Cervical Cancer

Question 1

Risk factors for cervical cancer

Answer 1

HPV - 16 & !8
Smoking

Question 2

Cervical cancer screening pathway age and normal follow up if everything is normal.

Answer 2

25-64

25-49 = every three years
50-64 = every five years

Question 3

What is tested for in the initial cervical cancer screen?

Answer 3

High risk HPV

Question 4

If hrHPV is positive, what do you do next?

Answer 4

Send for cytology screen - check of cells are dysplastic at all.

Question 5

If a pt is hrHPV +ve, cytology negative, what do we do?

Answer 5

Rescreen in a year, then if again the same result, rescreen again in a year

Question 6

If a pt is hrHPV +ve, cytology negative, and then comes back a year later is again hrHPV +ve but cytology negative, what do we do? What do we do if this result comes back the same?

Answer 6

Rescan in 12 months. If 3x same result, then send for colposcopy

Question 7

When would you send for colposcopy

Answer 7

If hrHPV and cytology come back positive, or if hrHPV comes back positive but cytology negative and stays this way for another 24 months.

Question 8

Describe the anatomy of the cervix, types of cells etc.

Answer 8

The endocervix contains cuboidal COLUMNAR epithelium. The ectocervix contains squamous epithelium.

There are reserve cells which sit under the cuboidal COLUMNAR cells of the endocervix. These can differentiate to become basal cells of the squamous epithelium, or cuboidal cells of the endocervix.

The transformational zone (TZ) is the squamo-columnar junction where squamous cells become columnar cells.

Question 9

What can affect the transformation zone? What is this condition called?

Answer 9

It is normal for the TZ to change according to increasing levels of oestrogen e.g. COCP, pregnancy. This can result in cervical ectropion. Symptoms include bleeding after sex and vaginal discharge.

Question 10

Symptoms of cervical cancer

Answer 10

Post coital bleeding - PCB
PMB
IMB
Thick smelly discharge
Deep dyspareunia

Question 11

How does HPV 16 lead to cancer?

Answer 11

HPV 16 produces an E6 protein which inhibits the tumour suppressor gene p53

Question 12

How does HPV 18 lead to cancer?

Answer 12

HPV 18 produces an E7 protein which inhibits the tumour suppressor gene RB

Question 13

What other types of cancers do HPV 16 and 18 cause?

Answer 13

Head and neck, anal and genital cancers

Question 14

What is colposcopy? What happens?

Answer 14

It is a special microscope to visualise the cervix. Sometimes, acetic acid is applied to visualise abnormal areas with proteins which show up white.

Question 15

What happens after colposcopy?

Answer 15

LLETZ - large loop excision of the transformation zone

or Biopsy

Question 16

What are the stages of cervical cancerous changes?

Answer 16

CIN1 - 1/3 of the cells are cancerous
CIN 2 - 2/3
CIN 3 - 3/3 cancerous

2+ is bad

Question 17

If someone has had a hysterectomy, what do you do?

Answer 17

Vault smear, then remove from the programme

Question 18

What aftercare would you recommend for someone undergoing LLETZ?

Answer 18

4 weeks of no sex
RISKS: bleeding likely 3-5 days after, infection, failed procedure,

Question 19

If LLETZ fails, what other option is there? When might this scenario occur?

Answer 19

Cone biopsy - when the CIN is deeper inside

Question 20

What are the risks of a cone biopsy?

Answer 20

Increased risk of preterm labour

Question 21

What are the three colposcopy examination outcomes if the examination is adequate?

Answer 21

Adequate -> colposcopy confirms CIN 1+, or biopsy confirms CIN1+ -> manage pt for CIN.

Adequate -> but CIN not confirmed on colposcopy or biopsy, then check the grading of the cytology.
- If low grade, recall in 36 months.
If high grade -> MDT discussion within 2 months.

Question 22

What are the two colposcopy examination outcomes if the examination is inadequate?

Answer 22

Check the cytology - if low grade, repeat within 12 months (since colposcopy hasn’t necessarily disproved it). Consider LLETZ/what the patient wants.

If high grade, or borderline, do LLETZ.

Question 22

If CIN 1 shown on biopsy or colposcopy, what do you think about next? What do you do?

Answer 22

Think about hrHPV.

If hrHPV negative, recall in 36 months.

If hrHPV positive, arrange to do a cytology screen too. If abnormal, do further colposcopy.
If not abnormal, call back in 12 months. If hrHPV or cytology negative at that point, recall in 3 years, if not, refer for colposcopy again.

Question 23

If a pt has been treated for CIN2+ or CGIN, when do you recall?

Answer 23

In 6 months.

Question 24

If a pt recalled after 6 months has been treated for CGIN, what do you do?

Answer 24

If hrHPV -ve, recall in 12m, then repeat hrHPV screen. If negative, recall in 36 months.
If hrHPV positive a second time round, refer for colp; if colp normal, recall in 12 months.

If hrHPV+ve, refer for colposcopy.

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