Cancer du col de l'utérus

The cervix connects the uterus to the vagina and consists of two main parts:

• the exocervix, the outer part visible during a gynecological examination, 

• the endocervix, the part forming the canal connecting the vagina to the uterus. 

Most cervical cancers develop at the junction between the endocervix and the exocervix, called the transformation zone.

Cervical cancer is preceded by the appearance of abnormal cells in the cervical tissue. Over time, abnormal cells can turn into cancer cells and begin to grow and spread deeper into the cervix and surrounding areas.

During the early stages of this condition, cervical cancer may be asymptomatic. Once the tumor has begun to grow, symptoms may appear, such as:

• vaginal bleeding after sexual intercourse, between periods, or after menopause,

• unusually heavy or prolonged periods,

• unusual or foul-smelling discharge, 

• pelvic pain or pain during intercourse, or 

• unusual fatigue.

In 90% of cases, cervical cancer results from a persistent human papillomavirus (HPV) infection.
   
HPV infections are very common. The vast majority of sexually active people will be infected at some point in their lives. In most cases, the virus is eliminated by the immune system, but sometimes the infection persists and can cause either genital warts or precancerous lesions. 
 
There are more than 200 strains of HPV. Strains 16 and 18 are among the so-called high-risk strains and are responsible for more than 70% of cervical cancer cases. Persistent infection with a high-risk strain can cause dysplasia or intraepithelial lesions, which are considered precancerous and can develop into cervical cancer.
  
Strains 6 and 11, known as low-risk strains, most often cause genital warts.

Since cervical cancer is most often the result of HPV infection, which is sexually transmitted, the primary risk factor is the number of sexual partners. 

Other risk factors include:

No other cancer can be prevented as effectively as cervical cancer. Screening and vaccination are therefore essential.

In Switzerland, screening is carried out at the initiative of women or their doctors. There is no organized screening program as there is for other cancers such as breast or colon cancer. A cervical smear, known as a Pap test, is recommended to screen for cell abnormalities every three years for women between the ages of 21 and 29. For women between the ages of 30 and 70, either a cervical smear or an HPV test is recommended every three years. This frequency may vary depending on the results of previous tests. The HPV test, which is not currently covered by Swiss basic insurance, can detect the presence of high-risk HPV strains and thus allow for more regular monitoring. In the event of abnormal results following a Pap smear or HPV test, or in the event of worrying symptoms, a colposcopy will allow the condition of the cervix to be viewed and cervical tissue to be sampled for biopsy of suspicious tissue.

A sentinel lymph node biopsy may also be performed in some cases.

An endoscopy or hysteroscopy, which involves inserting a lighted optical tube into the uterus through the cervix, allows the uterine cavity to be visualized. During this procedure, cells may be collected by curettage for analysis.

Other tests may be necessary to confirm the diagnosis and determine the stage of the cancer:

• imaging: PET-CT scan, MRI, ultrasound, chest X-ray,
• laboratory tests,
• visual examinations: cytoscopy to examine the bladder and urethra; sigmoidoscopy to examine the rectum and colon.

Classification

There are four stages of cervical cancer, each of which is further subdivided into sub-stages. 

Stage 1: the tumor is confined to the cervix
Stage 2: the tumor extends beyond the cervix
Stage 3: the tumor has invaded the lower third of the vagina and/or spread to the pelvic wall
Stage 4: the tumor has spread to neighboring organs and/or formed metastases

There are various treatment options for cervical cancer or precancerous lesions. The choice of treatment will depend on the stage of the cancer, but also on the patient's general health and whether she wishes to become pregnant.

Active surveillance:

Given that in a large proportion of women with low-grade or intermediate-grade precancerous lesions, the cellular changes regress spontaneously, a wait-and-see approach may be adopted, with a Pap smear 6 months after diagnosis to monitor progress.

Laser vaporization:

Some low-grade or intermediate-grade precancerous lesions can be removed with a laser. This can usually be done under local anesthesia, but has the disadvantage of destroying the affected tissue without allowing a biopsy to be performed.

