and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Cancer of Cervix
Definition
Approximately 90 % of cervical cancers are squamous in origin (arising from the stratified squamous epithelium of the cervix). The remaining 10 % are adenocarcinomas (arising from the endocervical columnar cells).
Incidence
In the UK, cervical cancer accounts for approximately 2 % of all cancers in women. Cervical cancer is the 12th commonest cancer in females with an incidence of 8/100,000.
Due to screening programs, the incidence of cervical cancer has decreased by roughly 50 % during the last four decades.
Cervical cancer is most common in women aged 30–34.
Aetilogy and Pathogenesis
Squamous cell carcinoma is caused by oncogenic subtypes of Human Papilloma Virus (HR-HPV), the commonest of which are type 16 and 18. Ninety eight percent of infections will resolve spontaneously due to the immune system. When the immune system is unable to prevent viral replication, precancerous changes develop, which may lead to cervical cancer. This is more likely to occur in the presence of co-factors such as cigarette smoking.
It has also been recognised for many years that cervical dysplasia develops over a number of years, long before a woman develops cancer. Recognisable graded abnormalities may be detected on cervical cytology during this time and these abnormalities are known as dyskaryosis (graded as mild, moderate and severe). Cervical cytology, first described by Papanicolaou in 1943 is used to detect these precancerous changes, and has reduced mortality.
Adenocarcinoma arises in the glands of the cervical canal. It is becoming more common in association with HPV type 18.
Clinical Assessment
History
The most significant symptom is abnormal bleeding. This can be post-coital or inter-menstrual bleeding.
Examination
A speculum examination may detect a cervical lesion (squamous cell) or abnormal tissue arising from the endo cervix (adenocarcinoma).
Investigations
Women with dyskaryosis on cervical cytology, in association with HR-HPV infection need to be investigated by colposcopy.
This is a non invasive inspection of the cervix with a binocular magnifying microscope (colposcope), often with the use of acetic acid or iodine staining, to determine the site, nature and the extent of any lesions.
A cervical biopsy should be performed for histological confirmation of any abnormality. On histological examination the changes are graded as Cervical Intraepithelial Neoplasia (CIN) I, II and III.
Low grade CIN often regresses without treatment. However in some women the changes may progress to moderate or high grade CIN, necessitating excision biopsy (large loop excision of the transformation zone (LLETZ)).
If invasive changes are diagnosed on biopsy, the cancer is staged. The woman is examined under anaesthesia, including cystoscopy and proctoscopy. A full evaluation involves a chest X-ray, a CT scan, MRI, and sometimes PET scanning.
Staging is carried out using the T (tumour extent), N (lymphatic spread) and M (metastasis) scale.
Treatment
Medical
Hormonal – There is no hormonal treatment for CIN or cervical cancer.
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