CERVICAL CANCER

Bonjour mes amis! C’est la grande finale! July has finally come to an end and sadly that means the spotlight has to shift from us to the so-called “superior sex”, men. But, before we shift the onus, let us look at Cervical cancer. This one is a personal topic as my wonderful grandma Elizabeth succumbed to this ruthless monster. If we knew then what we know now I’m sure she’d still be alive reading my blogs too but heaven gained an angel. Continue resting with the angels Lizzy.

Commencons!

Cervical cancer is cancer arising from the cervix. This is the 3^rd most common type of cancer after endometrial and ovarian cancer. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The most common histological type of cervical cancer is squamous cell carcinoma (90%), and adenocarcinoma (10%). Its peak incidence is between 35-44 years of age. Mortality is highest in individuals aged 55- 64 years.

In most cases, long-lasting infection with types 16 and 18 of the Human Papillomavirus (HPV) is the main cause of cervical cancer, amounting to almost 75% of all cases, while types 31 and 45 are the causes of another 10%. HPV type 16 is most common in squamous cell carcinoma whilst HPV type 18 is most common in adenocarcinoma. Risk factors are;

i) Associated with HPV infection:

-multiple sexual partners (strongest risk factor)

-early-onset of sexual activity

-multiparity (a woman who has carried more than one fetus to the point of viability (.20 weeks)

-immunosuppression (e.g., HIV infection)

-history of STIs (sexually transmitted infections e.g., chlamydia, herpes simplex)

-oral contraceptives (long-term use)

ii) Environmental risk factors:

-cigarette smoking and/ or exposure to second-hand smoke (passive smokers) for squamous cell cancer types only.

-low socioeconomic status (related to poor access to gynecological care (Pap smears) and follow-up treatment).

When it comes to the signs and symptoms, the early stages may be completely asymptomatic and symptoms develop later in the course of the disease.

Early symptoms:

–abnormal vaginal bleeding: irregular vaginal bleeding, heavy, irregular menstrual bleeding, postcoital spotting (bleeding from the vagina after sex, may/ may not be associated with pain)

–abnormal vaginal discharge: blood-stained or purulent (pus) malodorous discharge (not necessarily accompanied by pruritus (itchiness))

–dyspareunia (pain during or after sex)

–pelvic pain

Late symptoms:

–hydronephrosis

–lymphedema

–fistula formation (an abnormal connection between two epithelium-lined surfaces e.g., gastrocolic fistula)

–loss of appetite

–weight loss

–fatigue

–back pain

–leg pain

–swollen legs

–(rarely) leakage of urine or feces from the vagina.

Bleeding after douching or after a pelvic exam is a common symptom of cervical cancer.

Before we go any further, there are some words I would like you to know definitions to so we remain on the same page. They are:

• Pap smear (Papanicolaou test): a test used to assess for cellular abnormalities in a cervical sample using a microscope
• Primary HPV test: a test used to detect the DNA of high‐risk types of HPV using a cervical sample (only certain tests are approved by the US-FDA for primary HPV testing)
• Co-test: a test that combines a Pap smear test and an HPV DNA test from the same cervical sample
• Reflex HPV test (triage HPV test) :

-A test used to detect the DNA of high-risk HPV types

-Performed after an abnormal Pap smear, typically using the same Pap smear sample showing abnormal cells

• Average-risk patients: refers to asymptomatic, immunocompetent, individuals with a normal cervical cancer screening history 
• High-risk patients: individuals with HIV, immunosuppression, or exposure to diethylstilbestrol (DES)
• Screening test: cervical cancer screening tests(primary HPV test, Pap smear, or co-test) performed to identify individuals in the population who require a further workup for cervical cancer
• Routine screening

–Primary HPV testing and co-testing every 5 years

–Pap smear every 3 years

• Surveillance: a repeat test using primary HPV testing, Pap smear alone, or co-testing, performed at a shorter interval than the recommended routine screening interval

Screening for cervical cancer is very important and the tests must be performed regularly. 3 screening strategies are used; Pap smear alone, co-testing (Pap smear with HPV DNA screening), and primary HPV screening. In 2019 the American Society of Colposcopy introduced new screening guidelines which apply to all individuals with a cervix, including of the female sex transgender men, and individuals who have had a supracervical hysterectomy. These guidelines state the following:

a)Age of initial screening is now 25 years from the previous 21 years.

b) Primary HPV tests every 5 years are the preferred screening strategy instead of Pap smear or co-testing.

c) Routine screening intervals: apply to asymptomatic individuals who do not require surveillance.

d) Surveillance: 

*A follow-up test, performed at a shorter interval than for routine screening either using HPV primary testing or co-testing.

*Done in individuals with prior abnormal results.

*The frequency of surveillance will depend on the individual’s screening results and calculated risk for developing cervical cancer.

*Patients at risk of CIN III (cervical intraepithelial neoplasia) or higher but lower than the risk at which colposcopy (examination of the vagina and cervix with a colposcope (magnifying instrument)) is recommended (e.g., HPV-negative ASC-US)

*Retesting is done at intervals of 12 months to less than 5 years

*The recommendations of previous guidelines (Pap smear for average-risk patients starting at 21 years of age) still apply if the primary HPV tests, required for screening, are not available.

b) If FDA-approved primary HPV testing is not available:

*The age of initial screening is 21 years of age

*Screening is performed with Pap smear

*Screening performed with both Pap smear and HPV DNA (co-testing) can be used for individuals ≥ 30 years of age

*Patients with invasive disease detected during screening, need further workup including pelvic examination and pelvic, abdominal, and thoracic imaging is done to determine the disease stage.

Cervical screening tests:

–Papanicolaou test aka Pap smear/cervical cytology.

–HPV DNA testing

–Colposcopy

–Cervical biopsy

There are many classifications available for cervical cancer such as the Bethesda system, CIN grading, and FIGO. The FIGO system is based on clinical examination, it allows only these diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray of the lungs and skeleton, and cervical. Staging by FIGO is ; 0;stage 1A(1/2), 1B(1/2/3); stage 2A(1/2),2B; stage 3A,3B,3C(1/2); stage 4A,4B.

Treatment of invasive cervical cancer may involve surgery, chemotherapy, and/or radiation.

Surgical procedures are indicated for early-stage cancer (FIGO stages 1A1,1A2,1B1,1B2,2A).  The surgical procedures performed here are, Cold-knife conization and loop electrosurgical excision procedure (LEEP), Expedited treatment, Trachelectomy, Pelvic exenteration, and Hysterectomy (either simple extra fascial, modified radical or radical).

Pharmacological treatment:

–Chemotherapy; The current standard of treatment is cisplatin-based chemotherapy. It is usually concomitant with radiotherapy.

–Radiotherapy; It can be used as primary therapy in conjunction with chemotherapy or as adjuvant therapy post cervical cancer surgery.

–Concurrent chemoradiation; this is the administration of chemotherapy and radiotherapy in one session.

Since HPV is responsible for the majority of cervical cancer cases, HPV immunization, and use of condoms during sex play an important role in primary prevention.

Secondary prevention is screening for cervical cancer and management of precancerous lesions for individuals with a cervix.

That is all ladies! I hope the month of July has taught you a thing or two.

Please share the link to the blog with your friends and family members and I kindly ask you to leave a comment down below. Your feedback is of outermost importance to me.

STAY SAFE & SEE YOU SOON!