Cervical Cancer Causes and Treatment

According to national cancer institute (2010) cervical cancer is the abnormal growth of the cervix cells. It is a slow growing cancer which initially shows no such symptoms.Cervical cancer is considered to be the 2^rd most common cancer in women above the age of 25 and under the age of 40 (WHO report, 2011). Literature proposes that the women who are diagnosed in early stages have 90% more chance for recovery and survival as compared to those who are diagnosed later (British Journal of Cancer, 2011). There are over 500,000 cases reported each year worldwide and among them more than 280,000 women expire (Cancer research UK, n.d.). The Worldwide increase prevalence of cervical cancer can be witnessed by an increment in cancer cases since long. As in 2005 the reported cases were 250000 but by the year 2008 the cases raised up to 530000 with 275000 deaths (Center of disease control and prevention, WHO, Kaarthigeyan 2012). American cancer society (Jan, 2014) is predicting that in 2014, 12360 new cases of cervical cancer will be diagnosed in the UK with 4020 deaths. According to Yang (2004) in South Central Asia, Latin America and Sub-Saharan Africa cervical cancer is the leading cause of reduce life expectancy besides AID’s, TB, and maternal conditions in women. Moreover, since 2010 cervical cancer incidences amplified to a large extent in Pakistan as well. Study showed that in 2010, 899 women’s were diagnosed with cervical cancer in Karachi with fatalities of 7311 women (British Journal of Cancer, 2011). Likewise, in 2011 Pakistan was considered as having a 7th highest number of deaths with cervical cancer. Recently in 2013 it shoots up till 5233 cases with 2876 deaths (WHO, UN, World Bank, 2011). The mortality rate is increasing with a great momentum due to lack of awareness, lack of appropriate health facilities or preventive measures and greater number of sexual intercourse with multiple partners. So we well thought-out it would be a better initiative if we discuss this burning health issue faced by Pakistani women at the present time.

Agent, host and environment forms epidemiological triad which clarifies the progression of all infectious diseases including cervical cancer. According to center of disease control and prevention (2012), the agent in this triad is HPV, which is a small double stranded DNA virus. The only host is a human being and the environmental factors involved are number of sexual partners, smoking habits and exposure to combustion products (Bosch et al, 2006). This cancer also satisfies the Bradford Hill criteria of causation and Henle-Koch’s postulates. It is a potent virus that initiates infection by disrupting the basal epithelium of the cervix (Cancer foundation, n.d).

There are several host factors which predispose an individual towards cervical cancer but the main cause is HPV which is a sexually transmitted infection. HPV infection initially spreads by having sex with a person already infected with HPV. Other modes of transmission can be through contact with the skin of the mouth, anus and genitals (Annals of Oncology, 2011). Associated factors with cervical cancer include a history of multiple sexual partners and sexual intercourse at the age 17 years or earlier. Women who never involved in sexual activities are at lower risk for developing cervical cancer (Zandberg et al, 2012). Age is also one of the factors. In accordance with Dunne and Markowitz (2007) HPV infection is 64%, prevalent among adolescent girls and young adults. Furthermore, in United States, Hispanic women are more prone to get cervical cancer as compared to African-American women because high poverty levels are connected with low screening rates as well as lack of health insurance and limited transportation (University of Maryland Medical Center, 2014). Family history also plays a vital role. Women have a first-degree relative (mother, sister) with cervical cancer are at greater risk for acquiring it (University of Maryland Medical Center, 2014). According to cancer research UK (2008) a woman’s who use oral contraceptives for at least five years are at double risk for developing cervical cancer. This risk factor is not completely clear. Some researchers suggest that the hormones in OCs may facilitate the virus to enter the genetic core of cervical cells. Another probable reason is that the OCs users don’t prefer condoms as a birth control method and literature suggests that latex condom is beneficial in reducing HPV infection and other STDs (Vecchia, 2014). Moreover, smoking is highly associated with a risk of dysplasia of cervical cells and development to invasive cervical cancer. William, Salama and Carlos (2006) hypothesized that tobacco byproducts triggers the destruction of cervical cell DNA along with that it makes the immune system less capable of fighting with HPV. A research conducted on Nigerian women’s in 2013 who were suffering from HIV infection escorts us towards the fact that women’s suffering from HIV AIDS and immunocompromised patients are also at an elevated risk for acquiring HPV infection (Ononogbu et al, 2013).

