Cervical cancer natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Common complications of cervical cancer include pain, vaginal bleeding, fistula and renal failure. Prognosis is generally good, and the 5 year survival rate of patients with cervical cancer is approximately 70%.

Natural history

• Prognosis is generally good, and the 5 year survival rate of patients with cervical cancer is approximately 67.9%.
• 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.
• 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, edema hands/feet.
• Once the cancer spreads to the other organs, it is most likely fatal.

Complications

Advanced stage of cervical cancer can cause varieties of complications, some of these are include:

• Pain
• Vaginal hemorrhage
• Enterovaginal, rectovaginal, and vesico- or ureterovaginal fistulas
• Renal failure and/or uremia
• Malnutrition
• Anemia
• Mental depression

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.

• Prognostic Factors

• Clinical stage

• 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.