Cervical cancer

Question 1

What group in Australia is more at risk of cervical cancer and why?

Answer 1

Aboriginal and Torres Strait Islanders - barriers to access screening programs like pap smears

Question 2

What are the current screening recommendations for cervical cancer?

Answer 2

Pap test recommended every 2 years for women with an intact cervix who have had sex, either starting from age 18-20 or from first sexual intercourse (which ever is later) until 70 years

So a sexually active 14 year old would get her first Pap at 18, whilst a 24 year old who’s just had sex for the first time should have a Pap test in the next 2 years

Question 3

What are the new guidelines to cervical cancer screening starting in 2017? Give 2 reasons why we’re switching to these guidelines

Answer 3

Women 25 - 74 (vaccinated or unvaccinated) should have a screening test every 5 years (details still to be determined - probably HPV + pap)

Reasons for switching:

• HPV levels more accurately reflect likelihood of cervical cancer than Pap result
• Number of HPV positive women will decrease due to widespread uptake of vaccine (reducing false positive rates)
• No evidence to suggest that people under 25 should be screened (very low incidence, and no improvement in mortality due to screening)

Question 4

What HPV vaccine is used in Australia and what strains of HPV is it active against? What two diseases do these strains of HPV lead to?

Answer 4

Gardasil - quadrivalent vaccine against HPV16, 18 (cause 70% of cervical cancer), 6 and 11 (cause 90% of genital warts)

Question 5

Go through the pathophysiology of how HPV leads to cervical cancer. How long does it usually take to get from infection to cancer?

Answer 5

HPV infection (especially strains 16 and 18) can result in oncoproteins that bind to and inhibit cell cycle regulators (E6 binding to p53, and E7 binding to Rb), leading to hyperproliferation of the cervical transformation zone. This can eventually lead to cervical intraepithelial neoplasia (CIN), which can then progress to cervical cancer

Takes on average 15 years to go from infection to cancer

Question 6

Name 3 common features on history (if not picked up on screening) and and 1 feature on examination of cervical cancer. Give 5 risk factors for the disease

Answer 6

Hx - pelvic or back pain, dyspareunia, postcoital bleeding, vaginal bleeding/discharge
Ex - cervical mass, cervical bleeding on vaginal/speculum examination

Risk factors - Low socioeconomic class, early intercourse, multiple partners, age (peaks around 55-65 years), no/few Pap tests, smoking (impairs immune system = greater risk of HPV), multiparity, OCP, immunosuppressed

Question 7

What is the primary investigation for cervical cancer, either after a positive Pap smear, or symptoms suggestive of the disease? Name 2 signs of cancer from this investigation. If asymptomatic, give 2 Pap smear results that are indications for ordering this investigation.

Answer 7

Colposcopy with biopsy for staging - on speculum examination, apply acetic acid to cervix, which coagulates malformed proteins in cytoplasm of tumour (aceto-white epithelium). In aceto-white epithelium, look for mosaicism, punctation and dilation of blood vessels (from compression of blood vessels by expanding neoplasm). Also look for iodine uptake (decreased uptake reflects higher grade tumour).

If asymptomatic, should order colposcopy if patient has:

• 2 tests positive for low-grade squamous intraepithelial lesions (LSILs - CIN1 or less) 12 months apart
• 1 high-grade SIL (CIN 2/3)
• smear reported as potential invasive carcinoma, glandular neoplasm, or adenocarcinoma

Question 8

If you do a Pap smear and the cervix looks irregular but the Pap comes back as negative, what should you then do?

Answer 8

Refer to colposcopy! Irregular cervix needs biopsy regardless of Pap result

Question 9

What is the recommended management for low-grade vs high grade pre-cancerous lesions confirmed by colposcopy? What is the recommended follow-up?

Answer 9

LSIL - conservative follow-up (no surgery)
HSIL - get it out! wire-loop excision, laser or cryotherapy if well-defined, cone biopsy if extent of disease cannot be fully visualised, or invasive disease is suspected

Follow up - repeat colposcopy and pap smear in 6 months, repeat pap and HPV at 12 months. If normal, then 2 years after that

Question 10

What is the most common form of cervical cancer?

Answer 10

Squamous cell carcinoma

Question 11

Name the 3 outcomes from the natural history of a HPV infection

Answer 11

Spontaneous regression (85 - 90% in 36 months)
Chronic infection (5-15%)
Progression to CIN (

Question 12

Name 3 complications of cervical biopsy

Answer 12

Immediate - bleeding, pain

Long term - cervical stenosis or incompetance

Question 13

What are the main forms of management of cervical cancer?

Answer 13

Surgery or chemo-radiation (depending on stage)