Cervical Cancer Flashcards
Describe epidemiology of cervical cancer
50% occur in women under 45
80% are squamous cell cancers
20% are adenocarcinoma
What are features of cervical cancer?
may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge
What are RFs for cervical cancer?
HPV serotypes 16,18 and 33
Smoking
HIV
Early first sexual intercourse, many partners
High parity
Low socioeconomic status
Combined OCP
How does HPV cause cervical cancer?
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
How does cervical screening work?
HPV first system - sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive
Who is screened for cervical cancer and how often?
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)
in Scotland, it is offered from 25-64 every 5 years
What are special cases in terms of cervical cancer screening?
cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
women who have never been sexually active have a very low risk of developing cervical cancer therefore they may wish to opt out of screening
When in the menstrual cycle is cervical screening performed?
Mid-cycle
How is a negative hrHPV interpreted?
return to normal recall, unless
the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
How is a positive hrHPV interpreted?
Cells examined cytologically and if samples are abnormal, colposcopy recommended.
Examples of abnormal cytology are:
borderline changes in squamous or endocervical cells.
low-grade dyskaryosis.
high-grade dyskaryosis (moderate).
high-grade dyskaryosis (severe).
invasive squamous cell carcinoma.
glandular neoplasia
If cells are normal, test repeated at 12 months
How are repeat test results interpreted?
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
What is done if the sample is inadequate?
repeat the sample in 3 months
if two consecutive inadequate samples then → colposcopy
How is CIN treated?
Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic.
Alternative techniques include cryotherapy.
What is cervical cancer management determined by?
FIGO staging
What are FIGO stages?
IA: Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep
IB: Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter
II: Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement
III: Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall
Any tumour causing hydronephrosis or non-functioning kidney is considered stage 3
IV: Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis
