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Cervical Cancer Treatment And Diagnosis

CERVICAL CANCER TREATMENT AND DIAGNOSIS

What are the Cervical Cancer Treatments in Singapore?

Squamous cell carcinoma and adenocarcinoma of the cervix are the most common types of cervical cancer and are treated in similar fashion. Neuroendocrine small cell cancer of the cervix is rare cancer and the treatment will not be discussed here.

Treatments of Cervical Cancer depend on the extend of disease spread as well as the fitness level of the patient. Surgery, radiation, chemotherapy, targeted drug therapy; immunotherapy or a combination of the above therapies may be used.

When deciding on treatment plans, cervix cancer can be classified into

  • Early cancer
  • Locally advanced cancer
  • Advanced cancer
Cervical cancer treatment and diagnosis Singapore

Early Cervical Cancer

Surgery

Early cervix cancers are cancers that are confined to the cervix. Most early stage cervical cancers are treated with surgery – hysterectomy which involves removing the cervix and the womb (uterus). Part of the vagina, the ovaries and nearby lymph nodes in the pelvis may also be removed. For many women, surgery is all the treatment that is required, but some women may require additional treatments such as radiation plus minus chemotherapy to reduce the risk of the cancer recurring. Majority of women with early cervical cancer can expect to be cured.

Fertility sparing surgery for early stage cervical cancer:

Removing the uterus makes it impossible to become pregnant. Women who have not completed their family can discuss with their oncologist about the feasibility of surgical procedures that will retain fertility.

  • Cone biopsy:

For very small cancers, it may be possible just to remove the cancer with a cone biopsy. This procedure involves cutting away a cone-shaped piece of cervical tissue, but leaving the rest of the cervix intact.

  • Trachelectomy

Removal of the cervix and some surrounding tissue. The uterus remains intact and pregnancy is still possible.

Ovarian Transposition:

Young women may discuss with their oncologist about ovarian transposition surgery in case radiation treatment is required following surgery. Ovaries are hitched to a higher position to prevent ovarian failure induced by radiation treatment.

Radiation

In patients who are not fit for surgery, radiation treatment is an alternative treatment option.

Locally Advanced Cervical Cancer:

These are cancers that are bulky or have spread to the surrounding organs or to the lymph nodes in the pelvis. Radiation treatment is often combined with chemotherapy (concurrent chemo-radiation). Chemotherapy enhances the effectiveness of the radiation treatment. 

Cervical cancer treatment: Radiation therapy

Radiation:

High Energy X-rays are used to kill cancer cells. Radiation therapy consists of external beam and internal radiation:

  • External beam Radiation: Radiation beam is directed at the affected area from outside the body.
  • Internal Radiation (Brachytherapy): Insertion of hollow tube (applicator) that contains radioactive material into the vagina. This allows high-dose radiation to be delivered to the cervix and the vagina. The radioactive material is inserted for a few minutes and then removed.

Chemotherapy:

The most commonly used chemotherapy is a drug called cisplatin. This is given in low-doses.

The radiation treatments are given 5 days a week for a total 6 weeks. Each radiation treatment lasts only a few minutes. The cisplatin chemotherapy is an infusional treatment given once a week during the radiation and can be administered in the outpatient setting without a need for hospital stay.

 

Possible Side Effects of Radiation may include:

  • Tiredness
  • Diarrhea
  • Skin changes
  • Radiation cystitis: Radiation to the pelvis can irritate the bladder (radiation cystitis), causing painful urination or an urge to urinate often.
  • Vaginal pain: Radiation can make the vulva and vagina more sensitive and sore, and sometimes causes a discharge.
  • Infertility: Pelvic radiation can affect the uterus leading to inability to become pregnant.
  • Pelvic radiation can affect the ovaries, leading to early menopause in pre-menopausal women

Long-term side effects include:

  • Vagina stenosis : narrowing of the vagina due to the formation of scar tissue which may make sexual intercourse painful. This can be prevented with the use of vaginal dilator.
  • Rarely, women may develop a second cancer many years after their radiation treatment.

Possible side effects of Cisplatin Chemotherapy:

  • Tiredness
  • Nausea and vomiting
  • Loss of appetite
  • Lowering of white blood count which may increase the risk of infection
  • Anaemia
  • Bleeding due to lowering of platelets
  • Kidney damage
  • Tingling or numbness in hands and feet

Cisplatin chemotherapy is given in low doses and therefore generally well-tolerated. Of note, it does not cause hair loss.

