What is cervical cancer?
Cervical cancer is cancer of the neck of the womb (cervix). It is the 9th most common cancer in women in Ireland, with almost 200 women on average developing the disease every year. In contrast to most other cancers, cancer of the cervix affects mainly younger women, with 60% of cases occurring in women aged 50 or younger.
Approximately 70 women in the Republic die from cervical cancer each year. However, it can be prevented in two ways, by means of a simple test – the cervical smear test or by being vaccinated against the human papilloma virus (HPV), which is the main cause of cervical cancer.
How does cervical cancer develop?
Cervical cancer normally develops over time, starting off with early abnormal ‘pre-cancerous’ changes to the cells in the cervix. These pre-cancerous changes occur gradually, often over a period of more than 10 years. The changes to the cells go through three stages, classed as mild, moderate and severe dyskaryosis.
Often, mild cell changes may return to normal after a few months. However, in other cases the changes may persist or progress leading to a pre-cancerous stage called ‘carcinoma in situ’. At this stage, some of the cells appear cancerous, but they are all contained within the skin covering the cervix. This only becomes a ‘true cancer’ if it is left untreated, and then the cells may break through the skin covering the cervix and spread into the tissue underneath.
Around 800 women in Ireland develop pre-cancerous lesions every year, 95% of whom are under the age of 50.
What causes cervical cancer?
A virus called Human Papilloma Virus (HPV) is considered to be the main cause of cervical cancer. HPV infection is very common and in most people, the virus causes no symptoms and the infection clears within a few months. However, some people seem to be more susceptible to persistent infections and this can lead to abnormal changes in the cervix.
Risk of contracting the HPV virus increases with the number of sexual partners you have had or that your partner has had. Smoking, long-term use of the combined contraceptive pill and having a high number of children can also increase risk.
What are the symptoms of cervical cancer?
The initial abnormal cell changes that take place do not cause any symptoms. However, if these changes progress, various symptoms such as abnormal vaginal discharge and abnormal vaginal bleeding – i.e., bleeding after sex or between periods, may occur.
If left untreated, the cancer spreads from the surface of the cervix into the deeper parts of the cervix and then out into the pelvic tissues, causing pain. Eventually the cancer may spread to the bladder, rectum and surrounding pelvic tissue, causing symptoms such as pain or bleeding from the rectum after a bowel movement or pain or difficulty urinating.
How can cervical cancer be prevented?
The good news is that the early pre-cancerous changes that occur to cells in the cervix can be detected by means of a simple test, called a smear test (or ‘Pap’ test). This means that the abnormal pre-cancerous cells can be destroyed before they even turn into cancerous cells. It is estimated that smear tests can detect up to 90% of potential cervical cancers.
It is important to have regular smear tests (at least every 3-5 years) if you are aged 25-60 years and sexually active, or have been sexually active in the past. In women under the age of 25, the cervix is still developing, and screening may pick up on abnormalities that are insignificant – leading to unnecessary treatment. Cervical cancer is highly unlikely in women over the age of 60 who have previously had negative smear tests.
Is there a National Screening Programme for cervical cancer?
A national cervical screening propgramme has been in operation since September 2008.
CervicalCheck – The National Cervical Screening Programme provides free smear tests to women aged 25 to 60. A smear test is a simple procedure that only takes minutes, and is the most effective way to detect changes in the cells of the cervix. CervicalCheck has a register (list) of women aged 25 to 60.
Over the next three years, CervicalCheck will send every eligible woman on the register who has not yet had a free CervicalCheck smear test a letter of invitation by post.
From 1 September 2009, women who have not yet had a free CervicaCheck smear test can make an appointment when they receive their letter of invitation. With an invitation letter, a woman can have a smear test with any Smeartaker (GP or practice nurse) registered with CervicalCheck. GPs, Women’s Health, Family Planning and Well Woman Clinics all over Ireland are registered to take smear tests.
A woman who has already had a CervicalCheck smear test is advised by the Programme when her next smear test is due.
