 Greetings from Manipal Hospital, Bhaner Pune, I am Dr. Karan Chanchlani, I am a clinical and radiation oncologist. Today we will be talking about carcinoma of the cervix or uterine cervix or cervical cancer as we call it. So cervix is basically the opening of the uterus, we can understand with this diagram. So in the female reproductive organs, this is the uterus, these are the ovaries and this is the vaginal tract. But when the vagina ends and the uterus opens, this region is called as the cervix and it is the part of the uterus which is most exposed to foreign antigens and trauma. So that is how there is a preponderance of cancer development mainly in the uterine cervix. Cervical cancer is one of the most common cancer of Indian females, it is the most common cancer of the female reproductive tract. These days because of certain lifestyle changes and all breast cancer has also become equally or maybe slightly more prevalent until now carcinoma cervix has remained the most common killer amongst the cancers of the female in general. So what are the common causes or risk factors for a female to develop cervical cancer? So one of the most common or the most impactful is any sexually transmitted infection especially HIV virus. So much so that cervical cancer is notified by the WHO as a part of AIDS complex also. Apart from that there are conventional risk factors so early childbirth, early age at the first sexual exposure, multiple sexual partners, multiple childbirths or children and a history of repeated infections and in general poor hygiene of the genital region is these are some of the common factors that are known to be causative for cervical cancer. All these risk factors are basically giving rise to an increased chance of infection with the virus called as HPV virus or human papilloma virus. So it has been observed that HPV virus is nearly associated with more than 99% of the cancers of the cervix so either early or somewhere in the middle of the carcinogenesis this HPV virus is involved in almost every case that we see. So few of the common symptoms they depend again on the location so we can better understand with this diagram and these symptoms are initially mild in early stages they become more prominent and more distressing with advanced stages. So one of the earliest symptoms is like discharge from this region so it is typically a very common wide discharge which is sometimes associated with foul smell sometimes even associated with a bloody discharge additionally the ladies may actually complain of post-coital bleeding or bleeding during the time of intercourse so these are telltale signs for the early stages as and when the tumour starts expanding it starts to invade the surrounding structures so just ahead of this or anterior to this is the urinary tract and behind this uterus is the bowel or the rectum or the motion tract. So depending upon whether they are involved then you may have urinary symptoms like dysuria or bleeding sometimes through the urine also or leakage of urine and similarly leakage of stool or sometimes even constipation or bleeding through the rectum. Additionally there are certain other symptoms like vague abdominal discomfort in the lower abdomen, loss of appetite, difficulty in passing urine so these are the common symptoms that the patient of carcinoma cervix present with. So coming to the treatment at the outset cervical cancer is one of the most amenable cancers for a complete cure or a radical treatment so much so that even in certain stage 4 patients also we have long-term survival beyond 5 years after adequate treatment. So briefly it is divided into 4 stages 1, 2 are called as early stage, stage 3 is sort of intermediate or advanced stage and stage 4 is either spread to the other organs which is a proper metastasis or it can also involve complete involvement of the urinary or the bowel the rectum tract so in which case it is 4A. So typically in very early stages like stage 1 they can be cured with even simple radical hysterectomy or even with single modality of brachytherapy which is a form of internal radiation therapy and usually in these cases there is no role of multiple modalities or multimodality treatment. From stage 2 onwards sometimes there is a requirement to add multiple modalities typically in stage 2B onwards definitive radiation therapy with or without chemotherapy depending upon the tumor factors and the patient fitness is the standard of care for these type of treatments. Up to stage 4A so from 2B to 4A definitive radiation therapy with or without chemotherapy is the standard of care. Radiation therapy is basically a form of treatment of cancer with x-rays or photons as we call it sometimes other modalities like electrons or protons can also be used specifically for carcinoma of the cervix deep penetrating higher energy photons are typically used and the entire pelvis is usually our target region as we can see so if this is the cervical region where the tumor is located it can have spread along the parametrium as we call it it can spread to certain lymph nodes around so the entire pelvic region is our target. Of course we try to delineate certain critical organs like rectum like anal region like urinary tract urinary bladder to prevent excessive doses from getting delivered there and maybe we can have a more conformal form of radiation delivery thereby reducing doses to the normal structures and preventing long term side effects. In general a small discomfort in passing urine is expected during the treatment which is self limiting later on similarly some amount of loose motions or diarrhea which is typically because of the malabsorption state is expected and it is usually again very well controlled with medications and certain dietary precautions that we advise to the patient. These days there is also a role of sparing bone marrow sparing IMRT or that is sparing the radiation doses to the surrounding bones wherein resides the bone marrow which is the active site of new blood synthesis or hematopoiesis as we call it in adults so this helps in better tolerance with for the concurrent chemotherapy regimens that we give along with radiation so chemotherapy typically is given to potentiate the form of radiation or to achieve better results and there are time tested studies which show that it adds to the overall cure or overall survival of these patients. Once this external radiation is completed we later on go for internal radiation or that is called as brachytherapy. Brachytherapy is also a single modality for very early stage of CA service which is sufficient by itself and sometimes there is no need of external radiation in very early stages. For all practical cases that we see internal and external radiation both are combined. Internal radiation is typically delivered after 5 to 7 days of completion of external beam radiotherapy and during which time the side effects and all have settled and it is usually delivered with an applicator under general anesthesia so because of the anesthesia we can examine the area properly and place our applicator so those applicators are thin tube like structures and then once the placement is confirmed with the CT scan and sometimes these days we use MRIs also so we plan the doses in and around the residual which is there and we deliver very high doses in single sessions usually these sessions are once in a week and the total treatment gets completed in somewhere around 7 to 8 weeks that is the ideal time for the completion of treatment. If we talk about success rate so once this entire treatment is completed we have really excellent survival outcomes of to the tune of 80 to 90 percent in early stage cancers in advanced stage cancers also we can expect a long term survival in more than 60 percent of the cases it also depends on the tumor factors the stage and everything so but overall the success rates are very good. So coming to preventive aspects so how can we prevent cancer cervix formation or more importantly how can we prevent HPV infection which is associated with nearly all the cancer formations so these days HPV is understood that it is a sexually transmitted virus and there are certain variants amongst the human papilloma virus which are more likely to cause these cancers and there are vaccines that are available against these selective variants so commonly there were two vaccines which were available till now covering almost up to like nine such variants recently we have an indigenous innovation from India from the Serum Institute which is again a welcome move as it can it is expected to bring down the cost of such vaccines and it also is more it is also expected to cover the variants which are more prevalent in India. So typically these vaccines are advisable before the onset of sexual activity or first sexual exposure so typically they are advised before the age of 18 so anywhere from 12 to 18 years these days we have seen guidelines to be extending this cover up to girls up to the age of 25 years but certainly it has it is advisable before the onset of first sexual exposure there has been some benefit of decrease in the incidence and decrease in the aggression of the tumor in women who are vaccinated between the age of 25 to 45 years also after their sexual activity has started so we may see in near future that the guidelines may extend coverage up to those women also in India it is again a big challenge to cover vaccination for such a large population wherein our focus is mainly on the young girls as I said up the age of 25 and it is a welcome move by the government recently that they have decided to promote the HPV vaccination and very soon we may have developments in the national program also on this front so with this I would like to have a take home message that maintaining genital hygiene having appropriate precautions like condoms having avoiding multiple sexual partners avoiding multiple child births more importantly together can go a long way in preventing this HPV infection and subsequent ca cervix or cervical cancer generation so that is how we can prevent ourselves from cervical cancer