Gynecologic cancers include cervical cancer and endometrial.
The most important thing to know about gynecologic cancers is that there are things that you can do to prevent them.
Cervical cancer is caused by the HPV (human papilloma virus). If you’ve ever been sexually active, then you’ve likely been exposed to HPV. HPV is the most common sexually transmitted disease. The good news is that our immune systems typically keep the virus in check and it never causes problems. If you get regular pap smears, then your gynecologist can check for HPV and ensure your cervix is normal. If anything is abnormal, then it can be biopsied and treated before it ever spreads to lymph nodes or other organs.
Unfortunately, for some women, their immune systems do not keep HPV controlled, and if these women do not get routine pap smears, then the virus has time to cause a cancer in the cervix. Here are the facts about HPV from the CDC.
If you are diagnosed with cervical cancer you will likely undergo CT scans or a PET scan of your body to determine if the cancer has spread. These scans are important as they allow your doctors to assess the stage of your cancer which will then determine treatment.
Stage I cervical cancer is typically treated with surgery to remove either the tumor or the entire cervix (trachelectomy). If the tumor is large you may need to undergo a hysterectomy which includes removal of the cervix as well as the uterus. The need to remove the fallopian tubes and ovaries will be based on a discussion with your Gynecologist Oncologist.
Later stage cervical cancers, Stage II and III, can sometimes still be treated with surgery; however, typically these cancers will require additional chemotherapy and radiation afterward. For this reason, your doctors may recommend chemotherapy and radiation together as the sole form of treatment.
You will meet with a Radiation Oncologist like Dr. Gullett to review the plan for treatment. Typically women need to receive 5 – 5.5 weeks of daily external beam radiation delivered Monday – Friday. The first step is a radiation planning session called a “CT simulation.” The steps involved in a CT simulation, or “CT sim” as we call it, are outlined here. For cervical cancer, a mold will be created to immobilize the pelvis.
In order to cure cervical cancer, a high dose of radiation is required. It’s tricky to deliver as the cervix is located directly behind the bladder and in front of the rectum as shown below.
Consequently, there are 2 types of radiation used for cervical cancer. External beam radiation followed by an internal boost called brachytherapy. First you will receive 25-28 treatments of radiation delivered using an external beam. Often a low dose of weekly chemotherapy is delivered with the external radiation to help sensitize the tumor cells to the radiation damage. For each external radiation treatment, you lie on the treatment table and a machine rotates around you to deliver the radiation. The treatment is painless and lasts 10-15 minutes. This treatment will target the cervical tumor as well as the lymph nodes in the pelvis, where cervical cancer likes to spread.
After the external radiation is delivered, you will be started on the internal radiation called brachytherapy. Brachytherapy is used because the bladder and rectum received low dose radiation during external beam treatment due to their location next to the cervical tumor. Hence, brachytherapy is the medical term used to describe a process by which a device is placed into the vagina, up into the uterus and directly onto the cervix. This allows Dr. Gullett to target just the cervical tumor and protect the bladder and rectum from additional radiation. She uses a tandem and ring applicator made by Varian Medical Systems.
Here is how brachytherapy for cervical cancer is delivered:
1. After your external beam radiation, you will be scheduled to go to the operating room for an “EUA” exam under anesthesia. Dr. Gullett and your Gynecologist Oncologist will exam your cervix and assess how much the tumor has decreased in size from the dose of radiation already delivered. A Smit sleeve will be inserted in to your cervix to allow an opening for the tandem and ring device (called a T&R).
2. Once the Smit sleeve is secured, Dr. Gullett will place the tandem into the sleeve which extends into the uterus. She will then place the ring up against the cervix and ensure it is in good position to target the residual tumor. Another applicator is then inserted to move the rectum backward, away from the cervix, to protect it from additional high dose radiation. Sterile gauze will be inserted into the vagina to hold the device in place.
3. You will wake up in the recovery room with the T&R in place. Pain medicine is administered to ensure you are comfortable. You will then be transferred to the department of Radiation Oncology for radiation planning and treatment.
4. Once you arrive in Radiation Oncology, you will be placed on the CT scanner for another simulation. Dr. Gullett will use the CT scan to verify that the Smit sleeve and T&R are appropriately placed and that the brachytherapy planning can proceed. A plan will be generated that targets the residual cervical tumor with the goal of avoiding the rectum and bladder.
5. Once Dr. Gullett approves the brachytherapy plan and the necessary quality assurance is complete, you will be moved into the treatment room. A device called an afterloader will be wheeled into the room and catheters will be connected to the T&R device that is secured in the vagina.
6. Dr. Gullett and the Medical Physicist will review the setup to ensure the catheters are connected correctly to the tandem and ring. Once the setup is approved, the afterloader will send radioactive seeds into the catheters and into the tandem and ring. This will result in radiation being delivered directly to the residual cervical tumor and up into the uterus which can harbor residual microscopic tumor cells. You will not feel the radioactive seeds entire the device, nor will you feel the radiation being delivered. Treatment lasts anywhere from 10-15 minutes typically.
7. After treatment is complete, the Medical Physicist will survey the room using a Geiger counter to ensure no active radioactive seeds are in the body or room. Dr. Gullett will then come in, remove the gauze, T&R, and the rectal applicator. Radiation Oncology nurses will help you get dressed and ensure you are in stable condition for discharge home.
Most patients tolerate brachytherapy very well. Typically 5 insertions are necessary to target the remaining cervical tumor and attempt cure. The exact number of treatments will depend on your tolerance of the procedure as well as how much tumor is left to target at the time of brachytherapy planning.
If you would like more details regarding brachytherapy for cervical cancer, check out AboutBrachytherapy.com