Cervical cancer natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
If left untreated, 30-70% of patients with in situ cervical cancer may progress to develop cervical cancer. Common complications of cervical cancer include vaginal bleeding, fistula and renal failure. Prognosis is generally good, and the 5 year survival rate of patients with cervical cancer is approximately 67.9%.
Natural history
- Cervical cancer arises from squamous-columnar junction.
- The earliest microscopic change corresponding to cervical intraepithelial neoplasia(CIN) is dysplasia of the epithelial or surface lining of the cervix,are associated with HPV infection, such as koilocytes, are also commonly seen in Cervical intraepithelial neoplasia (CIN).
- However most CIN spontaneously regress. Left untreated, about 70% of CIN-1 will regress within one year, and 90% will regress within two years. About 50% of CIN 2 will regress within 2 years without treatment.
- Progression to cervical cancer in situ (CIS) occurs in approximately 11% of cervical intraepithelial neoplasia(CIN1) and 22% of cervical intraepithelial neoplasia(CIN2). Progression to invasive cancer occurs in approximately 1% of cervical intraepithelial neoplasia (CIN1), 5% in cervical intraepithelial neoplasia (CIN2) and at least 12% in cervical intraepithelial neoplasia (CIN3).
- . This process can be quite slow. Longitudinal studies have shown that in patients with untreated in situ cervical cancer, 30% to 70% will develop invasive carcinoma over a period of 10 to 12 years. However, in about 10% of patients, lesions can progress from in situ to invasive in a period of less than 1 year. As it becomes invasive, the tumor breaks through the basement membrane and invades the cervical stroma.[1]
- Extension of the tumor in the cervix may ultimately manifest as ulceration, exophytic tumor, or extensive infiltration of underlying tissue, including the bladder or rectum.
- In advanced disease, metastases may be present in the abdomen, lungs.the patient may present with dyspnea, cough with blood-stained sputum, persistent pain or discomfort in the chest, swelling in hands/feet,
- Once the cancer spreads to the other organs, it is most likely fatal
Complications
- Vaginal bleeding
- Pelvic pain
- Renal failure
- Fistula
- Vaginal dischrage
- DVT/Pulmonary embolism
Prognosis
The prognosis for patients with cervical cancer is markedly affected by the extent of disease at the time of diagnosis. More than 90% of cervical cancer cases can be detected early through the use of the Pap test and HPV testing.Pap and HPV testing are not performed on approximately 33% of eligible women, which results in a higher-than-expected death rate.[2]
- Prognostic Factors
- Clinical stage
- Clinical stage as a prognostic factor is supplemented by several gross and microscopic pathologic findings in surgically treated patients.
- Gynecologic Oncology Group identified the following variables that were significant for progression-free interval and survival:
- Periaortic and pelvic lymph node status.
- Tumor size
- Patient age
- Performance status
- Bilateral disease
- Clinical stage
- Other prognostic factors
- Other prognostic factors that may affect outcome include the following:
- Human immunodeficiency virus (HIV) status: Women with HIV have more aggressive and advanced disease and a poorer prognosis.
- C-myc overexpression: A study of patients with known invasive squamous carcinoma of the cervix found that overexpression of the C-myc oncogene was associated with a poorer prognosis.
- Number of cells in S phase: The number of cells in S phase may also have prognostic significance in early cervical carcinoma.
- HPV-18 DNA: HPV-18 DNA has been found to be an independent adverse molecular prognostic factor. Two studies have shown a worse outcome when HPV-18 was identified in cervical cancers of patients undergoing radical hysterectomy and pelvic lymphadenectomy.
- A polymorphism in the Gamma-glutamyl hydrolase enzyme, which is related to folate metabolism, has been shown to decrease response to cisplatin, and as a result is associated with poorer outcomes.
Average years of potential life lost from cervical cancer are 25.3 (SEER Cancer Statistics Review 1975-2000, National Cancer Institute (NCI)). Approximately 4,600 women were projected to die in 2001 in the US of cervical cancer (DSTD), and the annual incidence was 13,000 in 2002 in the US, as calculated by SEER. Thus the ratio of deaths to incidence is approximatley 35.4%.
5-Year Survival
- Between 2004 and 2010, the 5-year relative survival of patients with cervical cancer was 69.6 %.[3]
- When stratified by age, the 5-year relative survival of patients with cervical cancer was 71.9% and 48% for patients <65 and ≥ 65 years of age respectively.[3]
- The survival of patients with cervical cancer varies with the stage of the disease. Shown below is a table depicting the 5-year relative survival by the stage of cervical cancer:[3]
| Stage | 5-year relative survival (%), (2004-2010) |
| All stages | 67.9% |
| Localized | 90.9% |
| Regional | 57.4% |
| Distant | 16.1% |
| Unstaged | 54.3% |
- Shown below is an image depicting the 5-year conditional relative survival (probability of surviving in the next 5-years given the cohort has already survived 0, 1, 3 years) between 1998 and 2010 of cervical cancer by stage at diagnosis according to SEER. These graphs are adapted from SEER: The Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.[3]
References
- ↑ https://en.wikipedia.org/wiki/Cervical_intraepithelial_neoplasia
- ↑ http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#link/_285_toc
- ↑ 3.0 3.1 3.2 3.3 Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.