see also:

• human papilloma virus (HPV)
• neoplasia / cancer / tumours
• oncology
• wikipedia

• 500,000 cases world-wide annually
• 2nd most common gynaecologic malignancy and is essentially a sexually transmitted disease
• in the early 20th century it was noted that cervical cancer is rare in Jewish women who only have Jewish men as partners, and is rare in virginal nuns, but common in 2nd wives of men whose first wife died from cervical cancer.
• cervical cancer is mainly caused by the human papilloma virus (HPV) and is characterised by its slow progression from normal cervical tissue, to precancerous (or dysplastic) changes in the tissue, to invasive cancer.
  • 100% of cervical carcinoma biopsies have HPV DNA (cw 50-90% of penile & vaginal cancers) - HPV DNA was first identified in 1963 and first detected in cervical cancer cells in 1976.
  • 70% of cervical cancer cases are associated with HPV types 16 or 18
    • over 50% of sexually active women become infected over their lifetime, risk in proportion to number of sexual partners
    • risk of neoplastic change is higher with cigarette smoking, OCP use, other STDs such as Chlamydia infection, HIV / AIDS, dietary factors, multiple pregnancies, exposure to the hormonal drug diethylstilbestrol (DES) and a family history of cervical cancer, exposure of cervix to semen. There is a possible genetic risk associated with HLA-B7.
    • also at risk of vulval cancer
• this slow progression allows early detection of pre-cancer stages through regular Pap smears.
  • regular two-yearly Pap tests can reduce the incidence of cervical cancer by up to 90% in Australia, and save 1,200 Australian women dying from the disease each year.
  • Papanicolaou developed the Pap technique in 1928, and use of it for screening in 1941.
• as human papilloma virus (HPV) is by far the main causal factor, it is hoped that the new vaccines will reduce incidence by up to 70-85%.
• cervical cancers don't always spread, but those that do most often spread to the lungs, the liver, the bladder, the vagina, and/or the rectum.
• 80-85% are squamous cell carcimomas, ~15% in the UK are adenocarcinomas

• cervical cancer does not usually cause pain, although it may in very advanced stages.
• the most common symptom is abnormal vaginal bleeding.
• abnormal vaginal discharge may also occur.

• referral to a gynaecologist for colposcopy:
  • staining and examination of the cervix using a special microscope (colposcope - invented in 1925) which magnifies the cervix 8-10x
  • abnormal areas are biopsied and sent for histology
• low grade lesions may need only close follow up with repeat Pap smears +/- colposcopy
• high grade lesions usually require further diagnostic and therapeutic procedures such as LEEP, cone biopsy, laser diathermy, cryotherapy or cauterisation diathermy and follow up.

• formerly called mild dysplasia or CIN-1
• may go away on their own, but over time, they may become more abnormal, eventually becoming a high-grade lesion.

• also called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ.
• usually do not become cancerous and invade deeper layers of the cervix for many months, perhaps years.

• usually seen in women aged over 40 years - but perhaps earlier now with the rising widespread sexual promiscuity since 2001

• CXR
• LFT's +/- CT scan of the liver
• bladder CT scan
• EUA of vagina and rectum

• cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system which is analgous to the TNM staging system:
  • Stage 0 - full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ)
  • Stage I - limited to the cervix
  • Stage II - invades beyond cervix
  • Stage III - extends to pelvic wall or lower third of the vagina
  • Stage IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis
  • Stage IVB - distant metastasis

• usually involves a combination of surgery and radiotherapy.
• survival improves when radiotherapy is combined with cisplatin-based chemotherapy

• With treatment, the 5-year relative survival rate for the earliest stage of invasive cervical cancer is 92%, and the overall (all stages combined) 5-year survival rate is about 72%.
• With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are alive 5 years after diagnosis. Only 25 to 35% of women with stage III cancer and 15% or fewer of those with stage IV cancer are alive after 5 years