CERVICAL cancer is the second most common cancer in women worldwide, and is the leading cause of deaths in developing countries like Jamaica. Half a million women are diagnosed with cervical cancer yearly and every two minutes a woman dies from the illness.

The age-specific rate in the Caribbean is 33.5/100,000 with a rate of 27.9/100,000 in Jamaica. The death rate is 15.8/100,000 in Jamaica. Mortality rates vary widely by region, with the highest rates seen in the poorest countries, primarily because of the unavailability of effective screening programmes.

Almost all cases of cervical cancer are linked to a human papillomavirus (HPV) infection of the cervix, which is the lowest part of the womb. There are more than 100 subtypes of HPV. Most are benign, but certain types, such as HPV 16 and 18, are linked to cervical cancer.

The virus is transmitted sexually and HPV infection has no symptoms. Most women’s immune system will clear the infection, but some persist, resulting in the development of cancer.

Those at risk include:

• Women with high risk HPV (16 and 18);

• Women older than 30;

• Women who smoke;

• Women who have a suppressed immune system (HIV/Diabetes);

• Women who had an early onset of sexual intercourse;

• Women who use the pill;

• Women of lower socio-economic status;

• Women who have multiple sexual partners;

• Women with a history of teen pregnancy.

SYMPTOMS

Early-stage cancer may have no signs or symptoms. Later stage cancer may present with the following: Abnormal vaginal bleeding; foul-smelling discharge; bleeding after sex.

Advanced cancer may present with pelvic or back pain, difficulty passing urine or kidney failure, loss of appetite, weight loss or leg swelling.

There are steps that should be taken to prevent cervical cancer.

1. Women between the ages of nine and 26 years should get the HPV vaccine, which should be given before the onset of sexual activity.

2. Every woman should have regular pap smears, beginning at the onset of sexual activity or age 21.

3. Be monogamous, practice safe sex and avoid smoking.

THE RADIOLOGIST’S ROLE

Cervical cancer can be cured if caught at an early stage.

The radiologist often becomes involved with staging established cervical cancer. Whereas the introduction of cervical cancer screening programmes and treatment strategies have caused a reduction in mortality rates in industrialised nations, there has been little change in developing countries where tumours are usually detected at an advanced stage.

The International Federation of Gynaecology and Obstetrics (FIGO) staging system — a way for members of the cancer care team to summarise the extent of a cancer’s spread — is the most widely accepted method for staging cervical cancer. Cancer staging is fundamentally important in treating patients with cancer and must be reliable, reproducible and practical. Consensus must be established to enable treatment planning, assess tumour response, predict prognosis, and allow information to be shared between different treatment centres. Identical cases should be assigned the same stage so that consistent management decisions can be made and outcomes can be predicted within reason.

Cervical carcinoma continues to be staged at clinical examination, with anaesthesia and often with cystoscopy and sigmoidoscopy (scoping the bladder and sigmoid colon) according to the FIGO classification system.

There are acknowledged discrepancies between tumours staged at clinical examination according to the FIGO staging system and those that are staged at surgery, with an error rate as high as 32 per cent in patients with stage IB disease and 65 per cent in patients with stage III disease.

In addition, clinical staging has been shown to be limited in evaluating important factors such as spread outside the uterus and to the pelvic sidewall, tumour size, and lymph node spread. Overall, the accuracy of magnetic resonance (MR) imaging for depicting tumour size is 93 per cent, whereas that of clinical staging is less than 60 per cent.

At first glance, it might seem that physical examination should be abandoned for more accurate methods of staging. Remember though that the highest incidence of cervical cancer resides in developing countries where the patients have limited access to high-quality imaging because of cost or availability.

The revised FIGO staging now recommends performing computed tomography (CT) or MR imaging where available. For my referring colleagues, CT is of limited benefit for local staging, but it is able to show extrauterine spread of disease, including large lymph nodes, fistulation into the bladder or rectum, and distant metastasis.

In contrast, MRI is able to show the extent of local disease with great accuracy. As a rule of thumb, disease, which is thought to be limited to the pelvis, is best imaged with MRI. Chest radiography, CT, or positron emission tomography CT may be considered in patients with distant disease spread.

The details of the individual FIGO stages are not necessary for the purposes of this article, however the following is relevant:

1. 1B tumour is the first clinically visible stage.

2. Stage IIB tumour extends outside the uterus. This is not treated surgically; radiotherapy is utilised.

3. Stage III tumour extends to pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis.

4. Stage IV tumour invades mucosa of bladder or rectum and/or extends beyond the true pelvis.

The stages are further divided based on size of the mass and extent of spread.

The take-home message is that imaging is vitally important for first visualisation of the mass, determining if the mass can be removed surgically, and determining the extent of metastatic spread.

The ideal arrangement for management of any cancer involves a tumour board comprised of radiologists, surgeons, oncologists and other relevant specialists. The idea is for all the specialists to get together to plan the specific intervention for the surgical patient. Outside of a hospital setting, collaboration is more difficult, but I would still implore all the relevant specialists involved in the care of these patients to get to know their radiologists. We are always happy to contribute to patient management.

Dr Duane Chambers is a consultant radiologist and founding partner of Imaging and Intervention Associates located at shops 58 and 59 Kingston Mall, 8 Ocean Boulevard. He may be contacted through the office numbers 618-4346 or 967-7748.