cervical cancer

Quick Overview

• What is cervical cancer? A malignant cell proliferation in the cervix.
• Frequency: For the year 2018, about 4,300 new cases of cervical cancer are expected in Germany. This incidence rate has been largely stable since the late 1990s. The mean age of onset is 53 years. Women who develop a precursor to cervical cancer (in situ carcinoma) are on average 34 years old.
• Causes: especially an infection with the sexually transmitted human papillomavirus (HPV). Other risk factors include smoking, frequently changing sexual partners, many births, poor genital hygiene and long-term use of the “pill”.
• symptoms: usually only in advanced stages of cancer, e.g. Bleeding after intercourse or after menopause, heavy menstrual bleeding, intermittent or spotting, discharge (often foul-smelling or bloody), lower abdominal pain, etc.
• Therapy: Surgery, Radiation and / or Chemotherapy, Targeted Therapy (Antibody Therapy)
• Forecast: The sooner cervical cancer is detected and treated, the higher are the chances of recovery.

Cervical cancer: anatomy

Of the Cervix (cervix) forms the transition between the uterine body (uterus) and the vagina (vagina). Through it, sperm pass through the vagina into the uterine cavity inside the uterus during sexual intercourse.

The opening of the cervix becomes the vagina Outer cervix called. The opening to the uterine body is called internal cervix.

The cervix is ​​inside of one mucous membrane lined: It consists of a covering tissue (squamous epithelium) and embedded therein mucous glands. When the mucous membrane of the cervix changes badly, one speaks Cervical cancer (cervical carcinoma), He goes in most cases from the squamous epithelium and then counts to the so-called squamous, Rarely, cervical carcinoma develops from the glandular tissue of the mucosa. Then it is a question adenocarcinoma

In most patients, cervical cancer develops in the area of ​​the outer cervix.

Cervical cancer should not be confused with uterine cancer (uterine cancer). The latter is also called “uterine carcinoma, endometrial carcinoma” or “corpus carcinoma” in medical terminology.

Cervical Cancer: Causes & Risk Factors

Cervical cancer is usually caused by a chronic infection with the Human papilloma virus (HPV) triggered. There are about 200 different types of this virus. Some of them are considered to be particularly aggressive and dangerous and are therefore called “high risk” types. These include HPV 16, 18, 31, 45, 51 and 52. Types 16 and 18 alone account for more than 70 percent of all cervical cancers.

Although the low-risk HPV types are not involved in the development of cervical cancer. But they can cause warts on the genitals of both man and woman.

HPV becomes almost exclusive transmitted through sexual intercourse, Even condoms are not sufficient protection against the human papillomavirus. The pathogens can already be transmitted through skin contact in the genital area.

Almost every person comes into contact with HPV at least once in their lives. In most cases, the immune system can cope with the viruses, even if it is a high-risk type of virus. So sick less than one in every 100 womenwho are infected with a high-risk HPV type, actually cervical cancer.

Cervical cancer: other risk factors

Another big risk factor for cervical cancer is this Smoke, Certain toxins from the tobacco are specifically deposited in the tissue of the cervix. This makes the tissue more vulnerable to viruses such as HPV.

Other risk factors for cervical cancer are:

• large number of gender partners: The more sexual partners a woman has in her life, the higher her risk of cervical cancer.
• early onset of sexual activity: Girls who have sexual intercourse before the age of 14 are at increased risk for HPV infection – and therefore for the development of cervical cancer (or its precursors).
• bad genital hygiene: It makes you more susceptible to HPV infections and many other sexually transmitted diseases. For example, the HPV infection rate is lower in circumcised men than in uncircumcised men.
• low socioeconomic status: Low-income people are more likely to be infected with HPV than people of higher social strata.
• many pregnancies and births: Any pregnancy that persists for at least five to six months, or every birth, increases the risk of HPV infection and therefore of cervical cancer. This is due either to tissue changes during pregnancy or to the fact that especially women with low socioeconomic status become pregnant several times.
• Long-term oral contraceptive pill (pill): Women who are infected with a high-risk HPV type and are taking a contraceptive pill containing estrogen and progestagen for five years or more have a slightly increased risk of developing cervical cancer.
• other venereal diseases: In women who are infected with HPV, an additional sexually transmitted disease (such as genital herpes or chlamydia) can also contribute to the development of cervical cancer.
• weakened immune system: An immune deficiency can either be caused by a disease (such as Aids) or by drugs that suppress the immune system (administered, for example, after transplantation). In any case, a weakened immune system is unlikely to effectively fight an HPV infection.

