Cancer is a genetic mutation of the way cells grow in the body. Changes in the DNA cause cells to over produce in an uncontrolled way creating a cell mass, commonly known as a tumour. If left untreated the cells continue to grow and the cancer can spread to other organs and systems in the body.

Cervical cancer develops in the cervix or neck of the womb, affecting the cells lining this area. Over a woman’s life time the cells in the cervix change and in some cases these cells can become cancerous. This normally develops over a period of years and changes can often be detected before the cancer becomes advanced.

Prior to developing cervical cancer there is a pre-cancerous condition called CIN (cervical intraepithelial neoplasia) which means ‘new changes in the outer layer of the cervix’. This may not be a problem initially, but may in a minority of cases develop into cancer in the future. It is these pre-cancerous stages that the NHS Cervical Screening Programme is designed to detect, monitor and treat before cancer develops.

The majority of cervical cancers are caused by a virus called HPV (human papilloma virus). HPV is extremely common and 80 percent of sexually active women will have been infected with HPV before they reach the age of 50. Only in a minority will the infection persist and it is a small proportion of these women who would develop cancer if they were not screened.

Causes and risk factors

HPV- the main cause of cervical cancer is infection by the HPV virus, caused by genital contact during sexual activity. The HPV virus causes changes in the cells of the cervix which can eventually cause them to reproduce uncontrollably leading to the development of a cancer. This usually takes place over several years and cell changes can be detected before this and treated if women undergo regular screening.

Smoking- increases your chances of developing cervical cancer; this is thought to be because of the effects of chemicals found in cigarettes.

The Pill – if the contraceptive pill is taken for more than 5 years there is a small increased risk of developing cervical cancer. Oral contraception has many other important benefits to take into account and regular screening provides a high level of protection against developing cancer.

Weakened immune system- certain medications which suppress the immune system or other conditions such as HIV can make the body less able to fight off HPV and early cancers. Transplant recipients should be regularly screened.

Vulval cancer- women with vulval cancer have a greater risk of developing other gynaecological cancers, particularly cervical cancer.

Screening and Vaccination

Cervical cancer is one of the few preventable cancers, which is why regular screening is so important.

Screening

Cervical screening, previously known as a ‘smear test’ is designed to detect early cell changes before they become cancerous. Since the start of the UK wide screening programme the survival rate for women with cervical cancer has doubled.

You will automatically be sent a letter advising you that a screening test is due, you will need to go and make the appointment at your surgery or health centre.

In England the standard NHS frequency of screening is:

• 25yrs – first test
• 25-49yrs- a test every 3 years
• 50-64yrs a test every 5 years
• 65+ only tested if no screening since the age of 50 or if previous tests have been abnormal.

The beginning and frequency of testing may vary according to where you live. If you experience any symptoms do not wait until a scheduled test, see your GP for advice.

The test

During a test a nurse or doctor will collect some cells from the cervix using a swab or brush inserted into the vagina. The samples are then sent to a laboratory to be tested for cell changes.

Test results

Most women will simply receive a letter from the screening service advising them that the test results were normal. However if the letter advises that an abnormal or positive result has been found then a follow up visit to the GP is essential.

An abnormal or positive result does not usually mean actual cervical cancer, it does mean that the test has picked up some cell changes which need to be investigated. If the changes are mild the sample is retested for HPV positivity. If the HPV result is negative, then no further referral is required and a next recall letter will be sent in 3 or 5 years time. If the mild changes are positive for HPV or if the changes are more severe, then a colposcopy examination will be offered, usually at the local gynaecology unit. Colposcopy is a test to look more closely at the cervix and also a biopsy (a small sample) taken from the cervix to test further in a laboratory.

If the cells show moderate or severe pre-cancerous changes, the likely treatment will be a procedure to remove these cells called a LLETZ. This is a wire loop with a safe current running through it which is used to remove the affected cells. It leaves a raw area on the cervix which normally heals well and leaves only healthy tissue. A single treatment achieves cure in 90-95 percent of cases; in 5-10 percent of cases a second treatment may be required. Only 1 in 200 women treated for CIN will go onto develop actual cancer.

Vaccination

In 2008 the UK government launched a vaccination programme to prevent HPV infection which is the main cause of cervical cancer.

The Department of Health recommends that all 12-13yr old girls are vaccinated against HPV. The vaccine protects against the strains of HPV which cause 70 percent of cervical cancers in women. Because of this it remains very important for vaccinated women to have cervical screening in later life, and for the NHS cervical screening programme to continue alongside vaccinations.

Symptoms

In early stages of cell changes there are no obvious symptoms and therefore it is essential for women to take part in free NHS cervical screening programmes, however, some symptoms may indicate possible cancer in the cervix.

The main symptoms to watch out for are:

• bleeding between periods
• heavier than normal bleeding during periods
• bleeding during or after sex
• bleeding after the menopause when periods have stopped

Other less common symptoms:
 

• pain or discomfort during sexual intercourse
• unpleasant smelling vaginal discharge

Most of these symptoms could also be caused by other non cancerous conditions and therefore you should consult your GP if you experience any of them.

