Cervical Cancer

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California State University San Bernardino Marina Mejia HSCI 451- Epidemiology Term Paper- Winter 2012 03/01/12

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Cancer is with no doubt one of the most feared diseases today, and though there are prevention and early detection methods available, it stills seems to be one of the modern common causes of death. Cervical cancer, more specifically, is a gynecologic cancer that affects many women in the United States, fortunately, incidence and mortality rates have dropped over the years. However numbers are still high, in 2007 12,280 women in the United States were diagnosed with cervical cancer, that same year 4,021 died from it (Cancer Statistics, 2010). Cancer is a disease in which cells grow out of control in different parts of the body. This type of disease is always named for the part of the body where it starts, even if it spreads to other body parts later. Cervical cancer is a disease that affects only women because of its location: the Cervix. The cervix is the lower, narrow end of the uterus that opens at the top of the vagina. Cervical cancers start in the cells on the surface of the cervix. In this area there are two main types of cells: squamous and columnar cells; most cervical cancers are from squamous cells (PubMed, 2011). The majority of cervical cancers are caused by the human papilloma virus (HPV), which is a common virus that is spread through sexual intercourse. This virus will be present in about 50% of women, but only in a small percentage will it develop into cancerous cells. Cervical cancer develops very slowly in its early stages and therefore most of the time it has no symptoms. However, when symptoms do occur the most common are abnormal vaginal bleeding between periods, after intercourse, or after menopause; continuous vaginal discharge which may be pale, watery, pink, brown, bloody, or foul-smelling; and heavier and longer menstrual periods. Symptoms of advanced cervical cancer may

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include back and leg pain, bone pain or fractures, fatigue, leaking of urine or feces from the vagina, loss of appetite, pelvic pain, single swollen leg, and weight loss (Cancer Network, 2011). Cervical Cancer is identified through testing. Pap smears are tests which can find cervical pre-cancer before it turns into cancer (Institute of Health, 1996). If abnormalities are found the patients cervix will usually be examined under magnification. This process is called colposcopy, in which pieces of tissue are biopsied (surgically removed) during this procedure and sent to a laboratory for examination. If the results are positive then further analysis will be done to determine how far the cancer has spread. These analysis can be done through, chest x-ray, CT scan of the pelvis, cystoscopy, intravenous pyelogram (IVP), or MRI of the pelvis (Smith, 2010). As mentioned above, having sexual intercourse will increase the chances of acquiring HPV, which is the major cause of cervical cancer. An article by the Disease Markers Journal states that: The association is causal in nature and under optimal testing systems, HPV DNA can be identified in all specimens of invasive cervical cancer. As a consequence, it has been claimed that HPV infection is a necessary cause of cervical cancer. The evidence is consistent worldwide and implies both the Squamous Cell Carcinomas (SCC), the adenocarcinomas and the vast majority (i.e. > 95%) of the immediate precursors, namely High Grade Squamous Intraepithelial Lesions (HSIL)/Cervical Intraepithelial Neoplasia 3 (CIN3)/Carcinoma in situ. (Bosch, 2007)

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But other risk factors include giving birth to many children, having many sexual partners, having first sexual intercourse at a young age, smoking cigarettes, using oral contraceptives and having a weakened immune system may increase the chances of acquiring cervical cancer. (Noller, 2007). In regards to the epidemiology of cervical cancer, we know that cervical cancer only affects the female population. A study on disparities in cervical cancer between 1992 and 2003 found that the mean age for cervical cancer diagnosis for all women is 48.214.0. Furthermore it concluded that Hispanics and African American women presented the highest incidence rates in the U.S (McDougall, 2007). Today according to the CDC, the majority of cases are roughly seen in women 30 years of age and above and still affect mostly African American and Hispanic women. Now if we continue to subdivide groups affected by cervical cancer, we find that socioeconomic status also accounts for the majority of the racial/ethnic disparities in cervical cancer incidence. The table below shows the subdivision of groups by annual income and its corresponding data according to race, where again Hispanics and African Americans are at a disadvantage.

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The CDC provides information on mortality rate from 19992007 which highly fluctuates depending on their race and ethnicity. The graph below shows that in between 1999 and 2007, black women were more likely to die of cervical cancer than any other group. Hispanic women had the second highest rate of deaths from cervical cancer, who were followed by women who are American Indian/Alaska Native, white, and Asian/Pacific Islander. (CDC, 2010)

The geography of cervical cancer according to the most recent data collected is mostly concentrated in the states of Alabama, Arkansas, Delaware, District of Columbia, Florida, Kentucky, Louisiana, Mississippi, New Jersey, Oklahoma, Texas, and West Virginia Prevalence, with rates varying from 8.5 to 11.2 (Watson, 2008). Data from the National Health and Nutrition Examination Survey published in the Journal of the American Medical Association (JAMA) showed an estimate of the prevalence HPV infection among women in the United States aged 14 to 59. The