Play according to the current state of knowledge genetic factors in the development of cervical cancer only a minor role.

Cervical cancer: symptoms

Cervical cancer causes in early stages usually no symptoms, Cervical cancer precursors also go unnoticed for a long time.

Only with time do the malignant cell changes become noticeable with discomfort, as for example vaginal discharge (vaginal discharge) – it can be bloody or smelly. Also Bleeding after intercourse can be a sign of cervical cancer. The same applies Bleeding after stress like cycling, riding or a hard bowel movement.

In women after the age of 35 are also valid heavy menstrual bleeding, intermittent or spotting as possibly cancerous. Likewise Bleeding after the menopause Cervical Cancer Symptoms.

The mentioned complaints are not clear signs of cervical cancer! They can also have other causes. As a precaution, however, you should seek medical clarification.

Some patients also report Pain in the lower abdomen, Also one unexplained weight loss often shows in women with cervical cancer.

Signs of infestation of other organs are added in advanced stages of cancer. Some examples:

• lymphedema (Swelling of the legs with moist, distended skin) are formed with extensive involvement of the lymphatic system.
• AReddening of the urine This can occur when the cancerous cells have invaded the urinary tract and bladder, causing bleeding into the bladder.
• Deep back pain, which also often radiate into the pelvis, are possible signs of a cancer attack of the pelvis and the spine.
• Strong stomach ache with paralysis of intestinal activity are possible when the abdominal viscera are attacked by cancer. In infestation of the intestine and the bowel movement may be disturbed.

In the last stage, the tumor spreads over the entire body. It comes to one Failure of many vital organswhich ultimately leads to death.

Cervical cancer: examinations and diagnosis

The most important investigation is the regular check-up at the gynecologist (cancer screening), This also applies to women who are vaccinated against the main HP viruses: A vaccine does not replace the precaution, but only complements the screening program.

In Germany every woman can once a year from the age of 20 have a check-up / screening test conducted at the gynecologist. All funds take over the costs. More information can be obtained from any gynecologist.

Women should definitely take advantage of the free cancer screening test! The sooner malignant cell changes are detected and treated, the better the prognosis.

The routine screening for cervical cancer is the same as that for a suspected cervical cancer (due to symptoms such as irregular bleeding):

anamnesis

First, the doctor in conversation with the woman to raise their medical history (anamnesis). For example, he asks how regular and severe menstrual bleeding is and whether there are occasional intermittent or spotting bleeding. He also inquires about possible complaints and previous illnesses as well as the use of contraceptives.

Gynecological examination & PAP test

After the conversation follows the gynecological examination: The gynecologist first examines the external genitalia as the labia for any abnormalities. Then he spreads the scabbard with the help of a metal spatula (speculum). So he can take a look at the vaginal walls and the outer cervix.

He also uses a small brush or cotton swab to take a cell sample from the mucosal surface of the cervix and cervix. It is examined more closely under the microscope. This allows the doctor to detect if there are any altered cell types under the mucosal cells. This investigation is called Cervical smear or cervical smear (PAP test) designated.

Sometimes the external cervix and its surroundings can not be adequately assessed with the naked eye. Then one is colposcopy (colposcopy): The gynecologist examines the inside of the vagina and the cervix with the aid of an illuminated magnifying glass. He can also dab the tissue on the cervix with an iodine solution: Healthy and diseased tissue then show a different color. From suspicious places the gynecologist can then take a tissue sample (biopsy). Investigations in the laboratory show whether he is actually cervical cancer.

conization

If the suspicious tissue change is only small, the gynecologist usually performs a so-called conization: A cone (cone) is cut out of the tissue, consisting of the pathologically altered cells and a seam of healthy cells all around. The latter should ensure that no altered cells remain. In the laboratory, the extracted tissue can be examined for cancer cells.

