Cervical Cancer

Question 1

What is the most common form of cervical cancer?

Answer 1

Squamous cell carcinoma, presenting as a malignant tumour on the cervix.

Question 2

What is it heavily associated with?

Answer 2

Persistent human papilloma virus (HPV) infection. The majority of cases are squamous cell carcinoma.

Question 3

What are 4 risk factors?

Answer 3

HPV 16 and 18 infection (accounts for 70% of cases)
Multiple sexual partners
Smoking
Immunosuppression (e.g. HIV or organ transplants)

Question 4

What are clinical features?

Answer 4

Vaginal discharge
Bleeding (e.g. postcoital or with micturition or defaecation)
Vaginal discomfort
Urinary or bowel habit change
Suprapubic pain
Abnormal white/red patches on the cervix.
Pelvic bulkiness on PV examination
Mass felt on PR examination

Question 5

What are 4 differentials and when would they be suspected?

Answer 5

Vaginitis: itching, burning, pain, and abnormal discharge

Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding

Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss

Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse

Question 6

What are the investigations?

Answer 6

Urgent colposcopy, which allows visualisation and biopsy of the cervix

CT chest/abdomen/pelvis is used for cancer staging

Question 7

How are IA stage cancers treated?

Answer 7

Conisation with free margins if aiming to spare fertility

Conisation is done using a scalpel (cold-knife conisation), laser, or electrosurgical loop, and is usually performed as an outpatient.

Question 8

What is a fertility sparing option apart from conisation?

Answer 8

Radical trachelectomy can be done for slightly more advanced, yet still early-stage cancers when the aim is to spare fertility. This involves removal of the cervix, the upper vagina and pelvic lymph nodes.

Question 9

What can be used if sparing fertility not prioritised?

Answer 9

Laparoscopic hysterectomy and lymphadenectomy is offered for women for early-stage cancer.

Question 10

What is used for infilitrating, invasive early metastatic cancer?

Answer 10

Radical (Wertheim’s) hysterectomy can be performed which involves removal of the uterus, primary tumour, pelvic lymph nodes, and sometimes the upper third of the vagina and uterovesical and uterosacral ligaments.

Question 11

What is used for late stage cancer?

Answer 11

If the cancer has spread outside the cervix and uterus, then surgical management is often unlikely to be curative. These cancers are treated with radiotherapy and/or chemotherapy.

Question 12

Who is cervical screening offered to?

Answer 12

For all women and people with a cervix between the age of 25-64 years.

Cervical sample is taken and tested for high-risk HPV viruses.

Patients are recalled every 5 years if normal.

Question 13

What is the target of cervical screening?

Answer 13

To identify dyskaryotic cells which are pre-cancerous allowing management before invasive cancer can develop.

Question 14

How are abnormal results divided up?

Answer 14

Borderline
Mild dyskaryosis
Moderate dyskaryosis
Severe dyskaryosis

Question 15

Where should abnormal cytology be referred?

Answer 15

Colposcopy

Question 16

HPV +ve but negative cytology?

Answer 16

Should have a repeat HPV test in 12 months and again at 24 months if still positive. If they remain positive at 24 months they should be referred to colposcopy.

Question 17

Who is offered the HPV vaccination?

Answer 17

Vaccine called Gardasil

Girls and boys aged 12 to 13 years are offered the HPV vaccine as part of the NHS vaccination programme

The vaccine helps protect against cancers caused by HPV, including cervical cancer, some mouth and throat cancers and some cancers of the anal and genital areas. It also helps protect against genital warts