Cervix

Question 1

Describe primary and secondary prevention of cervix cancer.

Answer 1

Primary prevention - HPV vaccination prior to sexual debut

Secondary prevention - screening for & treatment of precancerous lesions

Question 2

In low-resources countries, visual inspection of the cervix (with application of acetic acid) may be used instead of cytology for cervical cancer screening. How do the two tests compare?

Answer 2

Similar sensitivity, visual inspection less specific (therefore risk of over-treatment), visual inspection more cost-effective, visual inspection easier to learn

Question 3

Which of the following is the most effective test for reducing diagnosis of & death from cervix cancer?

• Visual inspection
• Cytology
• HPV testing

Answer 3

HPV testing

Question 4

A woman is referred to you with an ASC-H Pap. Colposcopy does not reveal any lesions. What is your next diagnostic step?
How would your next step be different if she were referred with an HSIL Pap?

Answer 4

ASC-H: Follow up colposcopy, cytology, and HPV testing in 6 months (diagnostic excisional procedure not necessary at this time)
HSIL: Immediate diagnostic excisional procedure

Question 5

How would you manage a 32-year-old woman whose Pap was normal but who tested positive for HR-HPV?

Answer 5

Repeat Pap & HPV testing in 12 months - return to routine screening if both negative, refer to colposcopy if either positive

Question 6

Under what circumstances can you consider ablative treatment of precancerous lesions?

Answer 6

Fully visible transformation zone
No suspicion invasive or glandular disease
No disparity between cytology and histology
No previous treatment for dysplasia
Lesion is CIN 2 or less (cryo only)

Question 7

What cervical cancer screening is recommended for women who are HIV positive?

Answer 7

Annual Pap (colposcopy for usual indications only)

Question 8

What two investigations are permitted when staging cervical cancer?

Answer 8

CXR

IVP

Question 9

What are the three components of the GOG score for cervical cancer?

Answer 9

Tumour size
Depth of invasion
Presence of LVSI

Question 10

You are a gynecologic oncologist and have done a cone biopsy for HSIL. Final pathology diagnoses an invasive cervical cancer. The endocervical margin is positive. What is the most appropriate next step?

Answer 10

Repeat cone biopsy - more deeply invasive disease may be identified which will impact your treatment (simple hysterectomy vs radical hysterectomy vs non-surgical management)

Question 11

Describe some of the reasons why a woman might choose surgery rather than primary radiation therapy for a stage IB1 or IIA1 cervical cancer.

Answer 11

Cure rates are equal, surgery is typically less morbid

• Injury to bladder/bowels/vagina heals better as blood supply is not compromised
• Sexual dysfunction may be more easily treatable since the unirradiated vagina is more elastic and more responsive to local estrogen
• Ovarian function is preserved, where applicable
• Fertility preservation may be an option

Question 12

What is the rationale behind the addition of chemotherapy to primary RT for advanced (inoperable) cervical cancer?

Answer 12

Chemo makes the tumour more radiation-sensitive, allows sterilization with a lower total dose of RT (therefore less RT-associated morbidity)