The cervix

The cervix is at the lower part of the uterus (womb), which extends into the vagina. The cervix is sometimes called the neck of the womb. There is a small opening in the cervix, the cervical canal, which leads through the cervix into the main part of the uterus.

The cervix has several important functions. It produces some of the moistness that helps lubricate the vagina. It also produces the mucus that helps sperm travel up to the fallopian tubes to fertilise an egg from the ovary. The cervix holds the baby in the uterus during a pregnancy. During labour the cervix opens to allow the baby to be born.

Pap tests and dysplasia

Cervical cancer develops in stages. Pap tests are useful because they can detect abnormal cell changes that may one day become cancerous. Early detection means they can be treated before cancer happens. These changes are known as dysplasia. Pap tests are not designed to pick up cancer, although they sometimes do.

Pap test

A Pap test checks for abnormal cell changes in the cervix at the top of the vagina. It is a screening test to find early warning signs that cancer might develop in the future. If abnormal cell changes are found, your doctor may advise further tests to see if treatment is needed.

The Pap test is quick and simple. The doctor or nurse gently inserts an instrument called a speculum into the vagina. This allows the cervix to be clearly seen. A small sample of cells are taken from the cervix and placed on to a glass slide. The slide is then sent to laboratory, where it is examined under a microscope.

The result usually comes back to your doctor or nurse within two weeks. Ask when you should contact your doctor to find out your result.

You may bleed a little after a Pap test.

Regular Pap tests can find most cell changes that could become cancerous if not detected and treated. It is advised that women have a Pap test once every two years. Women who have had abnormal cell changes may need to have more frequent Pap tests for a period of time. Visit PapScreen Victoria for more information about Pap tests.

Dysplasia

Dysplasia means abnormal changes in the cells of the cervix. Abnormal cell changes are grouped as:

  • Low-grade squamous intraepithelial lesions (LSIL). These are minor changes that normally go away within 12 months.
  • High-grade squamous intraepithelial lesions (HSIL). These are more serious changes that require further tests and sometimes treatment.

Doctors may call abnormal cell changes ‘cervical intraepithelial neoplasia (CIN)’. CIN is graded into CIN I, CIN II and CIN III: that is, mild, moderate and severe cervical cell changes. These are not cancer but could develop into cancer if not treated.

Sometimes the term ‘carcinoma in situ’ is used to describe abnormal cell changes in the cervix. These changes are high-grade (serious) and need further tests.

Cervical cancer

There are two main types of cervical cancer, named after the type of cell they start in. Squamous cell carcinoma, the most common type of cervical cancer, starts in the squamous or skin-like cells that cover the outer surface of the cervix at the top of the vagina. Adenocarcinoma is a less common type of cervical cancer. It starts in the glandular cells, in the cervical canal.

In addition, cervical cancer may be microinvasive or invasive.

Microinvasive cervical cancer

This is when cancer cells have just broken through the bottom layer of the skin of the cervix. At this stage, the cells have not spread more than 5mm into the tissues of the cervix.

Invasive cervical cancer

This is when cancer cells have spread from the surface skin of the cervix into the deeper tissues of the cervix. The cancer may also have spread to part of the vagina or to the lymph nodes and other tissues around the cervix, within the pelvis, or beyond the genital and pelvic areas into nearby organs.

How common is cervical cancer?

In Victoria about 150 women are diagnosed with cervical cancer each year.

Cervical cancer takes a long time to develop. This is one reason why it is more common in women over the age of 40. However, cervical sometimes develops very quickly and is sometimes diagnosed in younger women.

Causes of cervical cancer

Some factors seem to put some women at a higher risk of cervical cancer. These risk factors include:

  • Human papilloma virus (HPV): almost everyone is infected with HPV at some stage in their life. Most cases of HPV resolve without treatment and have no ill effects. Most women who have HPV don’t ever show signs of abnormal cell changes. However, in some women it can cause cell changes that lead to dysplasia. If untreated, these changes may become cancer. HPV is the cause of almost all cases of cervical cancer. There is a vaccine that prevents the types of HPV most commonly linked to cervical cancer. The vaccine is most effective if given to young girls before they are exposed to HPV, that is, before they start having sex. Through the government-funded National Immunisation Program, most girls will receive the vaccine at around the age of 12.
  • Being the daughter of a woman who used the drug diethylstilboestrol (DES) during pregnancy. DES was used to prevent a miscarriage. Its use has declined since the 1940s and 1950s. DES has been linked to a rare type of cervical cancer in a small number of daughters of women who took DES while pregnant.
  • Smoking, which increases the risk of cervical cancer, especially in women who have had a persistent infection with a high-risk HPV type.

