Cervical cancer

Overview: What is cervical cancer?

In the case of cervical cancer, the tissue on the cervix proliferates and a malignant tumor develops. However, this change usually takes years. It can take decades for benign cell changes to develop into malignant cervical cancer through the development of precancerous lesions.

The cervix connects the uterus to the vagina. The outer cervix is located at the lower end of the cervix. Here the mucous membrane in the cervical canal borders on the mucous membrane covering the visible part of the cervix (cervix). This so-called transformation zone changes in precancerous stages of cervical cancer. Experts distinguish between three stages of cell changes in the epithelial layer, CIN (cervical intraepithelial neoplasia):

• Mild dysplasia (CIN I): Only the upper layer of the epithelium is affected.
• Moderately severe dysplasia (CIN II): Several layers of the epithelium are affected.
• Severe dysplasia (CIN III): There are cell changes in all layers.

However, such dysplasia does not mean that those affected have cancer!

Precancerous stages of cervical carcinoma

Dysplasia, i.e. a change in the mucous layer of the cervix, is a precancerous condition. It does not necessarily lead to cancer! In the case of CIN I and CIN II stages, it is very unlikely that cancer will develop. In around half of the cases, such changes disappear on their own. Regular checks by the gynecologist are therefore necessary for mild dysplasia, but no direct intervention. In the case of severe dysplasia (CIN III), the risk of cervical cancer is high. That is why you will usually intervene here.

Cervical cancer: frequency and age

Every year, around 250 women in Switzerland are diagnosed with cervical cancer. In addition, around 5,000 women are diagnosed with precancerous lesions. Cervical cancer is the fifth most common type of cancer in Switzerland in women aged between 20 and 49. The HPV viruses that cause the disease are widespread: An estimated 70 to 80 percent of sexually active women and men become infected with HPV at some point. In the vast majority of them, the virus disappears again within two years without them noticing. However, in around ten percent of those affected, viruses remain in the body. They can later trigger the precancerous stage. On average, cervical cancer is diagnosed at the age of 53.

Cervical cancer: causes and risk factors

The main cause of cervical cancer is an infection with certain human papillomaviruses (HPV). Around 70 percent of all women become infected, usually at the beginning of their sexual activity. In most cases, these viruses do not initially cause any symptoms. This is why infected people do not notice their infection – but are still contagious. However, certain HPV viruses can also cause genital warts. These are benign and cannot degenerate.

In around 90 percent of all infected people, the body’s own immune system eliminates the viruses without leaving any residue within one or two years at the latest. However, in around ten percent of cases, the viruses lie dormant in the body and can become active again later – for example if the immune system is weakened. They can then trigger changes in the cervix.

There are also other risk factors that promote cervical cancer:

• Sexually transmitted diseases: According to some studies, the risk of cancer increases with other infections, such as chlamydia or herpes simplex (genital herpes).
• Smoking (including passive smoking!): Researchers have detected tobacco breakdown products in the cervical mucosa of smokers. These ensure that pathogens can penetrate the cells of the mucous membrane more easily. This risk of infection increases the more cigarettes or other tobacco products a woman consumes per day and the earlier she starts smoking.
• Poor hygiene: Regular washing of the genital area – preferably only with clean water – helps to prevent infections of various kinds. It is also important that no germs are transferred from the anus to the vagina.
• Unprotected sexual intercourse: Anyone who has sex without a condom and perhaps with frequently changing partners has a significantly higher risk of cervical cancer.
• Weakened immune system: Anyone who has to take certain medication due to an HIV infection or after an organ transplant, for example, has a weaker immune system (immunosuppression) and is also less able to fight off HPV pathogens.

Symptoms: Prevention is important to avoid cervical cancer

In very many cases, cervical cancer does not cause any symptoms. This is why cancer screening by a gynecologist is so important, because in many cases the gynecologist can detect and treat precancerous lesions in good time. In Switzerland, basic health insurance covers the cancer smear test every third year as part of the preventive check-up. Sometimes the following symptoms can also indicate a cervical carcinoma:

• Irregular periods
• Bleeding after sexual intercourse
• Bleeding after cycling or having a hard bowel movement
• foul-smelling discharge
• Pain in the lower abdomen, for example during urination or bowel movements
• Unexplained weight loss

However, all these symptoms can also have completely different, often harmless causes.

