HPV and Cervical Cancer

Cervical cancer ranks 10th among all cancers in women and 3rd among genital organ cancers in Turkey. Its incidence is 4.5 per 100 thousand women.

Cause of cervical cancer and women at risk

Today we know the cause of cervical cancer. The cause of this cancer is a virus called HPV (human papilloma virus = Human papilloma virus). There are hundreds of types of this virus, but only 18 types are responsible for cervical cancer and we call them high-risk HPV types. The most common of these types is HPV type 16. In the second rank, it varies according to the countries. While it is type 18 in some countries, it is type 51 in our country. However, all over the world, types 16 and 18 are considered to be higher risk types than others.

HPV causes infection in the cervix, and most of these infections are temporary, especially in young women. However, some of the infection may be permanent, especially in women who smoke, people with compromised immune systems, and those with other sexually transmitted infections. When HPV infection is permanent, it first makes superficial changes in the cervix, and these changes often pass when they are mild. More advanced changes may progress into the depths of the tissue after a certain period of time and cause cancer. This is quite a long time. The average time from HPV contact to cancer is 20 years. This superficial disease before the development of cancer is called precancerous lesions (cervical intraepithelial neoplasia = CIN, or SIL; squamous intraepithelial lesion). These changes occur first and then cancer occurs.

The main transmission route of HPV is through sexual activity. HPV virus is not found in people who have never had sexual contact. It is transmitted by any sexual activity. The risk of contracting HPV infection is higher in those who start sexual activity at an early age, in polygamous women or those who are monogamous, have a polygamous male partner, smoker, take birth control pills, and have other sexually transmitted infections.

Cervical cancer screening

Cervical cancer is a cancer with screening. In other words, women who do not have any complaints are screened to identify risky women, and by taking necessary precautions, the risk of developing cancer or the chance of catching it at an early stage occurs. There are two tests for this; one is smear (cytology) and the other is HPV test. These tests begin at a certain age and continue at certain intervals until the age of 65-70. In the United States (USA), screening with a smear test begins at the age of 21 (in those with sexual activity) and is repeated every 3 years. At the age of 30, HPV testing can be done. HPV testing under the age of 30 is not approved in the USA. HPV tests are done every 5 years. In Turkey, cervical cancer screenings are carried out free of charge in health centers, family physicians or KETEM (Cancer Early Diagnosis Center). Two tests are taken from women for smear and HPV test. If HPV is negative, the smear is not checked and the woman is called for a retest after 5 years. In women who are positive for HPV, both the type of HPV and the smear test are checked. If 16 and/or 18 HPV types are positive, even if the smear results are normal, they are referred to an Obstetrician for Colposcopy. If the other types are positive, if the smear result is abnormal, they are referred to the Obstetrician. However, in cases with positive smear results other than HPV types 16 and 18, both tests are repeated one year later.

Cervical cancer diagnosis

Cervical cancer is diagnosed by biopsy. Some of the patients may present with abnormal bleeding, bleeding or discharge after sexual intercourse. If there is a visible lesion in these patients, a biopsy can be taken from here and a diagnosis can be made.

Women with positive screening results and referred to a gynecologist should undergo colposcopic examination. Colposcopic examination is the examination of the cervix by enlarging it with a system called colposcope. It is a painless method. During this examination, abnormal places in the cervix are determined and a biopsy is taken from these places. No diagnosis can be made without a biopsy.

According to the results of colposcopic biopsy, the patient may be diagnosed with superficial lesions called CIN or cancer.

Biopsies are sometimes insufficient to diagnose cancer. In this case, larger tissue should be removed. For this, LEEP (loop electrosurgical excisional procedure) or conization may be required. With these procedures, larger tissue is removed and the depth of the lesion is revealed more clearly.

Determining the extent (stage) of cervical cancer

The determination of the stage is made by pelvic examination and imaging techniques (MR or CT). If there is a visible mass during the examination, its dimensions and whether it extends into the vagina or the side walls are checked. This situation is also evaluated with other imaging techniques and it is evaluated whether there is growth elsewhere, especially in the kidneys. Because when cervical cancer spreads to the side walls, it can cause obstruction in the urinary tract and eventually enlargement of the kidneys.

Treatment

Determining the stage of the tumor is very important in choosing treatment. While cancer cases that have not protruded beyond the cervix are treated with surgery, radiotherapy and chemotherapy are more appropriate in the disease that extends to the side walls. When choosing the treatment, especially in early stage disease, the fertility of the woman and the demand for children are also important. If the tumor is smaller than 2 cm, only the cervix can be removed to protect the uterus and pregnancy can occur. In advanced age, in cases where there is no fertility, the uterus should be removed. In addition to the removal of the uterus, in some cases, lymph nodes are also removed and it is investigated whether there is a tumor there.

Protection from cervical cancer

Since HPV is the causative agent in cervical cancer, vaccines have been developed against some of the HPV types in recent years. The most effective period of the vaccine is 11-12 years of age. It can be done up to the age of 26 in those who cannot be done in this period. Although the vaccine is not very effective after this age, there is no harm in administering it. It is recommended to use condoms in case of sexual intercourse with new partners other than vaccination, but it is not 100% protective.

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