Most women with abnormal cell changes feel well and have no symptoms. Having symptoms usually means a cancer is present. Some women may have irregular bleeding, discomfort or bleeding during or after sex or unusual vaginal discharge. Pelvic pain, excessive tiredness, swollen legs or backache can be signs of more advanced cancer.

These symptoms can also be due to other more common problems, but you should still have them checked by your doctor. You may need to be referred to a specialist for further diagnosis and treatment.

Doctors and other health professionals you may see

Your doctor will examine you and refer you for tests to see if you have cancer. This can be a worrying and tiring time, especially if you need to have several tests.

If the tests show you have or may have cancer, your doctor will refer you to a specialist, who will examine you and may ask you to have more tests. If you have cancer, one or more specialists will advise you about treatment options.

You should expect to be cared for by a team of health professionals from the relevant major fields (see following list). Ideally, all your tests and treatment should be available at your hospital; however, this may not be possible.

Health professionals who care for women with cervical cancer include:

  • gynaecological oncologists, surgeons who diagnose and treat women with cervical cancer
  • radiation oncologists, who specialise in using radiotherapy to treat cancer
  • medical oncologists, who specialise in chemotherapy and hormone therapy to treat cancer
  • nurses and general practitioners, who will help you through all stages of your cancer
  • dietitians, who will recommend the best diets to follow during and after treatment
  • social workers, physiotherapists, psychologists and occupational therapists, who will advise you on support services and help you to get back to normal activities.

Tests to diagnose dysplasia and cervical cancer

Various tests are used to detect dysplasia and cervical cancer. The tests reveal more about the cell changes and allow the doctor to make decisions about further tests or treatment. When discussing these tests with your doctor, make sure you understand what is being discussed and what will happen.

The tests may not be very pleasant but are designed to be as quick and painless as possible. Some women feel uncomfortable about having them. It helps to understand exactly what the tests involve. Having a partner or friend with you can give you extra support at this time.

Colposcopy

Colposcopy gives a magnified view of the cervix. It can often be done in the doctor’s room. As with a Pap test, the doctor puts a speculum into your vagina to hold the walls slightly apart. The doctor looks at your cervix through the colposcope, which is like a microscope on a stand. The doctor may paint your cervix with a vinegar solution, which

causes healthy cells to turn pink and abnormal cells to turn white. Some colposcopes have a special TV screen so you can watch the procedure if you wish.

If you are pregnant a colposcopy is quite safe. However, you should always tell your doctor if you are or think you may be pregnant, as you may need different treatment.

Sometimes the doctor takes a biopsy at the same time.

Treatment for dysplasia

If you are diagnosed with dysplasia (abnormal cell changes that may become cancer but are not yet cancer), you may need treatment to remove the abnormal cells from the cervix.

In mild cases, all you may need is more frequent Pap tests, to watch that the cells return to normal.

In more severe cases, the abnormal cells may be removed using laser surgery, loop excision (sometimes called LEEP or LLETZ procedure) or cauterisation (burning). These destroy the abnormal cells without harming normal tissue. A cone biopsy may also remove all the abnormal cells.

These treatments can cause temporary cramping or other pain, bleeding or a watery discharge for several weeks.

Although it is not cervical cancer, the diagnosis and treatment of dysplasia may still be a shock and it may take you some time to recover emotionally. Talking with friends, partners or relatives may help.

Cervical biopsy

In a cervical biopsy, a small piece of tissue is removed from the cervix. The doctor uses the colposcope to see the area that needs to be removed.

You may feel a little pain when the biopsy is taken: ask the doctor to tell you when this might happen.

The tissue is sent to a laboratory for examination. Usually, a definite diagnosis cannot be made until the results of the biopsy are received. This may take several days, or sometimes longer.

A biopsy can cause some bleeding or other discharge, but it usually heals quickly. Some women have pain afterwards, similar to menstrual cramping, which can be helped by pain relievers.

To allow your cervix to heal after a biopsy, your doctor will tell you for how long you should avoid sex and tampons.

