Cervical cancer overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [5]
Overview
Cervical cancer once was one of leading cause of cancer related death in US and worldwide before introduction of Pap smear and screening, now ranked 14th in terms of frequency in US . Cervical cancer is malignant cancer of cervix. It may present with vaginal bleeding but symptoms may be absent until the cancer is in its advanced stages, which has made cervical cancer the focus of intense screening efforts using the Pap smear. In developed countries, the widespread use of cervical screening programs has reduced the incidence of invasive cervical cancer by 50% or more. Most scientific studies have found that human papillomavirus (HPV) infection is responsible for virtually all cases of cervical cancer.[1][2] Treatment consists of surgery (including local excision) in early stages and chemotherapy and radiotherapy in advanced stages of the disease. An effective HPV vaccine against the two most common cancer-causing strains of HPV has recently been licensed in the U.S. (see Vaccine section, below). These two HPV strains together are responsible for approximately 70%[3][4] of all cervical cancers. Experts recommend that women combine the benefits of both programs by seeking regular Pap smear screening, even after vaccination.
Historical Perspective
Cervical cancer was first described in 400 BC. In 1928, the Papanicolaou technique was developed by Papanicolaou to diagnose cervical cancer. In 1976, Harald zur Hausen and Gisam were the first to discover the association between HPV and development of cervical cancer.
Classification
Cervical cancer may be classified into many subtypes based on WHO histological classification.
Pathophysiology
Cervical cancer arises at squamous-columnar junction.
Differential diagnosis
Cervical cancer must be differentiated from other diseases that cause abnormal vaginal bleeding, such as cervical polyp, cervical leiomyoma, invasion of the cervix from primary uterine malignancy, vaginal cancer, cervical lymphoma, adenoma malignum, metastases to cervix, and cervical ectopic pregnancy.
Epidemiology and Demographics
Risk Factors
The most potent risk factor in the development of cervical cancer is Human papillomavirus (HPV) infection. Other risk factors include smoking, increased number of sexual partners, and young age at time of first sexual intercourse.
Screening
According to the American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology, screening for cervical cancer by pap smear is recommended every 3 years among women age 21.
Natural History, Complications and Prognosis
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%.
Diagnosis
Staging
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervicalcurettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton, and cervicalconization.
History and Symptoms
Physical examination of patients with late cervical cancer is usually remarkable fore cervical mass, pallor, and pedal edema.
Chest Xray
Chest radiography (CXR) is the initial imaging modality used in the detection of suspected pulmonary metastasis.
CT
CT scan may be helpful in the diagnosis of cervical cancer.
MRI
Pelvic MRI is helpful in the diagnosis of cervical cancer.
Ultraasound
On ultraasound, cervical cancer is characterized by hypoechoic, heterogeneous mass involving the cervix.
Other Diagnostic Studies
Cervical biopsy is the confirmatory test for the diagnosis of cervical cancer or pre-cancer.
Treatment
Medical therapy
The optimal therapy for cervical cancer depends on the stage at diagnosis.
Surgery
The feasibility of surgery depends on the stage of cervical cancer at diagnosis.
Cervical cancer during pregnancy
During pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, although expert colposcopy is recommended to exclude invasive cancer.Patients with early stage (IA) disease may safely undergo fertility-sparing treatments.For patients with advanced disease, waiting for viability is generally not acceptable.The standard of care is curative intent chemotherapy and radiation therapy.
Primary Prevention
Prevention of cervical cancer includes a comprehensive approach involving awareness, screening, and preventative vaccinations.