The conization is not only used to remove suspicious tissue, so it can be accurately examined in the laboratory. It can also be considered as a therapeutic option: a small, demarcated tumor can be completely removed by means of conization (see below).

HPV test

Also useful in clarifying a possible cervical cancer disease may be Test for Human Papilloma Viruses (HPV test): In this case, a smear from the cervix is ​​examined for the presence of HP viruses (more precisely: on their genetic material).

The HPV test can be used in women from the age of 30 routinely Supplement the cervical cancer screening. The costs have to be borne by women themselves.

In younger women, the HPV test makes no sense, because they often HPV is found, but the infection usually subsides by itself.

Regardless of the woman’s age, an HPV test is indicated if the PAP smear produces an unclear result. The costs for the test are then taken over by the health insurance companies.

Further investigations

If the diagnosis is cervical cancer, further investigations are necessary. They are intended to show whether the tumor has already spread to surrounding tissue and has formed secondary tumors (metastases) at more distant sites. For example, one is suitable for this Ultrasound On the one hand, the doctor makes a transvaginal ultrasound by inserting the ultrasound probe into the vagina. On the other hand, a “normal” ultrasound examination (from the outside) is used to assess the kidneys for noticeable changes.

Sometimes the doctor also assigns a computed tomography (CT) and / or magnetic resonance imaging (magnetic resonance tomography, MRI). This can be used, for example, to detect metastases in the pelvis, abdomen or chest. A X-ray examination of the ribcage (Chest X-ray) can also reveal metastases in the chest.

There is a suspicion that the cervix cancer has spread to the bladder or rectum, is one Bladder reflexion (cystoscopy) respectively Endoscopy (rectoscopy) necessary. This can be a possible evidence of cancer evidence.

Cervical cancer may also be a so-called operative staging As part of an operation, the doctor takes a look at the organs in the pelvis and lower abdomen, in order to be able to better assess a possible spread of the tumor. He can take tissue samples from various organs and lymph nodes to check for cancer cells in the laboratory.

Sometimes the surgical staging also immediately follows the treatment. So the doctor may decide during the examination to cut out the cancerous tumor (usually together with the whole uterus). Of course, the patient must have given her consent beforehand.

staging

Depending on how far the cervix cancer has spread at the time of diagnosis, physicians distinguish different stages of cancer. This is important for therapy planning. In addition, the doctor can estimate the course and prognosis of the cancer better based on the stage.

Cervical cancer: treatment

The type of treatment for cervical cancer depends mainly on how advanced the disease is. But other factors also influence the treatment planning, for example the general condition of the patient and whether she still wants to have children or is already in menopause. Also possible side effects and consequences of the individual therapeutic procedures are considered.

In principle, there are three treatment options for cervical cancer. They can be used individually or in combination:

• surgery
• Irradiation (radiotherapy)
• drug treatment (chemotherapy and targeted therapies)

Some women only have a precursor to cervical cancer (dysplasia). If these cell changes are only slight, one usually waits for the first time because they often regress on their own. This can be checked by the doctor during regular check-ups.

Cervical cancer: surgery

In early stages of cervical cancer, surgery is the treatment of choice. The goal is to completely excise the tumor – for safety along with a seam of healthy tissue. How much tissue to remove altogether depends on the size and spread of the cancerous tumor.

