Cervical Cancer

Cervical Cancer - What it is

What is cervical cancer?

The cervix is the neck of the womb (uterus) that connects the body of the womb to the birth canal (vagina).

Cervical cancer is a type of cancer that affects cells of the cervix.

Cervical cancer is the 10th most common female cancer in Singapore. Every year, more than 200 women in Singapore are diagnosed with cervical cancer. High-risk strains of the human papillomavirus (HPV) cause most cervical cancers. HPV can be transmitted through sexual intercourse or close genital contact.

Cervical cancer is a highly preventable cancer, because it can be detected in the pre-cancerous stages through screening tests (e.g., Pap smear or HPV test). HPV vaccines can also help to protect against HPV infection, reducing the risk of cervical cancer.

What are the types of cervical cancer?

The two most common types of cervical cancers are squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma: This type begins in the thin, flat cells lining the outer part of the cervix. It is the most common type of cervical cancer, accounting for the majority of cases.
Adenocarcinoma: This type starts in the glandular cells of the cervix, which produce mucus. Although less common than squamous cell carcinoma, it can be more challenging to detect.

Cervical Cancer - Symptoms

What are the symptoms of cervical cancer?

Early-stage cervical cancer generally has no signs and symptoms. Signs and symptoms of more advanced cervical cancer include:

Irregular or abnormal vaginal bleeding – after sexual intercourse, between periods or after menopause
Watery, bloody vaginal discharge with a foul odour
Pelvic pain or pain during sexual intercourse

When should you see a doctor?

Make an appointment with your doctor if you experience any abnormal vaginal bleeding or if you have any signs or symptoms that worry you.

Any bleeding or spotting after menopause is abnormal. Consult a doctor if you experience this.

Cervical Cancer - How to prevent?

How is cervical cancer prevented?

Cervical cancer is highly preventable and curable when detected through regular screening and treated early.

There are abnormal cellular changes in the cervix before cervical cancer develops. These abnormal changes are known as cervical pre-cancer or cervical intraepithelial neoplasia (CIN). Successful treatment of CIN removes a woman’s risk of developing cervical cancer.

Cervical cancer can be prevented by having regular screening with Pap smear tests and human papillomavirus (HPV) tests so that any pre-cancer can be treated early.

HPV vaccination during adolescence is also effective in reducing a woman’s risk of cervical cancer in the future.

Screening test

As part of the National Cervical Screening Programme, all women aged between 25 and 69 who have ever had sexual activity are recommended to go for regular screening (Pap smear test or HPV test). Cervical cancer screening can be done every 3 to 5 years, as advised by your doctor.

During the Pap smear test or HPV test, a scraping of cells from the surface of the cervix is obtained during a vaginal examination. It is a quick, simple, and painless test.

HPV vaccination

In Singapore, HPV vaccines can be administered to females aged between 9 and 45. The full vaccination includes three vaccine doses spread over a 6-month period. HPV vaccination is available at polyclinics and GP clinics. The vaccine is most effective when taken between 9 to 26 years old, before sexual debut.

Vaccine efficacy is extremely high for women who have not been exposed to HPV-16 and HPV-18 infection and the protection is long-lasting. However, the HPV vaccine does not protect against all types of HPV, so regular Pap smear or HPV test screening is still recommended for women who have had the vaccine.

Cervical Cancer - Causes and Risk Factors

What causes cervical cancer?

Infection with Human Papillomavirus (HPV) is the most common cause for cervical cancer. These viruses are transmitted during sexual intercourse, as well as via oral or anal sex.

What are the risk factors for cervical cancer?

Other risk factors for cervical cancer include:

Human Papillomavirus (HPV) infection
Sexual intercourse at an early age (before age 20)
Having multiple sexual partners
Other sexually transmitted infections (STIs), e.g. chlamydia, gonorrhoea, syphilis and HIV/AIDS
Medical conditions or treatments that affect the immune system, e.g. autoimmune disease, taking long-term steroids or immunosuppressant drugs
Solid organ transplant
Past diagnosis of pre-cancerous cervical changes (i.e., cervical intraepithelial neoplasia [CIN))
Smoking

Cervical Cancer - Diagnosis

How is cervical cancer diagnosed?

Tests and procedures used to diagnose cervical cancer include:

Screening:

Cervical cancer screening (Pap smear test or HPV test)

Cervical cancer screening tests (Pap smear test or HPV test) help to detect pre-cancer changes. During this examination, a scraping of cells from the surface of the cervix is obtained during a vaginal examination. This is a quick, simple, and painless test.
In general, women with pre-cancer changes do not have any symptoms. If any abnormalities are detected, further investigations such as colposcopy need to be performed.

Diagnosis:

Colposcopy

A colposcopy is a simple outpatient procedure done using a colposcope (microscope) to check for any abnormal changes of the cervix. A biopsy (a small amount of tissue) may be taken and sent to the laboratory for further evaluation.

Cone biopsy (conisation) or Loop electrosurgical excision surgery (LEEP)

Your doctor may recommend a cone biopsy or a LEEP procedure for treatment of pre-cancerous changes of the cervix (CIN) or if there is suspicion of microscopic invasion. Your doctor will discuss with you regarding the suitability of these procedures.

Investigations:

Once cervical cancer is confirmed, further tests may be done to determine the extent (stage) of the cancer and most suitable treatment. The tests may include:

Computed Tomography (CT scan)
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET scan)
An examination under general anaesthesia or scope of the bladder (cystoscopy) may be recommended if additional information is required that may affect your treatment

Cervical Cancer - Treatments

How is cervical cancer treated?

