CERVICAL CANCER
Cervical cancer is the third most common cancer among Malaysian women after breast and colorectal cancer being the first and second respectively. According to World Health Organization (WHO), the highest rates of cervical cancer incidence and mortality are in low- and middle-income countries. This reflects major inequities driven by lack of access to national HPV vaccination, cervical screening and treatment services and social and economic determinants.
Cervical cancer begins from uncontrolled cell growth in the cervix. A cervix is an organ located at the opening of the uterus (womb) and connects it to the vagina. In Malay, we call it 'pangkal rahim'. The cervix has two main parts: ectocervix and endocervix. These two zones are lined by different types of cells. Ectocervix is lined by non-keratinized stratified squamous epithelium while the endocervix is lined by simple columnar epithelium.
Between ectocervix and endocervix, there is a region known as a transformation zone or histologically known as squamo-columnar junction (SCJ). So the cells change from squamous type to columnar type of epithelium. This process is called metaplasia, meaning change from cell type A to type B. This transformation zone is prone to Human Papilloma Virus (HPV) infection. Depending on the virus type, it may contribute to the oncogenic effects towards the infected cells thus causing abnormal cell growth (cancer).
There are different types of cervical cancer but the most common one includes squamous cell carcinoma (90% of cases) that develops in ectocervix and adenocarcinoma that grow in endocervix. Other types of rare cervical cancer includes adenosquamous and neuroendocrine that accounts for about 5% of cases.
Signs and symptoms related to cervical cancer:
1. Foul smelling vaginal discharge
2. Post coital bleeding (bleeding after sexual intercourse)
3. Dyspareunia (pain during sexual intercourse)
4. Intermenstrual bleeding
5. Post-menopausal bleeding
Risk factors of cervical cancer:
1. Sexual behaviours: early exposure to sexual intercourse, multiple sex partners and sexual intercourse with a high risk behaviour partner. This is because HPV infection is transmitted through sexual relationships.
2. Consumption of Combined Oral Contraceptive (COC) that contains both oestrogen and progesterone hormone. The cervix is highly responsive to the action of oestrogen hormone. During the menstrual cycle, cervical epithelial cells proliferate and differentiate as estrogen levels increase, resulting in hyperplastic epithelium without pathological changes.
3. Persistent HPV infection especially by type 16 and 18
4. Cigarette smoking
5. Immunosuppressed patients (weakened immune system)
6. Low socioeconomic group
In Malaysia, there is cervical cancer screening provided in our healthcare facilities throughout the nation. The most common screening method is the pap test. Pap test is a cytological study (study of the cell type) where a sample is obtained from the transformation zone of the cervix to detect any abnormality, discharge, pre-malignant or malignant lesion. Pap test is recommended to all sexually active women and it is not necessary to sexually naive women. Highly recommended to pap test screening especially those who have multiple sexual partners, history of sexually-transmitted infection (STI), family history of cervical cancer, or if in previous pap smear, any abnormality detected.
During the pap test procedure, a speculum will be inserted into the vaginal opening and sample or mucus from the cervix is scraped using cytobrush or cytobroom. Once the sample is obtained, this cytobrush or cytobroom will be taken out and smeared onto the slide or the sample will be put into a container containing liquid, if liquid-based cytology is done. This smeared sample will be examined under a microscope to look for any presence of cancerous cells. Other procedures to detect the presence of cancerous cells at the cervix include colposcopy (a special magnifying instrument to look at the cervical lining). HPV DNA testing can also be done to check and confirm infection by HPV virus.
On the other hand, to prevent HPV infection, there is HPV vaccine available. It is designed especially to reduce the incidence of cervical cancer caused by HPV type 16 and 18. Alhamdulillah, KKM is giving the immunisation for FREE for all girls in Form 1 and girls currently aged 13. According to the Centre for Disease Control (CDC), HPV vaccine is highly immunologic as more than 98% of recipients develop an antibody response to HPV types included in the respective vaccines 1 month after completing a full vaccination series. The HPV vaccine is safe and can provide immune protection to women.
Early detection is key to fighting cervical cancer. The earlier we detect the abnormality, the greater the chance for the patient to survive and has good prognosis (disease outcomes). Take your vaccination and consult your doctor for a cervical cancer screening procedure. InshaAllah, prevention is better than cure.
Other prevention measure includes
avoiding multiple sexual partners, having routine pap test, HPV vaccine and avoid cigarette smoking.
P/s: The picture of me performing a pap test during the OSCE session on 4/7/2024. It was such a good and insightful experience. Thank you to Dr Natasha for facilitating the session. Looking forward to learning more clinical procedures. We also got the chance to perform an ultrasound on a pregnant dummy model and saw a colposcopy machine.
"The good physician treats the disease. The great physician treats the patient who has the disease"
- Sir William Osler-
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