Cervical cancer

Epidemiology• Cervical cancer is the 5th most common cancer in women worldwide • In some parts of Africa, South America and South Eastern Asia is the

second most common cancer after breast cancer• Cervical cancer is the most common cancer for women in Central America

and Southern Africa.

Risk factorsI. Environmental• HPV=main risk factor• Smoking• AIDS • Diabetes (high glucose levels)• Daughters of women who had used DES

(diethylstilbestrol) to prevent miscarriages (~1950-1970) (although it doesn’t decrease the risk of miscarriage)

II. Genetic

-there is sometimes familial aggregation of the disease

Human Papilloma Virus

• =“human wart virus”

Classification

• More than 150 subtypes of HPV1.High risk: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56,

58, 59, 68, 73, 82-16 and 18 present in ~70% of cervical cancers2. Probably high risk: 26, 53, 663. Low risk: 6, 11, 40, 42, 43, 44, 54, 61, 70, 72,

81

Vulvar cancer

Anal canal cancer

Oral cavity, oropharyngeal, nasopharyngeal and esophageal

cancer

Discovery

• 2008 Nobel-prize in medicine: Harald zur Hausen: HPV causes cervical cancer (1977).

Incidence of infection• 80% of women will be infected with at least one

subtype of HPV during their life, but the immune system eliminates the infection in most of the cases

• In some cases the infection will be chronic and leads to dysplasia (a premalignant condition) and later to cancer

• The time from infection to cancer is usually long (10-15 years), but it can be shorter, especially in younger women

• Plus younger women eliminate the infection less frequently

Histology

• Squamous cell carcinoma (80-90%)• Adenocarcinoma of the cervix-more rare and

not related to HPV infection

Routes of spread• Local extension: vagina, parametria, rectum,

bladder, uterine corpus

Lymphatic spread

Metastases

• Para-aortic lymph nodes-potentially curable• Other non-regional lymph nodes:

supraclavicular, neck• Lung• Rarely: bone, liver

Symptoms• Vaginal hemorrhage-postcoital-intermenstrual (metrorrhagia)- heavy and prolonged menstrual bleeding

(menorrhagia)-in menopause (metrorrhagia)• Leucorrhea• Pelvic pain• Urinary symptoms: hematuria• Rectal symptoms: rectorrhagia, obstruction• Lumbar pain: para-aortic metastases or

hydronephrosis

Diagnosis• Pelvic examination• Biopsy• Pelvi-abdominal CT/MRI/PET-CT• Rectal symptoms=> rectoscopy• Hematuria=> cystoscopy• Chest radiography• General work-up• Laparoscopic lymphatic staging-if available

Treatment• Stage IA=tumor not

seen by the naked eye and diagnosed only microscopically

a)Total hysterectomyb)Younger patients:

conization for fertility preservation

c)Brachytherapy

Treatment• Stage IB-IIA-tumor seen

by the naked eye, but not extending to the parametria

a) Total hysterectomy and bilateral salpingo-oophorectomy (TH+BSO) plus pelvic lymphadenectomy

+ adjuvant RTb) Exclusive radio-

chemotherapy

Treatment• Stage IIB-IVA-tumors

extending at least to the parametria or the lower third of the vagina

a) Exclusive radio-chemotherapy

b) Radio-chemotherapy followed by surgery

Radiotherapy

• External beam radiotherapy• Brachytherapya) Intracavitaryb) Interstitial

Vaccines

• Cervarix: 16, 18

• Silgard = Gardasil: 6, 11, 16, 18

• When is ideal to vaccinate? Before the first sexual contact. (Furthermore girls

age 10-14 develop the strongest immunity.)But can vaccinate at any age, because of the low

probability to have been infected with all subtypes (6, 11, 16, 18).

• How many people have been vaccinated to date?Over 30 000 000.• How many adult women have been vaccinated in

Romania?Over 35 000.• How many girls were vaccinated in RO during the

2008-2009 school campaign?Over 10 000.• No serious side effects. (Medical events after

vaccination couldn’t be linked with the vaccination.)

=> Vaccine appears to be safe.

Screening for cervical cancer• Cervical cytology = Pap smear-cells from the cervix are removed with a swab

• Starting at 3 yrs from first vaginal intercourse• Yearly• Women aged 70 may discontinue screening if during the last 10

years did not have abnormal cytology

Questions• What are the risk factors for cervical cancer?• What are the symptoms of cervical cancer?• What are the treatment options for cervical

cancer?• How should be cervical cancer screened for?