Cone biopsy/loop excision

If the biopsy shows abnormal cells on the surface of the cervix, you may need to have a cone biopsy or loop excision. This removes a larger and deeper area of tissue from the cervix. Sometimes it removes all the abnormal cells and no further treatment is needed. In other cases, it shows that the cells have spread into the cervix, and further treatment is needed.

You will usually have a general anaesthetic. You may be treated as a day patient or stay overnight in hospital.

Most women do not have any problems after a cone biopsy,although some women may have difficulty with their periods. You may have some bleeding or cramping for a short while after the cone biopsy. Avoid sex and tampons for three to four weeks. This allows time for your cervix to heal.

Your cervix may be weaker after a cone biopsy. You can still become pregnant but may be at more risk of having a mid-pregnancy miscarriage. Some supportive stitches can be put in early in the pregnancy; these stitches are not always required and are usually removed before the baby is due. If you want to become pregnant, you should discuss this and possible side effects with your doctor before you have a cone biopsy.

Further tests to diagnose cervical cancer

If you have been diagnosed with invasive cervical cancer, you will need further tests. These will tell your doctor how the cancer has spread.

When the test results come back, you and your doctor can discuss the best treatment plan for you.

The further tests may include some or all of the following.

Examination under anaesthetic (EUA), cystoscopy and proctosigmoidoscopy

These tests check whether the cancer has spread to other organs in your abdomen.

You will be admitted to hospital, usually as a day patient, for an extensive physical examination. While you are under anaesthetic, your gynaecological oncologist will examine your bladder, bowel, vagina and pelvic area very carefully.

Your doctor will use a cystoscope and a proctosigmoidoscope. A cystoscope is a thin, lighted instrument that is used to examine your bladder. A proctosigmoidoscope is a thin, lighted instrument that is used to examine the lower end of the bowel.

You may also have a biopsy of your cervix. Most women also have blood and urine tests.

Magnetic resonance imaging (MRI)

This test uses magnetism to build up pictures of the organs in your abdomen. It is very good at imaging the tissues of the pelvis where the cancer is.

MRI is painless, and the magnetism is harmless. You will be asked to lie down inside a large metal tube that is open at both ends. You will probably have an injection, to help show up blood vessels. The test may take up to an hour. The tube makes some people feel claustrophobic (afraid of being in a small space). You can usually take someone into

the room with you for company. The machine can be quite noisy.

Computed tomography (CT) scan

A CT scan is a type of x-ray that gives a cross-sectional picture of organs and other structures (including any tumours) in your body.

CT scans are usually done at a hospital or a radiology clinic. It takes about 30 to 40 minutes to complete this painless test.

You will be asked not to eat or drink before the scan, except you may have a liquid dye, in a drink and an injection. This dye makes your organs appear white on the scans that are taken, so anything unusual will show more clearly.

You may also be asked to put a tampon into your vagina before the scan; this also makes it easier to detect any problems.

You will lie on a table while the CT scanner, which is large and round like a doughnut, moves around you. Most people are able to go home as soon as their scan is over. There is a small possibility of the injected dye causing an allergic reaction. You should tell your doctor if you are allergic to iodine or to contrast dyes, or if you are diabetic or have abnormal kidney function.

Other tests

If your doctor thinks you may have cancer that has spread, they will advise some further tests.

A positron emission tomography (PET) scan can check to see if cancer has spread to other parts of the body. You will have an injection of a glucose solution containing a very small amount of radioactive material.

The scanner moves around you, detecting the radioactive material in the glucose solution. Cancer cells show up as areas where glucose is being used by actively growing cells.

To show this accurately, you will need to not eat beforehand, and have a catheter in the bladder during the procedure.

If you have not had a CT or MRI scan, an intravenous pyelogram (IVP) will check your kidneys, bladder and ureters (the tubes that connect the kidneys to the bladder).

An IVP can be done in a hospital x-ray department or at a special clinic. You may be asked to go on a low-fibre diet and take something to help empty your bowels before you have the IVP.

Before the test, a dye that shows up on x-ray will be injected into a vein in your arm. This dye concentrates in your kidneys, ureters and bladder so that the x-rays can show any problems. An IVP should not cause any side effects.

Instead of an IVP, some specialists may advise you to have an ultrasound to check your kidneys.

