Cervical Cancer: Prevention, Detection and Treatment

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Erica Newlin, MD:

Hi everyone, I'm your host, Dr. Erica Newlin, welcome to Ob/Gyn Time. During this season we are focusing on topics related to gynecologic oncology, meaning cancers of the female reproductive organs. On this episode I'd like to welcome Dr. Sudha Amarnath and Lindsey Beffa, who will be talking to us about cervical cancer. Dr. Amarnath, Dr. Beffa, thank you so much for joining me on the podcast.

Sudha Amarnath, MD:

Thanks for having us.

Lindsey Beffa, MD:

Happy to be here.

Erica Newlin, MD:

Can you each tell us a little about your role in the Cleveland Clinic and a little about your background?

Sudha Amarnath, MD:

Sure, so I'm Dr. Amarnath, I've been at the Cleveland Clinic now for almost 11 years, and I am a radiation oncologist who primarily specializes in taking care of patients who have gynecologic cancers and colorectal cancer, so really kind of cancers that live in the pelvis. And I work really closely with Dr. Beffa, who's going to introduce herself, to take care of our patients who have cervical cancer.

Lindsey Beffa, MD:

And I'm Dr. Lindsey Beffa. I am a gynecologic oncologist, so specialize in the surgical management but also chemotherapy, immunotherapy and systemic therapies for cancers of the female reproductive tract.

Erica Newlin, MD:

Let's start by clarifying anatomy. So, where is the cervix and what purpose does it serve?

Lindsey Beffa, MD:

So, the cervix is essentially at the top of the vagina, and it's almost, you can think about it like the entrance into the uterus. The cervix is the part of the body that if someone were to have a vaginal delivery, it's the part that opens to the allow the baby to be delivered through the vagina.

Erica Newlin, MD:

Great. And then, we go into a lot of detail about cervical cancer screening and prevention in our first episode of the season, but could you briefly recap how we screen for cervical cancer?

Lindsey Beffa, MD:

Yeah, so that answer may differ depending on where in the world you live. But in the United States we typically use a combination of a pap smear and HPV testing. And the combination of those two together is most often how we screen for cervical cancer.

Erica Newlin, MD:

Great. And I often tell patients that the pap and how often someone gets a pap and HPV testing may differ based on age or prior tests, but still keeping up with those regular exams, making sure someone's looking at the cervix is helpful.

Lindsey Beffa, MD:

Absolutely. Absolutely.

Erica Newlin, MD:

And then, who may be more at risk for developing cervical cancer?

Lindsey Beffa, MD:

Yeah, so patients who have had any HPV disease. So, what I mean by that is somebody who has had any type of genital warts, or an HPV positive pap smear anytime in their life, those patients are at higher risk of developing cervical cancer in their lifetime. People who have a suppressed immune system. So whether that's from medications, or for example they've had a transplant, patients living with HIV, those patients are at higher risk of cervical cancer as well as people who smoke.

Erica Newlin, MD:

Does family history ever matter when it comes to cervical cancer?

Lindsey Beffa, MD:

In general, no. Not for cervical cancer directly.

Erica Newlin, MD:

Great. And then, what symptoms would raise suspicion for cervical cancer?

Lindsey Beffa, MD:

So the trick is, cervical cancer early or cervical pre-cancer dysplasia, as we call it, has no symptoms. So, if you have symptoms of cervical cancers, we worry about that being a little bit more progressed or further along in the cancer continuum. But things like abnormal uterine bleeding, bleeding after intimacy or intercourse, pain ... so whether that's pelvic pain, back pain, pain with intimacy or intercourse, those would be the most common.

Sudha Amarnath, MD:

Sure. And these are often things that you'd see your primary Ob/Gyn for and would be screened for during annual exams.

Lindsey Beffa, MD:

Absolutely, yep.

Erica Newlin, MD:

And then, how is cervical cancer diagnosed? And again, we talked a little bit about screening and prevention beforehand, but cervical cancer itself.

