Cervical Cancer

Cervical cancer is the leading cause of death from cancer among women in developing countries. Globally there are 600,000 new cases and 300,000 deaths each year, a nearly 80% occur in developing countries. These facts make cervical cancer ranks second cancer in women in the world, and ranks first in developing countries. Currently, cervical cancer to women's cancer in Indonesia is about 34% of all cancers in women and is now 48 million women in Indonesia in the risk of getting cervical cancer.
Cervical cancer is cancer that occurs in the cervical area of ​​the uterus that connects the top of the uterus with the vagina. The average age of cervical cancer incidence was 52 years old, and the distribution of cases peaked 2 times at the age of 35-39 years and 60-64 years. 

Cervical cancer itself is a malignancy that can be prevented because:
1. Having preinvasif period (before they become malignant) of the old
2. Cytology (cells) to detect early cervical cancer are already available
3. Preinvasif lesion therapy (seeds malignancy) is quite effective

Figure 1. Location Cervical Cancer

Signs and Symptoms
The most common symptom of cervical cancer is abnormal vaginal bleeding or spotting (spotting) of the vagina. Abnormal bleeding is especially true after sexual intercourse, but can occur also between two menstrual bleeding, menorrhagia, or spotting / bleeding postmenopause. If the bleeding lasts for a long time the patient may complain of fatigue and weakness due to anemia experienced. Watery yellowish spots which can be followed with the fishy smell is a sign of malignancy. Symptoms usually only appear when the abnormal cells turn into malignancy and infiltrate into surrounding tissue.
In later stages, patients may complain of smelling vaginal spotting, weight loss, and obstruction (blockage) in urination. If the cancer has spread to the pelvis back pain may occur followed by a bottleneck in urination as well as hydronephrosis (enlarged kidneys). Symptoms of bladder or rectum (hematuri <kencing berdarah>, hematoschezia <CHAPTER bloody>, fistulas) may be associated with spread to the bladder and rectum in invasive tumors.
To become cervical cancer takes up to a dozen years. Lesions (wounds or marks) in early cervical cancer can be a lesion induration (hard) or ulceration (ulcers), or areas of little elevation (elevated) and bergranul that bleed easily when touched.
Examination Support
Required inspection is an examination of chest radiology, kidney, and bone, and biopsy.

Figure 3. Cone biopsy of the cervix (cervical)
 

Therapy
Surgery and radiation therapy are the two main modalities in the treatment of invasive cervical cancer. In general, surgery limited to patients with stage I and IIA, while radiation can be done at all stages of the disease. Chemotherapy is a treatment in patients with stage IVB or those with recurrent cancer (frequent relapses) who can not do radiation therapy and surgery. Each stage has a major therapeutic options are performed.
Prevention and Early Detection
Unlike Sexually Transmitted Diseases (STDs) are spread through other bodily fluids, HPV is a virus that spreads through skin-to-skin contact, therefore the use of condoms is not fully effective because the condom does not cover the entire area of ​​skin where HPV can be found.

Early detection is especially regular screening examination once a year to find precancerous lesions. Prevention is done is to avoid the above risk factors.

HPV Vaccine
HPV vaccine is now used to prevent cervical cancer and genital warts due to HPV. The vaccine works by protecting the 4 types of HPV that most commonly cause disease, namely types 6, 11, 16, and 18, the type that causes 70% of cervical cancers and 90% of genital warts. The vaccine was issued by USFoods and Drugs Administration (FDA) in 2006 and has been declared safe for women aged 9-26 years.
The vaccine is given in three doses within a period of 6 months of initial granting, 2, and 6 months later. Not yet known effectiveness in women who received only 1 or 2 doses only. Since this is essential given the full 3 doses for women. The effectiveness of the HPV vaccine is expected according to the study for 5 years, how long the vaccine can provide protective effects remains unclear.

Should the vaccine be given before first sexual contact or before women are exposed to HPV. This is because the vaccine prevents disease in women who have not been exposed to one or several types of HPV that can be protected by the vaccine. This vaccine does not work too effective in women who already have the HPV virus in her body before receiving the vaccine. The most common side effects of pain when injected.

The vaccine is not recommended in pregnant women because it is still little information about keamananya in pregnant women. HPV vaccine is only protective of exposure that has not happened, and not to treat. Screening is still required after obtaining the HPV vaccine because the vaccine does not protect for all types of HPV.

