Cervical cancer is the second leading cause of cancer-related death after breast cancer in young women between 20 to 40 years. The death rate due to this disease has declined over time due to better screening modalities, however, it still remains the leading cause of death in many countries. It is particularly high in Latin America, southern and eastern Africa, India, and Polynesia. Unlike most types of cancer, there are specific risk factors that may lead to the development of cervical cancer.
Most cervical carcinomas arise at the junction between the primarily columnar epithelium of the endocervix (in the lumen of the cervix) and the squamous epithelium of the ectocervix (part of cervix protruding into the vagina). This junction is a site of continuous change in the lining epithelium of cells, which is greatest during puberty and first pregnancy. The greatest risk of cancerous transformation coincides with periods of greatest cellular activity during these periods of life. Squamous cell carcinoma accounts for 80%, and adenocarcinoma for 20% of cancer cervix.
Cancer becomes invasive after an average period of 15 years. Once invasive, cancer penetrates through vascular channels. From the cervix, the tumor spreads to the uterus above, the vagina below, and to the rectum behind. In less than 5% of cases, it may spread to the urinary bladder in front.
Clinical features
The earliest symptom of cervical cancer is abnormal vaginal bleeding, which often occurs after sexual intercourse. It is associated with a clear or foul-smelling vaginal discharge. Pelvic pain may result from the local spread of cancer. There may be swelling of the legs and sciatica-like pain due to the involvement of nerves. Advanced disease may present with bowel and urinary symptoms such as hematuria (passage of blood in urine), hematochezia (passage of blood in stools), or the passage of urine/stools through the vaginal opening.
Cervical cancer risk factors
The incidence of cervical cancer in various countries is dissimilar due to different attitudes towards sexual promiscuity and the effectiveness of mass screening programs. The highest incidence is found in countries with poor screening rates, high human papillomavirus (HPV) infection, and sexual promiscuity. Promiscuous sexual behavior in male partners is also a risk factor because it can also lead to transmission of the human papillomavirus. On the positive side, a lower rate of HPV infection was found in circumcised males, leading to a reduced risk of cervical cancer in their female sexual partners.
Persistent HPV (human papillomavirus) infection with types 16 and 18 is associated with 70% of cases. Most HPV infections are not persistent, especially in young women (<30 years)
Smoking is associated with a higher risk of cancerous changes in the cervix
Low socioeconomic status – is associated with a lack of cervical cancer screening facilities. Lack of education and awareness may also be a factor adding to the risk
Multiparity – history of multiple full-term pregnancies is a risk factor
Contraceptive use – long term use of oral contraceptives (>5 years) is associated with a risk of cervical cancer
The early age of onset of coitus is associated with a higher risk of cancer cervix. A woman who has never been sexually active has a very low risk for developing cervical cancer
Early first pregnancy
Multiple sexual partners
High-risk sexual partners
History of sexually transmitted disease increases the chances of getting HPV infection
Chronic immunosuppression, particularly HIV-related immunosuppression is associated with an increased risk of genital HPV infection in females. Many scientific studies have shown an inverse relationship between CD4+ count (helper T lymphocyte cells in the blood which boost immunity) and the risk of HPV infection. Patients with low CD4+ counts have higher HPV nucleic acid levels in their bodies. Drug-induced immunosuppression in organ transplant recipients is also associated with an increased prevalence of cervical cancer.
Cervical cancer has high morbidity and mortality once it becomes invasive. It can be prevented by following the ‘safe sex’ practices. That includes the use of condoms, health education, avoiding tobacco, and access to early screening.
