Cervical Cancer is a Preventable Disease!

Anadolu Medical Center
Gynecology, Obstetrics and Gynecologic Oncology Surgery Specialist
Professor Dr. Murat Dede
“Surgical treatment is a method used in the early stages of the disease, and radical removal of the uterus is the cornerstone of treatment. If there is a cancer-leading lesion in the cervix, surgical trimming of the cervix is will be sufficient (LEEP).”

Anadolu Medical Center
Pathology Specialist
Professor Dr. Hüseyin Baloğlu
“Treatments that capture cervical cancer during abnormal cell proliferation and remove risky cells from this environment are the most effective early measures for cancer.”

Anadolu Medical Center
Medical Oncology Specialist
Professor Dr. Serdar Turhal
“With targeted treatments in the early stages of cervical cancer, we are now able to increase our chances of success that were around 20% with fewer side effects.”

Anadolu Medical Center
Director of Radiation Oncology Department
Professor Dr. Hale Başak Çağlar
“Radiotherapy is one of the basic methods of treatment in cervical cancer. With the new radiotherapy devices, success rates increase and side effects decrease.”

Anadolu Medical Center
Infectious Diseases Specialist
Assoc. Dr. Elif Hakko
“HPV vaccine is the most important and most economic method applied to prevent cervical cancer.”

HAVE YOU HAD YOUR SCREENING DONE?

HPV-DNA or PAP smear screenings in the cervical cancer screening program are implemented in Turkey and applied to the women aged between 30-65 years Screening for women in this age range without risk is repeated in every five years. The national screening program is run by the Cancer Early Diagnosis, Screening and Training Centers [KETEM] within the Family Health Centers and Community Health Centers.

Cervical cancer is one of the most common cancer types in women all over the world, especially in the less developed and developing countries. While the figures indicate 569,847 new cases in 2018, more than half of these cases have resulted in death.

Cervical cancer is still a common type of cancer in Turkey. The main reason for this is the low screening rates due to timidity of women. For instance, current figures indicate that more than 50 percent of women who have applied with cervical cancer have not attended to screening in the past five years. In fact, we can say that it is one of the cancer types about which we are a little bit lucky, because it is an easily accessible organ for examination. With the measures to prevent its frequency (screening program, HPV vaccines ...), it depends on individuals to stop or cease it. Treatment of cervical cancer is dominant with multidisciplinary approaches and we also applied a multidisciplinary approach. Gynecology, Obstetrics and Gynecologic Oncology Surgery Specialist Professor Dr. Murat Dede, Pathology Specialist Dr. Hüseyin Baloğlu, Medical Oncology Specialist Dr. Serdar Turhal, Infectious Diseases Specialist Assoc. Dr. Prof. Elif Hakko and Director of Radiation Oncology Dr. Hale Başak Çağlar from Anadolu Medical Center discussed the issue with their own expertise and we share it on our pages…

SYMPTOMS

If a diagnosis is not made through a screening program, patients usually seek medical advice if symptoms occur. When we look at these symptoms, we see that the most common ones are; flix, flix with a bad odor, extra menstrual bleeding, bleeding during and after sexual intercourse.

Cervical cancer is often confused with uterine cancer in society. But the place where the tumor occurs (cervix, part of the uterus facing the vagina) is the most significant difference that distinguishes this type of cancer from uterine cancer. From this point of view, we can say that it is located in a more accessible place in terms of medical treatments. We can give examples from Turkey in order to explain the specific areas it is spread at: 10 % is spread to pelvic lymph nodes, ovaries and tubes, 33 % is spread to side walls of abdomen and neighboring organs and 10 % is spread to distant tissues, lungs, bones and brain (rarely) via blood.

“CHILD BRIDES” THE MOST RISKY GROUP!

Particularly the women who experience sexuality at an early age, with men who have more than one partners or more than one female partners, who do not pay attention to genital hygiene, who smoke and carry microorganisms of sexually transmitted diseases are in the most risky group. At this point, it is also very important to underline that “child brides”, which is an open wound in our society, are also in the risky group.

HPV HAS ALMOST 200 DIFFERENT TYPES

Almost all life-threatening cancers are originated from the cellular changes caused by a DNA virus named as human papilloma virus (Human Papilloma). HPV causes cervical cancer and it is a challenge for the scientific world with more than 200 different types it has. HPV also causes anogenital cancers, vaginal, vulvar and penile cancers. Some of the varieties of HPV have a lower incidence of cancer, while some have a higher incidence. For example, 70% of cervical cancers are caused by the virus called as 16-18. But that does not mean that the remaining types of viruses are safe. That is why the HPV vaccine has dual, quadruple and nine-up applications, each developed for different types of HPV. (You can read more about the HPV vaccine later in this topic).

As a result of uncontrolled propagation of squamous epithelial cells (transformation zone- the epithelial lining of the single-layered uterine canal), thickness of this cell tegmina increases and it becomes irregular. This irregularity can sometimes be detected in the early stages during the cervical examination (colposcopic evaluation) using special devices. Since a significant portion of these early epithelial changes cannot be detected by normal genital examination, microscopic examination (PAP smear) of the cells to be sampled from this region and the detection of HPV in these samples (HPV-DNA screening and typing) are the ideal methods.

