Cervical cancer is a malignant neoplasm arising from the cervical epithelium. It is strongly associated with the human papillomavirus (HPV). 80% are squamous cell carcinomas, while 20% are adenocarcinomas.
It peaks between 30 and 40 years.
- Risk factors
- Human papillomavirus (HPV) infection
- High-risk strains HPV 16 and 18 are more likely to cause cervical cancer
- Immunocompromised women are more likely to develp cancer since they cannot clear the infection
- Sexual activity
- Early sexual activity
- Multiple sexual partners
- Having a partner who has had multiple sexual partners
- Smoking
- This is an independent risk factor
- HIV infection
- Immunosuppression enhances the susceptibility to HPV infection
- Low socioeconomic status
- This may be due to limited access to screening services and lower quality of care
- High parity
- History of sexually transmitted infections
- This may be due to cervicitis
- Human papillomavirus (HPV) infection
- Pathophysiology
- HPV infection → viral proteins E6 and E7 inhibit p53 and Rb respectively → uncontrolled cell proliferation and impaired apoptosis → genetic instability and accumulation of mutations
- Signs and symptoms
- Asymptomatic in the early stages
- Vaginal bleeding
- Post-coital bleeding
- Vaginal discharge
- Watery or foul-smellin
- Pelvic pain or pressure
- Rectal or urinary tract symptoms depending on invasion or pressure effects
- Physical exam
- Bimanual examination
- Cervical mass
- Invasive lesions in the upper vagina, cul-de-sac or adnexa may be present
- Speculum exam
- Friable and bleeding cervical lesion which may invade other parts of the vagina
- Bimanual examination
- Differentials
- Cervical dysplasia
- Endometrial polyps
- Pelvic inflammatory disease
- Investigations
- MRI and CT scans are useful to determine the extent of disease (e.g. distant metastases) but not for staging
- Examination under anaesthesia
- Cystoscopy
- Proctoscopy
- Intravenous pyelography
- Barium enema
- Chest X-ray
- Treatment
- Stage 1A
- Hysterectomy +/- lymph node clearance
- Nodal clearance for stage IA2
- Cone biopsy with negative margins for patients who with to preserve fertility
- Radical trachelectomy for stage IA2
- Stage IB
- Radical trachelectomy for stage IA2 with radiotherapy and chemotherapy for stage IB1
- Radical hysterectomy with pelvic lymph node dissection for stage IB2
- Stage II and III
- Radiation therapy and chemotherapy
- Hydronephrosis or nephrostomy may be considered
- Stage IV
- Radiation therapy and chemotherapy
- Palliative chemotherapy
- Recurrent disease
- Chemoradiation or radiotherapy if it was treated with surgery
- Surgery if it was treated with radiotherapy
- Stage 1A
- Prevention
- Vaccination
- Gardasil is a vaccine containing recombinant virus-like particles (VLPS)
- It is given to both girls and boys
- It is also safe for those who are immunocompromised or lactating since it does not have HPV DNA
- Gardasil 4 covers HPV 6, 11, 16 and 18
- Gardasil 9 covers HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58
- First dose at 10-years – it has a higher efficacy when given at younger years
- Second and third doses can be given 6 monthly thereafter
- The vaccine may also be effective against head and neck squamous cell carcinoma (HNSCCs)
- Vaccination
FIGO Staging and Treatment
| Stage | Description | Standard Treatment |
|---|---|---|
| 0 | Carcinoma in situ (CIN III) | Conization, LEEP/loop excision, laser ablation, cryotherapy |
| I | Cancer confined to cervix | Primarily surgery in early disease |
| IA | Microscopic invasive disease ≤5 mm depth | Fertility-sparing or surgery |
| IA1 | Stromal invasion ≤3 mm | Cone biopsy (fertility preservation) or simple/total hysterectomy |
| IA2 | Stromal invasion >3 mm and ≤5 mm | Radical hysterectomy + pelvic lymph node dissection OR radical trachelectomy + lymphadenectomy |
| IB | Clinically visible lesion or >5 mm invasion confined to cervix | Surgery or chemoradiation depending on size |
| IB1 | <2 cm | Radical hysterectomy + pelvic lymphadenectomy OR radical trachelectomy if fertility desired |
| IB2 | 2–4 cm | Radical hysterectomy + pelvic lymphadenectomy OR chemoradiation |
| IB3 | >4 cm | Concurrent chemoradiation usually preferred |
| II | Beyond cervix but not pelvic wall/lower 1/3 vagina | Usually chemoradiation |
| IIA | Upper 2/3 vagina, no parametrial invasion | Radical hysterectomy or chemoradiation |
| IIA1 | ≤4 cm | Surgery or chemoradiation |
| IIA2 | >4 cm | Concurrent chemoradiation preferred |
| IIB | Parametrial involvement | Concurrent cisplatin-based chemoradiation |
| III | Pelvic wall/lower vagina/hydronephrosis/nodal disease | Concurrent chemoradiation |
| IIIA | Lower 1/3 vagina | Chemoradiation |
| IIIB | Pelvic wall involvement or hydronephrosis | Chemoradiation |
| IIIC1 | Pelvic lymph nodes | Chemoradiation |
| IIIC2 | Para-aortic lymph nodes | Extended-field chemoradiation |
| IV | Spread beyond pelvis or bladder/rectal mucosa | Often palliative/systemic treatment |
| IVA | Adjacent pelvic organs | Chemoradiation |
| IVB | Distant metastases | Systemic chemotherapy ± immunotherapy ± palliative radiation |
5-year survival by stage
| Stage | 5-year survival |
|---|---|
| Stage I | 85-90% |
| Stage II | 65-70% |
| Stage III | 35-45% |
| Stage IV | 15-20% |