Cervical Cancer

Cervical Cancer

 

Carcinoma of the cervix was once the most common cause of cancer in women.

Epidemiology

  • Prevalence – >11,000 women diagnosed in 2008
  • Age
    • High-grade dysplasia – 30-39 years
    • Invasive carcinoma – 40-49 years
  • 15% of U.S. women 14-59 years old test positive for a high-risk strain of human papillomavirus (HPV)

Risk Factors

  • Sexual activity
    • Infection with human papillomavirus, genital warts
    • A history of sexual activity as a teenager, especially if more than 1 sex partner
    • Multiple sex partners now
    • A partner who began sexual activity at an early age or who had many previous sexual partners
    • A history of a sexually transmitted disease
  • A family history of cervical cancer
  • A previous diagnosis of dysplasia on a Pap test or a prior gynecological malignancy
  • Tobacco use
  • Exposure to diethylstilbestrol (DES) before birth
  • HIV infection
  • Weakened immune system due to such factors as an organ transplant, chemotherapy or chronic corticosteroid use

Clinical Presentation

  • Abnormal vaginal bleeding or a significant unexplained change in menstrual cycle
  • A friable cervix that bleeds easily following intercourse or contact such as the insertion of a diaphragm or collection of a Pap smear
  • Pain during sexual intercourse
  • Abnormal vaginal discharge containing blood-tinged mucus

Pathophysiology

  • Etiology – human papillomavirus, an oncogenic virus, is the typical cause
    • HPV 16 and 18 are responsible for >70% of invasive cervical cancers
  • 80% are squamous cell carcinoma, 10-15% are adenocarcinoma
  • Usually evolves from cervical dysplasia
    • 1/3 of high-grade dysplasias progress to invasive carcinoma

Diagnosis

  • Laboratory
    • Cervicovaginal cytology (Pap test) is used for screening, particularly for detecting early pre-cancerous lesions
  • Biopsy
    • Colposcopy and/or cervical biopsy are necessary for a definitive diagnosis

Screening

Screening Guidelines for Cervical Cancer
  American Cancer Society (Nov 2002) U.S. Preventative Services Task Force (Jan 2003) American College of Obstetricians and Gynecologists (Aug 2003)
When to initiate screening
  Approximately 3 years after onset of vaginal intercourse or age 21, whichever comes first
Recommended screening intervals
Conventional Pap Annually; every 2-3 years for women ≥30 with 3 negative cytology tests At least every 3 years Annually; every 2-3 years for women ≥30 with 3 negative cytology tests
Liquid-based cytology Every 2 years; every 2-3 years for women ≥30 with 3 negative cytology tests   Annually; every 2-3 years for women ≥30 with 3 negative cytology tests
If HPV testing used Every 3 years if HPV negative, cytology negative   Every 3 years if HPV negative, cytology negative
When to discontinue screening
  Women ≥70 years of age with ≥3 recent, consecutive negative cytology tests, and no abnormal tests in the past 10 years Women ≥65 years of age with negative cytology tests, who are not in a high-risk category for cervical cancer  
Women who are status post total hysterectomy
  May discontinue testing if hysterectomy was for benign reasons and there is no history of high-grade dysplasia (CIN) May discontinue if hysterectomy was performed for benign indications May discontinue testing if hysterectomy was for benign reasons and there is no history of high-grade dysplasia (CIN)

Treatment

  • Management

Click here for consensus guidelines from American Society for Colposcopy and Cervical Pathology.

Prevention

  • FDA-approved quadrivalent vaccine for HPV 6, 11, 16 and 18 (Gardasil) approved for use in females 9-26 years of age

See Also