Cervical cancer treatment

Many years of treating cancer patients and testing treatments in clinical trials has helped doctors to know what is likely to work for a particular type and stage of cancer. Your doctor will advise you on the best treatment for your cancer. This will depend on the results of your tests, where the cancer is and if it has spread, your age and general health, and what you want.

Treatments for cervical cancer include surgery, radiotherapy, chemotherapy or a combination of these treatments.

Cone biopsy

Some very early cervical cancers may be treated with cone biopsy. However, great care is needed to ensure that all the cancer cells are removed, so the margins of the tissue removed are carefully examined. Most women who have a cone biopsy will not have any long-term side effects.

Hysterectomy

A hysterectomy is the removal of the uterus by surgery.

There are two kinds of hysterectomy:

  • a total hysterectomy, in which the uterus including the cervix is removed
  • a radical hysterectomy, in which the uterus, cervix, support ligaments and top part of the vagina are removed. The ovaries are usually not removed in women who are still having periods. Lymph node dissection may also be done during a radical hysterectomy for cervical cancer.

For both types of hysterectomy, you will need a general anaesthetic.

A radical hysterectomy is a longer operation and it may take you longer to recover.

When you wake up from the surgery, you will have several tubes in place. You will have an intravenous drip that will give you fluid and drugs. You may have a drain tube in your pelvis for a few days. You will also have a catheter put into your bladder to drain away urine. As you improve after the operation, these tubes will be removed.

After the operation

As with all major operations, you will have some discomfort or pain. You can have pain relievers to control this. They may be given through an intravenous drip or through an epidural tube into your spine. The epidural pain relief is similar to that given to women during childbirth.

Let the doctor or nurse know if you have any pain – don’t wait until the pain becomes severe.

A hysterectomy is a major operation. You may be in hospital for five days for a total hysterectomy. If you have a radical hysterectomy you will need to be in hospital for about five to seven days.

Don’t expect to get back to your normal activities too quickly. For some women, recovery may take six weeks or even longer. During this time, avoid heavy work or lifting. It may take some time before you feel completely well.

Before you go home from hospital, ask your doctor what you can do and what you should avoid for a while, for example, when you can start to have sex again.

There are many books about hysterectomy. Check your local library or bookshop.

Radiotherapy

Radiotherapy uses radiation to destroy or injure cancer cells. The radiation can be targeted to cancer sites in your body. Treatment is carefully planned to do as little harm as possible to your normal body tissue.

Radiotherapy may be advised if you are not well enough for major surgery. It may also be advised if the cancer has spread into the tissues around the cervix, or if the tumour is very large, because this would be hard to cure by surgery alone. Radiotherapy may also be used after surgery or combined with chemotherapy.

Radiotherapy can be given in two ways: from outside or inside the body. Usually both are used to treat cervical cancer.

If radiotherapy is advised, a doctor who specialises in radiotherapy treatment for women with cervical cancer will treat you. This doctor will work closely with your gynaecological oncologist.

External radiotherapy

In external radiotherapy, rays from a large machine are directed at the part of the body needing treatment. For women with cervical cancer, this is the pelvic area.

You will probably have radiotherapy as an outpatient, five days a week for four to six weeks. The actual treatment takes two to three minutes each time. However the waiting and preparation time is longer.

Like a normal x-ray, radiotherapy does not cause pain or discomfort as it is being given.

If you have external radiotherapy, it is likely that you will also have chemotherapy once a week.

Brachytherapy (internal radiotherapy)

Brachytherapy is radiotherapy given internally. It is put into the cancer from inside your body. Your radiation oncologist will discuss the method to be used with you before you begin treatment.

Brachytherapy is usually given after a course of external radiotherapy with weekly chemotherapy (see above). This is because most cervix cancers become smaller during this treatment. Brachytherapy involves placing implants with a radiation source inside the cervix and vagina, as close to the cancer as possible. This gives adequate radiation to the tumour while minimising the dose (and side effects) to nearby organs, such as the bowel and bladder. You may need three to five treatments.

The implants are inserted for a short time while you are under anaesthetic. The radiation is placed into the implant for only a few minutes. The implant is removed before you wake up. Because the radiation is removed, there is no radiation risk to other people around you. You will usually go home on the same day.

Less commonly, brachytherapy is given over 48-72 hours. You will go into hospital as an inpatient and have a general or spinal anaesthetic.