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investigation found that 26.8 percent of women overall tested positive for one or more strains of HPV, this with a confidence interval of 95% [CI], 23.3%-30.9% (Dunne, 2007). Still following the epidemiology of cervical cancer and to assess treatment, a study was conducted to evaluate the efficacy of postoperative concurrent chemoradiotherapy (CCRT) and investigate the recurrence and survival rates after CCRT was used in high-risk early patients. From July 1994 to June 2001, medical records were retrospectively reviewed for 151 patients. CCRT was performed in 30 patients with high-risk factors such as possible lymph nodes or positive surgical margins. Chemotherapy consisted of cisplatin (70 mg/m2 on day 1) and 5-fluorouracil (5-FU; 1000 mg/m2 on days 25) for four cycles every 4 weeks beginning 23 weeks after surgery. Pelvic radiotherapy was started concurrently at the second and third cycle of chemotherapy. Recurrence pattern and survival rates of 114 patients (control group) who received no therapy after surgery were also analyzed. The mean follow-up period was 49 months. The results came up to be 3 recurrences in patients after CCRT (10%) and 5 recurrences in the control group (4.4%). The actuarial 5-year overall survival rates for patients in CCRT and control group were 96.7% vs. 97.7% [and] the progression-free survival rates were 88.7% for the high-risk group and 95.4% for the non-high-risk group. The results of this study indicated that concurrent chemoradiotherapy seems to be effective in specific stages (IA2IIA) of cervical cancer patients with high-risk factors (Ryua, 2005). Treatment of cervical cancer depends on the stage of the cancer, the size and shape of the tumor, the general health of the patient among many other factors. Early cervical cancer can be cured by removing or destroying the cancerous tissue from the

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cervix (PubMed, 2011). There are various surgical ways to do this without removing the uterus or damaging the cervix. A loop electrosurgical excision procedure (LEEP) is used to electrically remove any abnormal tissue, while Cryotherapy freezes the abnormal cells. A hysterectomy, or a removal of the uterus keeping the ovaries, is not often performed for cervical cancer that has not spread, but it may be done in women who have repeated LEEP procedures. Treatments for more advanced cancer include radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina. Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed (Dunne, 2007). Radiation and Chemotherpy, as mentioned in the previous study, are also treatment used for not only cervical cancer, but cancers in genera. Radiation (internal or external) may be used to treat cancer that has spread beyond the pelvis, or cancer that has returned. Chemotherapy uses drugs to kill cancer. Some of the drugs used for cervical cancer chemotherapy include 5-FU, cisplatin, carboplatin, ifosfamide, paclitaxel, and cyclophosphamide (PubMed, 2011). Ways to prevent cervical cancer include screenings, such as pap smears. This particular test, according to the CDC, has made a significant difference in the reduction of incidence in the last 40 years. Also in June 2006, the U.S. Food and Drug Administration (FDA) approved the vaccine Gardasil, which prevents infection against the two types of HPV responsible for most cervical cancer cases (PubMed, 2011). Other ways of prevention are the practice of safe sex to reduce risk of HPV transmission, limitation in number of sexual partners, avoiding high-risk sexual activities. Smoking has

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also been associated with an increased risk of cervical cancer, so quitting smoking will also help prevent the risk of developing it. Cervical cancer, though more preventable nowadays, it still continues to be a medical challenge in our society, but it is important that epidemiologists understand the distribution of such disease in order to find better and more effective treatments. And maybe in a future the 5 year survival rate will no longer be the norm for any cancer.

Cervical Cancer Works Cited

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Bosch, F. , & de Sanjose, S. The epidemiology of human papillomavirus infection and cervical cancer. Disease Markers, (2007). 23(4), 213-227. Center for Disease Control. Gynecologic Cancers. Cervical Cancer Rates by Race and Ethnicity: Death Rates by Race/Ethnicity. (2010). Available at www.cdc.gov/cancer/cervical/statistics/race. htm Chien L., E. Kathleen A., Lisa C. Treating cervical cancer: Breast and Cervical Cancer Prevention and Treatment Act patients. American Journal of Obstetrics and Gynecology. (2011) Volume 204, Issue 6 533.e1533.e8. Dunne E., Unger E., Sternberg M., McQuillan G., Swan D., Patel S., Markowitz L. Journal of the American Medical Association. Prevalence of HPV infection among females in the United States. (2007) 297(8):813-9. McDougall, J. , Madeleine, M. , Daling, J. , & Li, C. (2007). Racial and ethnic disparities in cervical cancer incidence rates in the united states, 1992-2003. Cancer Causes & Control, 18(10), 1175-1186. National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: Cervical Cancer Screening. v.1.2011. National Institutes of Health. Cervical Cancer. NIH Consensus Statement. 1996;14(1):138. Noller KL. Intraepithelial neoplasia of the lower genital tract (cervix, vulva): Etiology, screening, diagnostic techniques, management. In: Katz VL, Lentz GM, Lobo RA,

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Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 28. PubMed Health. Cervical Cancer: Cancer- Cervix. A.D.A.M. Medical Encyclopedia. Reviewed Dec 15, 2011. Available at: www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001895/ Ryua H., Mison C., Ki-Hong C., Hye-Jin C., Jung-Pil L. Postoperative adjuvant concurrent chemoradiotherapy improves survival rates for high-risk, early stage cervical cancer patients. (2005) V 96-2, Pps 490495. Smith RA, Cokkinides V, Brooks D, Saslow D, Brawley OW. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2010;60:99-119. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 19992007 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2010. Available at: http://www.cdc.gov/uscs. Watson, M., Saraiya, M., Benard, V., Coughlin, S. S., Flowers, L., Cokkinides, V., Schwenn, M., Huang, Y. and Giuliano, A. (2008), Burden of cervical cancer in the United States. Cancer, 113: 28552864. doi: 10.1002/cncr.23756