Cervical cancer treatment: Radiation therapy

Treatment of Advanced or Recurrent Cancer of the Ovary:

Advanced cancers are cancers that have spread to distant organs such as the lungs, the liver or the bones. Recurrent cancers are cancers that have returned after treatment. The mainstay treatments of advanced or recurrent cancers involve drug treatment to control the cancer and to minimize any symptoms caused by the cancer. In the past, chemotherapy is the most common drug treatment. There are now newer drug options beyond chemotherapy such as targeted drug treatment and immunotherapy. These drug therapies can be administered in the outpatient setting.

Drug Treatments:

  • Chemotherapy

Anti-cancer drugs given as infusions. The drugs enter the bloodstream and reach all areas of the body to kill cancer cells that has spread. There are several drugs that are effective in the treatment of cervical cancer. Commonly used drugs include cisplatin, carboplatin, paclitaxel, gemcitabine and vinorelbine. It can used on its own, but more commonly given as a two-drug cocktail.  A typical course of chemotherapy treatment takes approximately five months.

Possible Side effects of treatment do vary depending on the drugs used and on individuals. They are mostly reversible upon the completion of treatment. Not all chemotherapy drugs will cause hair loss.

 

  • Targeted treatment

Bevacizumab is a targeted treatment that disrupts the blood vessels which supply nutrients to the cancer cells, thereby causing cancer cell death through deprivation of nutrients. This is a short infusional treatment, given once every 3-weekly, usually given with chemotherapy and as maintenance treatment to control the cancer better.

Possible Side effects :

Common side effects can include:

  • High blood pressure
  • Loss of protein in the urine

Less common but more serious side effects can include:

  • Bleeding
  • Blood clots
  • Poor wound healing
  • Fistula : abnormal connection between the vagina and part of the intestine. This is more common in women who have undergone radiation to the pelvis previously.

 

  • Immunotherapy

These are drugs that boost the body’s immune system to recognize and fight cancer cells. Immune checkpoint inhibitor, such as Pembrolizumab, works by releasing the natural brake on the immune system so that the immune system can attack the cancer. It is given as a short infusion every 3 weeks.

Possible side effects

Side effects of these drugs can include fatigue, nausea, skin rash, loss of appetite, jointor muscle pain.

Immune checkpoint inhibitors are generally well tolerated, though there serious side effects may occur due to the activation of the immune system attacking the organs in the body, such as the intestines, the thyroid gland, the lung , the liver  or other organs.

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What do I need to do if I have Cervical Cancer?

Doctor in Singapore examining cervical cancer test results

If you’re worried about getting cervical cancer, you can ask your doctor about getting vaccinated against HPV (Human Papillomavirus) and go for regular pap test screenings to help reduce your risk for cervical cancer.

If you or your loved one already have cervical cancer, do schedule an appointment with a qualified and experienced medical oncologist with experience in treating gynecological cancers. OncoCare specialises in treating patients with late stage or advanced stages of cervical cancer. Many of our patients come to us when they need to seek a second opinion on their condition.

Oncologists at OncoCare with Clinical Interests in Cervical Cancers

Dr Lim Sheow Lei

Senior Consultant, Medical Oncologist

MBBS (Australia, Honours), MRCP (United Kingdom), MD (United Kingdom) 

Dr Lim specialises in the treatment of gynaecological cancers, such as cancer of the ovary, uterus, cervix and vulva. She trained under several renowned oncologists, including Professor Hani Gabra, a world renowned expert on ovarian cancer.  

Dr Lim joined the Department of Gynaecological Oncology at KK Women’s and Children’s Hospital, specialising in the treatment of gynaecological cancers (cancers of the ovary, uterus, cervix and vulva). She also led the Chemotherapy Centre at KK Hospital and served as chairperson of the Singapore Cancer Network (SCAN).

MEDICAL PROFILE

  • Graduated from Monash University, Australia (Honours) in 1996 
  • MRCP (UK), Royal College of Physicians of the United Kingdom, 2001 
  • Certification in Medical Oncology by the United Kingdom Postgraduate Medical Education Training Board in 2008 
  • Doctor of Medicine (MD) , United Kingdom in 2009 
  • Executive Committee Member of the GyneCologic Cancer Group Singapore (GCGS) since 2018 
  • Former Senior Consultant Medical Oncologist at the Department of Gynaecological Oncology at the KK Women’s and Children’s Hospital (KKH), Adjunct Associate Professor at DUKE-NUS Medical School 
  • Visiting Consultant at KK Women’s and Children’s Hospital

Dr Kevin Tay

Senior Consultant, Medical Oncologist

MBBS (Singapore) – ABIM Int. Med (USA) – ABIM Med Onc(USA) – FAMS (Medical Oncology)

Dr. Tay has been recognised as one of the top cancer doctors doing research. He was awarded the prestigious center grant by the National Medical Research Council of Singapore.  He actively collaborates with other leading Asian researchers based in Korea, Taiwan, Hong Kong and USA. Dr Tay has published his findings in numerous journals, including Nature Genetics, the Journal of Clinical Oncology, The Lancet Hematology, American Journal of Medicine, Leukemia & Lymphoma and Seminars in Hematology.