Lindsey Beffa, MD:

So, early cervical cancer often can be diagnosed from those screening tests that people get, and that's the ideal scenario when you find it very early before anybody has symptoms. So, sometimes people will have an abnormal screening test, which will then result in a biopsy or a small procedure to take out kind of a larger biopsy or section of the cervix to look at under the microscope, and then you can detect cervical cancer that way. Other times, if it's more advanced, then we do an exam and we can see with our eye-

Erica Newlin, MD:

Mm-hmm.

Lindsey Beffa, MD:

... something that looks like a cervix cancer.

Erica Newlin, MD:

Sure. And then if someone has received that diagnosis of cervical cancer and is preparing for their first visit with a Gyn oncologist, what could they expect for next steps of work up?

Lindsey Beffa, MD:

Yeah, so I think, you know, depending on where they're at in their work up for that diagnosis or how far along that is, you know, people might need additional biopsies. I would definitely expect an exam, and so a vaginal exam in the office, if people are able to tolerate that. And then usually additional imaging. And there's lots of different options that we'll talk about, but some type of additional imaging is often a part of that as well as blood work.

Erica Newlin, MD:

Sure. What kind of imaging and blood work might someone expect?

Lindsey Beffa, MD:

Yeah, so that can vary depending on the individual person and what the situation is, but it could be a CAT scan, an MRI, a PET scan, any of those things. And then blood work in general, there's not a specific blood test that can tell you if somebody has cervical cancer.

Erica Newlin, MD:

Mm-hmm.

Lindsey Beffa, MD:

But some of the complications from cervical cancer that can affect the bladder or other organs in the body, so we just in general check things like how their kidneys and their liver are functioning, their blood counts, things like that.

Erica Newlin, MD:

And can you review what cancer staging means and then how is cervical cancer staged?

Lindsey Beffa, MD:

Yeah, so cancer staging in general means, where is the cancer and has it spread to anywhere? Every cancer is staged differently, so specific to cervical cancer, in general there's a lot of nuances to this that their doctor will go over with them, but in general stage one is just involving the cervix, nothing else. Stage two is growth outside of the cervix, but not too far away. Stage three, again, a little bit further but still in the pelvis. And then in general stage four is other organs either nearby like the bladder-

Erica Newlin, MD:

Mm-hmm.

Lindsey Beffa, MD:

... the rectum or further away, like lungs, liver, something like that.

Erica Newlin, MD:

And then what do we usually group together as early stage cervical cancer?

Lindsey Beffa, MD:

Yeah, so for cervical cancer, again, every cancer is different, but for cervical cancer early stage is stage one, and there's even some more specific nuances to that, not all stage ones we consider early stage. But anything more than a stage one we would consider advanced or locally advanced, one of the two.

Erica Newlin, MD:

Okay. And then can you discuss when surgical treatment for cervical cancer would be the recommended treatment?

Lindsey Beffa, MD:

Yeah, so of course this is a conversation with the patient and their doctor-

Erica Newlin, MD:

Sure.

Lindsey Beffa, MD:

... that's not always straightforward. Sometimes people have a lot of medical problems that might not make surgery a safe option for them, but in general if somebody is a safe and appropriate surgery candidate, then patients who are stage one and technically 1B1 to 1B2 or less, I know that's getting in the weeds a little bit, but-

Erica Newlin, MD:

Sure.

Lindsey Beffa, MD:

... would be potential candidates for surgery.

Erica Newlin, MD:

And then, what surgeries are usually performed for cervical cancer?

Lindsey Beffa, MD:

Yeah. So, there (laughs) are a lotta trials over the last couple years that are changing the landscape of this and what the right answer or right answers could be, but anywhere from, you know, one of the big questions is, is somebody done having children? And so that's one of the first things we would find out, 'cause it could be surgery from a cone biopsy with lymph nodes, kind of your traditional hysterectomy, something called a radical hysterectomy, which is extra tissue around the uterus-

Erica Newlin, MD:

Mm-hmm.

Lindsey Beffa, MD:

... and cervix. Again, with lymph nodes often. So those are some options.

