Nearly 3,000 women are diagnosed with cervical cancer each year, recalls Public Health France. However, according to the WHO, this disease could be totally eliminated thanks to screening and the vaccine which prevents human papillomavirus (HPV) infections. What warning symptoms? At what age ?
[Mis à jour le 31 janvier 2022 à 10h00] Cervical cancer would affect almost 3,000 women each year. 1,100 women die from it, according to latest figures from Public Health France for January 2022. Cervical cancer is the 12th leading cause of cancer death in the woman. However, for the World Health Organization, the Cervical cancer could be totally eliminated thanks to two interventions: screening and vaccinationwhich prevents human papillomavirus (HPV) infections included in the vaccine. It is a cancer with a good prognosis. with a 5-year survival rate of 63% for the period 2010/2015. What are the warning signs of this cancer? The causes and risks of transmission? How to protect yourself through screening? What are the most effective treatments to cure it? Know everything.
Definition: what is cervical cancer?
L’uterus is a female genitalia preponderant for reproduction, since it is at its level that the whole pregnancy will take place. Nevertheless, this organ can be affected by cancerous tumours, of which there are 2 types:
- cervical cancer,
- endometrial canceranother name for the uterine lining, the layer of cells lining the inside of this cavity.
“Endometrial cancer is cancer of the body of the uterus and not of the cervix. On the other hand, there are glandular cancers of the cervix called adenocarcinomas. They are not dependent on the papillomavirus discovered on the smear. These are rarer but have a poorer prognosis.“, details Dr. Philippe Mironneau, gynecologist and obstetrician in Dijon.
What is the average age of diagnosis?
According to an epidemiological bulletin published in September 2019 by Public Health France, 40% of cases are diagnosed in women under the age of 50, the median age being at 53 years and thehighest incidence is observed in women aged 45-49. This cancer causes 1,100 deaths per year.
What are the stages of cervical cancer?
For each cancer, different stages exist to define a level of severity and the extent of the disease. Regarding cervical cancer, the disease is classified into four stages ranging from 1 to 4. The higher the number, the more the cancer has spread. When it is called “local” it has not spread to other areas of the body.
What are the symptoms ?
There are few specific signs that can reveal cervical cancer. Among them :
- From bleedingoften triggered by sexual intercourse
- From pains pelvic (lower abdomen)
- From vaginal discharge smelly or heavier than usual.
In case of persistent gynecological symptoms, it is necessary to speak about it to the doctor who will be able to prescribe a smear and confirm a diagnosis. He will examine the cervix and if he finds any abnormalities, he will perform a biopsy directly to the office. In some cases, it may a colposcopy with the application of dyes which will highlight any lesions, even if the lesions are generally seen on biopsy.
What are the causes ?
Cervical cancer is the consequence of a persistent infection with a papillomavirus human (HPV) oncogenic. There are more than 100 types of HPV but two of them, HPV 16 and 18, are responsible for approximately 70% of cervical cancers in industrialized countries, such as France.
What are the risks of transmission?
Contamination mainly takes place during unprotected sex. The HPV virus is then transmitted by simple contact with the skin and mucous membranes and reaches around 80% of people who have sex.
60% of HPV infections occur during the first year of sexual life.
It is recommended to be vaccinated before the start of sexual life since 60% of HPV contaminations occur during the first year of sexual life.
What are the risk factors?
The risk factors include:
- early first sexual intercourse,
- multiple partners,
- an infection of the partner(s) with HPV or other sexually transmitted infections,
- the tobacco.
Prevention: what does screening consist of?
If the screening is positive, it does not mean that there is cancer but that the virus or abnormal cells have been detected. In this case, additional examinations may be prescribed.
Cervical cancer prevention begins with screening for pre-cancerous and cancerous lesions caused by the human papilloma virus. It is based in particular on the regular practice of a smear which, by taking cells from the cervix, allows analysis under a microscope. At the same time, in July 2019, the Haute Autorité de Santé (HAS) recommended that the HPV test replaces Pap smear in primary screening for cervical cancer in women aged 30 and more. It is based on a levy at the level of the cervix which makes it possible to detect abnormal cells as early as possible (cytological examination) or the presence of the papillomavirus (HPV test). If the screening is positive, it does not mean that there is cancer but that the virus or abnormal cells have been detected. In this case, additional examinations may be prescribed. If precancerous lesions are detected by these additional examinations, they can be treated before the appearance of cancer. If cancer is detected, it will usually be detected at an earlier stage and can be treated with lighter care to preserve fertility further.