Dr Tay’s subspecialty interest is in women related cancers such as breast cancers & gynaecological cancers, melanoma, brain cancers, soft tissue & bone sarcomas and also hematological malignancies such as lymphoma, multiple myeloma and leukemia.

​MEDICAL PROFILE

  • Graduated from the National University of Singapore in 1998. 
  • Board Certified, Internal Medicine, American Board of Internal Medicine, 2006 
  • Board Certified, Medical Oncology, American Board of Internal Medicine, 2009 
  • Chief Resident, Department of Medicine, John A. Burns School of Medicine, University of Hawaii, 2006 
  • Chief Fellow, Medical Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, 2008

What is Cervical Cancer?

Cervical Cancer is cancer that arises from the cervix, an organ situated between the vagina and the womb (uterus). In Southeast Asia, cervical cancer is the 2nd most common cancer affecting women. In Singapore, the incidence of cervical cancer has been falling, largely due to cervical cancer screening, and is now the 10th most common cancer affecting women in Singapore.

What are the Signs and Symptoms of Cervical Cancer?

Early cervical cancer may not produce any symptoms. Signs and symptoms of cervical cancer may include : 

  • Vaginal bleeding after intercourse, between periods or after menopause 
  • Watery or bloody vaginal discharge that may be heavy and have a foul odor 
  • Pelvic pain or pain during sexual intercourse
  • Frequent urge to urinate or discomfort when urinating
  • Back pain
  • Unexplained weight loss, fatigue or loss of appetite

How Cervical Cancer is Diagnosed

If cervical cancer is suspected, several investigations will be undertaken. This often involves colposcopy examination, whereby a magnifying instrument (colposope) will be used to inspect the cervix and any abnormal areas will be biopsied and sent to the laboratory to  test for cancer. 

If cervical cancer diagnosis is confirmed, further tests, such as MRI scan of the pelvis,  CT scan or PET-CT scan, will be undertaken to determine if the cancer has spread and help to stage the cancer.

What are the Causes and Risk Factors of Cervical Cancer?

Almost all cases of cervical cancer (99.7%) are due to infection with the human papilloma virus (HPV). 

HPV infection, acquired through sexual contact, is the single most important risk factor for cervical cancer. It is a prevalent infection in sexually active women. However, most women’s immune system are able to get rid of this infection spontaneously. In the minority of women with persistent infection with the cancer-causing HPV strains  (“high-risk” HPV), this may lead to cervical cancer.  

Other Risk factors include: 

Multiple sexual partners

Starting to have sex at an early age (before age 18)

Weakened immune system and therefore less likely to clear the HPV infection eg. Organ transplant recipients on medications to suppress the immune system ; women with Human Immunodeficiency virus (HIV) infection

Smoking

Oral contraceptive pills

Can Cervix Cancer be Prevented?

HPV vaccine is very effective at preventing HPV infections that cause cervical pre-cancers or cancers. It provides up to 90% protections against cervix cancer.  The Singapore Cancer Society recommends HPV vaccination for females between aged 9-26 year old. This vaccine has also been shown to be effective in women below the age of 45.  This vaccine is most effective if administered prior to first sexual encounter as it cannot cure an existing HPV infection. Women who are vaccinated need to continue with PAP smear screening as the HPV vaccine does not confer 100% protection. 

Screening for cervix cancer with PAP smear helps to detect cervical pre-cancers and early cancers. The HPV testing is a newer and more effective screening test than PAP smear. It detects  HPV virus. The presence of high-risk cancer causing HPV strains predicts for a higher risk of cervical pre-cancers of cancers. The Singapore Cancer Society recommends sexually active women to commence PAP smear screening starting from age 25 and HPV testing from age 30. 

Doctors using screening test to diagnose cervical cancer

What are the Stages of Cervical Cancer?

The International Federation of Obstetrics and Gynaecology (FIGO)  is the most commonly used staging system for cervical cancer.  

Stage I : cancer confined to cervix 

Stage II : cancer spread to surrounding organs – uterus, upper vagina or tissues surrounding the cervix (parametrium) 

Stage III : cancer spread to lower vagina or pelvic wall or causing kidney blockage or spread to lymph nodes in pelvis or abdomen 

Stage IV :  spread to organs such as bladder or rectum or to distant organs such as lung, liver or bones