There are several techniques available for cervical cancer surgery. In addition, there are various access routes to remove the diseased tissue (via the vagina, abdominal incision or a laparoscopy = laparoscopy).

conization: The above-mentioned conization is suitable for small tumors that can be well differentiated from healthy tissue. Here, the diseased cells are cut out conically together with surrounding healthy tissue. Pregnancy is still possible, but with an increased risk of premature birth. After all, the cervix is ​​more or less unstable – depending on how much tissue was removed. As a precautionary measure, women should wait a while after being kidnapped (details are given by the attending physician).

trachelectomy: Sometimes it is not possible to remove the entire cancerous tissue by means of conization – a major intervention is necessary. If the patient still has a desire to have children, under certain circumstances, a so-called trachelectomy The surgeon removes a portion of the cervix (up to two-thirds) and the inner latches of the uterus. However, the internal cervix and the uterine body are retained (the internal cervix is ​​connected to the vagina).

Pregnancy after a trachelectomy is associated with an increased risk of complications (such as premature birth). In addition, the child must be delivered by caesarean section. Once the woman has completed family planning, the entire uterus is subsequently removed (hysterectomy).

Hysterectomy: If a woman with cervical cancer no longer wishes to have children, the complete uterus is often removed. In addition, the procedure is also necessary if the tumor has already grown deeper into the tissue. The woman is no longer able to get pregnant after this operation.

If the uterus is removed by surgery alone, it is called a simple hysterectomy, If surrounding tissue has to be excised (adjacent lymph nodes, the upper part of the vagina, etc.), it is a radical hysterectomy, In cervical cancer patients after menopause usually the two ovaries and fallopian tubes are mitentfernt. In younger women, this is avoided as far as possible in order to preserve hormone production in the ovaries.

The bladder and rectum must also be removed if the cervix has already spread to these organs.

Cervical cancer: radiotherapy

If extensive surgery is not possible (such as in poor general condition of the patient) or rejected by the woman, the cervix can alternatively with a radiotherapy or a combination of radiation and chemotherapy (chemoradiotherapy) be treated. Sometimes, radiotherapy is also performed after surgery to kill any remaining cancer cells. Then doctors speak of one adjuvant irradiation.

In radiotherapy, two methods are possible: Either the tumor is irradiated through the skin (percutaneous irradiation). Or the doctor brings the radiation source over the vagina to the tumor. This radiotherapy will be from the inside brachytherapy called.

Radiation in cervical cancer can acute side effects trigger. These include, for example, a painful mucosal irritation in the vagina, bladder or intestine as well as diarrhea and infections. Such symptoms disappear within a few weeks after the radiation. In addition, the treatment can take months or years afterwards late effects sometimes persistent, such as impaired bladder function, loss of control in defecation, mucosal inflammation with bleeding, or a narrow, dry vagina.

Cervical cancer: chemo

In the chemotherapy At regular intervals, the patient receives infusions of medications designed to prevent cervical cancer from growing. Because these chemotherapeutic agents (cytostatics) work throughout the body, it is also called a systemic treatment.

The rapidly dividing cancer cells are particularly sensitive to these drugs. However, the proliferation of fast-growing healthy cells is affected, such as hair root cells, mucosal cells and hematopoietic cells. This explains the possible ones side effects Chemotherapy such as hair loss, nausea and vomiting and changes in the blood picture with increased susceptibility to infection.

Cervical cancer (as mentioned above) is usually combined with radiotherapy. Sometimes, however, it is also used alone, for example in case of relapse or secondary tumors far away from the primary tumor in the cervix (distant metastasis).

Cervical Cancer: Targeted Therapy

Sometimes a cervical carcinoma with a artificially produced antibodies (bevacizumab) which specifically targets the tumor: Once the cancer has reached a certain size, it needs its own, newly formed blood vessels to ensure the supply of oxygen and nutrients. The antibody bevacizumab inhibits a certain growth factor and thus the formation of new blood vessels. The tumor can not continue to grow.

Bevacizumab will as an infusion administered. The purposeful therapy comes however only in certain cases in question, namely, if the cervix cancer:

• has already metastasized,
• can not be pushed back with other therapies or
• returns after a successful initial therapy (relapse).

Complementary treatments

Malignant tumors like cervical cancer can partly severe pain cause. The affected then receive a customized pain Management.

Many patients develop one anemia (Anemia) – either through cancer itself or through treatment (such as chemo). In some circumstances, the affected women receive blood transfusions.

