recurrence can make them upset and anxious. Other women are concerned about the change in their appearance and how it will affect their lives and relationships. Many women discuss these feelings and thoughts with their local health workers, family and friends. Staff at the AntiCancer Foundation are available to talk about any of these concerns.

ACKNOWLEDGEMENTS
The Anti-Cancer Foundation of South Australia would like to acknowledge the Anti-Cancer Council of Victoria for the original preparation of this information sheet. Consultation with a gynaecological oncologist also occurred in the development of this resource. We would also like to thank the SA Cancer Registry of the Department of Human Services and project staff of the SA Cervix Screening Programme for information supplied in this document.

REFERENCES
1. 'Screening for the Prevention of Cervical Cancer'
Department of Health, Housing and Community Services, November 1991.

2. 'Cervical cancer in Australia', 1995, Paul Jelfs.  Australian Institute of Health and Welfare. Department of Human Services and Health Cancer Services No 3.