What You Should Know About the Side Effects of Surgery for Cervical Cancer

A hysterectomy is a common surgical treatment of early stage cancer and precancerous disease of the cervix in women. With any treatment of cancer it is important to first understand your responsibility and your medical team’s role as well as explore treatment options and get a second opinion(s) before you begin treatment. Since the side effects of surgery can be significant, talk to your doctor prior to treatment so that you understand the specific type of surgery you will undergo and the expected side effects. The type of hysterectomy used to remove the cervical cancer depends on the extent of the cancer. A radical hysterectomy removes the entire uterus, including the cervix with the cancer and an area of normal tissue through a low abdominal incision. This area of normal tissue also includes a portion of the upper vagina, and may result in vaginal shortening after the operation. A modified radical hysterectomy is similar to a radical hysterectomy but less invasive. A less extensive operation, called a simple hysterectomy, is used when the cancer is not invasive (precancerous, stage 0) or in the earliest stage of invasion (stage IA). A simple hysterectomy removes a smaller rim of normal tissue, and spares most of the length of the vagina. With both types of surgery, the ovaries and Fallopian tubes can be removed as well, and this is known as a bilateral salpingo-oophorectomy. The decision to perform a bilateral salpingo-oophorectomy depends on your age and whether the ovaries are still functioning.
A radical hysterectomy is most effective if the exploration during surgery shows that the cancer has not spread beyond the cervix. However, some patients will have cancer that has spread outside the cervix into the lymph nodes in the pelvis. Before performing a hysterectomy, the doctor will sometimes perform a pelvic lymph node dissection. Pelvic lymph node dissection involves the removal of lymph nodes to determine the presence or absence of cancerous cells. If the lymph nodes contain cancer, usually the surgeon will not proceed with a radical hysterectomy. Instead, another form of treatment, usually radiation therapy and chemotherapy, is generally recommended.
Despite undergoing surgical removal of cervical cancer, some patients may experience recurrence of their cancer. Cancer recurrence occurs more commonly with bulky stage IB or stage II cervical cancer. It is important to realize that some patients with cervical cancer already have small amounts of cancer that have spread outside the cervix and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix are referred to as micrometastases. The presence of these micrometastases causes recurrence following the initial treatment. External beam radiation therapy with or without implant radiation and chemotherapy are often recommended to cleanse the body of micrometastases in order to improve the cure rate achieved with surgical removal of the cancer.
Surgery on top of living with a diagnosis of cancer can be both an emotionally and physically draining experience. Understanding associated surgical risks, short-term side effects and long-term side effects, as well as asking your doctor pertinent questions before surgery, will give you the tools to mange and cope after your surgery.
Any form of hysterectomy is major surgery with associated surgical risks. Hemorrhage, blood clots, surgical wound complications or allergic reaction to anesthesia are surgical risks that should be discussed with your doctor. In-hospital death occurs after radical hysterectomy in less than 1% of cases.
Normal and expected temporary effects of surgery for the treatment of cervical cancer may include pain, nausea, fatigue and anxiety. Urinary tract infection after the surgery is also common. Additional temporary side effects may include difficulty urinating or having a bowel movement. Since the bladder may be pushed and pulled due to all of the dissection around it, a temporary catheter (tube in the bladder to drain the urine) is usually required to give the bladder time to heal. With a simple hysterectomy, disturbance to the bladder is minimal making urinary complications rare. However, approximately one-third of women undergoing a radical hysterectomy may experience temporary bladder difficulties which may last a few weeks after surgery. Although most women return to normal bladder functioning, a very small percentage may require more permanent self-catheterization. Depending on the type of hysterectomy, your age and general health, recovery from short-term side effects may take 6 to 8 weeks.
In addition to rare bladder dysfunction, injury to the rectum and lower leg lymphedema are also potential long-term side effects of a hysterectomy. In a few cases, injury to the rectum or tubes that drain the kidneys (ureters) or bladder can occur. This may be in the form of a "fistula" or abnormal connection to the vagina. This is a chronic problem that may require surgery to repair the opening. Lower leg lymphedema (swelling) as a result of lymph node dissection may also occur in some cases. Elastic stockings or support hose as well as preventing infection and injury to the leg, can help minimize lymphedema.
Long-term sexual complications due to the removal of the uppermost part of the vagina are reportedly minor. In a few cases, patients indicate some loss of sensation and lubrication, as well as intercourse difficulty due to vaginal shortening. The emotional impact of the surgery may also affect libido in some patients.
The physical loss of reproductive organs has significant long-term physical and emotional side effects and should be discussed with your doctor before surgery. Some patients may want to investigate having their eggs harvested for possible surrogacy before surgery. Once the uterus is removed, women no longer menstruate and can no longer have children. Furthermore, if the ovaries are removed in a woman of child-bearing age, menopause will be induced. Some of the side effects of early menopause include hot flashes, irritability, vaginal dryness, sweats and nervousness. Hormone replacement therapy may be used to help control some of the side effects associated with menopause. The impact of losing reproductive organs is far reaching, affecting future plans as well as emotional well-being.
Surgery is a common form of therapy in the treatment of early stage cervical cancer. The risks of surgery, while remote, should be discussed with your doctor prior to surgery. The potential short-term side effects may cause varying degrees of discomfort that can usually be managed by you and your doctor. Potential long-term effects such as bladder and bowel problems, early induced menopause, as well as the physical loss of reproductive organs, are reportedly the most difficult for patients to deal with emotionally and physically. Using a surgeon and medical team highly experienced in performing hysterectomies may decrease your surgical risks and provide optimal management of side effects. Support groups, family support or professional support may help patients emotionally cope with side effects. Before undergoing any treatment you should understand your responsibility, your medical team’s role, explore treatment options, ask questions and get a second opinion(s).

