Q: Where does cervical cancer occur? Does cervical cancer occur in the first place among gynecological tumors?
A: The vagina is connected to the outside of the body and above the cervix is the uterus. Cervical cancer occurs in the location of the cervix and further development will spread to other places. Among the common gynecological tumors, cervical cancer ranks second only to breast cancer. There are about 500,000 new cases of cervical cancer worldwide every year, 80% of which occur in developing countries, and there are about 130,000 cases in China, accounting for about 1/3 of the total number of cases.
Q: Are there any symptoms of cervical precancerous lesions?
A: 1. Bleeding after sex. 70%-80% of cervical cancer patients have this symptom; 2. Cervical erosion. Young women who have cervical erosion for a long time or still have cervical erosion after menopause should pay attention to it; 3. Contact bleeding, bleeding after sex or uterine bleeding after gynecological internal examination are signs of cervical precancerous lesions; 4. Mixed blood in leucorrhoea, except for uterine bleeding caused by IUD, women with mixed blood in leucorrhoea for a long time should be examined in time.
Q: What are the methods to screen and confirm the diagnosis of cervical cancer?
A: According to medical history and clinical manifestations, especially those with contact bleeding, the possibility of cervical cancer should be thought of. Detailed general examination and gynecological examination should be done, and the following auxiliary examinations should be used: ① cervical cytology examination; ② iodine test; ③ cervical and cervical canal biopsy; ④ colposcopy; ⑤ conical hysterectomy.
Q: At what age are women prone to get cervical cancer?
A: Any woman between 20 and 70 years old can get cervical cancer, and the high incidence age is 40-50 years old. Fewer women get cervical cancer before 20 years old, but in recent years there is a rising trend of young women getting cervical cancer, and there are reports of 16 or 17 year old virgins getting cervical cancer.
Q: What is the current cure rate of cervical cancer?
A: The recovery of cervical cancer is generally better after cure, mainly depending on which stage of the disease the cervical cancer is in. After in situ cancer is detected, the healing effect is quite good, the five-year survival rate can reach 100%, the five-year survival rate of middle stage is about 70~80%, and the five-year survival rate of late stage is only about 30~50%. Therefore, as long as cervical cancer is detected early and diagnosed early, the treatment outcome is quite good.
Q: What treatment measures are available for cervical cancer?
A：Surgical treatment (extensive hysterectomy + pelvic lymph node dissection) is feasible for early stage patients; radiotherapy is feasible for those with middle and late stage or contraindicated to surgery; some patients need combined treatment of surgery and radiotherapy. Chemotherapy is mainly used for patients with advanced stage or recurrent metastasis, or as adjuvant treatment to surgery or radiotherapy.
Q: What are the symptoms of cervical cancer recurrence?
A: The main symptoms of recurrent cervical cancer are pain in one lower limb, soreness in the abdomen and pelvis, vaginal bleeding and foul-smelling leucorrhea. In addition, there are different manifestations depending on the site of recurrence, such as cough, chest pain, hematuria, rectal bleeding, etc.
Q: Prevention of HPV infection = prevention of cervical cancer?
A: HPV (Human Papilloma Virus, Human PaoillomaVirus) is a necessary factor in causing cervical cancer. Without HPV infection, cervical cancer almost never occurs. Currently, humans still lack a definitive approach to deal with HPV. The HPV vaccine under development is the most promising means of prevention and treatment, but only a preventive vaccine is currently available; a therapeutic vaccine has not yet entered clinical trials.
Q: Does HPV infection inevitably lead to cervical lesions?
A: HPV infection does not necessarily lead to cervical lesions, just like hepatitis B. HPV infection is very common and does not cause any symptoms after infection, only persistent HPV infection leads to precancerous lesions (CIN) or cervical cancer. So far, there is no clear and effective medicine for HPV virus. However, HPV virus is as common as a cold virus. Most of them can be cleared automatically if the body has good immunity. So there is no need to panic if you are infected with HPV, but if you continue to be infected, you will need regular follow-up monitoring.
Q: How is the HPV virus transmitted?
A: HPV can be transmitted through saliva, sexual contact and skin-to-skin contact. Even condoms are not effective in preventing the spread of HPV because the virus can survive in any area around the anus and genitals, including areas that cannot be covered by condoms, and can survive for years.
Q: As the incidence of cervical cancer is getting younger, which patients can preserve their fertility?
