Cervical Cancer

What is cervical cancer?

The cervix is made up mainly of:

Ectocervix – The outer part of the cervix that extends into the vagina and is covered by squamous cells.

Endocervix – The inner part of the cervix that leads to the uterus and is lined with glandular cells.

Stroma – The supportive connective tissue that surrounds and supports the cervix, including blood vessels and lymphatic vessels.

Cervical cancer affects the lower part of the uterus (womb) connecting the body of the uterus to the vagina (birth canal). Although cancer of the cervix can take many years to develop, it is important to know that it is a preventable disease, with a combination of early vaccination and regular cervical cancer screenings. Before cancer occurs, the cervix undergoes pre-cancerous phases. These pre-cancerous phases cause changes in the cervix known as Cervical Intraepithelial Neoplasia (CIN) which can develop into cancer if left untreated.

---

What are signs and symptoms of cervical cancer?

Most cervical cancer may not show any noticeable signs. Majority of patients start to get symptoms at the late stages.

Below are some symptoms although other conditions may also be the cause:

• Vaginal bleeding (between periods or after sexual intercourse)
• Blood-stained vaginal discharge

Please consult your doctor if you have any of the symptoms listed above.

---

What are the risk factors?

All women who have had sexual activity are at risk of cervical cancer, but certain groups of women are found to have an increased risk. Regardless of your risk, it is recommended that all eligible women go for regular cervical cancer screenings as recommended by national guidelines.

1. Increased exposure to cancer-causing HPV infections

• Multiple sexual partners
• Early onset of sexual intercourse

2. Weakened immunity, causing persistent HPV infections

• Smoking
• Weakened immune systems e.g. HIV positive, solid organ transplant recipient or those on more than 2 immuno-suppressive medications.
• History of sexually transmitted infections e.g. chlamydia/gonorrhoea
  

---

What can I do to prevent cervical cancer?

There are two ways to prevent cervical cancer:

• Go for regular cervical cancer screening
• Get vaccinated against the Human Papillomavirus (HPV)

Please talk to your doctor regarding this.

Cervical cancer is caused by a common virus called the Human Papillomavirus (HPV). The HPV vaccine works best if given before the first sexual intercourse. The vaccine is approved for use in females aged 9 to 26 years old. From 2019, a schools-based HPV vaccination programme was introduced to allow Secondary 1 female students to opt in for a free cervical cancer vaccination.

For females who have ever had sex and are between 25 to 29 years old, they are advised to have a pap smear test every 3 years. A pap smear test is a simple procedure where cells are collected from the surface of the cervix to test for any abnormal changes. If you have an abnormal pap smear, the doctor may then do a closer examination with a colposcopy.

A HPV test is recommended for females aged 30 and above, and who have ever had sex. The test is similar to the pap smear test, except that it checks for whether your cervix cells have the DNA of the high-risk HPV strains. If the results are normal, you would only need to do the next screening in 5 years.

---

Screening for cervical cancer

The best way to protect yourself from cervical cancer is to go for regular cervical cancer screenings. Early detection through Pap smears and HPV tests can help identify abnormal cervical cells before they become cancerous.

• Women who have had hysterectomy (surgical removal of the uterus and cervix) should consult their doctor about screening needs.
• Women with weakened immune systems (e.g., HIV-positive) may need more frequent screenings.
  

---

How is cervical cancer diagnosed?

If you have symptoms that suggest cervical cancer, your doctor will conduct several tests to determine whether cancer or another condition is the cause. Your doctor may ask about your personal and family medical history.

You may undergo one or more of the following tests:

• Physical Exam: Your doctor checks general signs of health and may perform a pelvic examination to assess the cervix.
• Pelvic Exam: The doctor examines the cervix and nearby organs for lumps or abnormalities in size or shape.
• Pap Smear (Pap Test): A sample of cervical cells is collected and examined under a microscope to detect abnormal or precancerous changes.
• HPV Test: This test checks for high-risk human papillomavirus (HPV) strains known to cause cervical cancer.
• Colposcopy: A colposcope (a magnifying instrument) is used to closely examine the cervix for abnormal areas. If needed, a small tissue sample (biopsy) is taken for further testing.
• Cervical Biopsy: If abnormalities are found, a biopsy is performed to confirm whether cancer is present.
  • Punch Biopsy: Small samples of cervical tissue are taken for examination.
  • Endocervical Curettage (ECC): Scraping of cells from the cervical canal for deeper analysis.
  • Cone Biopsy (LEEP or Cold Knife Cone Biopsy): A larger, cone-shaped portion of the cervix is removed for further evaluation.
• Imaging Tests: If cervical cancer is diagnosed, further tests such as CT scans, MRI, PET scans, or X-rays may be used to determine whether the cancer has spread.

Early detection through regular screenings improves treatment success and survival rates. Women are encouraged to follow national screening guidelines and consult a doctor for any unusual symptoms, such as abnormal vaginal bleeding, pelvic pain, or pain during intercourse.