Erica Newlin, MD:

Okay. And you touched on this a little bit, what are the options for people who may want to retain their child bearing options?

Lindsey Beffa, MD:

Yeah. So, depending on the stage and if that is safe, appropriate, again a big conversation in the office. But sometimes people are appropriate candidates for a cone procedure with lymph node sampling, and so then they're able to retain part of their cervix and their uterus. Sometimes even, if that's not quite enough or the safest option, some patients might be candidates for something called a trachelectomy, which is the removal of the entire cervix, where they still can retain their uterus. That can get a little bit complicated, but those would be the potential options for fertility sparing surgery.

Erica Newlin, MD:

And then of then often when I, as a generalist am talking about performing a hysterectomy, we're talking about minimally invasive options, so laparoscopic or robotic, is that an option for cervical cancer patients?

Lindsey Beffa, MD:

That is a really good question, and this answer has changed over the last few years. I would say big conversation to have with their doctor, in some very specific scenarios we do have some newer data that that might be an option, meaning robotic or laparoscopic surgery. In general many patients who are surgical candidates would require an open or a big incision surgery.

Erica Newlin, MD:

Mm-hmm. And then in people who were good candidates for surgical management of their surgical cancer, how do you decide who needs additional treatment in addition to surgery?

Lindsey Beffa, MD:

Yeah, so that is where we have something called a tumor board conference, where we have multiple disciplines who all take care of people with cervical cancer, like Dr. Amarnath. And so we look at the different imaging studies somebody might have, we look at the microscope results from any biopsies or surgeries, and then depending on a number of different factors, we then decide, using our best clinical trial evidence, whether somebody might require additional treatment after surgery.

Erica Newlin, MD:

And then what sorts of additional treatment will we be talking about?

Lindsey Beffa, MD:

Most of the time radiation, which Dr. Amarnath can take it away.

Sudha Amarnath, MD:

(laughs) Well, I was just going to add in that previous answer that Dr. Beffa kind of so well-articulated, you know, our goal is to minimize the number of treatments-

Lindsey Beffa, MD:

Mm-hmm.

Sudha Amarnath, MD:

... that a patient with cervical cancer will undergo, and so a lot of the upfront work up is very important to determine the stage as accurately as possible, so that we can appropriately choose that treatment. And so the goal is generally, if a patient is going to have surgery, that they are a good candidate for surgery and that the surgery is going to be curative, so we don't require any additional treatment afterwards. And if they are not necessarily going to be cured by surgery, that we avoid surgery altogether and go down a totally different pathway of treatment involving chemo and radiation. And there are a number of studies that show that chemo and radiation together is a curative treatment for patients who have what we consider to be more locally advanced cancers, so kind of 1B3 or above cancers.

Erica Newlin, MD:

Okay. And then, can you describe what does radiation treatment look like for cervical cancer?

Sudha Amarnath, MD:

Yeah, so radiation treatment is typically kind of a black box for a lot of providers and patients, but essentially with radiation treatment we use a large machine called a linear accelerator, to deliver really high energy X-rays essentially to the areas of the body that we want to treat with cancer. And we have a lot of kind of modern techniques that allow us to minimize the amount of radiation to the other surrounding tissues that are nearby. So, generally for a cervical cancer patient, the patient will undergo around five weeks of daily radiation treatment, Monday through Friday, with combination chemotherapy that's generally given in each week of treatment.

And then there's typically a second step with what we call internal radiation treatment or Brachytherapy, which allows us to give even higher doses of radiation directly to the tumor itself, while again trying to do our best to spare as much of the normal tissues that are nearby so that patients have good long term functional outcomes, you know, with their bladder function, their rectal function, their bowel function, after undergoing all of this treatment.

Erica Newlin, MD:

And would someone expect to stay in the hospital during their treatment?

Sudha Amarnath, MD:

So, for the most part, most treatment for cervical cancer with radiation and chemo is done as an outpatient. There are some specific circumstances where a patient may require a short inpatient hospitalization, but in general most of this treatment is done as an outpatient.