Cone biopsy:

Surgical conization is suitable for high-grade precancerous lesions or very early-stage cervical cancer. The affected part of the cervix is cut out in a cone shape. This method preserves the uterus and the possibility of pregnancy. In this case, however, the cervix will be weakened and the risk of miscarriage or premature birth will be increased.

Trachelectomy, cervicectomy, or extended conization:

Intended primarily for patients who plan to become pregnant, this technique involves removing either only part of the cervix (simple) or also part of the uterine support structure and part of the vagina (radical).

Surgery with removal of the uterus (hysterectomy):

Depending on the type, location, and stage of the cancer, this surgery may also involve other nearby organs such as the lymph nodes, upper vagina, ovaries and fallopian tubes, bladder, or rectum.

Radiochemotherapy:

This technique involves administering drugs that make tissues and therefore cancer cells more sensitive to the effects of radiation.

Radiotherapy:

Radiation destroys cancer cells or prevents them from proliferating by damaging their DNA. Radiotherapy can be external or internal. This technique can also be used as palliative treatment to alleviate the symptoms of cervical cancer and improve the quality of life of patients with advanced-stage cancer.

Chemotherapy:

Drugs stop the growth of cancer cells by either destroying them or preventing them from dividing. Chemotherapy can be used as a single treatment or in combination with other treatments.

Targeted therapies:

Drugs or other substances can block the action of certain enzymes, proteins, or molecules involved in the growth and proliferation of cancer cells.

Immunotherapy:

Immunotherapy aims to give the patient's immune system the means to fight cancer cells.

The risk of HPV infection or untreated cervical cancer is the spread of cancer cells to neighboring areas such as the rectum, vagina, bladder, and affected lymph nodes.

Since the main cause of cervical cancer is persistent HPV infection, vaccination against HPV is the primary preventive measure for this type of cancer. The vaccine currently available protects against the nine most common and virulent strains of HPV (6, 11, 16, 18, 31, 33, 45, 52, 58). HPV 16 and 18 are responsible for 70% of cervical cancers.

Vaccination is ideally recommended before any exposure to the virus, i.e., before the onset of sexual activity. In Switzerland, it is recommended for all adolescents, both girls and boys, between the ages of 11 and 14, with the possibility of catch-up vaccination up to the age of 26. However, vaccination remains beneficial even after the onset of sexual activity. It can and should be considered for all individuals who may not have been exposed to all strains covered by the vaccine. Thus, it can be offered at any age, although financial coverage is not always guaranteed beyond the age limits recommended by vaccination programs.

A Pap smear is also recommended for all women every three years, in the absence of abnormal results, until the age of 70. As HPV vaccination does not protect against all HPV infections, this test is recommended even for vaccinated women.

In addition to regular check-ups with a gynecologist and regular Pap smears, a medical consultation is necessary as soon as any of the above symptoms appear.

The treatment of cervical cancer will depend on its stage and the patient's wishes. At Hôpital de La Tour, our multidisciplinary teams of highly specialized doctors and caregivers work together to determine the best treatment strategy in order to provide the best care for our patients. A dedicated nurse ensures personalized follow-up for each woman, tailored to her specific concerns and needs.

What are the main symptoms of cervical cancer?
Abnormal vaginal bleeding, signs of pelvic infection

What is the prognosis for cervical cancer?  
The 5-year survival rate after diagnosis of early-stage cervical cancer is 91%. When the cancer has spread to surrounding tissues or regional lymph nodes, the survival rate is 60%.

What are the treatments for cervical cancer?
In the early stages, in the event of cellular changes (dysplasia), conization is the standard treatment. In advanced stages, removal of the uterus may be necessary. In some cases, this surgery may be supplemented by chemotherapy, radiotherapy, immunotherapy, or other targeted therapies.

Can cervical cancer be prevented?
Yes, by getting vaccinated and following screening recommendations. A healthy lifestyle helps prevent not only cervical cancer but also several other cancers and diseases.

What are the implications for fertility?
In women of childbearing age, precancerous lesions can sometimes be treated with conization. However, this technique weakens the cervix, putting the woman at greater risk of miscarriage or premature birth.