---

Treament options for cervical cancer

Treatment for cervical cancer is unique for each woman and depends on multiple factors including the stage of the cancer and the health of the woman. The three main types of treatment include surgery, radiation, and chemotherapy.

Surgery

Surgery can be offered to most women who has been diagnosed with early-stage cervical cancer. This may involve removing the uterus (womb) and the cervix. Sometimes, surgery is not the best option and other forms of treatment such as radiation therapy and chemotherapy may give a better outcome or prognosis. Your cancer specialist will be able to advise you on this further.

Radiation Therapy

Radiation therapy is a treatment that uses high energy x-rays or other types of radiation to kill cancer cells or to keep them from growing. There are two types of radiation therapy – external and internal. The way the radiation therapy is given depends on the type and stage of the cancer being treated. Radiation can be used after surgery for early-stage cervical cancer. It is also the main treatment for later stage (stage 2 and above) cancers. For cervical cancer, when radiation is the main treatment, it is often given along with low doses of chemotherapy for it to work better.

Chemotherapy

Chemotherapy is the use of drugs to help kill cancer cells and shrink the size of the tumour. It is often combined with radiation therapy. Usually, the drugs are given into a vein. Once the drugs enter the bloodstreams, they spread throughout the body. In cervical cancer, chemotherapy is also given to women with advanced or recurrent cancer. The treatment will vary depending on each patient's case. There is no one-size-fits-all solution for cervical cancer and the doctor will advise on the most suitable option for each individual.

Treatment options (by stages):

[Stage 0] Cancer is confined to the innermost lining of the cervix and has not spread.

• Surgery is required and can be either:
  • Loop Electrosurgical Excision Procedure (LEEP): Removes abnormal cells using a heated wire loop.
  • Cold Knife Conization: A surgical procedure that removes a cone-shaped piece of cervical tissue.
• Regular follow-ups with Pap smears and HPV testing are necessary to monitor for recurrence.

[Stage 1] Cancer is relatively small and has not spread beyond the cervix.

• Surgery is required and can be either:
  • Radical Hysterectomy: Removes the uterus, cervix, part of the vagina, and surrounding tissues.
  • Trachelectomy: A fertility-preserving procedure that removes only the cervix while leaving the uterus intact.
• Radiation therapy may be used if surgery is not an option or if the cancer is high-risk.

[Stage 2] Cancer has spread beyond the cervix but has not reached the pelvic wall or lower third of the vagina.

• Main treatment is Chemoradiation:
  • Radiation therapy combined with weekly chemotherapy (Cisplatin) to enhance effectiveness.

[Stage 3] Cancer is larger and has spread to the lower vagina, pelvic wall, or nearby lymph nodes.

• Treatment includes:
  • Chemoradiation (Primary Treatment) – Combination of external beam radiation therapy (EBRT) and chemotherapy.

[Stage 4] Cancer has spread to distant organs such as the bladder, liver, lungs, or bones.

• Treatment includes:
  • Systemic chemotherapy to control cancer spread and relieve symptoms.
  • Targeted therapy (Bevacizumab/Avastin) – Blocks blood supply to tumors.
  • Immunotherapy (Pembrolizumab) – Used in cases where the tumor is PD-L1 positive.

Surgical Options:

1. Loop Electrosurgical Excision Procedure (LEEP) – Removes abnormal or precancerous cervical tissue using a heated wire loop.
2. Cold Knife Conization – Removes a cone-shaped section of the cervix for deeper tissue analysis.
3. Simple Hysterectomy – Removes the uterus and cervix while leaving the ovaries intact.
4. Radical Hysterectomy with Bilateral Pelvic Lymph Node Dissection – Removes the uterus, cervix, part of the vagina, and surrounding tissues, along with lymph nodes.
5. Trachelectomy – Removes the cervix and surrounding tissues while preserving the uterus for fertility preservation.
6. Pelvic Exenteration – Removes the uterus, cervix, vagina, bladder, rectum, and part of the colon in advanced or recurrent cases.
7. Debulking Surgery – Removes as much of the tumor as possible to relieve symptoms in advanced stages.
8. Urinary Diversion Surgery – Creates a urostomy if cancer blocks the bladder.
   

---

Post-treatment

After completing treatment for cervical cancer, regular follow-ups and lifestyle adjustments are essential to monitor recovery and prevent recurrence.

Regular Medical Follow-Ups

• Routine pelvic exams, Pap smears, and imaging scans every 3-6 months for the first 2 years, then annually.
• Watch for signs of recurrence, such as abnormal bleeding or pelvic pain.

Managing Treatment Side Effects

• Radiation therapy effects – Possible bowel or bladder changes, requiring dietary adjustments.
• Surgical recovery – If a hysterectomy was performed, hormone replacement therapy (HRT) may be needed.

Emotional & Sexual Health

• Vaginal dryness or discomfort can be managed with lubricants or estrogen therapy.
• Psychological support is important—counseling or support groups can help with emotional recovery.

Lifestyle Changes to Reduce Recurrence Risk

• Quit smoking, as it increases the risk of cervical cancer recurrence.
• Maintain a healthy diet and exercise routine to boost immunity and overall well-being.