A: Firstly, she should have a strong demand for fertility and be willing to take some risk of tumor recurrence or metastasis. Secondly, it depends on the stage of the disease. Cervical cancer is divided into 4 stages according to the International Federation of Gynecology and Obstetrics (FIGO) staging system, and each stage can be subdivided into IA1, IA2, IB1, IB2 or IIA1, IIA2, etc.. Among them, IA1 and IA2 belong to microscopic early invasive carcinoma, with infiltration not exceeding 3 mm as IA1 and between 3-5 mm as IA2, while 1 and 2 in IB1, IB2 or IIA1 and IIA2 are intended to suggest the size of the mass. If the maximum diameter of the mass is more than 4 cm, it is IB2 or IIA2, which is a large mass. Among them, those who are staged as IA1, IA2, IB1 and meet other conditions can be considered to preserve their reproductive function. Again, it is related to the nature of cervical cancer. Squamous cervical cancer and adenocarcinoma meet the above two requirements and can be considered for preserving reproductive function. However, some special types, such as cervical mucinous adenocarcinoma and small cell neuroendocrine tumor, are rare types with very rapid recurrence and metastasis, and fertility preservation is generally not recommended. To summarize, young cervical cancer patients who strongly request fertility preservation and patients with stage IA1, IA2 and IB1 squamous, adenocarcinoma, or adenosquamous carcinoma of the cervix may be considered for fertility preservation.
Q: Is there a critical line between preservable and high-risk?
A: Depending on the extent and conditions of preservation. Some high-risk factors for recurrence and metastasis of cervical cancer are detected by pathological examination, such as: parametrial infiltration, positive cut margins, positive lymph nodes, deep muscle infiltration, vascular involvement, and the specific pathological types mentioned above. All of these can affect the outcome of fertility preservation surgery. For example, some patients have a relatively large mass that happens to be 4 centimeters from the critical lesion, and after the surgery is opened in, it is found that there are already many metastatic lesions inside. At that time, the uterus had to be completely removed and fertility could not be preserved. There are also some patients who are found to have infiltration of the vasculature during surgery, and preserving fertility has the risk of recurrence of metastasis in the short term. Usually, for patients with stage IA2 or IB1 cervical cancer, or stage IA1 patients with vascular infiltration, we first do lymphatic dissection during surgery and all lymph nodes are taken for frozen section. If the results show that the lymph nodes have metastasized, the uterus cannot be preserved. Of course, there are some patients who show negative lymph nodes in the intraoperative frozen section, but then the postoperative pathological diagnosis is reported positive. At this point, the patient has a very difficult decision to make, whether to have a second surgery, remove the uterus, or adjuvant radiotherapy, which destroys fertility, or to risk adjuvant chemotherapy, complete fertility, and continue treatment. Again, another common reason that may influence a change in surgical approach is a positive cutting edge. A patient who can successfully preserve the uterus should have a surgical margin free of any residual lesions and the margin should be at least 3mm away from their lesion.
Q: In lymph node dissection in cervical cancer surgery, is the entire pelvic lymph nodes swept?
A: Firstly, the highest pelvic lymph, i.e. common iliac lymph, should be swept. If the lymph biopsy is positive, fertility cannot be preserved, and the lymph will have to continue to be swept higher up to the abdominal aortic lymph nodes.
Q: If the surgery preserves the uterus but the lymph nodes are found to be positive after surgery, can fertility be preserved through adjuvant therapy?
A: When we encounter this situation, we will give the patient an in-depth communication and tell her the pros and cons of various treatment options. The options available are as mentioned earlier: continuing surgery, radiotherapy, or chemotherapy. For patients with a strong desire to have children, we recommend that the patient complete at least 4 courses of chemotherapy. Prior to chemotherapy, prophylactic medication can be administered to protect ovarian function appropriately. After chemotherapy, if menstruation can be resumed on time, there is a chance of fertility. However, radiotherapy should not be done. Radiotherapy will completely destroy the bad ovarian function, leading to uterine cavity adhesion, radioactive amenorrhea and complete loss of ovulatory function of ovaries.
Q: Does fertility preservation for cervical cancer patients mean preserving the uterus? How can it be preserved? Will it lose its support and prolapse?
A: Fertility preservation for cervical cancer patients means preserving the body of the uterus (where the fetus grows and develops). The uterus is divided into two parts, including the body of the uterus and the lower end of the cervix. In patients with cervical cancer, the lesion grows on the cervix. Surgery for fertility-preserving cervical cancer requires, on the one hand, the removal of a sufficient amount of the lesion and its surrounding tissue (the excised portion is removed vaginally) and, on the other hand, the preservation of the normal body of the uterus.
There is a concern that the preserved uterus will lose its support and will not stay in place. This concern is actually superfluous. The uterus is maintained in this position in the pelvis by a series of ligaments that tug on it and suspend it in the pelvis like a hammock. The surgery requires the removal of the lesion of the cervix, as well as part of the main ligament and the uterosacral ligament. However, the round ligament and part of the broad ligament are kept intact, and there is a lot of fibrous connective tissue that holds the uterus together. Moreover, after removal of the diseased cervix, the lower end of the uterus and the vaginal wall need to be sewn back together. In this way, generally, the body of the uterus remains suspended in the pelvic cavity after surgery, relatively fixed, rather than wobbling around.
Q: How long can a cervical cancer patient get pregnant after surgery?
