Cervical screening and cervical cancer

Question 1

Outline the stage-based therapy in managing cervical cancer.

Answer 1

Stage IA1: Microinvasive

• Surgery - e.g. knife cone biopsy or hysterectomy if family complete

Stage IA2, IB, IIA: Early stage

• Radical hysterectomy
• Chemoradiation

Stage IIB, III, IVA: Locally advanced

• Chemoradiation

Stage IVB: Metastatic

• Chemotherapy

Palliative care

Question 2

What surgical options are available for cervical cancer?

Answer 2

• Cervical knife conisation
• Total hysterectomy
• Radical hysterectomy
• Radical vaginal trachelectomy
• Pelvic lymphadenectomy

Question 3

What cervical cancer vaccines are available, and what do they protect against?

Answer 3

Gardasil

• HPV 16, 18, 6, 11

Cervarix

• HPV 16, 18

Question 4

What are recognised risk factors for cervical cancer?

Answer 4

• Persistent HPV infection
• Recurrent HPV infection
• Smoking
• HIV
• Immunocompromise

Question 5

What is the investigative workup for patients with possible cervical cancer?

Answer 5

• Colposcopy & biopsy
• FBC
• LFT
• U&E
• Further imaging (CT, MRI) may be warranted if metastasis is suspected or to assess nodal status prior to deciding management
• Examination under anaesthesia to formally determine size of lesion, parametrial involvement and carry out cystoscopy to exclude bladder extension

Question 6

If a patient tests positive for HPV, what are their chances of developing cervical cancer? Explain.

Answer 6

• Roughly 5% will go on to develop CIN.
• 90% of HPV infections resolve spontaneously in 1-3 years
• Not all HPV types cause cancer. Some (6, 11) only present with skin symptoms.
• HPV infection is extremely common in sexually active men and women in their 20’s.

Question 7

Which HPV types are most likely to cause cervical cancer?

Answer 7

• 16 - Highest risk!! (50% of cervical cancers)
• 18 (20%)
• Others: 31, 33, 35, 45, 52, 58

Question 8

How will the National Cervical Screening Program change in May 2017?

Answer 8

• Pap smear (cytology) to HPV test
• Ages 18-70 to Ages 25-74
• Every 2 years to Every 5 years
• Asymptomatic to all women, including those with symptoms at any age

Question 9

Case:

Mrs S is a 42 yo woman who has been referred to you the gynaecologist following 2 repeated LSIL pap smears.

• She doesn’t understand what is going on.
• Counsel her on what an LSIL result means?

Answer 9

Topics to talk about. PAP = SCEENING TEST

Not cancer. Low grade abnormality of epithelium around the cervix.

Not cancer. Result of Human Papilloma Virus

Not cancer. Sexual transmission. Shedding of virus in vagina. Contact and transmission.

Not cancer. Premalignant condition needs progression to HSIL.

LSIL is often cleared normally by body over time

Need to carry out colposcopy to determine if cervical lesion present - i.e. dysplasia

Question 10

Mrs S is a 42 yo woman who has been referred to you the gynaecologist following 2 repeated LSIL pap smears.

• You’ve explained what an LSIL is.

You are concerned because after her LSIL paps she got worried and didn’t initially come into see you the gynaecologist.

What Sx might you ask?

Answer 10

Symptom-wise you want ask about features that might indicate cervical cancer. CIN is asymptomatic

Post coital bleeding

Vaginal bleeding/discharge

Dyspareunia

Urinary sx (local invasion to bladder)

Consitutional sx – lethargy, weight loss.

Question 11

Case:

Mrs S is a 42 yo woman who has been referred to you the gynaecologist following 2 repeat LSIL pap smears.

You have already spoken to her about what an LSIL is.

Would you like to do any procedures during the consultation? Explain what you would like to do.

What might you counsel the patient to expect following the examination? How long might it last?

Answer 11

Yes. Colposcopy is indicated.

1. Genital examination.
2. Speculum
3. Acetic acid
4. Lugols – iodine staining
5. +/- biopsy.

NB: lithotomy exam, microscope-like examination from externally

Biopsy of any areas that are suspicious, histology and pathologist review.

Aferwards expect some vaginal discharge, discomfort and maybe blood from the iodine, acetic acid and trauma of the spec exam. 7-10 days.

Question 12

Case:

Mrs S is a 42 yo woman who has been referred to you the gynaecologist following a CIN III after colposcopy 2 weeks ago.

Histology results have identified a CIN III.

What would you have expected to see with the initial acetic exam? Lugols?

You took a bit of a rubbish history and forgot to ask about risk factors. What are they?

Answer 12

A/ Patchy white areas around transformational zone.

B/ Patchy areas which don’t take up brown dye.

Risk factors: Immunosuppression. HPV exposure – sexual partners. Smoking. Age. Oestrogen exposure (early menarche and late menopause, OCP, HRT, nulliparous). Prolonged time between Pap smears

Question 13

23yo F presents for her first pap smear.

What important vaccination history would you take?

She mentions that she hasn’t had any school age vaccinations. What history maybe important to take in regards to assessing her risk?

What information would you provide to her in regards to the vaccination?

Answer 13

A/ Gardasil.

B/ Sexual history = important. Previous exposure to HPV virus will reduce the efficacy of future vaccinations.

PS – partners, practices, prevention, pregnancy, pill, past STI screen.

C/ Gardisil = government funded school vaccination program.

• 3x vaccinations @ 12yrs of age.
• coverage variety of strains

6-11 which cause genital warts

16-18 which cause 70% of cervical cancer.

Question 14

Answer 14

A – squamous epithelium

B – Transitional zone. Metaplastic zone of squamous and columnar epithelium

95% of cervical cx in this area.

Pap sampling of this area.

Colp = visualisation + application of acetic acid and lugols iodine

C – Columnar epithelium. Ectotropium

D – External os.