18. Cervical Cancer

Question 1

What is cervical cancer and where is it most common?

Answer 1

Cervical cancer is the most common cancer affecting women in many developing countries, often ranking second to breast cancer in some places. Around 85% of the 500,000+ new cases globally occur in developing countries.

Question 2

What is the incidence of cervical cancer globally and in South Africa?

Answer 2

Globally, cervical cancer affects 500,000+ women, with 85% of new cases in developing countries. In the USA, the incidence dropped from 56 cases per 100,000 women in the 1940s to 6 in the 1990s. In Africa, the average age-standardized incidence is 30-40/100,000 women. In South Africa, the incidence is 31/100,000 in black women and 12/100,000 in white women, highlighting disparities in healthcare access.

Question 3

How can cervical cancer be prevented?

Answer 3

Cervical cancer can be prevented through mass cervical screening campaigns. However, due to financial and infrastructural constraints, these campaigns have not been widely implemented in developing countries.

Question 4

What are the types of cervical cancer?

Answer 4

Cervical cancer is classified into:

1. Squamous cell carcinoma
2. Adenocarcinoma
3. Other epithelial tumors

Question 5

What is the FIGO 2009 staging system for cervical cancer?

Answer 5

The FIGO 2009 staging system for cervical cancer is as follows:

Stage 1: Cancer is strictly confined to the cervix (extension to corpus is disregarded).

Question 6

What defines Stage 1A cervical cancer?

Answer 6

Stage 1A is invasive carcinoma that can only be diagnosed by microscopy, with the deepest invasion ≤ 5 mm and the largest extension ≤ 7 mm.

• 1A1: Stromal invasion ≤ 3 mm deep and ≤ 7 mm wide.
• 1A2: Stromal invasion > 3 mm but < 5 mm deep and < 7 mm wide.

Question 7

What defines Stage 1B cervical cancer?

Answer 7

Stage 1B includes clinically visible lesions limited to the cervix or pre-clinical cancers greater than Stage 1A.

• 1B1: Cancer > 5 mm deep and > 7 mm wide but less than 4 cm in greatest diameter.
• 1B2: Cancer greater than 4 cm in greatest diameter.

Question 8

What defines Stage 2 cervical cancer?

Answer 8

In Stage 2, the cancer extends beyond the cervix but does not reach the pelvic side wall. The cancer involves the vagina but not as far as the lower third.

Question 9

What defines Stage 2A cervical cancer?

Answer 9

Stage 2A involves no parametrial involvement but extends to the upper vagina.

• 2A1: Clinically visible lesion ≤ 4 cm in diameter.
• 2A2: Clinically visible lesion > 4 cm in diameter.

Question 10

What defines Stage 2B cervical cancer?

Answer 10

Stage 2B involves parametrial involvement but does not extend to the pelvic side wall.

Question 11

What defines Stage 3 cervical cancer?

Answer 11

In Stage 3, the cancer has extended to the pelvic side wall. There is no cancer-free space between the tumor and pelvic wall on rectal examination. The tumor also involves the lower third of the vagina. All cases with hydronephrosis or non-functioning kidneys are included unless the cause is known to be something else.

Question 12

What defines Stage 3A cervical cancer?

Answer 12

Stage 3A involves the cancer in the lower third of the vagina

Question 14

What defines Stage 3B cervical cancer?

Answer 14

Stage 3B includes the extension of cancer to the pelvic side wall and/or the presence of hydronephrosis or non-functioning kidney.

Question 15

What defines Stage 4 cervical cancer?

Answer 15

In Stage 4, the cancer has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum (biopsy proven). Bullous edema does not permit a case to be classified as Stage 4.

Question 16

What defines Stage 4A cervical cancer?

Answer 16

Stage 4A involves the spread of cancer to adjacent organs, such as the bladder and rectum.

Question 17

What defines Stage 4B cervical cancer?

Answer 17

Stage 4B involves the spread of cancer to distant organs

Question 18

How are macroscopically visible lesions classified in cervical cancer staging?

Answer 18

All macroscopically visible lesions, even with superficial invasion, are classified as Stage 1B carcinomas. The invasion is limited to a measured stromal invasion with a maximum depth of 5.0 mm and a horizontal extension not greater than 7.0 mm. The depth of invasion is measured from the base of the epithelium (squamous or glandular) and should always be reported in mm, even in cases of “early (minimal) stromal invasion” (<1 mm).