Erica Newlin, MD:

Great, and you touched on this a little bit, but what kind of side effects might someone experience from radiation treatment?

Sudha Amarnath, MD:

So, you know, from a side effects standpoint, we kind of break the side effects down into two different time points, so kind of short-term side effects, these are things that can happen during and sometimes shortly after radiation, and then long-term side effects. I tell my patients we expect most of the short term side effects to occur in most patients, the severity can vary from person to person. But those are mostly related to kind of inflammation of the tissues that are nearby, so that's, like, the bladder, so bladder irritation going more frequently, more urgently, sometimes having some burning with urination.

The rectal area is of course nearby as well, and so having looser stools, diarrhea, discomfort with bowel movements is also very common. And the fatigue is also a very common side effect-

Erica Newlin, MD:

Mm-hmm.

Sudha Amarnath, MD:

... see with radiation. Those side effects tend to build up over the course of treatment, and then typically for most patients are mostly resolved by about four to six weeks after they finish treatment. The long-term side effects of radiation are mostly related to scar tissue formation and sometimes some chronic inflammation that can occur. Those are the things that can happen months to years after someone has had radiation, and ultimately with modern radiation our goal is to minimize the chances of those side effects occurring as much as possible.

So there's a lot we do with the planning of the radiation and then the actual delivery of treatment, to really kind of minimize a lot of those long-term effects as much as possible.

Erica Newlin, MD:

Great. And then what about chemotherapy, what is that looking like-

Lindsey Beffa, MD:

Yeah, so for locally advanced cervical cancer like Dr. Amarnath was just speaking about, we give a dose of chemotherapy once a week while people are receiving their approximately five weeks of radiation. That is generally over a few hours, so a few hours addition to that specific day of the week. And side effects, some of them are pretty similar to radiation as far as fatigue, sometimes some changes in your stools, looser stools. Other things that we specifically watch for from side effects for the chemotherapy portion are, sometimes people can get numbness and tingling in their fingers or toes, even almost ringing in their ears, effects on their kidney function, which we watch closely with blood work, and then it can affect your blood counts and somebody's immune functions. So, those are all things that we're watching during treatment.

Erica Newlin, MD:

Mm-hmm.

Sudha Amarnath, MD:

And I would just add, you know, nausea is probably a really big one as well, but in the modern era we have much better medications to help support our patients through the side effects that come from both chemo and radiation, so we really can help patients really kind of maintain a pretty good quality of life as they're going through treatment, and that's what we aim for.

Erica Newlin, MD:

And then for people who have completed their treatment, what does surveillance look like for them?

Lindsey Beffa, MD:

Yeah, so surveillance, typically they're meeting with both Dr. Amarnath and our team, especially early on, for visits in the clinic. So, we sit down, we talk about symptoms, we figure out how can we make different symptoms better if people are experiencing symptoms, also including a vaginal exam so that we can assess any scarring in the vagina, making sure that there doesn't appear to be any evidence that the cancer is coming back. And then right after, kind of the short term after they've completed treatment, we usually do additional imaging as well. I'm not necessarily in the further, kind of as people get further away from treatment, but especially shortly thereafter. The other kind of additional piece of that is once a year we will also do pap smear and HPV testing as well as part of the surveillance plan for cervical cancer.

Erica Newlin, MD:

Is there a time when someone can plan to go back to their general Ob/Gyn or primary care doctor for surveillance?

Lindsey Beffa, MD:

Yeah, so that is a little bit dependent on exactly where people live, what the situation is. I will say most of the time we often keep them in our clinic just especially after somebody has had radiation or chemotherapy. The anatomy can be a little different, and so if someone is not used to doing exams, let's say, on people who have had radiation, just understanding what's normal, what's not normal, can be very difficult. So we often keep those patients in our clinic long-term.

Erica Newlin, MD:

Sure.

