Sonal Sura, MD, MBA

Rates of cervical cancer diagnoses and deaths among women have dropped steadily since 1975, thanks to new targeted treatments, refined diagnostic tools and a vaccine against the virus that causes most of these reproductive system cancers.

Even though any cancer diagnosis can be frightening for women, physicians and oncologists can provide their patients with reassuring guidance about a range of preventive measures and targeted treatments that lower a woman’s lifetime risk of contracting or dying from cervical cancer.

Depending on where the cancerous cells develop, and how invasive they are once detected,

 that include surgery, radiation therapy, chemotherapy, targeted cellular therapy, and immunotherapy.

Reassuring Statistics About Cervical Cancer

Several factors have changed the treatment of cervical cancer over the past 5 decades. Beginning in the 1970s, the widespread use of Pap smears to detect cervical cancer began reducing its incidence. Rates continued to decline after a German scientist conclusively linked cervical cancer to the human papillomavirus (HPV), a discovery in the 1980’s that spurred wider HPV screenings and eventually an HPV vaccine.

Now, thanks to better screenings and earlier interventions, cervical cancer ranks as the 20th most common cancer among U.S. women, responsible for about 14,100 new cases and nearly 4,300 deaths each year. Just about 0.7% of all new cancer cases and deaths are attributed to cervical cancer, according to the American Cancer Society.

 Worldwide, cervical cancer ranks 4th among women at about 570,00 cases diagnosed in 2018 and 311,000 deaths, according to the World Health Organization.

One hopeful message to deliver to patients is that there is a 66.7% relative survival rate for cervical cancer in the U.S., according to the American Cancer Society, and survival rates are higher for cancers that have not spread beyond the cervix and lower for cancers that metastasized.

The key challenge for physicians and their patients is that cervical cancer often develops without symptoms, according to the National Cancer Institute. The most common are vaginal bleeding, unusual vaginal discharge, and pelvic pain.

Besides HPV, common risk factors for cervical cancer include initiation of sex at an early age; numerous sexual partners; suppressed immune system; high number of childbirths; long-term oral contraceptive use, but risks decline gradually when contraceptives are stopped.

Discussions with women about cervical cancer should focus heavily on prevention, including the value of regular Pap smears throughout a woman’s life to look for cellular changes of the lining of the cervix. In addition, women should be advised to schedule preventive HPV vaccines for their pre-teen and adolescent daughters.

The first vaccine should be administered between ages 9-12, with routine follow-ups through late adolescence and early adulthood. A 2021study from Denmark found that cervical cancer risks were lower in women vaccinated against HPV between ages 16-19 compared with unvaccinated women.6

When your patients present with cervical cancer, following accepted guidelines will help you identify, diagnose, classify, and explore treatment options for cervical cancer.

Providing specific information about the type and stage of their cancer will give them the information they need to better understand your recommendations and their options. Cervical cancers are classified in a spectrum of stages I-IV, with stage I representing cancer cells/tumors that remain small and localized to the cervix, while stage II, III, and IV cancers progressively interfere with or invade nearby organs/tissues (e.g., block the kidneys, ureter, rectum) or spread to the vagina, uterus, pelvic wall, distant lymph nodes, liver or lungs.

It is also important to follow accepted protocols for examinations and laboratory tests to identify the specific type of cancer. These include:

Physical exam and health history of the patient.

Pelvic exam, is a physical exploration of the vagina, cervix, uterus, fallopian tubes, and rectum for signs of disease.

Pap test, in which a small brush collects cells in and around the cervix; the specimen is examined microscopically for signs of abnormal cells or HPV infection.

Endocervical curettage and/or colposcopy, usually performed as follow-ups to questionable Pap smears; both procedures involve a more extensive exam of the cervix and deeper collection of cervical tissues for signs of cancer or abnormal cells.

DNA tests, magnetic resonance imaging (MRI) or computed tomography (CT) scans to fine-tune the location of the tumor and inform targeted, effective treatments.

Aided by data from exams and laboratory results, you can then shift the conversation options about treatments, decisions that are guided by the type of cancer, whether it is localized to the cervix or has spread to nearby tissues/organs, the size of the tumor(s), the patient’s age and/or menopause status, and whether the patient wants to have children after treatment for their cancer.

The good news is that oncologists and physicians today have a range of treatment options, and they should tailor their suggestions based on input and discussions with their patients, especially if treatments will impact future decisions about childbirth and menopause.

