Definition
A.Types of cervical cancer.
1.The most common type of invasive cervical cancer is squamous cell carcinoma (about 70%–80%).
2.The second most common subtype is adenocarcinoma (10%–15%).
3.Other types include adenosquamous carcinoma, adenoid cystic carcinomas, neuroendocrine tumors of the cervix, undifferentiated cervical cancer, and mixed epithelial and mesenchymal tumors.
Incidence
A.Cervical cancer remains the fourth most common cancer of women worldwide with a mortality rate of ∼52%.
B.Approximately 86% of deaths from cervical cancer are in the developing world.
C.Cervical cancer is the third most common gynecologic cancer (after uterine and ovarian cancer) and the 12th most common cancer of women in the United States.
D.An estimated 12,990 new cases of invasive cervical cancer were diagnosed in 2016 and approximately 4,120 deaths from cervical cancer occurred in the United States in 2016.
Pathogenesis
A.Caused by an abnormal growth of cells. Human papillomavirus (HPV) must be present for cervical cancer to develop.
Predisposing Factors
A.Early age of sexual activity: The relative risk of having cervical cancer is 2.5 if the age of first sexual exposure is less than 18 years of age.
B.Multiple sexual partners: Relative risk is 2.8 if the number of partners is five or more.
C.Lower socioeconomic status.
D.Promiscuous sexual partners.
E.Tobacco use.
F.Immunocompromised conditions.
G.In utero exposure to diethylstilbestrol (DES) increases the risk of clear cell carcinoma of the cervix.
H.HPV infection.
1.HPV is a double-stranded DNA virus that belongs to the Papillomaviridae family.
2.There are more than 100 different types of HPV identified, and they are divided into two groups.
a.Low-risk HPV.
b.High-risk HPV.
Subjective Data
A.Common complaints/symptoms.
1.At early stages, many patients are asymptomatic.
2.Postcoital bleeding (most common).
3.Thin, clear, or blood-tinged vaginal discharge.
4.Abnormally heavy or prolonged menses.
5.Vaginal bleeding becomes heavier, frequent, and may become continuous with progressive disease.
6.Pelvic pain, often seen with advanced disease.
B.Common/typical scenario.
1.The most common cervical lesions are exophytic and friable, arising from the ectocervix.
2.Endocervical lesions are more commonly adenocarcinomas arising from the mucus-producing glands.
3.Cervix may be firm with or without mass or ulceration.
4.May find an ulcerated tumor eroding through the cervix.
Physical Examination
A.When patients present with symptoms suggestive of cervical cancer, they should undergo complete physical examination including a pelvic examination.
B.It is important to determine if the disease has spread into the parametria or the pelvic sidewalls.
C.Rectovaginal examination is also important to assess the spread.
Diagnostic Tests
A.Pelvic examination, including Pap smear.
B.If no lesions are noted, perform a colposcopy to identify any abnormalities.
C.Histologic confirmation is important for accurate diagnosis. If a visible lesion is noted, obtain a biopsy. The best site to take the biopsy is from the edge of the tumor, where the transition from invasive to noninvasive can be clearly seen.
D.Once diagnosis is confirmed by biopsy, the following tests may be beneficial.
1.Laboratory data: Complete blood count (CBC) and comprehensive metabolic panel (CMP).
2.Chest x-ray.
3.CT imaging to assess extrauterine spread and adenopathy.
4.MRI (best imaging modality to assess extent of disease).
5.PET scan to assess for lymphatic metastasis.
6.Cystoscopy.
7.Proctoscopy.
8.Exam under anesthesia (EUA) may be needed for a thorough examination.
E.Staging.
1.Cervical cancer is staged clinically.
2.Staging is used to determine the treatment and prognosis.
Differential Diagnosis
A.Cervicitis.
B.Endometrial carcinoma.
C.Vaginitis.
D.Pelvic inflammatory disease.
Evaluation and Management Plan
A.General plan.
1.Treatments for cervical cancer depend on the age of the patient, type of cervical cancer, stage, and desire for children.
2.Prognostic factors.
a.Pathologic types.
b.Tumor size.
c.Depth of invasion.
d.Lymphovascular invasion.
e.Nodal metastases.
3.Surgery is the treatment of choice for stage I–IIA1 cervical cancer.
4.Most patients with stage I disease do not require further treatment if they do not have adverse prognostic factors (see following).
5.Surgical options depend on the stage of cancer and/or are based on the fertility needs.
a.Simple hysterectomy.
b.Radical hysterectomy.
c.Fertility preserving surgeries.
d.Pelvic exenteration surgery: Type of radical surgery that removes organs from urinary, gastrointestinal, and gynecological systems.
6.Chemotherapy.
7.Radiation therapy.
B.Acute care issues in cervical cancer.
1.Cervical cancer patients are only admitted for certain types of surgeries.
a.Radical hysterectomy.
b.Pelvic exenteration.
c.Other surgeries, including simple hysterectomy and fertility preserving surgical procedures, can be done as outpatient.
2.Radiation therapy.
3.Other situations where cervical cancer patients may need inpatient admission include postoperative complications or due to chemotherapy side effects including nausea, vomiting, and neutropenic fever.
Follow-Up
A.The goals of postoperative management include pain control, fluid and electrolyte balance, early ambulation, and return of bowel and bladder function.
B.Follow-up care should focus on identifying, preventing, and controlling long-term and late effects of cervical cancer.
C.Coordination of all the patient’s providers should be navigated by the primary/leading care provider.
D.Follow-up standards for frequency of follow-up have not been established.
Consultation/Referral
A.Gynecologist, gynecologic oncology, radiation oncology, and surgery.
Special/Geriatric Considerations
A.Cervical cancer is common in elderly women, and treatment disparities are significantly associated with mortality in this population.
B.Despite evidence that elderly women tolerate treatment well, they are less likely to be offered surgery and adjuvant radiation.
Bibliography
Bruni, L., Barrionuevo-Rosas, L., Albero, G., Serrano, B., Mena, M., Gómez, D, … de Sanjosé, S. (2016, December 15). ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in the World.
Eskander, R. N., & Bristow, R. E. (Eds.). (2014). Gynecologic oncology: A pocketbook. New York, NY: Springer Science + Business Media.
National Cancer Institute. (2016, September 12). Surveillance, epidemiology, and end results program. Retrieved from https://seer.cancer.gov/faststats/selections.php?series=cancer
Noor, R., Tay, E. H., & Low, J. (2014). Gynaecologic cancer: A handbook for students and practitioners. Boca Raton, FL: Pan Stanford.
Siegel, R., Naishadham, D., & Jemal, A. (2013). Cancer statistics, 2013. CA: A Cancer Journal for Clinicians, 63(1), 11–30.