A few centuries back Erasmus; a great philosopher declared “prevention is better than cure.” Being a preventable disease, the burden of cervical cancer could lessen to a greater extent through implementing prevention strategies at all levels. Primordial prevention comes first, which includes providing health teaching and developing a healthy lifestyle (Center for disease control and prevention, 2012). Cervical cancer can be primarily prevented by taking the HPV vaccine named as Gardasil and Cervarix or treated if identified early by regular Pap test. These vaccines are premeditated to generate an immune response to those parts of the virus which are liable for the abnormal multiplication of cervical cells. It is believed that this immunity will either kill the cancer cells or stop them from replicating (Castellsague et al, 2009). According to the guidelines of the American cancer society & United States Preventive Services Task Force (2013) each and every woman of age 21-29 should start cervical cancer screening along with the regular Pap test within 3 years. Women of age 30-65 should screen either a Pap Test or HPV test every 5 years. Furthermore the ladies who had a hysterectomy without the removal of the cervix require continuing cervical cancer screening too. According to the cohort study of Alliana and Cornelia (2012) a single round of HPV testing led to a significant reduction in cervical cancer. In addition the other possible ways to prevent cervical cancer are to inhibit smoking as tobacco products destructs the DNA of normal cervical cells, limit the use of oral contraceptives, minimize the number of sex partners or select a sex partner who has had no or few sex partners, use a well balance diet (Cancer research UK, n.d). Some studies revealed that the use of an intrauterine device (IUD) might help in preventing cervical cancer. The IUD doesn’t reduce HPV infection, but seems to decrease the probability that HPV would develop into cervical cancer. In one of the women’s studies who used IUD as birth control had lessen the risk of developing cervical cancer as compared to those who didn’t use (American college of obstetricians and gynecologists, 2012). If unfortunately cancer develops so we can use secondary preventions to avoid complications. Thus, potential treatment options are chemotherapy, radiotherapy and different surgeries (NCI, 2013). Chemotherapy is the use of cytotoxic drugs to obliterate widespread cancer cells. Platinum-based drug is the essential chemotherapy treatment for cervical cancer. Radiotherapy is another method to treat cancer. Radiotherapy for cervical cancer can be external or internal, and is often provided in combination with chemotherapy. It is probably given in early-stages of cervical cancer or in the cases where cancer has extended outside cervix and is not curable with surgery alone (American cancer society, 2014). Surgeries, which could help to treat precancerous and cancerous lesion of cervix are cryosurgery used to treat precancerous lesions of the cervix by cooled nitrogen gas that kills the cells by freezing it. Another one is colonization which is the removal of a cone shaped tissue from the cervix. Besides using as diagnostic procedure, it also serves in treating early stage cancer in women who desire to protect their ability to conceive. With the similar reason of not harming the ability to conceive radical trachelectomy is used which removes the upper part of the vagina along with cervix, but not the body of uterus, however hysterectomy deprives the ability of giving birth and in Pakistan radical hysterectomy is used as the most common surgical procedure (Ghazala et al, 2009). With tertiary prevention further complications and disability could be limited

Prevention of cervical cancer is one of the crucial elements in achieving the Millennium Development Goal for improving maternal health by the year 2015. According to WHO 275,000 women expire every year from cervical cancer, including 85% in developing countries where it is a leading cancer killer of women (WHO report, Jan 2014). Awareness is the most vital way for prevention. It is important for health care providers to notify females about alarming signs of cervical cancer plus precautions like using protection during sexual intercourse limit the use of oral contraceptives and adopt an alternate birth control method, screening via gynecologic examinations. Cigarette smoking and eating unhealthy food should be avoided to limit cancer. It could be done by providing pamphlets, planning, teaching sessions, using role plays and media for the patients at individual and group level (National cancer institute of cancer. 2014). The vaccine for cervical cancer is highly effective but there are uncertainties in equitable distribution of this vaccine.

Developing countries with low socioeconomic status often encounter significant obstacles to incorporate new vaccines into their national immunization programs as a result, people living in these countries don’t have access to life-saving interventions for many years, which are currently available in higher-income settings (PATH, n.d) so it is recommended that governmental agencies should ensure appropriate vaccine distribution and supply to every region of Pakistan. In 2000 an act was signed named as financial help for cervical cancer, which aimed to provide funds for treatment of cervical and breast cancer (Mahmud et al, 2013) so with the help of government authorities we could bring this act into action via administering HPV vaccine at low cost. Females who are at high risk should be screened with a Pap test or HPV testing every year to be on the safe side. A recent research conducted in Pakistan summarized that worldwide 80% of the cervical cancer cases occur in low-resource countries (Mahmud et al, 2013) so we can articulate the fact that the woman living in underdeveloped countries are more prone to getting cervical cancer due to lack of screening facilities, less quality assured screening laboratories or their incapability to afford the expensive screening test. In response to that WHO approved the older method of screening, i.e. Visual Inspection of cervix via acetic acid or Lugol’s iodine for women’s who can’t afford expensive HPV testing so this will ultimately minimize the risk for cervical cancer in low resource countries as well (Badar et al, 2008). In addition, government should improve the infrastructure by establishing quality assured cytology laboratories so that screening should take place effectively in low resource settings as well. Janet (2010) reported that HPV vaccines should be stored at 35°–46°F or (2°–8°C) and protected from light. In Pakistan load shedding is a serious problem which consequence in the unavailability of electricity to save vaccination in refrigerator, thus cold boxes having thermometers should be made available in health centers to sustain the effectiveness of vaccine at preferred temperature.

Since cytology base screening is very costly in low resource settings, including Pakistan so alternative low technology approaches besides VIA should be discovered. In addition, alternate treatment approaches need be explored for screening positive women’s in developing countries (Badar et al, 2008). It is also suggested to conduct case control researches in Pakistan to identify the association between oral contraceptive uses with the occurrence of cervical cancer.

In conclusion, cervical cancer is a sexually transmitted infection caused by HPV, which amplifies socioeconomic and health burden in Pakistan. Though, it can reduce if vaccination is taken on accurate time. Similarly, diverse prevention strategies and early detection could assist its control and management. Cervical cancer could be eliminated by effective collaboration with government at the community as well as national level so that sustainable prevention becomes possible.

This article is written by shazia ghazi,Alizah, Nadia, Yasmin, Asmat and Mohammd nasir