Who Should be Screened for Cervical Cancer?

Cervical cancer accounts for 6% of all cancers in women. Approximately 15,000 new cases of cervical cancer are diagnosed each year in the United States and roughly 5,000 women die annually from this disease. Screening for abnormal, precancerous or cancerous cells in the cervix is critical for prevention, early detection and diagnosis of cervical cancer.
The National Cancer Institute recommends that women over the age of 18 or those sexually active before the age of 18 should be screened for cervical cancer annually. Women at an increased risk of developing cervical cancer should be particularly diligent in their annual screening. Risk factors include early age at first intercourse (16 or younger), history of multiple sexual partners, smoking and poor nutrition. In addition, a history of sexually transmitted diseases, such as chlamydia, human immunodeficiency virus (HIV), and especially human papillomavirus (HPV) appear to increase the risk of developing cervical cancer. Thirteen different HPVs (wart-causing viruses) have been linked to almost every case of cervical cancer. However, the converse is not true, as the presence of HPV does not guarantee that cervical cancer will develop.
Annual cervical cancer screening involves a pelvic exam and Pap smear. Patients who have an abnormal Pap smear may undergo a relatively new screening test called a Hybrid Capture II to determine the nature of the abnormal cells.
A pelvic examination screens for any palpable abnormal growths or irregularities. During a pelvic exam, a health-care provider inserts a gloved and lubricated finger into the vagina to feel the vagina, cervix, uterus, ovaries, fallopian tubes, bladder and rectum. The pelvic examination is usually performed in conjunction with the Pap smear.
Routine screening with a Pap smear is used to detect cancerous cells as well as abnormal cells that may or may not be precancerous in the cervix. During a Pap smear, a sample of cells from the cervix is taken with a small wooden spatula or brush and examined under a microscope. The results of a Pap smear are classified into five categories: negative or within normal limits (normal); atypical squamous cells of undetermined significance (ASCUS); low-grade squamous intraepithelial lesions (abnormal); high-grade squamous intraepithelial lesions (abnormal); or carcinoma (cancer).
If the Pap smear results are normal, no further evaluation is necessary. Women who have normal results will simply need to continue undergoing an annual examination and Pap smear.
Abnormal results from a Pap smear do not necessarily indicate cancer. Other conditions such as inflammation and sexually transmitted diseases can cause abnormal changes in cells. Some women will exhibit mild dysplasia (abnormal cells), in which case they may need to schedule frequent Pap smears to monitor for any changes. Women with severe dysplasia may need to undergo a biopsy for closer examination of abnormal tissue. A relatively new test called the Hybrid Capture II is used to determine the presence of 13 HPV viruses specifically linked to cervical cancer. The presence of one of these key HPV viruses may further define the nature of abnormal cells identified by a Pap smear. The presence of abnormal cells and one of the 13 high risk HPV virus may indicate that the abnormal cells are precancerous in nature. Conversely, if a high-risk HPV is not present, then abnormal cells are less likely to be precancerous.
Pap smear screening techniques have facilitated the early detection of cervical cancer and have reduced the incidence of cervical cancer by 75% over the past 50 years. To determine if you are at high risk and require additional follow-up other than yearly screening, please consult your doctor.

Understanding Cervical Cancer

What Is Cervical Cancer?
The cervix forms the opening to the uterus from the vagina. It is covered with two main types of cells: squamous cells, which cover the part of the cervix that extends into the vagina, and columnar cells, which line the cervical opening. Most cervical cancers develop close to where these two cell types come together, in an area called the transformation zone. Once cervical cancer develops, it can spread throughout the cervix to neighboring organs or to distant sites in the body.
Cancerous and precancerous changes in cervical cells are often first detected by a Pap test, wherein a sample of cells is removed from the cervix using a small wooden or plastic spatula and a brush. The cells are then examined under a microscope in a laboratory. If Pap test results are abnormal, a physician may perform a colposcopy, using a microscope called a colposcope to better see the cervix. The physician applies a mild vinegar solution to the cervix, which makes abnormal cells appear more white than pink. If abnormal areas are identified, the physician may remove samples of tissue so that the cells can be further evaluated—a procedure called a biopsy.
The results of the biopsy allow the physician to diagnose cancer or precancerous conditions. Precancerous changes to the cervix are called cervical intraepithelial neoplasia (CIN). The severity of CIN is graded on a scale of 1 to 3, with 3 being the most severe. CIN2 and CIN3 are considered “high-grade” CIN and may progress to cancer if not treated.

