Specialties

Screening for precancerous lesions and vaccination against HPV

Vaccines against HPV have been available since 2006. Two commercially available vaccines provide protection against HPV 16 and 18, which are responsible for 80% of cervical cancers. Since 2015, vaccination against HPV has been recommended for all girls between the ages of 11 and 14. The vaccine is particularly effective in girls who have not yet been exposed to the risk of HPV infection, but vaccination is also recommended for girls and young women between the ages of 15 and 19.

Screening for cervical cancer involves a simple examination, known as a Pap smear or Pap test. All women between the ages of 25 and 65 are advised to have the test, initially once year and then every three years if the first two tests are normal. Precancerous lesions of the cervix, known as dysplasia, are asymptomatic but will be detected by the Pap test.

If your Pap test result is abnormal, the doctor will use a microscope to examine your cervix for signs of disease. This simple procedure called a colposcopy, is usually carried out during a normal consultation. The doctor may also take a small tissue sample (biopsy) for closer examination in the laboratory. If precancerous lesions of the cervix are found, the next stage will depend on the exact nature of the lesions and may involve regular monitoring, laser vaporization, or a cone biopsy to remove the abnormal cells. Cone biopsies are carried out as an outpatient surgery under either local or general anesthetic, depending on the case. Laboratory analysis of the cone biopsy will show whether the lesion is precancerous or the early stages of cancer.

 

Patient care

Cervical cancer

Most cases of cervical cancer are linked to a persistent infection by a virus from the human papillomavirus (HPV) family. HPV infections are a common form of sexually transmitted infection and are usually transitory. However, in approximately 10% of cases, the virus persists and can cause modifications to the cervix, including precancerous lesions that may evolve into an invasive cancer. This evolution is slow, so the cancer does not usually appear until 10 or 15 years after the persistent infection.

Diagnosis

Signs of cervical cancer often appear quite late.

If the cancer evolves, it will produce symptoms that must not be ignored, including:

  • Vaginal bleeding after sex;
  • Vaginal bleeding between periods;
  • Pain, especially during sex;
  • Vaginal discharge;
  • Pain in the lower back or pelvis.

 

These symptoms are not specific to cervical cancer and may be due to other causes, but they should not be ignored. It is essential to consult your doctor if they appear. Diagnoses are confirmed via a biopsy, if a tumor is visible on the cervix, or via a cone biopsy, if the tumor is very small.

If these tests suggest you have cervical cancer, an MRI examination will be carried out to assess the size of the tumor and determine whether it has spread beyond the cervix, especially to adjacent lymph nodes.

In some cases, a PET (positron emission tomography) scan may be carried out as a further check on whether the cancer has spread to the lymph nodes or to other, more distant organs.

 

Treatment

Regular multidisciplinary team (MDT) meetings bring together specialists from all the disciplines involved in treating cancer (surgeons, radiation therapists, oncologists, anatomopathology physicians, radiologists, nuclear medicine physicians), who discuss every case in detail. They examine the results of all tests, biopsies and scans in order to determine the most appropriate treatment program for each patient.

The medical team may ask if you would be prepared to take part in a clinical trial. As well as giving patients the opportunity to benefit from a new form of treatment, clinical trials may be used to improve understanding of how cancer arises and develops, or to evaluate patients’ quality of life and see how it can be improved.

Treatment is mostly centered round surgery and radiotherapy.

 

Surgery

Whatever the size of the tumor, if the radiology examinations do not show anomalies within the lymph nodes, surgery begins by carrying out what is known as a sentinel lymph node biopsy, which involves removing and analyzing under the microscope the first lymph node draining the tumor. The results of this analysis are used to guide further treatment. Doing this during the surgery avoids the need for a second operation. If the nodes are healthy and if the tumor is small and localized, the next stage in the treatment is to surgically remove the uterus (hysterectomy), an operation that is sometimes preceded by brachytherapy. For young women who would like to have children, it may be possible to perform a procedure called a trachelectomy, in which the cervix and upper part of the vagina are removed, but the womb is left in place. This very complex procedure can only be carried out by highly specialist surgeons.

In most cases, all these operations can be performed using a type of keyhole surgery called celioscopy or robot-assisted celioscopy.

Not only is this type of surgery just as effective in treating the cancer as traditional surgery, it avoids the need for a large incision in the abdominal cavity (laparotomy) and reduces:

  • Postoperative pain;
  • The time spent in hospital;
  • The risk of postoperative complications;
  • The length and discomfort of postoperative convalescence.


If cancer cells are found in the lymph nodes and/or if the tumor is locally extensive and/or bulky, treatment is based entirely on external radiotherapy, after sensitizing the tumor by administering a small, weekly dose of chemotherapy, and brachytherapy.

 

Radiotherapy

Radiotherapy uses ionizing radiation to destroy cancer cells. Two radiotherapy techniques are used to treat cervical cancer: external radiotherapy and brachytherapy, generally in combination.

Radiotherapy: Before treatment can begin, a scan has to be taken in order to define the area to be treated (preparation stage). A medical physicist then calculates the dose of radiation you will receive and how it should be distributed (dosimetry stage). This is why there is always a waiting period between the decision to use radiotherapy and the start of treatment.
A course of radiotherapy usually lasts 5 to 6 weeks and involves 25 radiotherapy sessions, provided from Monday to Friday (5 sessions a week). Each session lasts 15 minutes. Radiation is invisible and the treatment is completely painless, so you will not feel a thing. Radiotherapy does not make you radioactive and you do not have to take any precautions with respect to the people around you when the session is over.

Brachytherapy: This is a form of internal radiotherapy in which radiation is applied directly to the area being treated. It involves inserting an applicator, under general anesthetic, so it is in contact with the tumor, and then injecting a radioactive material (iridium) through it. Brachytherapy requires a short stay in hospital (2 or 3 days) and you have to remain lying down throughout the treatment. However, you are isolated only during the periods in which the radiation is injected, so you can receive visits from healthcare staff and from family and friends for 30 minutes every hour. You will not be radioactive, even during the treatment periods, and your room will be a traditional hospital room apart from the presence of an afterloader (machine that delivers the radiation dose).

Brachytherapy may seem restrictive because you have to remain lying down throughout, but it is entirely painless, so you won’t feel a thing during treatment sessions. In addition, no anesthetic is needed to remove the applicator. The nursing staff will answer any questions you may have.

 

Recurrent cervical cancer

The IUCT-Oncopole team regularly treats patients with recurrent cervical cancer from throughout southwest France and is internationally renowned for its expertise in this field. MDT meetings are even more important in these difficult situations. The specialists involved examine each patient’s scans (MRI, CT, PET) and determine the best treatment options, taking into account the nature of the relapse site(s) (local, nodal or distant) and the patient’s treatment history. Treatment may involve surgery, radiotherapy or chemotherapy, or a combination of these methods. In the case of an isolated relapse, the IUCT team has great expertise in complex relapse surgery (sometimes requiring pelvic exenteration, that is the removal of neighboring organs such as the bladder or rectum) and masters all the techniques used in this type of surgery: