Cancer Of The Cervix

Introduction

Cervical cancer is a type of cancer that occurs in the cells of the cervix, the lower part of the uterus that connects to the vagina.
According to WHO, almost all cervical cancer cases (99%) are linked to infection with high-risk human papillomaviruses (HPV), an extremely common virus transmitted through sexual contact.
In most developing countries, up to 75% of the patients present in advanced stages due to lack of organized screening programmes for detection of the preclinical stages.

Aetiology/risk factors

Aetiology not known but several risk factors have been implicated:

  • Early sexual exposure
  • Multiple sexual partners
  • A promiscuous male partner
  • History of sexually transmitted infections particularly Human Papilloma Virus, infection; Herpes simplex type 2; chlamydia trachomatis
  • Early first child birth
  • Low socio-economic status.
  • Smoking
  • High parity
  • Micronutrient deficiency.
  • Poor sexual hygiene

Clinical features

  • Two age groups with highest incidence: 35 – 40 years; 45-55 years.
  • May be asymptomatic
  • Picked up in the early stage by routine PAP smear screening
  • Abnormal vaginal bleeding:
    • Post-coital
    • Contact
    • Spontaneous
    • Inter-menstrual
  • Post-menopausal Vaginal discharge.
  • Becomes offensive in advanced disease.
  • Pyometria with uterine enlargement
  • Haemorrhagic, ulcerative or fungatingl esion on the cervix, with extension to the vagina wall in advanced stages.
  • Vesico-vaginal fistula in advanced stages.
  • Also, there may be recto-vaginal fistula in advanced stages
  • Cachexia
  • The presence of a lesion on the cervix

Presumptive Diagnosis

Based on:

  • Typical history of risk factors
  • Histological confirmation of malignancy

Differential diagnoses

  • Endometrial cancer
  • Endometrial hyperplasia
  • Endometrial polyps.
  • Cervicitis,
  • Cervical polyps,
  • Cervical erosion
  • Vaginal lesions: vaginitis, vaginal
    malignancy
  • Functioning tumours of the
    ovary leading to endometrial hyperplasia and vaginal bleeding
  • latrogenic: hormonal drugs
    and IUCD in-situ,
  • Blood disorders: bleeding dyscrasias, leukaemia

Investigations

  • Packed cell volume; haemoglobin
    concentration
  • Urinalysis
  • Blood Group
  • White cell count, and differentials.
  • Electrolytes and Urea, Liver function tests
  • Midstream urine specimen for microscopy, culture and sensitivity;
  • Chest radiograph;
  • HIV screening.
  • Intravenous urography

Principles of management

  • Examination Under Anaesthesia
  • Staging and Biopsy
  • Treatment of invasive carcinoma of the cervix
  • Surgery
  • Radiotherapy
  • Surgery plus radiotherapy
  • Chemo-radiation

Treatment options will depend on
the skill of the surgeon, availability of
facilities, the stage of the disease, Age of the patient, and the Ability of available personnel to manage untoward effects of the modality of treatment chosen

Stages I to IIA

  • Surgery or radiotherapy (as primary modes of treatment respectively). Radiotherapy can be used as primary mode of treatment in all stages of the disease
  • Follow up: This is for life.
  • Regular cytology of vault smears for early detection and prompt treatment of recurrence.

Prevention

Adequate screening programmes:

  • Papanicolaou smear
  • Visual inspection of the cervix after acetic acid lavage (VIA).
  • Testing for the human papilloma virus.
  • DNA Specific programmes targeted at eliminating or mitigating the effects of recognized risk factors