Sudha Amarnath, MD:

I think a big part of the follow up schedule is not only based off of surveillance to make sure the cancer, you know, doesn't come back, but it's also to make sure that we're being proactive about potential long-term side effects that may arise. A lot of our patients who have cervical cancer are young women, and so we think a lot about some of the vaginal changes that can occur, whether it's from surgery or chemo and radiation, and so really kind of getting these patients vaginal dilators, we often send these patients to our urogynecology team, to pelvic floor physical therapy, to really try to be very proactive to help our patients maintain, you know, kind of an active sex life and other quality of life measures that are important to them as young women.

And so I think that's really important to emphasize that, you know, this diagnosis of course can be shocking to many but it's also highly curable and we want to make sure that our patients have a really excellent quality of life in the long term.

Erica Newlin, MD:

For sure. And we'll have another episode coming up specifically for survivorship, and I think that's a really important part of care. What would you say to someone or recommend to someone newly diagnosed with cervical cancer, Dr. Amarnath?

Sudha Amarnath, MD:

I would say the most important thing is to find healthcare professionals who are used to taking care of cervical cancer patients and have a lot of experience doing so. The challenge with cervical cancer is that ultimately, as I mentioned before, knowing the correct stage, doing all of those tests up front before jumping into treatment can have really major implications as to what treatments you get and then the associated kind of side effect and toxicity profile that someone may have in the long term.

And so it is always better to find a team of people who does this frequently and can make sure that, you know, kind of all those Ts are crossed, those Is are dotted before jumping into any sort of treatment.

Erica Newlin, MD:

What about you, Dr. Beffa?

Lindsey Beffa, MD:

Yeah, I think just knowing that finding a team and provider that is going to listen to you. This is complex, and I think like Dr. Amarnath mentioned, it happens to a lot of young women.

Erica Newlin, MD:

Mm-hmm.

Lindsey Beffa, MD:

So, whether they are in their reproductive years, they are or are not done having a family, Dr. Amarnath also touched on the importance of sexual function, also sometimes we end up making people surgery or other treatments like chemotherapy and radiation menopausal earlier than they normally would be, so I think finding people who are willing to listen to you is incredibly important, both short term and long term.

Sudha Amarnath, MD:

For sure. And I would mention, because you brought up the menopausal piece, and this is a really big deal. So, even if someone is not interested in childbearing moving forward and kind of fertility, you know, we know that estrogen that's made by our ovaries is really, really important for a lot of other health outcomes in women. And so, early menopause is a big deal. There are a number of things that can be done for young women, sometimes we can move the ovaries out of the pelvis, to help protect them. Sometimes we refer our patients to get some hormone replacement in the future as well, but again, you know, if someone is listening to this and they have not heard about these options, it's really important to talk to their healthcare provider.

Erica Newlin, MD:

And then, are there any promising treatments on the forefront that may change how we treat cervical cancer in the future?

Lindsey Beffa, MD:

I would say yes, cervical cancer, the trials for cervical cancer and treatment are changing rapidly right now, which is very exciting for patients. We're finding new combinations of treatment that are making people live longer. We're finding different surgical techniques that are better. Also sometimes less radical, which means less potential complications down the road. But again, all of these trials are trying to figure out who are the right patients for these specific interventions. And the addition of immune therapy in the treatment of cervical cancer is becoming more and more important. And again, I would just say, if somebody's listening to this, that is something that they should be discussing with their provider, absolutely.

Sudha Amarnath, MD:

Yeah, and I think that there is some exciting work that's happening with HPV vaccine trails. You know, and so that's all a little early right now, but I think that we're really going to see the landscape of cervical treatment change dramatically over probably even the next five years or so. And so for us as providers who are lucky to cure a number of patients, you know, that's exciting, but our goal is always to cure more people and so, when we get patients who sometimes have more locally advanced disease, the treatments we have are good but we can always get better. And so, you know, that is the hope is that as these new treatments are kind of coming out, that we continue to improve upon the outcomes for our patients moving forward.

Erica Newlin, MD:

Well, thank you both so much for joining us.

Lindsey Beffa, MD:

Thank you.

Sudha Amarnath, MD:

Thank you.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/obgyntime.