Cervical cancer: diagnosis with the Pap test

Cervical cancer is usually detected during a screening examination. We therefore recommend that all women up to the age of 70 keep their screening appointments every three years. We start by asking about any complaints and abnormalities. This is followed by a physical examination on the gynecological chair. We feel the cervix and the neck of the womb. With the second hand on the patient’s abdomen, we take a picture of the uterus and ovaries.

The smear test, called a Pap test by experts, is important: Using a speculum – an examination device that carefully opens the vagina slightly – we can look at the cervix. We then use a spatula and a small brush to take a cell sample from the cervix. These cells are then placed on a slide or a suitable liquid and examined under a microscope in the laboratory. This makes it possible to determine whether the cells are healthy or whether there is inflammation or a cell change(dysplasia). In the event of abnormal findings, a cervical endoscopy(colposcopy) provides further clarity. This is an examination in which the cervix can be viewed with a magnifying glass. Certain solutions can be applied to make the smallest tissue defects visible. The examination is completely painless.

Procedure for an abnormal Pap test

If there is only a slight change in the mucosal cells, we will recommend close monitoring examinations. We will also sometimes carry out an HPV test and occasionally take tissue samples from the cervix and uterine orifice (biopsy). This allows us to confirm or refute a suspected diagnosis of cervical cancer or a preliminary stage. We use an ultrasound to see how far the cancer has spread.

In the case of advanced tumors, we often also use imaging procedures such as magnetic resonance imaging (MRI) or computer tomography (CT). Depending on the results, X-ray examinations of the lungs or an endoscopy of the rectum may also be necessary in individual cases. Positron emission tomography (PET) is used to detect any metastases in lymph nodes or organs. A blood test shows the general physical condition of those affected.

Cervical cancer: prevention, early detection, prognosis

Young women should now be vaccinated against the human papillomavirus (HPV ) to significantly reduce their risk of developing cervical cancer. Anyone who (probably) already carries the virus can reduce the risk by adopting a healthy lifestyle and avoiding cigarettes. Early detection is an important factor in preventing cervical cancer: if you have a check-up every three years, there is a good chance that your gynecologist will detect any changes in the lining of the uterus at an early stage. This means that cancer can be combated at an early stage with lighter weapons.

Progression and prognosis (cervical cancer)

It often takes many years or even decades before a precancerous stage actually develops into cancer. If cervical cancer is detected early, it can be completely cured and the affected woman can become pregnant again. After a conization (removal of a piece of the cervix), the tissue recovers over the course of four to six weeks: The wound heals and the mucous membrane rebuilds. If the entire uterus has to be removed, the woman can no longer carry a pregnancy to term. Even after complete removal of the uterus, cancer can recur in the surrounding organs. In this case, or in the case of metastases outside the abdominal region (distant metastases), the long-term prognosis is rather unfavorable. Regular follow-up examinations are necessary in all cases.

Self-help groups

The exchange with people who are affected by the same disease can be a great support in coping with the disease. Advice on finding a suitable self-help group is available from Selbsthilfe Zürich. Self-Help Zurich and the University Hospital Zurich are cooperation partners in the national project “Health literacy thanks to self-help-friendly hospitals”.

Cervical cancer: Treatment by conization for mild forms

If there is severe dysplasia or if the cell changes remain unchanged over a long period of time, we usually recommend conization. We remove a cone-shaped part of the cervix. This is then examined in the laboratory for the spread of the altered cells. We scrape out the surrounding mucous membrane in the cervical canal (curettage) to rule out any involvement of the cervix above the removed conus. The mucous membrane then forms again.

Conization is performed on an outpatient basis under short anaesthesia or local anaesthesia. If the cancer has not yet spread too far, it can often be completely removed with conization. This means that women remain fertile and can continue to have children. However, they have an increased risk of premature birth.