Gynecological Cancer – 2 Cervix Treatment of Localized disease

Gynecological Cancer  – 2

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for this very interesting and important information. Cervix cancer is a result of HPV infection in most cases, how it is acquired, and how a vaccine can prevent it. So essentially this is a first vaccine against at least one common cancer in fact. Also, PAP smear is able to detect pre cancerous changes up to 5 years in advance, and that too is such an easy, inexpensive and outpatient test.
HOPE OUR READERS WOULD REMEMBER AT LEAST THESE TWO POINTS AND APPLY IN THEIR PRACTICE, FAMILIES, FRIENDS…

HPV Vaccine
PAP Smear
Ans: Thank you for re emphasizing. Everyone asks if cancer can be cured, prevented, can they do anything etc. EVEN IF MOST WOMEN ADOPT JUST ONE OF THESE TWO MEASURES, cervix cancer can be reduced by about 80% in India, that means we can save about 1 lac lives just from one cancer. Just as in USA, I believe all general practitioners and physicians in India (at the least women doctors) should also learn how to collect PAP smear. And more NGOs should provide support for this test, rather than PSA, mammogram etc tests with much lesser efficacy, and higher cost too.
Que: That is a very good point as well. Now, can you tell us how to evaluate and treat a patient with suspected cervix cancer?
Ans: Sure. But first let me remind you, that for pre cancerous lesions, detected by PAP smear (known as CIN stage), no further evaluation is required. They are directly treated by something known as colposcopy (kind of endoscopy of vagina one may say) where the abnormal area is excised. This is an outpatient procedure, requiring no general anesthesia, and patient goes home same day.
For invasive cancer, evaluation is like most other cancers, involving biopsy confirmation and staging. Staging for cervix cancer has traditionally been done mainly using local examination, with minimal old tests like IV Urography (as per FIGO staging system). However, now that CT scan/MRI are much more widely available, most oncologists would prefer these over IVU. This is also important since the treatment is now chemoradiation in large majority, rather than surgery. And lymph node involvement, if identified by CT/MRI requires adjustment of radiotherapy fields to include these nodes. Some centers would even perform a PET-CT scan to ensure there are no nodes involved, in higher stages, especially to rule out para aortic node involvement. If a CT/MRI is done, IVU is not required.
If creatinine is high, it is extremely important to ensure it is not due to ureteric obstruction by tumor.
In very early stages, such as non bulky stage 1 (and even stage 2A), surgery is preferred. There are experts who do recommend chemoradiation even for many of these patients. Among patients who are surgically treated, some of them need postoperative radiation or chemoradiation. Choice depends on various factors, mainly risk level. Intermediate risk only radiotherapy. High risk chemoradiation. High risk features include positive surgical margins, parametrial extension, involvement of lymph nodes. It is good to know that overall survival (cure rates) are very high in stage 1, low risk patients, in the range of about 90%.
In India, majority patients however present in stage IB2-4. For such patients, preferred treatment is CHEMORADIATION. This is based on enough scientific data and hence recommended by all guidelines too. Many patients and doctors too, in India, believe that if a patient has been asked to undergo chemoradiation rather than surgery, it must be because tumor is “too advanced for surgery”. Studies have clearly shown that in stage IB2 to 4, chemoradiation provides better survival compared to surgery, followed by chemoradiation. Also, the toxicity is doubled when a patient undergoes surgery followed by chemoradiation, compared with only chemoradiation. Most patients in these stages, will need postoperative chemoradiation due to high risk features as mentioned above. Hence guidelines recommend proceeding directly to chemoradiation, and exclude surgery in these stages.
Traditionally, in India, we have had very few centers with good radiotherapy facilities. Hence at most places, surgery remained mainstay of treatment even in advance stages. Also, when radiotherapy facilities are at long distance, even patients prefer that due to logistics issues. WE MUST RECOGNIZE HOWEVER THAT standard of care is chemoradiation, not surgery. And that if patient is living in a city or close to a place where GOOD radiotherapy facility is available, they must be offered this option as first choice.
January 14th 2016.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com