What Is HPV?
There are more than 100 different types of human papillomavirus (HPV), and different types of HPV cause different conditions. Some types of HPV are linked with common skin warts, others cause genital warts, and still others are linked with cancers of the cervix, vulva, vagina, penis, and anus as well as some cases of head and neck cancer. HPV types 6 and 11 account for a majority of cases of genital warts, and HPV types 16 and 18 cause roughly 70 percent of all cases of cervical cancer. The remaining cases of cervical cancer are linked with other high-risk types of HPV.
The types of HPV that cause genital warts or cervical cancer are transmitted sexually. Sexual transmission of HPV is extremely common and generally occurs soon after an individual becomes sexually active. Most infections resolve on their own, but others persist. Persistent infection with a high-risk type of HPV can lead to precancerous changes to the cervix and, if these changes are not treated, to cervical cancer.

How is HPV linked to Cervical Cancer?
The sexually transmitted types of HPV most commonly linked with cervical cancer are HPV 16 and HPV 18 (transmitted sexually), but several other high-risk types contribute to cancer as well.
Though a link between cervical cancer and a sexually transmitted infection was long suspected, studying HPV was historically a challenge because it could not be grown in cell or tissue cultures like some other organisms. It would take the molecular techniques that were introduced in the 1970s to adequately study and understand the virus. Once these techniques were applied, it became apparent that most cervical cancers contained evidence of HPV.
Infection with a high-risk type of HPV does not necessarily lead to cancer. Many infections disappear on their own, and others may persist without causing cancer. Infection does, however, increase the risk of cancer, and virtually all cases of cervical cancer can be linked to infection with a high-risk type of HPV.

Is There a Test for HPV?
The recognition that specific types of HPV are the cause of cervical cancer led to the development of tests to identify women infected with high-risk types of HPV. Information about HPV status may guide decisions about follow-up care.
HPV testing may also have a role in initial cervical cancer screening, but conclusive evidence about this is still lacking. In the meantime some organizations have supported the combination of HPV testing and Pap testing for screening women over the age of 30. Women who test negative for both tests may need not be rescreened for up to three years. The combination of HPV testing and Pap testing is not recommended for screening younger women because most will have HPV infections that will clear without causing precancerous cervical lesions.

What are HPV Vaccines and How Might They Prevent Cervical Cancer?
HPV vaccines fall into two broad categories: preventive and therapeutic. Preventive vaccines are designed to prevent infection with the virus, whereas therapeutic vaccines would treat the infection, precancerous lesion, or cancer in individuals who are already infected. Although prevention of infection is the ultimate goal, treatment of existing infections and cervical changes would benefit the many women who are currently infected.
The two vaccines that are farthest along in development are preventive vaccines. Gardasil™, developed by Merck, targets HPV types 6 and 11 (which are linked with genital warts) as well as the cancer-associated types 16 and 18. Cervarix™, developed by GlaxoSmithKline, targets HPV types 16 and 18 only. Clinical trials of these vaccines suggest that they are likely safe and highly effective. The duration of effectiveness is still uncertain, but it appears to be at least four to five years. Because HPV types 16 and 18 are thought to account for roughly 70 percent of all cases of cervical cancer, widespread use of these vaccines would have the potential to eliminate most (but not all) cases of cervical cancer and precancerous changes to the cervix.
Because infection with HPV is extremely common and generally occurs soon after an individual becomes sexually active, the vaccines are likely to have the greatest effect when administered before the teen years. In addition to being less likely than older children to be sexually active, younger children versus older adolescent and young adult women appear to develop a stronger immune response after HPV vaccination. This may increase vaccine effectiveness.
It is thought that for these vaccines to have the greatest impact it will ultimately be important to vaccinate both girls and boys. Vaccinating a larger number of individuals will reduce transmission of these viruses in the community and will make it less likely that an unvaccinated individual will become infected. Furthermore, in addition to reducing the risk of cervical cancer, the vaccines are likely to reduce the risk of other HPV-related cancers, such as cancer of the penis, anus, and oropharynx (part of the throat). Protection against genital warts would also benefit both boys and girls.
In June 2006, Gardasil was approved by the U.S. Food and Drug Administration (FDA) for use in girls and women between the ages of nine and 26 years. Approval for use in males may be considered after more data become available. GlaxoSmithKline plans to apply to the FDA for approval of Cervarix by the end of the year.