A: Contraception is recommended for about two years after surgery. This time is mainly for the repair of the lower end of the uterus. The surgery cut off a large piece of the cervix and the lower end of the uterus is almost open. During the operation, we will use a polypropylene sling and tie the lower part of the uterus tightly, which is equivalent to artificially creating a section of the cervix. This wound will take some time to repair, and if you get pregnant too early, the “cervix” may not be fully functional and you may miscarry.
Q: If I have chemotherapy after surgery, how long does it take to get pregnant?
A: It is also two years for contraception. The length of time is not extended by chemotherapy.
Q: Is there any difference between patients with cervical cancer with preserved uterus and other patients in terms of follow-up?
A: This is important, and there are indeed some differences. Patients with preserved uterus need to be reviewed more frequently. For the first two years after surgery, they have to come in for follow-up every 3 months. Each time, you have to check for HPV and do a TCT smear. These are indicators that are closely related to the causation of cervical cancer. If it lasts for 1-2 years and HPV is all high risk positive and fails to turn negative, and the TCT shows abnormalities, it needs to be treated again, preferably with extensive surgical removal of the body of the uterus.
Q: Can these patients have children naturally, or do they need assisted reproduction?
A: Most of them can have children naturally and we encourage them to have children naturally. If other factors of infertility are combined before surgery, such as tubal obstruction or ovarian hypofunction, assisted reproduction is required.
Q: Do these patients have a higher risk of miscarriage and preterm birth than others?
A: Yes. There are many reasons for this. The rate of miscarriage and preterm delivery in the general population is generally less than 10%. According to international data, after cervical cancer surgery that preserves fertility, 40% of people will actually change their minds about not having children, or their conditions will not allow them to have children. Of the remaining 60 percent who want to have children, 60 percent are able to get pregnant; however, about half miscarry in the early stages. About 1/4 of those who eventually manage to have a baby are slightly above this percentage for patients operated on in our hospital. There are also individual reports of 60-70% fertility rates.
Q: Can you prevent miscarriage and premature birth?
A: The purpose of sewing a sling to the lower part of the uterus during surgery is to prevent and reduce the chances of miscarriage and preterm delivery. This sling is non-absorbable and will stay tied there.
Q: How can a patient with cervical cancer in pregnancy insist to keep the fetus, what should I do then?
A: We did encounter such a situation. There was a patient who came to our hospital when she was 18 weeks and 3 days pregnant. She was 1B1 preoperatively and had a large lesion that was exactly 4 centimeters full. She happened to have stage 1B1 cervical mucinous adenocarcinoma, and after seeing many hospitals in Jiangsu and Zhejiang, she was advised to terminate her pregnancy and have her uterus cut out. This is also the standard treatment plan. However, she did not want to give up her first pregnancy, and we wanted to make her whole, since she would never have a chance after the uterus was removed. Therefore, at the patient’s request, we prepared well and performed a laparoscopic pelvic lymph node dissection + extensive hysterectomy. During the operation, we found that the lesion was large and the upper cervical margin was very close to the fetal membranes. If the cut was higher, the cutting edge could be taken more, but the fetal membranes were likely to rupture. However, it was not possible to cut too little in order not to leave residual lesions. We also sutured the opening of the lower end of the uterus in order to save the baby. The postoperative pathology section showed infiltration of her lymphatic vasculature, and the surgical incision margin was less than 3 mm from the lesion. we had advised her to give up, but she refused to give up the opportunity to be a mother and was willing to take the risk. So she was given additional chemotherapy while continuing her pregnancy. She had chemotherapy 3 times during the whole pregnancy. Generally, chemotherapy is not recommended in early pregnancy, 1 month before delivery, for fear that the drugs will affect the fetus. During mid-pregnancy, there are many reports on the safety of chemotherapy. Fortunately, the chemotherapy was completed very successfully. In the meantime, we asked the patient to be bedridden at all times. Finally, we performed a cesarean section on her, and after the fetus came out, a hysterectomy was performed immediately. And after the operation, she was supplemented with simultaneous radiotherapy. It has now been more than 1 year since her delivery. Follow-up visits revealed that the patient is recovering well and the baby is healthy. Similar cases have been reported internationally in more than a dozen cases, with the majority of successful pregnancies. What makes us different from other international cases is that most of them did open and negative surgery, while we are the world’s first to continue pregnancy after extensive laparoscopic hysterectomy in mid-trimester.
Q: Some patients with precancerous cervical lesions worry that the change in estrogen and progesterone levels in the body during pregnancy will affect the course of the disease; others worry that the treatment with conization will affect the pregnancy. Is there such a situation?
A: The cause of cervical cancer is HPV infection, which is not an estrogen-sensitive disease. Therefore, pregnancy does not alter the prognosis of cervical cancer or precancerous lesions. Clinical data show that the overall recurrence and metastasis rates of patients with cervical cancer in combination with pregnancy are no different from those of ordinary patients.
Cervical precancerous lesions are mainly treated by conization. It has no effect on pregnancy after surgery. If you are already pregnant and undergo conization, as long as the conization does not affect the fetus, fetal membranes and placental integrity, you can follow up closely and do not necessarily terminate the pregnancy.