Cervical cancer

Question 1

What puts you at risk of acquiring HPV infection?

Answer 1

• Multiple sexual partners
• Early age at first intercourse infection
• Older age of first partner - they’re more likely to have HPV infection as they are older
• Cigarette smoking

Question 2

Why are you more at risk of HPV infection if you have sex at a young age?

Answer 2

Due to immaturity of the cervix and so the transformation zone is more susceptible to HPV infection

Question 3

Cigarette smoking and HPV

Answer 3

• Smoking affects cell mediated immunity
• Nicotine is detected in cervical mucus

Question 4

Cervical cancer has 2 peaks of incidence in women. What ages are these peaks?

Answer 4

One in younger women and then again in older women (70-80s) who may not have benefited from screening (only introduced in 1980s)

Question 5

Deprivation and cervical cancer

Answer 5

​See cervical cancer more in deprived women:

• Less likely to access screening
• More likely to smoke cigarettes
• Or other contributing factors like nutrition etc

This link to deprivation has been lost due to high uptake of HPV vaccine in school age children

Question 6

Cervical cancer red flag symptoms

Answer 6

• Abnormal vaginal bleeding i.e Post coital bleeding, inter-menstrual bleeding, PMB
• Discharge? Sometimes woman describe bleeding as discharge as it can be brown and smell. However this can be the case if it is bleeding or a necrotic tumour
• (Pain) - not a common presentation - pain would be associated with advanced cancer i.e spread out to pelvic side walls (get neuropathic pain) or if there is obstruction of ureters and get back pain

Question 7

How is cervical cancer diagnosed?

Answer 7

• Clinical - examination
• Screen detected - asymptomatic patient attends for screening and cancer is detected on examination or smear test comes back as high grade
• Biopsy

Question 8

Look

Answer 8

If a patient has symptoms and attends their GP and the GP decides to take a smear test because they haven’t had one then this is a clinical cancer

Not a result of the screening programme

Question 9

Look

Answer 9

Remember screening aims to detect pre-cancerous disease NOT cancer

Question 10

How can you differentiate between Cervical intraepithelial neoplasia (CIN) and cancer using histology?

Answer 10

Tumour cells from the epithelium invade into the underlying stroma if cancerous

Question 11

What are the 2 types of cervical cancer?

Answer 11

• Majority squamous carcinoma (80%)
• Adenocarcinoma (endocervical) rising in relative incidence

Question 12

Describe stage 1A of cervical cancer

Answer 12

• Invasive cancer identified only microscopically. There is nothing clinical to see in this stage.
• 1a1 is a small invasion 1a2 is deeper

Question 13

Describe stage 1B of cervical cancer

Answer 13

Clinical tumours confined to the cervix

Question 14

Most of the cancers detected in young woman are of which stages?

Answer 14

Stage 1A or B

Question 15

Local spread of cervical cancer

Answer 15

• Stage 2: Vagina (upper 2/3)
• Stage 3: lower vagina, pelvis
• Stage 4 bladder, rectum

Question 16

Where does cervical cancer metastasise to?

Answer 16

Metastases is not as common in cervical cancer, however, if it does metastasie it spreads via:

• Lymphatics – pelvic nodes
• Blood – liver, lungs, bone

Question 17

What imaging is used to stage cervical cancer? (2)

Answer 17

• PET-CT
• MRI

Do both usually

Question 18

Treatment of cervical cancer

Answer 18

• Stage 1a - Excision of the cervical Transformation Zone or hysterectomy (if don’t need/want to preserve sexual function)
• Stage 1a or small stage 2 - radical hysterectomy (preserves ovaries for pre-menopausal women) or chemo-radiotherapy
• Advanced stages - chemo-radiotherapy

Question 19

What is removed in a radical hysterecomy?

Answer 19

• Removal of: Uterus, cervix, upper vagina, Parametria (connective tissue around the cervix) and Pelvic nodes
• Preserves ovaries
• Done laparoscopically

Question 20

Which is more successful - hysterectomy or chemo-radiotherapy?

Answer 20

Both have similar success rate so it depends on:

• Patient preference
• Their suitability for surgery
• Their menopausal status - do they want to preserve their sexual function?

Question 21

What to remember!!

Answer 21

• Major cause of female death in developing world
• HPV is single most important cause
• Screening detects pre-invasive changes which are asymptomatic
• Cancer causes abnormal vaginal bleeding
• Surgery or combined chemoradiation
• Effective cure of early stage disease