TREATMENT PROCESS

Surgical treatment is a method used in the early stages of the disease and radical removal of the uterus is the cornerstone of the treatment. If there is a cancer-leading lesion in the cervix, it is sufficient to surgically shave the cervix (LEEP). Uterine removal is a surgical procedure performed in the early stages (such as stage 1). If only a surgical intervention is performed on the cervix (cold stab-conization), the risk of miscarriage and preterm birth may increase during pregnancy. Of course, fertility-preserving surgical treatments can be applied. It should be noted that sometimes radiotherapy is used instead of surgery in early stage treatment. Chemotherapy is used to increase the effectiveness of radiotherapy in this process, and it can also be used as a treatment in the advanced stages if the disease is spread to distant organs.

Following the treatment of early stage cervical cancer, 15 % to 61 % of patients may have a relapse within two years. It is possible to rule out distant metastases by imaging methods, such as a pet scintigraphy, if there is a risk of relapse and metastasis. Radiotherapy with chemotherapy is an appropriate option if surgical treatment is not possible for the patients or if the disease has only relapsed to the operated area. But if the tumor has spread beyond the operated area, then chemotherapy can be applied. At this point, targeted drugs are used for better results. In patients who do not respond to combination therapy molecular genetic analysis makes it possible to control specific genetic disorders leading to tumor proliferation.

RATE OF SUCCESS INCREASES WITH THE USE OF NEW RADIOTHERAPY DEVICES

If the cervical cancer is at an ​​advanced level, that is, if there is spread to neighboring tissues, surgical treatment is replaced with radiotherapy. We can discuss a two-stage radiotherapy. External therapy called radiotherapy is applied simultaneously with chemotherapy on a weekly basis. The other one is called the internal therapy (brachytherapy), which is a non-surgical organ protection method. A method of treatment which increases the dose of radiation at a certain area by introducing radioactive particles via placing a number of applicators in the cervix and uterus, usually under general anesthesia. Nowadays, the success of radiotherapy treatments with MR and tomography compatible applicators has increased.

In early stage patients who undergo surgery or in cases of negative risk factors during the post-surgery, radiotherapy can be performed solely or with chemotherapy. Therefore, we can say that radiotherapy is one of the basic methods of treatment of cervical cancer. With the new radiotherapy devices, both success rates increase and side effects decrease. Particularly with the use of intensity-modulated radiotherapy, the side effects associated with external therapy are considerably reduced.

A TYPE OF CANCER OF WHICH THE FREQUENCY CAN BE REDUCED

To summarize, treatments that capture cervical cancer at the time of more abnormal cell proliferation (cancer precursor lesion) and remove the risky cells from this environment are the most effective early measures for cancer. In this stage, cervical cancer screening programs aiming to detect abnormal changes during the earliest stage at the cell level are being implemented in many countries around the world. In our country, Ministry of Health Public Health Agency carries out national cervical cancer screening program. HPV-based cervical cancer screening method is a proven screening method that is known to reduce the incidence of fatal cancer and the death rate caused by this cancer type. This screening should be carried out regularly at the recommended intervals to reduce the risk. We can say that the incidence of cervical cancers is significantly reduced with the optimal management of abnormal results obtained during screening. Because the incidence of cervical cancer and the reduction in mortality from this cancer can be achieved not only by screening, but by the proper treatment of the identified precursor lesions.

6 QUESTIONS AND 6 ANSWERS ABOUT PROTECTIVE HPV VACCINE!

How protective is it?

Long-term and permanent viral infection is a factor that increases the risk for cancer. HPV is a virus responsible for 70% of 16 and 18 cervical cancers, 90% of anal cancers, and a significant proportion of other types of cancers. HPV 6 and 11 account for 90% of genital warts. Therefore, the vaccine is prepared by taking these types into consideration. Vaccine applications developed according to HPV types are as follows:
1) 4-HPV vaccine / 6, 11, 16, 18
2) HPV vaccine of 9/ 6, 11, 16, 18, 31, 33, 45, 52, 58
3) Double HPV vaccine / 16, 18

Which ones are present in Turkey?

4 and double vaccines are available in Turkey. These vaccines are for protection purposes only and are not used for treatment.

What are the side effects?

The vaccine has no serious side effects other than local rash and pain on the arm it is applied.

At which age intervals should vaccination be done?

Vaccination should be given to girls aged 11-12 years. If the vaccination is not given at these ages, then it can be applied between the ages 13-26. For boys, the vaccination is recommended at the ages 11 or 12. It can be applied between the ages 13-21 if it has never been applied before, or if it was incomplete. It can be applied in later years but the effects will be weaker. For vaccination, it does not matter whether you have had a prior PAP smear test, a previous genital wart or an HPV infection or not. However, previous infection with HPV types in the vaccine will reduce the effectiveness of the vaccine. Ideally, it should be done before the first intercourse.

Should men be vaccinated as well?

It is recommended that men be vaccinated to prevent both anal and penile cancers and to reduce transmission.

How many doses are applied and for whom?

2 doses should be applied before the age of 15, with 6-12 months intervals, and 3 doses should be applied after the age of 15. There is no inconvenience for the simultaneous administration of other vaccines. If the doses are skipped, it can be resumed and there is no need to start again. As it provides long-term protection, re-vaccination is not recommended. If a person has been vaccinated with 2 or 4 vaccines before, it is not recommended to apply the 9, because it is unnecessary. Although there is no evidence that it is harmful during pregnancy, it will not be appropriate to apply during pregnancy. But it can be done during lactation.

Vaccination of 12-year-old girls in the United States prevents 200,000 HPV infections, 100,000 abnormal cervical examination findings and 3300 cervical cancers.