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FEMALE REPRODUCTIVE tract cancers can arise from the ovaries, the lining of the uterus (Carcinoma of the endometrium), the cervix (neck and mouth of the uterus-womb), the vulva, and more rarely, from the vagina and fallopian tubes. Of all the cancers of the female reproductive system, the commonest in Uganda is Carcinoma of the cervix accounting for 8 in every 10 patients seen with cancers of the genital tract (cf picture below from the internet-ADAM).
Cervical cancers pass through a precursor phase, during which even asymptomatic disease can be detected and treated in a timely manner to prevent the late onset of cancer. The number of new cases remains shockingly high and these usually present in advanced stages. It is of greatest importance that all women and men should be informed about the cervical carcinoma and how to prevent it.
Cervical carcinoma is regarded as a sexually transmitted disease caused by the human papilloma virus. A number of factors are linked to this cancer:
1) Coital Factors
Sexual intercourse is regarded as the most important risk factor for the development of cervical carcinoma. Age at first coitus is the next important risk factor. Women who have commenced sexual activity during adolescence appear to have the highest risk. Coitus with multiple sexual partners poses an increased risk, independent of other risk factors. Currently, strong evidence suggests that the human papillomavirus (HPV) especially types 16 and 18, are the causative organisms. Other types 6, 11, 31, 33,35 and 51 may also be involved. Herpes simplex type II virus was originally thought to be a cause this cancer, but this has been disproved.
Other sexually transmitted diseases are frequently encountered in patients with cervical carcinoma. This probably relates to different sexual partners and does not imply an aetiological role for these infections in carcinogenesis. Age at marriage and age at first pregnancy are secondary factors reflecting the age at first coitus. The frequency of coitus does not appear to play an important role.
2) Male Factors
There is the male role in sexual transmission of carcinogens. Promiscuity in males is an associated risk factor for spreading HPV virus, which in most cases will be apparent in the multiple sexual partners of the promiscuous male.
3) Racial and Cultural Factors
As racial, cultural and religious factors influence sexual practice, differences in sexual behaviour may account for the different incidences of cervical carcinoma among various racial and cultural groups. Women of low socioeconomic groups are said to have a higher incidence of cervical carcinoma than those in high-income groups. However, patients with cancerous cervical lesions come from all social classes.
4) Other Factors
The smoking of cigarettes is associated with a twofold increase in the risk for the development of cervical carcinoma. Users of the oral contraceptive pill may have a slight increased risk but this is influenced by all other and especially sexual risk factors. Lack of screening is also risky.
SCREENING, PREVENTION AND TREAMENT
A PAP smear is a screening test for cancer of the cervix. Looking at cells shed off from the cervix is a very good screening technique for the detection of cervical carcinoma and its precursors. This forms the basis of the Pap smear.
a) General Screening Recommendation:
The current recommendation is that all sexually active females undergo cervical cytology screening. The first smear should be taken three years after commencement of sexual activity. Initially, smears should be taken annually and after three normal smears, it is safe to take smears every 3 years.
b) HIV+ Female Patients:
For females who are HIV positive, the PAP smears need to be done more frequently, every 6 months. This is because the cancer spreads much faster and is more aggressive in this group. Cancer of the cervix is one of the AIDS defining cancers. PAP smear results will indicate the likely degree of abnormality present. The results may indicate the pre invasive stage or the invasive purely cancerous stage. Another simpler method of screening is Visual inspection with Acetic Acid (VIA). This is increasingly being used in many of the developing countries.
c) Cervical Cancer Stages:
The purpose of the screening is to get the pre-invasive treatable stage, called cervical intraepithelial Neoplasia (CIN I to III). Another classification calls it squamous intraepithelial lesion (SIL). This pre-invasive stage has no symptoms and can be treated with complete cure.
The invasion stage (stages I-early to IV-very late) however, which most of the patients in developing countries present with can only be treated in terms of five-year survival rates. If early, it is either extensive surgery, chemotherapy, radiation or a combination. It is not allowable for women to continue reaching a stage where the cancer status is showing symptoms, which include abnormal vaginal bleeding (especially after sex, cleaning the genital tract or in between periods), discharge or in the very late stage, pain and weight loss, before seeking for treatment. The mean age at diagnosis is 45 years, although patients of less than 30 years are not uncommon.
b) Preventing Cervical Cancer
Carcinoma of the cervix can be avoided by prevention of sexually transmitted infections, vaccination against the virus and routine screening as early as sexual activity commences. The purpose of screening is to get treatable disease and not to catch disease that has developed. Women should seek regular cervical cancer screening, even after vaccination.
About the Author: By Dr. Josaphat K Byamugisha holds MB ChB, Dip Obs., M.Med (OBS/Gyn) MaK, Cert. IP. (Jhpiego) and PhD from Karolinska Institutet in Sweden. He is a consultant Obstetrician and Gynaecologist with over 16 years in Medical practice in Uganda.