Cervical Cancer CPC

Question 1

High-risk HPV causes other less common cancers such as what?

Answer 1

acounts for nearly all cervical cancers

Question 2

how does HPV cause cervical cancer?

Answer 2

10-20 years form HPV infection to get a cancer

Question 3

what is the epidemiology of cervical cancer?

Answer 3

2500 cases per year in UK

1200 deaths

10th commonest cancer in women in Scotland

Good cure rate if detected early (particularly if we can prevent it by detecting precancer changes)

BUT major cause of death in in women in low income countries

Question 4

Accumulation of global HPV vaccine experience, October 2016 - what countries have vaccination?

Answer 4

mainly high income countries with low rates of disease (eception of south american counties)

Question 5

who tends to get cervicl cancer?

Answer 5

Peak age 45-55 years

HPV related (16 & 18)

Multiple sexual partners

Early age at first intercourse

Older age of partner (more likely to have HPV infection)

Cigarette smoking (effects cell mediated immunity)

Question 6

what are the rates in different age groups?

Answer 6

Question 7

how is cervical cancer related to deprivation?

Answer 7

most deprived - less likely to get screening and more likely to smoke cigarettes, nutrition may also indicate

in scotland we lose this link of deprivation due to the high uptake of HPV vaccine in kids at school

Question 8

how has the incidence of cervical cancer changed?

Answer 8

Question 9

Case:

40 year old P3 attends GP with heavy irregular periods

GP notices she has not had a cervical screening test since 2005

She says she does not have post coital bleeding (red flag symptoms of cervical cancer)

She does not have a regular partner and because of the bleeding she does not have sex

She smokes 25/day

Answer 9

GP does a speculum examination and large cervix

looks quite irregular

Question 10

what should her GP do next?

1. Take a smear test as it is overdue?
2. Take a chlamydia test as her history suggests chlamydia cervicitis?
3. Take a swab for high risk HPV?
4. Take a biopsy in case it is cancer?
5. Refer as urgent suspected cancer to Gynaecology?

Answer 10

5

due to her history and suspicious history

smear is for asymptomatic women and is not for cancer

Question 11

what are the symptoms of cervical cancer?

Answer 11

Abnormal vaginal bleeding

Post coital bleeding

Intermenstrual bleeding/PMB

Discharge

(Pain)

Question 12

how is the diagnosis of cervical cancer made?

Answer 12

Clinical

Screen detected - smear taker visualises the cancer but the patient is asymptomatic

Biopsy

Remember screening aims to detect pre-cancerous disease NOT cancer

Question 13

biopsy is crucial

what is the histology of a cancer like? and what types is there?

Answer 13

Difference between a CIN and a cancer is - Tumour cells from epithelium invade into underlying stroma

Majority squamous carcinoma (80%)

Adenocarcinoma (endocervical) rising in relative incidence

(biopsy from patient, cant see basement membrane thats been disrupted, darkly staining dysplastic cells invading into the underlying stroma)

Question 14

how is stage 1A identified? and what is it?

Answer 14

nothing clinical to see

Stage IA: Invasive cancer identified only microscopically

IA1 ≤ 3 mm depth and ≤7 mm diam (=microinvasive)

IA2: ≤ 5 mm x7 mm

Question 15

what is a stage 1B tumour?

Answer 15

Stage IB: clinical tumours confined to the cervix

most cancers in young women are stage 1A or stage 1B

Question 16

where does cervical cancer spread? and what are the different stages?

Answer 16

Local:

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

metastases (tender to be local spread in cervical cancer):

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

Question 17

what is used to stage cervical cancer?

Answer 17

use imaging to stage cancer to indivisualse the treamtent and we tend to do both of these:

• PET-CT
• MRI

Question 18

what is the treatment of cervical cancer?

Answer 18

Stage 1a1: Type 3 Excision of the cervical TZ (loop excision same as CIN3) or hysterectomy

Stage 1b - 11a: Radical hysterectomy (preserves ovaries for premenopausal women) or chemo-radiotherapy

Stage 11b - 1V: Chemo-Radiotherapy

Question 19

what is a radical hysterectomy and what is removed?

Answer 19

Exploration of pelvic and para-aortic space

Removal of:

• Uterus, cervix, upper vagina
• Parametria
• Pelvic nodes
• Ovaries conserved (conserved in pre-menopausal women)

Question 20

cervical cancer treatment - how is radiotherapy and chemotherapy done?

Answer 20

Radiotherapy- External Beam

Chemotherapy - once weekly during radiotherapy

Brachytherapy - Caesium Insertion (24 hours)

Question 21

what is the mortality rate of cervical cancer?

Answer 21

lot sof cases in younger women but higher mortality in older women who are more likely to present with advanced disease

Question 22

what is the survival rate of cervicla cancer?

Answer 22

survival rate is stage dependant

Question 23

What to remember:

Major cause of female death in _________ world

___ is single most important cause

Screening detects _________ changes which are _____________

Cancer causes ________ ______ ______ (so important to look at the cervix)

Surgery or combined ___________

Effective cure of _____ _____ disease

Answer 23

developing

HPV

pre-invasive

asymptomatic

abnormal vaginal bleeding

chemoradiation

early stage