Treatment for cervical cancer depends on several factors, such as staging of the cancer, other existing health problems and individual preferences.

Source: Schubert, M., Bauerschlag, D. O., Muallem, M. Z., Maass, N., & Alkatout, I. (2023). Challenges in the Diagnosis and Individualized Treatment of Cervical Cancer. Medicina, 59(5), 925. https://doi.org/10.3390/medicina59050925. Licensed under CC BY 4.0.

Surgery, radiotherapy, chemotherapy, or a combination of treatment may be recommended by your doctor.

Early stage

Surgery

This will be recommended since the cancer cells are localised in a small area of the cervix. The procedure may be either a simple hysterectomy (removal of the womb and cervix) or radical hysterectomy (removal of the womb, cervix and surrounding tissues) or a trachelectomy (removal of the cervix alone), depending on the stage of the cancer, your age and fertility wishes.

For younger women with cervical cancer, ovarian transposition may be recommended. This procedure serves the purpose to preserve the ovarian function such as reproductive or hormonal maintenance. Sometimes, the ovaries may be moved from the pelvis to the upper abdomen region if further radiotherapy is needed to prevent harmful effects to the ovaries. This surgery can be done via minimally invasive surgery to allow for enhanced recovery for patients. If a woman wishes to have a baby after this procedure, they would have to do so via In-vitro fertilisation (IVF) and surrogacy.

Beyond early stage

Cancers that have spread beyond the cervix region would not be recommended surgery. Instead, treatment involves one of the following:

Chemotherapy
Radiotherapy
Combination of chemotherapy and radiotherapy

Radiotherapy

Radiotherapy treats cancer by using high energy rays to destroy the cancer cells without harming the normal cells as much as possible. It can be given externally, internally or a combination of the two. Radiotherapy can also be used after surgery if there is high risk of cancer recurring. It can also be used in combination with chemotherapy.

Chemotherapy

Chemotherapy uses anti-cancer drugs to destroy cancer cells. It can be used in combination with radiotherapy to improve the effectiveness of the treatment for better cure rates.

Chemotherapy is used to shrink, control, and relieve symptoms to prolong good quality of life. It may also be used if the cancer has spread to other parts of the body or when the disease has recurred after radiotherapy treatment.

Targeted therapy

Targeted drug treatments focus on specific targets present within or on cancer cells. By targeting these markers on cells, targeted drug treatments work in combination with chemotherapy to better destroy cancer cells. Your doctor will advise you regarding the suitability of use of targeted therapy in your care.

Immunotherapy

Immunotherapy is a drug treatment that helps your immune system fight cancer. Cancer cells can sometimes evade the immune system. Immunotherapy drugs work by improving the process by which the immune system fights the cancer cells. Immunotherapy may be considered an option either alone or in combination with chemotherapy or other treatments in your care. Your doctor will advise you on the suitability of immunotherapy in your care.

Cervical Cancer - Preparing for surgery

How can you prepare for cervical cancer surgery?

Before surgery, your surgeon will perform comprehensive medical assessments including blood tests and scans, to see if you are suitable for surgery and advise on the risks involved. Your treatment recommendation is often based on consensus by a group of medical specialists' opinions (the tumour board), who come together to discuss the pros and cons of every treatment strategy.

The anaesthesia team will also assess your fitness for surgery and advise you on various aspects of general anaesthesia and pain control after surgery.

Specialist nurses will also provide pre-surgery counselling so that you know what to expect.

Cervical Cancer - Post-surgery care

After surgery, you will be given regular outpatient appointments to see your team of doctors. During these appointments, you may have blood tests and scans to check if the cancer recurs.

It is important to follow your doctor's advice, keep to your clinic visits and do the recommended scans and tests, so that timely treatment can be administered if the cancer recurs or other problems occur.

Cervical Cancer - Other Information

What signs might indicate cervical cancer?

Signs can include unusual vaginal bleeding, pain during sexual activity and pelvic discomfort, though early stages of cervical cancer may show no symptoms.

How do doctors detect cervical cancer?

Cervical cancer is commonly detected through screening methods like a Pap smear or HPV test, which help identify abnormal cervical cells before they become cancerous.

Is it possible to prevent cervical cancer?

Cervical cancer can often be prevented with regular screening and by getting the HPV vaccine, which protects against the most common cancer-causing strains of the virus.

References

Cervical cancer. Cancer Research UK. (2024, April 25). https://www.cancerresearchuk.org/about-cancer/cervical-cancer
(2023a). Prevention of Cervical Cancer: What Are the Risks and Benefits of Different Treatments? https://doi.org/10.3310/nihrevidence_60599
(2023b). Journal of Cervical Cancer Research, 5(1). https://doi.org/10.36959/749/5/1
Centers for Disease Control and Prevention. (n.d.). Cervical cancer. Centers for Disease Control and Prevention. https://www.cdc.gov/cervical-cancer/index.html
Cervical cancer: Causes, symptoms & treatments. Cancer Council. (n.d.). https://www.cancer.org.au/cancer-information/types-of-cancer/cervical-cancer
Garcia, F., Nuno, T., & Mitchell, A. L. (n.d.). Cervical cancer prevention. Fundamentals of Cancer Prevention, 423–445. https://doi.org/10.1007/978-3-540-68986-7_16