Figure 4. Gardasil, the HPV Vaccine

Risk factors :

1. Race
In the African-American race cervical cancer incidence increased by 2 times of Hispanic America. As for Asian-Americans have the same incidence of Americans. This is related to socioeconomic factors
2. Sexual and reproductive factors
First sexual intercourse before age 16 years associated with an increased risk of cervical cancer 2 times compared to women who had sexual intercourse after the age of 20 years. Cervical cancer is also associated with number of sexual partners. The more sexual partners increases the risk of cervical cancer. Increasing parity (number of pregnancies) is also a risk factor for cervical cancer
3. Smoke
Smoking is an important cause of cervical cancer types of squamous cell carcinoma. Risk factors increased 2 times with the highest risk found in people who smoke for long periods with high intensity (a lot)
4. Contraception
The use of contraceptive pills in the long term (5 years or more) increases the risk of cervical cancer 2 times. Use of barrier contraceptive methods (barrier), especially those using a combination of mechanical and hormonal showed decreased incidence of cervical cancer are expected due to decreased exposure to the causative agent of infectious
5. Conditions of immunosuppression (decreased immunity)
In women imunokompromise (decreased immunity) such as kidney transplants and HIV, can accelerate (speed up) the growth of cancer cells from noninvasive to invasive (malignant not become malignant)
6. Infection with HPV (Human Papilloma Virus)
Epidemiological studies show that HPV infection was detected using molecular studies in 99.7% of women with squamous cell carcinoma because HPV infection is the cause of neoplasm mutations (changes normal cells into malignant cells). There are 138 strains of HPV that have been identified, 30 of which can be transmitted through sexual contact. Of all HPV types that attack anogenital (anus and genitals), there are 4 types of HPV that usually cause problems in humans such as 2 subtypes of HPV high-risk malignancies namely types 16 and 18 were found in 70% of cervical cancers and HPV types 6 and 11, which cause 90% of cases of genital warts (genital warts)


Screening
Periodic examination for all women especially those with risk factors using the Pap smear is an effective way to detect early cervical cancer and early and adequate treatment. In addition to pap smears, another method is visual inspection with acetic acid (VIA) or Lugol's iodine (villi) and HPV-hybrid capture. The test is easy to do and have effective results. Screening is done 3 years after sexually active and repeated every year.

 Figure 2. Pap smear for cervical cancer early detection

Spread of disease
Cervical cancer can spread to various organs. Among the lymph nodes, vagina, bladder, rectum, endometrium (uterine lining), and ovary (ovarian). Each provides a different symptom. The spread of cervical cancer in general through the circulation of the lymph nodes, spread through the blood circulation is rare.

Stadium
International of Gynecology and Obstetrics (FIGO) staging system used for the evaluation and diagnosis of cervical cancer based on symptoms that occur.
Based on FIGO stages:
Stage I. Cervical cancer is only found in the cervix (cervical)
• Stage IA. Invasive cancer diagnosed by microscopy (using microscope), with the spread of tumor cells reach the stromal layer of no more than a depth of 5 mm and width 7 mm Stage IA1. Invasion of stromal layers as deep as 3 mm or less with a width of 7 mm or less
• Stadim IA2. Stromal invasion between 3-5 mm and width inside 7 mm or less
• Stage IB. tumors that are visible only in the cervix or by microscopy examination deeper than 5 mm with a width of 7 mm Stage IB1. Tumors are visible along the 4 cm or less
• Stage IB2. Tumors that look longer than 4 cm
Stage II. Cancer extends out from the cervix but does not reach the pelvic wall. Deployment involves the vagina 2 / 3 the top.
• Stage IIA. Cancer does not involve the connective tissue (parametrial) around the uterus, but involving two thirds of the vagina
• Stage IIB. Parametrial involve cancer, but not involving the pelvic sidewall
Stage III. Cancer extends to the pelvic sidewall and involve third lower vagina. Stage III includes cancers that inhibit the process of voiding urine, causing deposits in the kidneys and cause kidney disorders
• Stage IIIA. Cancer involves a third lower vagina but does not extend to pelvic wall
• Stage IIIB. Cancer extends to the side wall of the vagina that cause urinary disorders that result in renal impairment
Stage IV. Tumor spread to the bladder or rectum, or extends beyond the pelvis
• Stage IVA. Cancer spread to the bladder or rectum
• Stage IVB. Cancer spread to distant organs

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