Question 19

What does a rectal examination reveal in Stage 3 cervical cancer?

Answer 19

On rectal examination in Stage 3 cervical cancer, there is no cancer-free space between the tumor and the pelvic side wall. Additionally, all cases with hydronephrosis or non-functioning kidney are included in the staging, unless these conditions are known to be due to other causes.

Question 20

Clinical Presentation

Answer 20

There is a wide range of clinical presentations:

• asymptomatic and incidental finding on taking a cervical smear or performing a speculum examination
• abnormal vaginal bleeding:
   intermenstrual bleeding
   post-coital bleeding
   irregular bleeding
   post menopausal bleeding
• offensive vaginal discharge
• pelvic pain
• malignant vesical or rectal fistulae
• symptoms due to metastases

Question 21

How is cervical cancer diagnosed?

Answer 21

The diagnosis of cervical cancer is made by visualizing the cervix. If a woman presents with symptoms, it is mandatory to perform a speculum examination of the cervix. If an abnormal lesion is detected, a punch biopsy should be taken for histological confirmation of the cancer.

Question 22

How is cervical cancer staged?

Answer 22

The staging of cervical cancer is primarily clinical and involves performing a pelvi-rectal examination to assess the degree of local spread. The clinical examination includes checking for lymphadenopathy and conducting careful abdominal palpation.

Question 23

What additional investigations are performed to stage cervical cancer?

Answer 23

The clinical assessment is supplemented by the following investigations:

1. Renal function tests
2. Liver function tests
3. Chest X-ray
4. Ultrasound of the ureters or IVP
5. Cystoscopy to check for bladder involvement

Question 24

What additional tests should be performed for women with cervical cancer?

Answer 24

In addition to staging investigations, the following tests should be performed:

• VDRL and HIV tests
• Full blood count (FBC)
• If HIV positive, a CD4 count, viral load, and documentation of anti-retroviral medication use.

Question 25

Where should women with cervical cancer be referred, and how is treatment determined?

Answer 25

Women with cervical cancer should be referred to a tertiary referral institution for management. Treatment options are influenced by both the stage of the cancer and the general condition of the patient.

Question 26

What is the standard treatment for Stage IA cervical cancer?

Answer 26

For Stage IA, a simple hysterectomy (abdominal, vaginal, or laparoscopic) is considered adequate therapy. For Stage 1A2, a pelvic lymphadenectomy is also required.
In selected cases where fertility preservation is important, a cone biopsy may be considered if the lesion has been fully excised and the patient is available for follow-up. Alternatively, a trachelectomy may be performed (removal of the cervix to the level of the isthmus).

Question 27

What is the standard treatment for Stage IB1 cervical cancer?

Answer 27

Stage IB1 is treated with radical hysterectomy and bilateral pelvic lymph node dissection, also known as Wertheim-Meigs hysterectomy. This involves removing:

Uterus

Cuff of vagina (around 2 cm)

Both parametria (with extensive ureter dissection)

External iliac, internal iliac, and obturator lymph nodes, and sometimes common iliac nodes.
All macroscopically enlarged nodes should be removed if feasible.
Women with medical problems or obesity who are unsuitable for surgery are treated with primary radical chemoradiotherapy (weekly cisplatinum with daily radiation). The cisplatinum acts as a radio-sensitizer and improves survival compared to radiation alone.

Question 28

What is the standard treatment for Stage IB2 cervical cancer?

Answer 28

Stage IB2 is treated with primary radical chemoradiation due to the high risk of needing adjuvant chemoradiation post-surgery and the increased complication rate with two modalities of treatment.

Question 29

What is the standard treatment for Stage II and III cervical cancer?

Answer 29

Stage II and III are treated with primary radical chemoradiation.

Question 30

What is the standard treatment for Stage IV cervical cancer?

Answer 30

Stage IV is treated with palliative radiotherapy. If recto- or vesico-vaginal fistulae occur, surgical diversions may be performed.

Question 31

How is cervical cancer treatment adjusted for HIV-positive women?

Answer 31

HIV-positive women with CD4 counts >200 mm³ are treated the same way as HIV-negative women. However, when the CD4 count drops below 200 mm³, the immunosuppression caused by both anti-cancer treatment and HIV becomes life-threatening. In such cases, anti-cancer treatment needs to be adjusted. Women with low CD4 counts should be placed on HAART (Highly Active Antiretroviral Therapy) as soon as possible to enable the safe administration of chemoradiation.