The implant will be placed in your cervix and vagina and left in place for up to 72 hours. The brachytherapy will be given during this period, with breaks for staff to attend your needs. You may be in a room of your own. Nurses will explain how your visitors can protect themselves from radiation. After the treatment is complete, the implant will be removed and you can go home.

Side effects of radiotherapy

Radiotherapy may cause a number of side effects that are temporary and can be controlled. These include tiredness, loss of appetite, diarrhoea, pain when passing urine and skin problems. The skin between your buttocks may feel sore, like the feeling you get from sunburn. Radiotherapy to this area can also cause shortening, drying and adhesions of the vagina. A dilator or vaginal cylinder with oestrogen cream can be used to treat or prevent these side effects.

Special cream can relieve this burning feeling. If you have not been through menopause, radiotherapy will affect your ovaries and reduce their ability to produce normal hormones. This may cause infertility and symptoms of menopause. Vaginal spotting may also occur. It is unlikely to be a major problem.

When having radiotherapy, allow plenty of time to rest. Drink lots of water and have small but frequent meals. Ask the doctor or nurse how to manage any side effects.

Chemotherapy

This is the treatment of cancer with anti-cancer drugs. The aim is to destroy all cancer cells while doing the least possible damage to normal cells. The drugs work by stopping cancer cells from growing and reproducing themselves.

Chemotherapy is usually given to women with more advanced cancer or together with radiotherapy.

You will probably have chemotherapy through a vein. You may need to stay in hospital overnight or you may be treated as a day patient. This depends on the drugs you are given and how you are feeling. You will probably have a number of treatments, usually six, every three to four weeks over several months. This depends on the disease and other treatments being used. You will have blood tests before your next treatment to make sure your body’s normal cells have had time to recover.

Side effects of chemotherapy

The side effects of chemotherapy vary according to the drugs used. They may include:

  • feeling sick (nausea), vomiting
  • feeling off-colour and tired
  • some thinning or loss of hair from your body and head.

These side effects are temporary, and steps can often be taken to prevent or reduce them. There are effective medications to prevent many of the side effects.

Chemotherapy may also cause periods to stop, either temporarily or permanently, causing premature menopause.

Combined radiotherapy and chemotherapy

A combination of radiotherapy and chemotherapy is used to treat cervical cancer. Trials have found that women with invasive cervical cancer have better rates of survival when they have chemotherapy that includes the drug cisplatin along with radiotherapy.

Combined radiotherapy and chemotherapy can cause more side effects than radiotherapy alone. The side effects include a reduced number of white blood cells (leucopoenia), nausea and vomiting.

These are temporary and can be treated.

Complementary and alternative medicines

It’s common for people with cancer to seek out complementary and alternative treatments. Many people feel that it gives them a greater sense of control over their illness, that it’s ‘natural’ and low-risk, or that they just want to try everything that seems promising.

Complementary therapies include massage, meditation and other relaxation methods, which are used along with medical treatments.

Alternative therapies are unproven remedies, including some herbal and dietary remedies, which are used instead of medical treatment.

Some of these have been tested scientifically and found to be not effective or even to be harmful.

Some complementary therapies are useful in helping people to cope with the challenges of having cancer and cancer treatment. However, some alternative therapies are harmful, especially if:

  • you use them instead of medical treatment
  • you use herbs or other remedies that make your medical treatment less effective
  • you spend a lot of time and money on alternative remedies that simply don’t work.

Be aware that a lot of unproven remedies are advertised on the Internet and elsewhere without any control or regulation. Before choosing an alternative remedy, discuss it with your doctor or a cancer nurse at the Cancer Council Helpline on 13 11 20.

Prognosis

Cervical cancer can be effectively treated when it is found early. Most women with early cervical cancer will be cured.

For women whose cancer has progressed further, a cure is often still possible. For other women, treatment can keep the disease under control for long periods of time.

For information about your own prognosis, you should talk with your doctor, who knows your full medical history.

Even if your cancer is curable you may find that you often need to be reassured by your specialist. This is normal because you may feel that you can no longer trust your body. Over time you will find that you feel more confident.

Recovery and follow-up care

Recovering from treatment is different for each woman. It depends on the type and stage of cervical cancer you have and also the amount of treatment you have needed.

You will need to have regular check-ups with your specialist. These may include blood tests and physical examinations. Talk with your doctor about how often these may be.