Diagnosis

If cervical cancer is confirmed the doctors may recommend other tests to help asses the stage of the cancer. These may include: scans, blood tests, x-rays and pelvic examination.

The results of these tests should determine the stage of the cancer. These stages range from zero (no cancerous cells), to stage four ( advanced, spreading to other organs) and they are an indication of the likely success of treatment.  Survival rates for cervical cancer are improving and the 5 year survival rate is approximately 66 percent. If the cancer is diagnosed in the early stage over 90 percent of women will live for at least 5 years.

Treatment

Treatment options depend on the stage of the cancer. Early cervical cancer can be treated using surgery, radiotherapy or a combination of the two. More advanced disease is treated with a combination of chemotherapy and radiation. More advanced stages may require surgery, radiotherapy and chemotherapy.

Surgery- usually involves removal of the womb and cervix- a hysterectomy.

Chemotherapy- a drug given, over a specific course of time, it is designed to destroy cancerous cells.

Radiotherapy- destroys cancer cells using controlled doses of radiation.

Lymphadenectomy- the removal of lymph nodes (these are part of the infection fighting and fluid drainage system in the body). This is only done in appropriate situations.

Prevention

As well as having regular screening tests and girls getting vaccinated, there are other things women can do to help lower the risk of cervical cancer.

Contraception- using a condom can help reduce the risk of contracting HPV.

Stop smoking- smokers are less able to get rid of the HPV infection.
As with all cancer a healthy lifestyle and a balanced diet may help to lower the risk.

Balanced diet- a lower fat, high-fibre diet, which includes wholegrains and at least five portions a day of fresh fruit and veg.

Exercise- regular exercise.

Please consult your GP before starting exercise if this is not a regular activity or you have not exercised for some time.

If you would like to tell us your story so we can help and inform other women; there is more information available HERE

Screening and Colposcopy: Text Version

This interview was recorded in October 2009

Cervical Screening and Colposcopy

Hello, we are joined today by Mr Henry Annan, to discuss cervical screening and colposcopy. Thank you Mr Annan for joining us today.

Can I start by asking you what exactly is a smear test? And is there any difference between a smear test and a cytology test?

They are more or else the same thing. A smear test actually the process of taking the sample, cytology is taking the specimen to laboratory to be analysed for a result, it is more of a medical term but essentially they are the same thing.

Could you tell us what the standard procedure for a cervical screening is?

You mean how the test is taken?

Exactly.

Ok, as I told you a few minutes ago, up to third of young women will not go for a smear test because they think it is embarrassing or because it is going to be painful. The procedure itself is not at all painful. The person involved will need to be examined on a couch, the vagina has to be opened with a speculum to expose the cervix, and then a brush is used to gently rotated around the cervical os, and the surface, and the whole process takes about two to three minutes.

Could you tell us how the procedure has changed over the years?

Yes that is a very interesting question. Cytology or cervical tests started in the 1940’s by Papanicholau, in those days they used to take fluid from the vaginal fornix for analysis. Subsequently, the wooden [plastic] spatula that I have shown you was used to scrape the surface of the cervix, spread the sample onto a slide and then stained for microscopic analysis. The problem with that was that it was not very accurate as some of the cells stuck to the spatula, and for the past 3 or 4 years the whole country has gone over to using the brush. We use a soft brush to sweep around the cervical os. The sample is then put into a special medium, shaken up and all the cells are separated out, it goes to the laboratory and all the debris like mucus is separated by centrifuge, and the cells are spread on a slide and examined. The accuracy is much better. It is called a liquid based cytology.

You mentioned that many women feel embarrassed about going for a cervical smear? Can I ask who actually carries out the procedure and what could say to people who feel embarrassed?

They do not need to feel embarrassed because the invitation for a smear test comes from the primary care trust, and is from the GP and all GPs have nurses who are trained to take smears. Most practices also have women doctors who can take the smear. So women who are embarrassed can opt to have a female take it. A lot of people are embarrassed by the vaginal examination whether it is by a man or a woman. They are just embarrassed. But it is definitely not painful.

Can I ask you what the program is for cervical screening? How often does the test need to be carried out?

That’s a very good question, comprehensive screening started in this country in 1988, prior to that there was no comprehensive screening at all, I remember as a junior doctor each time we saw someone we just took a smear and the results came in a haphazard manner, therefore we were not getting the result we needed, it was not reducing the incidences of cervical cancer.

From 1988 the programme became comprehensive so people were invited to come for a smear, it was then if there was any abnormality they would be recalled, and your first invitation to have a smear comes from your GP when you are 25. Then assuming it is normal you have a smear every three years until you are 49 and then it is every 5 years until you are 64. Assuming there are no abnormalities that is the end of the screening programme. Obviously if you have some abnormalities, an abnormal smear we will take action. In a number of countries particularly in America and Europe the women have smears every year. We do not do that in this country. It can be counter productive and it is also quite expensive to smear a women every year and it is not necessary.