► The screening test must be performed within the recommended time intervals:
- All 3 years between 25 and 29 years old (after 2 tests carried out 1 year apart and whose results are normal)
- All 5 years between 30 and 65 years old.
Women who have not undergone screening within the recommended time intervals are invited by mail to carry out one and benefit from100% support for the test, without upfront costs, by their health insurance plan. These two provisions aim to facilitate access to screening for women who benefit little or not from it, whatever the reasons. In order to guarantee equitable access throughout the territory, sampling can be carried out by:
- a gynecologist,
- a general practitioner
- a midwife
- also in the biology laboratory on medical prescription.
Since March 24, 2020 (law published in Official newspaper), the HPV test is reimbursed by health insurance for women aged 30 to 65. This test is also reimbursed for all women treated for a precancerous lesion and also in situations of diagnostic doubt, after an abnormal smear. The reimbursement of the HPV test thus allows all women to benefit from optimal screening, which was until now reserved for those who could afford it, indicates the French Society of Colposcopy and cervico-vaginal pathology in a press release. Before the age of 30, it is recalled that the woman can benefit from a cervico-uterine sample called until now “smear” in liquid medium which makes it possible to carry out a cellular examination called cytology.
Does the condom reduce the risks?
The infection is common in women from their first sexual intercourse. The risk of infection increases with age and the number of partners. The use of condoms (female condom and male condom) during sexual intercourse makes it possible to limit the transmission of the virus but does not allow a complete eviction of any contact, because it is present at the level of the genital mucous membranes which are not covered by the condom.
Who should get vaccinated against HPV?
As cancer of the cervix is caused by an oncogenic papillomavirus (HPV), vaccination is to protect against this infection, from an early age. Vaccination against HPV infections was introduced into the French vaccination calendar in 2007. Three vaccines are available in France : a quadrivalent vaccine marketed since 2007, a bivalent vaccine since 2010 and a nonavalent vaccine since 2018. Vaccination is recommended in girls and boys aged 11 to 14 (with possible catch-up vaccination up to 19 years old): two doses between 11 and 14 years old or three doses between 15 and 19 years old. This vaccine does not offer protection against all carcinogenic papillomaviruses, nor against existing infections. He protects against 70 to 90% of HPV. Vaccination does not prevent the realization of the smear from the age of 25.
► Vaccination coverage of HPV vaccine among teenagers has been on the rise for several years but it remains insufficient. In 2020, it was estimated at 41% for a dose at 15 years (vs. 35% in 2019) and 33% for the complete scheme at age 16 (vs. 28% in 2019), indicates Public Health France.
In the face of an evocative clinical sign or during a screening examination, certain examinations are common.
- Examination with a speculum, a plastic tool allowing the cervix to be visualized, favors the identification of a possible lesion.
- If a lesion is present, samples will be required. These are usually done during general anesthesia where biopsies (samples) of suspicious areas will be taken and sent for analysis to identify their nature.
- An MRI can also complete the assessment as well as an ultrasound passing through the vagina.
- In the event of proven cancer, an extension assessment will be necessary, that is to say the search by various examinations for other locations of the cancer by cell migration.
The assessment evaluates the local and regional extension of the tumour. Local extension includes tumor size, invasion of neighboring organs and lymph nodes. The general extension includes the extension of the cancer and the existence of metastases in the lungs or the liver for example. A CT scan of the pelvis, an MRI of the abdomen, a chest X-ray or a pelvic ultrasound can be performed. Liver ultrasound and bone scintigraphy may be performed.
What are the treatments ?
The treatments offered are:
- surgery,
- radiotherapy,
- chemotherapy.
These examinations can be performed in isolation or in combination according to the protocols decided. The “conization” only removes part of the cervix. This procedure leaves part of the cervix in place. In the woman who has not had children, the intervention will always be as limited as possible… The surgeon is sometimes obliged to perform a hysterectomythat is to say a total removal of the uterus: This is usually accompanied by a control, or even the removal of the locoregional lymph nodes.
Thanks to Dr Philippe Mironneau, gynecologist and obstetrician in Dijon.
Source: Weekly Epidemiological Bulletin, Public Health France, Prevention of cervical cancer, n°22-23, September 17, 2019.