It may take some time for you to recover from the various types of treatment. You will find that there are physical changes as well as many emotional changes to cope with. It is important that you, your partner and family are prepared for this. You may also need to talk with your employer about how the treatment may affect your work.

When cancer can’t be cured

If your cancer has spread and it is not possible to cure it by surgery, your doctor may still recommend treatment. In this case, treatment may help relieve any symptoms, can make you feel better and may allow you to live longer.

Whether or not you choose to have anti-cancer treatment, symptoms can still be controlled. For example, if you have pain, there are effective treatments for this.

General practitioners, specialists and palliative care teams in hospitals all play important roles in helping people with advanced cancer. For more, contact the Cancer Council Helpline on 13 11 20

Making decisions about treatment

Sometimes it is very hard to decide which is the right treatment for you. You may feel that everything is happening so fast that you do not have time to think things through. Waiting for test results and for treatment to begin can be very difficult.

While some people feel they have too much information, others may feel that they do not have enough. You need to make sure that you know enough about your illness, the possible treatment and side effects to make your own decisions.

If you are offered a choice of treatments, you will need to weigh up the good and bad points about each treatment. If only one type of treatment is recommended, ask your doctor to explain why other treatment choices have not been advised.

For most women, cervical cancer can be cured. However, treatment may make it more difficult, or impossible, for you to become pregnant.

This may be a blow for many women, even if they already have a family. For women who have not yet had children, it can be very hard. Taking time over your decisions is even more important in this situation.

Some people with advanced cancer will always choose treatment, even if it only offers a small chance of cure. Others want to make sure that the benefits of treatment outweigh any side effects. Still others will choose the treatment they think offers them the best quality of life.

Some may choose not to have treatment except to have any symptoms managed to maintain the best possible quality of life.

Talking with doctors

You may want to see your doctor a few times before making a final decision on treatment. It is oft en hard to take everything in, and you may need to ask the same questions more than once. You always have the right to find out what a suggested treatment means for you, and the right to accept or refuse it.

Talking with others

Once you have talked about treatment options with your doctor, you may want to talk them over with family or friends, with nursing staff , the hospital social worker or chaplain, or your own religious or spiritual adviser. Talking it over can help to sort out which course of action is right for you.

You may be interested in searching for cervical cancer on the Internet. While there are some very good websites, you need to be aware that some websites provide wrong or biased information. We recommend that you begin with a Cancer Council website (see link below)

A second opinion

You may want to ask for a second opinion from another specialist. This is okay and can help you make your decision. Your specialist or local doctor can refer you to another specialist. You can ask for a copy of your results to be sent to the second-opinion doctor. You can still ask for a second opinion even if you have started treatment or still want to be treated by your first doctor.

Taking part in a clinical trial

Clinical trials are the most accurate way to determine the effectiveness of promising new treatments or new ways of combining cancer treatments. Always discuss treatment options with your doctor.

If your doctor suggests taking part in a clinical trial, make sure that you fully understand the reasons for the trial and what it means for you. Before deciding whether or not to join the trial, you may wish to ask your doctor:

  • What is the standard  (best available) treatment for my cancer if I don’t go in the trial?
  • Which treatments are being tested and why?
  • Which tests are involved?
  • What are the possible risks or side effects?
  • How long will the trial last?
  • Will I need to go into hospital for treatment?
  • What will I do if any problems occur while I am in the trial?

If you decide to join a randomised clinical trial, you will have either the best existing treatment or a promising new treatment. You will be allocated at random to receive one treatment or the other. In clinical trials, people’s health and progress are carefully monitored.

If you do join a clinical trial, you have the right to withdraw at any time. Doing so will not affect your treatment for cancer.

It is always your decision to take part in a clinical trial. If you do not want to take part, your doctor will discuss the best current treatment choices with you.

Research into cervical cancer

Research into cervical cancer is ongoing. Recent clinical trials have involved detection and screening methods, immunotherapy, fertility preserving surgery, targeted therapy and combination therapies. These may not be approved or available as standard treatments. Always discuss all diagnostic and treatment options with your doctor.

For information or cancer support call 13 11 20.

For more information, see the Cancer Council of Victoria website (see the link below).

Last Reviewed: 01/07/2010

Reproduced with kind permission from the Anti-Cancer Council of Victoria.