The Tribune

By Dr Osama Kellini, MBBCH

Medical director and clinical oncology specialist

The Cancer Centre Bahamas

Women with early cervical cancers and pre-cancers usually have no symptoms. Symptoms often do not begin until a pre-cancer becomes a true invasive cancer and grows into nearby tissue. When this happens, the most common symptoms are:

• Abnormal vaginal bleeding, such as bleeding after sex (vaginal intercourse), bleeding after menopause, bleeding and spotting between periods, and having longer or heavier (menstrual) periods than usual. Bleeding after douching, or after a pelvic exam is a common symptom of cervical cancer but not pre-cancer.

• An unusual discharge from the vagina − the discharge may contain some blood and may occur between your periods or after menopause.

• Pain during sex (vaginal intercourse).

These signs and symptoms can also be caused by conditions other than cervical cancer. For example, an infection can cause pain or bleeding. Still, if you have any of these problems, you should see your health care professional right away − even if you have been getting regular pap tests. If it is an infection, it will need to be treated. If it’s cancer, ignoring symptoms might allow it to progress to a more advanced stage and will lower your chance for effective treatment.

Even better, don’t wait for symptoms to appear. Be screened regularly.

• How is cervical cancer treated?

The options for treating each patient with cervical cancer depend on the stage of disease. The stage of a cervical cancer describes its size, depth of invasion (how far it has grown into the cervix), and how far it has spread.

After establishing the stage of your cervical cancer, your cancer care team will recommend your treatment options. Think about your options without feeling rushed. If there is anything you do not understand, ask for an explanation. Although the choice of treatment depends largely on the stage of the disease at the time of diagnosis, other factors that may influence your options are your age, your general health, your individual circumstances, and your preferences. Cervical cancer can affect your sex life and your ability to have children. These concerns should also be considered as you make treatment decisions. Be sure that you understand all the risks and side effects of the various treatments before making a decision.

Depending on the type and stage of your cancer, you may need more than one type of treatment. Doctors on your cancer treatment team may include:

• A gynaecologist: a doctor who treats diseases of the female reproductive system

• A gynaecologic oncologist: a doctor who specialises in cancers of the female reproductive system

• A radiation oncologist: a doctor who uses radiation to treat cancer

• A medical oncologist: a doctor who uses chemotherapy and other medicines to treat cancer

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, psychologists, social workers, rehabilitation specialists, and other health professionals.

Common types of treatments for cervical cancer include:

• Surgery

• Radiation therapy

• Chemotherapy

• Targeted-therapy

For the earliest stages of cervical cancer, either surgery or radiation combined with chemo may be used. For later stages, radiation combined with chemo is usually the main treatment. Chemo (by itself) is often used to treat advanced cervical cancer.

It is often a good idea to get a second opinion, especially from doctors experienced in treating cervical cancer. A second opinion can give you more information and help you feel more confident about choosing a treatment plan.

It is important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decisions that best fit your needs. It’s also very important to ask questions if there’s anything you’re not sure about.

Your recovery is the goal of your cancer care team. If a cure is not possible, the goal may be to remove or destroy as much of the cancer as possible to help you live longer and feel better. Sometimes treatment is aimed at relieving symptoms. This is called palliative treatment.

• Radiation therapy for cervical cancer

Radiation therapy uses high energy X-rays or particles to kill cancer cells.

• External beam radiation

One way to give radiation is to aim X-rays at the cancer from outside the body. This is called external beam radiation therapy (EBRT). Treatment is much like getting a regular X-ray, but the radiation dose is stronger. Each treatment lasts only a few minutes, although the setup time – getting you into place for treatment – usually takes longer. The procedure itself is painless, but does result in some side effects.

When radiation is used as the main treatment for cervical cancer, EBRT is usually combined with chemotherapy (called concurrent chemoradiation). Often, this is a low dose of a drug called cisplatin, but other chemotherapy drugs can be used as well. The radiation treatments are given 5 days a week for 6 to 7 weeks to complete.

EBRT can also be used by itself to treat areas of cancer spread or as the main treatment of cervical cancer in patients who can’t tolerate chemoradiation.

EBRT is well tolerated compared with the chemotherapy. Side effects including mild diarrhea and bladder inflammation (Cystitis) can be happened with minor percentage of patients, especially those who have comorbidity of chronic diseases, and these side effects improve in the weeks after radiation is stopped.

• Brachytherapy

Another type of radiation therapy is called brachytherapy, or internal radiation therapy. This involves placing a source of radiation in or near the cancer. For the type of brachytherapy that is used most often to treat cervical cancer, intracavitary brachytherapy, the radiation source is placed in a device that is in the vagina (and sometimes the cervix). This is often used in addition to EBRT as a part of the main treatment for cervical cancer.

To treat cervical cancer in women who have had a hysterectomy, the radioactive material is placed in a cylinder in the vagina.

To treat a woman who still has a uterus, the radioactive material can be placed in a small metal tube called a tandem that goes in the uterus, along with small round metal holders called ovoids placed near the cervix. This is sometimes called tandem and ovoid treatment. Another option is called tandem and ring. For this, a round holder (like a disc) is placed close to the uterus. Which one is used depends on what type of brachytherapy is planned.

Low-dose rate brachytherapy is completed in just a few days. During that time, the patient remains in bed at the hospital with instruments holding the radioactive material in place.

High-dose rate brachytherapy is done as an outpatient over several treatments (often at least a week apart). For each high-dose treatment, the radioactive material is inserted for a few minutes and then removed. The advantage of high-dose rate treatment is that you do not have to stay still for long periods of time.

In brachytherapy, radiation only travels a short distance, so the main effects of the radiation are on the cervix and the walls of the vagina. The most common side effect is irritation of the vagina. It may become red and sore and there may be a discharge. The vulva may become irritated as well. Brachytherapy can also cause many of the same side effects as external beam radiation, such as fatigue, diarrheoa, nausea, irritation of the bladder, and low blood counts. Often brachytherapy is given right after external beam radiation.

The Bahamas Cancer Centre has the capability to treat any type and any stage of cancer cervix using radiation therapy, we have external beam radiotherapy with modern techniques of planning systems as 3D conformal and intensity modulated radiotherapy.

We are one of three centers all over the Caribbean which have a brachytherapy unit treating patients from other countries in the Caribbean; we upgraded our brachytherapy machine and the planning system on May 2015 to use the most recent and updated treatment techniques.