Small tumors can be removed through a cone biopsy, or conization. Excision of a small portion of tissue from the cervix leaves surrounding healthy tissues untouched, and if the cancer has spread, a hysterectomy involves removal of the cervix and uterus. If a woman wishes to get pregnant, gynecological surgeons can perform a trachelectomy, which involves removal of part of the cervix and vagina but leaves the uterus intact and stitches it closed. Any subsequent pregnancy will have to be delivered by cesarean section.

This approach targets cancerous cells while preserving surrounding healthy tissue with the fewest [adverse events]. Options include external beam radiation therapy (EBRT) with radiation delivered from outside the body; internal radiation therapy (IRT) with radiation sources implanted in the body; intensity-modulated radiation therapy (IMRT) with precise radiation that matches the tumor’s shape, and intracavitary brachytherapy with radiation delivered to the tumor through small catheters.

Chemotherapy and Targeted Medicine Therapy

Whether used in conjunction with other procedures or as a standalone treatment, chemotherapy drugs destroy cancerous cells. Recent discoveries and pharmaceuticals enable oncologists to target and shut down specific cellular activities that help cancerous cells and tumors grow.

often used for tumors that continue to grow or spread after chemotherapy, musters the body’s own immune system to recognize and destroy cancerous cells. Clinical trials are also underway for cervical cancer.

Receiving a cancer diagnosis is always fraught with anxiety and fear for patients. Referring and treating physicians and oncologists can relieve the impact of those initial reactions by emphasizing the scope of successful treatment options and relatively high survival rates for a cervical cancer diagnosis.

1) Cervical Cancer Treatment (PDQ®)–Health Professional Version. National Cancer Institute. April 28, 2022. Accessed: August 30, 2022.https://bit.ly/3Sm7I6N

2) Cervical Cancer. Genesis Care. Accessed: August 28, 2022.https://bit.ly/3LCyuVz

3) Weiss RA. On viruses, discovery, and recognition. Cell. 2008 Dec 12;135(6):983-6. doi: 10.1016/j.cell.2008.11.022

4) Cancer Facts and Figures 2022. American Cancer Society. Accessed: August 30, 2022. https://bit.ly/3S8jKjM

5) Cervical Cancer. World Health Organization. Accessed: August 31, 2022. https://bit.ly/3Lz0UzO

6) Kjaer SK, Dehlendorff C, Belmonte F, Baandrup L. Real-World Effectiveness of Human Papillomavirus Vaccination Against Cervical Cancer. J Natl Cancer Inst. 2021 Oct 1;113(10):1329-1335. doi: 10.1093/jnci/djab080

Articles

For Gynecologic Cancer Awareness Month, Dr. Sonal Sura discusses the recent progress in the treatment of patients with cervical cancer.

Gynecologic Cancer Awareness Month: Progress Makes Cervical Cancer Highly Treatable, Increasingly Preventable

When it comes to treatments for sexual health issues caused by cancer treatments, women are vastly underserved.

Sexual dysfunction—including low libido, vaginal tightness, and vaginal dryness—is a prevalent adverse event, yet few effective treatments are available. Sonal Sura, MD, a radiation oncologist with GenesisCare in Naples, Florida, addresses the cause of this gap and outlines steps physicians can take to improve patient care for women.

The status of women’s sexual health, especially when they are affected by cancer, is where mental health was not too long ago. Many patients don’t feel comfortable speaking up about symptoms, and most physicians don’t have the training or tools to have meaningful conversations with patients. Further, pharmaceutical companies have not invested significant research dollars into treatments centered around women’s sexual health during and after a cancer diagnosis.

When men experience cancer treatments that could affect their sexual activity, an open discussion occurs with their physician. Most physicians receive training on how to speak to men about prostate cancer. Physicians are comfortable talking to a man about radiation vs surgery and what the effect on their sexual health might be. This is not always true for women.

That is not to say that sexual health is not being discussed in oncology. There is a difference between male and female patients who receive treatments affecting sexual health and what has been studied or what is discussed. Whenever patients receive high doses of radiation to the genital area, there’s a chance it can decrease sexual function and/or drive, regardless of whether they’re male or female.

Women feel sexual health issues are important but we, as a society, tend to undervalue women’s sexuality, and that’s perhaps even truer in the medical field. As health care providers, we may not emphasize the severity of symptoms like vaginal dryness, vaginal tightness, pain during intercourse, or loss of libido related to women’s sexual wellbeing during and after treatments.