Any woman who has not had a smear test in the last three years can opt-in and request an invitation letter from CervicalCheck by registering online at www.cervicalcheck.ie, completing and returning a Freepost form, or by calling CervicalCheck on Freephone 1800 45 45 55.
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What happens at a smear test?
The smear test is a very simple procedure, which takes less than 5 minutes. It can be a bit uncomfortable but should not be painful. While you are lying on your back, the nurse or doctor will gently insert an instrument called a speculum into your vagina to hold the vaginal walls open. A small spatula is then used to take a sample of cells from the cervix. The cells are spread on a glass slide, which is sent to the laboratory for examination under a microscope.
Smear tests can be done by your GP, as well as at family planning clinics, well woman centres, gynaecology clinics and some HSE clinics. Women who are not covered by the Irish Cervical Screening Programme (see above) will have to pay for their test.
What do my smear test results mean?
Changes detected in your smear test are early warning signals that cervical cancer may develop in the future if left untreated. A smear test result that is not normal does not mean that a woman has cancer, just that further testing and follow up may be needed. There is a one in ten chance of being recalled for a repeat smear when you get your results.
You will be recalled if your smear result was reported as being inadequate or unsatisfactory – this could mean that a poor sample was taken or the sample was damaged in transit. The smear may also show up an infection or inflammation unrelated to cervical cancer.
If abnormal cells have been detected, they may be classified using a system called the CIN (Cervical Intraepithelial Neoplasia) classification. This is a grading system used to classify the varying degrees of abnormality that may be seen in the cells obtained in a smear test. There are three grades: CIN I, CIN II and CIN III. These three stages may also be described as mild, moderate and severe dyskaryosis.
If mild changes are detected (or CIN I), you will be asked to return for another smear test in 6 months time, as these cells often return to normal by themselves. If the changes persist, you may then be referred to a specialist clinic for further investigation.
If you are shown to have moderate or severe changes (CIN II or III), you will be referred for a further examination called a colposcopy to decide whether you need treatment.
What is a colposcopy?
A colposcopy examination allows the specialist to look at any abnormal cells in your cervix more closely and decide if you need treatment. Your cervix will be looked at with a microscope, and the procedure is carried out in the same way as your smear test. The microscope does not touch you or go inside you, it just provides magnification so that any abnormal areas can be seen more clearly. If any abnormal areas are seen, a small sample of tissue (called a biopsy) may be taken from the surface of the cervix, or a patch of cells may be removed under local anaesthetic.
What treatment will I need?
The type of treatment you will receive depends on the stage at which you have been diagnosed.
There are a number of different options for the treatment of pre-cancerous changes, which are aimed at destroying or removing the abnormal cells. These include use of a hot wire loop, a laser beam or cryosurgery (intense cold) to remove the abnormal cells. In other cases, a cone biopsy may be carried out – where a cone shape of tissue is removed. A hysterectomy may also be performed.
Treatment of pre-cancerous changes is normally very effective in preventing development of cervical cancer.
If cancer has developed, treatment may involve surgery, radiotherapy, chemotherapy or a combination of any of these treatments. For earlier stage cervical cancer, the main form of treatment is surgery (hysterectomy) either with or without radiation therapy. For women with more advanced disease, treatment will usually involve radiotherapy together with chemotherapy.
The outcome for cervical cancer is strongly related to the stage at which it is diagnosed.
What about the vaccine against Cervical Cancer?
The latest development in the prevention of cervical cancer is the introduction of cervical cancer vaccines. These are most useful if administered in adolescence, before sexual activity begins.
Two cervical cancer vaccines are now available. Those wishing to avail of a vaccine must currently pay for it. However from this summer (2010), the vaccine is due to be made available free of charge by the State to 12-year-old girls. The vaccine is expected to be administered by HSE public health staff. Each girl will receive three doses of the vaccine.
There are currently no plans to undertake a 'catch-up' vaccination programme for older girls.