Others too Side effects of cervical cancer therapy are treated as needed. Some examples: Nausea and vomiting, which often occur during chemotherapy, can be relieved by medication. Also diarrhea as a result of chemotherapy or radiotherapy can be stopped with a suitable drug. Radiation therapy for cervical cancer can lead to a dry, narrowed vagina: Lubricants help against unpleasant dryness during sexual intercourse. A narrowing can be prevented by stretching the vagina regularly with aids for a few minutes.

The diagnosis and treatment of cervical cancer (or other cancers) can be psychologically distressing. Therefore patients should have one psycho-oncological care receive. Psycho-oncologists are specially trained physicians, psychologists or social educators who mentally support cancer patients and their relatives in dealing with the disease.

Cervical cancer: rehab and aftercare

The rehabilitation After cervical cancer (or any other cancer) aims to enable patients to return to their social and professional life. Various therapists and consultants (doctors, psychologists, physiotherapists, etc.) help the affected women to cope with possible consequences of the illness or treatment and to get physically fit again. All important information about rehabilitation is provided to patients by their doctor and the social service in the clinic.

The cervical cancer treatment is followed by the aftercare on: It includes regular check-ups. These are used to check the success of the treatment and to recognize any relapses at an early stage. In addition, women receive help in coping with the consequences of illness or therapy. Experts recommend the following schedule for the follow-up visits:

• In the first three years after treatment, women should every three months go to the check-up.
• I4th and 5th year After completion of the treatment will be a follow-up every six months recommended.
• From the 6th year should women once a year go to the follow-up examination.

The follow-up examination should consist of the following parts:

• Conversation and advice
• physical examination of the genital organs with palpation of the lymph nodes
• PAP test

In addition, an HPV test, an ultrasound examination of the vagina and kidney as well as a magnifying glass examination (colposcopy) can be performed at certain intervals.

Cervical cancer: course and prognosis

The earlier the tumor is discovered and treated, the better the cervical cancer healing chances are:

Early stages can usually be cured. If the tumor has progressed a bit further, but can be removed completely surgically, the prognosis is also favorable. In very advanced stages of cervical cancer, as well as relapse, healing is much more difficult, but still possible. If the cervical carcinoma has already formed secondary tumors (metastases) in other organs, the treatment usually only aims to relieve the patient’s discomfort and extend the lifespan as far as possible.

A cure-seeking therapy is called curative. If the treatment only serves to make the remaining lifetime of the patient as symptom-free as possible, it is a palliative treatment.

In recent decades, the chances of a cure for cervical cancer have improved significantly. Today, about 1,540 women in Germany die of cervical cancer each year. 30 years ago, it was more than twice as many.

Cervical cancer: prevention

A Vaccination against Human Papilloma Viruses (HPV) can reduce the risk of cervical cancer – after all, these viruses are responsible for most cases. The Standing Vaccination Commission (STIKO) at the Robert Koch Institute recommends vaccination for all girls between the ages of 9 and 14 years before the first sexual intercourse. The costs are covered by the health insurance companies.

Even boys should be vaccinated against HPV, experts advise. If they are not infected, they can not infect their sexual partners – this protects them from cervical cancer. In addition, the vaccine provides the boys themselves with protection against genital warts and cell changes that may lead to cancer (such as penile cancer).

Read all about the course, effects and side effects of the vaccine in the article HPV vaccine.

HPV infection can also be prevented to some degree by “safer sex”: the use of condoms can prevent infection in about half of all cases. Apart from that, condoms protect against other sexually transmitted diseases such as HIV or chlamydia.

A adequate genital hygiene as well as the Refrain from smoking also contribute to cervical cancer submissions.

Additional information

Books:

• Women and Cancer: Help for Concerned and Relatives, Christian Dadak and Sigrid Sohlmann, Maudrich, 2011

guidelines:

Patient Guideline “Cervical Cancer” of the Association of Scientific Medical Societies e. V., the German Cancer Society e. V. and the German Cancer Aid Foundation (2015)

Self-help:

• German Cancer Research Center – Cancer Information Service