Unfortunately, many patients are reluctant to talk about these issues, even with female physicians. They may feel that being concerned about sexual desire while undergoing cancer treatment is somehow shameful. Often, they are reluctant to discuss these types of issues when their partner is in the room with them. The partner is trying to be supportive by coming to appointments with them, but it can prevent an open discussion. Also, many patients with cancer are in their 70s or 80s and feel incredibly uncomfortable talking about their symptoms.

Addressing Women’s Sexual Health Issues In the long term, we need more research in this area. Physicians need to get involved in helping develop clinical trials, especially regarding potential treatments for hypoactive sexual desire disorder (HSDD). There are no FDA-approved medications specifically for women with HSDD secondary to cancer or its treatment.

 When you think about the number of TV advertisements we’ve all seen for sildenafil citrate (Viagra) and tadalafil (Cialis), you start to understand the gap in care.

We also need a more standardized way to assess women’s sexual health issues. We have the Sexual Health Inventory for Men to help us rate how happy a patient is with their ability to have and maintain an erection. There isn’t a widely used tool for women, so we don’t have an academic way for women to rate things like their ability to get aroused, their level of dryness, etc.

But there are several things we in oncology can do in the meantime; some are quite simple.

First, if we sense that the patient is uncomfortable talking about their symptoms with their partner present, we can politely ask them to step out of the room for part of the visit.

Second, it’s essential to keep the conversation light. When we use medical jargon, it can be difficult for patients to understand and open up. For example, when I talk about using a cylindrical dilator as part of treatment for a gynecologic cancer, if they don’t seem to understand, I’ll explain that it’s similar to a dildo; they get it and start laughing. I think when we speak more like normal humans, patients begin to feel more comfortable and they begin to open up.

Third, oncologists can educate themselves about treatment risks concerning women’s sexual health and prepare themselves to ask patients difficult questions. If we get to the point where a patient feels comfortable enough to answer particular questions, we can help them figure out what’s going on. For example, are you physically not able to have an orgasm? How do you have orgasms?

Many of these questions should be discussed as part of a typical oncology consult. And if we ask the right questions, we may be able to discover whether the issue is more physiological or psychological/emotional.

Fourth, it’s crucial to have an open mind regarding treatment recommendations. For example, we don’t have good choices for pharmaceuticals for HSDD, but we know that over-the-counter herbal remedies like ashwagandha can relax patients with low libido to the point where they are “in the mood.” Similarly, patients may not realize the effectiveness of lubricants and that there are some all-natural products available now. Another pathway could be antidepressants if we can determine that the issue is psychological rather than physical.

Need for More Sexual Health Medical Professionals

 The biggest problem is that not one specific clinician often manages this aspect of cancer care for women’s sexual health. If a male patient has poor sexual function after radiation, he can be referred to a urologist who is familiar with information on erectile dysfunction medications, penile implants, and other treatments. That person doesn’t exist for female patients—yet.

Gynecologists are not necessarily equipped to deal with issues like libido or vaginal tightness due to radiation. I take that role on with my patients by, for example, educating them on utilizing a vaginal dilator, prescribing the device, and having them come back every few months to check in.

But as more women survive breast and gynecologic cancers, we should continue to develop more survivorship programs and raise awareness about women’s sexual health issues going forward. In these survivorship programs, physicians can dedicate more time and resources to address these specific concerns and can advocate for women’s sexual health.

1. Del Pup L, Villa P, Amar ID, Bottoni C, Scambia G. Approach to sexual dysfunction in women with cancer. 

. 2019;0:1-5. doi:10.1136/ijgc-2018-000096 

2. Study shows positive preliminary results of flibanserin in breast cancer patients suffering from low libido. News release. Sprout Pharmaceuticals. March 15, 2022. Accessed June 24, 2022. https://prn. to/3yivedb

Sonal Sura, MD, a radiation oncologist with GenesisCare in Naples, Florida, addresses the cause of this gap and outlines steps physicians can take to improve patient care for women.

Sonal Sura, MD, MBA | Authors

Articles

Gynecologic Cancer Awareness Month: Progress Makes Cervical Cancer Highly Treatable, Increasingly Preventable

Sex, Health, and Cancer: Female Patients Deserve Better