If a woman is told that she has some abnormal changes and is called for a colposcopy what is the procedure for this? What does it entail?

The first thing to do is to reassure the woman that she does not have cancer, they are not examining her for cancer, it is so important as several women will come in tears, saying they have an abnormal smear, and think it means they have cancer.

Colposcory is a way of trying to diagnose what has caused the abnormal smear, and what it entails is lying on the couch, in the lithotomy position with your legs in stirrups. The doctor will use a pair of binoculars and very often this is linked to the CCTV so quite often the patient can watch as she is being examined if she wishes. And on the magnification we look at the cervix and apply weak acetic acid & sometimes an iodine solution to see if there are any specific changes, which we can relate to the abnormal cells being present this is colposcopy. You don’t need an anaesthetic and takes 3 or 4 minutes. Local anaesthetic is applied only if a biopsy needs to be taken.


Can I ask how severe abnormal changes in the cervix treated and will this protect against the further development of abnormal cells?

By severe abnormalities we usually mean CIN3, the mild abnormality is CIN1 – which can regress naturally without treatment, in 50% of the women, but most people wish to be treated, but if you left them alone 50% would disappear, in severe cases we have various methods of treatment. 30 years ago the standard treatment to use a cone biopsy which required a general anaesthetic and a knife to take a wedge of the cervix. This is now rarely used; the current standard treatment is called a loop cone biopsy. A hot wire loop is used to shave off the abnormal areas of the cervix under local anaesthetic. A carbon dioxide laser, cryotherapy [freezing] and electro-diathermy were techniques used in some centres in the past. 1-2 % of women has a persistence of the CIN3 in six months after one treatment and would need further treatment. Occurrence of CIN 3 after six months is considered as ‘new disease’. Treatment of CIN 3 with loop cone is therefore very effective.

There are a number of myths surrounding cervical smear tests such as; if you have an abnormal smear it means you have cancer. What is your reply to this?

No, the smear as we said it not a test for cancer it is a test for detecting abnormal /precancerous cells so their subsequent elimination will reduce the incidence of cancer. In England we take 4 million smear tests a year. The proportion of abnormal smears is something like 1 in 16,[around 6%]will have abnormal cells that require further investigation and only about 1 in 40 of them will need colposcopy. Having a borderline smear or an inflammatory smear doesn’t mean you need a colposcopy. The smear test will then be repeated in 6 months, or as advised by the laboratory.

Another is that you don’t have to bother to go back to the doctors if it says you have mild changes because you body heals it self.

Yes and no, mild changes, 50 – 60% will regress over a year, the reason you have to go back is so that you can see if they have regressed or not. If they have not you will be referred for a colposcopy. If your body’s immunity is very good your chance of regression is high as it is your body fights off the human papiloma virus, HPV which causes the CIN.

A colposcopy is a painful operation that requires anaesthetic?

A colposcopy is a quick and painless procedure; it lasts for approximately 3-4 minutes. It is a visual investigation of the cervix. No anaesthetic is required unless the patient needs to have a biopsy taken. In this case a local anaesthetic will be given in order to painlessly take the biopsy

Cervical Screening and Colposcopy

Cervical screening tests can be a cause of concern and embarrassment, in part due to misinformation. Discover the truth behind the myths surrounding cervical screening.

If you have an abnormal test it means you have cancer.

No, cervical screening is not a test for cancer it is a test for detecting abnormal /precancerous cells so their subsequent elimination will reduce the incidence of cancer. In England we take 4 million tests a year. The proportion of abnormal tests is something like 1 in 16, [around 6%]will have abnormal cells that require further investigation and only about 1 in 40 of them will need colposcopy. Having a borderline or an inflammatory test doesn’t mean you need a colposcopy. The cervical screening will then be repeated in 6 months, or as advised by the laboratory.

You don’t have to bother to go back to the doctors if it says you have mild changes because you body heals itself.

Yes and no, mild changes, 50 – 60% will regress over a year, the reason you have to go back is so that you can see if they have regressed or not. If they have not you will be referred for a colposcopy. If your body’s immunity is very good your chance of regression is high as it is your body fights off the human papiloma virus, HPV which causes the CIN.

A colposcopy is a painful operation that requires anaesthetic?

A colposcopy is a quick and painless procedure; it lasts for approximately 3-4 minutes. It is a visual investigation of the cervix. No anaesthetic is required unless the patient needs to have a biopsy taken. In this case a local anaesthetic will be given in order to painlessly take the biopsy.

To find out about our research follow these links:

• The effects of viruses and antiviral therapy on the development of cervical cancer in HIV+ve women
   
• Development of a novel therapy for the treatment of cervical cancer
   
• How does HPV cause cervical cancer and how can HPV be treated?

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information 
   
• Look Good.....Feel Better helps women manage the visible side effects of cancer treatment: http://www.lookgoodfeelbetter.co.uk
   
• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx