Cervical Cancer

1. Epidemiology
   1. Ages Effected
      1. Peak: Ages 40-60 years
      2. Range: 20 to 80 years
   2. Cervical Cancer Incidence
      1. United States: 15,000 cases per year (5,000 deaths)
      2. World: 500,000 cases per year
      3. Lifetime risk in U.S.: 0.8% if routinely screened
   3. Precursor lesion Incidence (Low Grade SIL)
      1. Low Grade SIL common in young (5-10%)
      2. Progresses to high grade SIL in 3 years (15-20%)
2. History
   1. Cervical Cancer had been as common as Breast Cancer
   2. Pap Smear markedly decreased U.S. Incidence after 1940
3. Risks
   1. Increased sexual partners
      1. More than one partner: 2-3 fold increased risk
      2. Prostitute: 4 fold increased risk
   2. Early age of first intercourse (under age 20 years)
   3. Male Partner with history of multiple partners
   4. Tobacco use confers 1.5-3 fold increased risk
   5. Immunosuppression
      1. HIV Infection
      2. Chemotherapy
      3. Immunosuppressive drugs
   6. Previous abnormal Pap Smear or cervical biopsy
      1. ASCUS most common abnormality before HGSIL or cancer
      2. Kinney (1998) Obstet Gynecol 91:973-6
   7. Lack of previous Pap Smear (50% of cancer patients)
   8. No Pap Smear in last 5 years (10% of cancer patients)
   9. History of Sexually Transmitted Disease (including HPV)
   10. Lower socioeconomic class
   11. Uncircumcised male partner
       1. Castellsague (2002) N Engl J Med 346:1105-12
   12. Vitamin Deficiency (unconfirmed)
       1. Vitamin C Deficiency
       2. B-Carotene deficiency
4. Etiology
   1. Cervical Cancer is a Sexually Transmitted Disease
   2. Human Papillomavirus (HPV) types: 16, 18, 31, 33, 35
      1. Inactivates gene locus p53
      2. Eliminates malignancy regulation, tumor suppression
5. Staging
   1. Carcinoma-in-situ (Pre-invasive Cervical Cancer)
   2. Stage 1: Cancer confined to Cervix
   3. Stage 2: Cancer spread to vagina and neighboring tissue
   4. Stage 3: Cancer extension to pelvic wall
   5. Stage 4: Cancer extension beyond Pelvis
6. Management
   1. Carcinoma-in-situ (Pre-Invasive Cancer)
      1. Hysterectomy
      2. Cryosurgery
      3. Cone biopsy
      4. Laser Surgery
   2. Stage 1
      1. Early: Hysterectomy
      2. Late:
         1. Radical Pelvic Surgery
         2. Pelvic Radiation Therapy
   3. Stage 2
      1. Radical Pelvic Surgery
      2. Pelvic Radiation Therapy
   4. Stage 3
      1. Pelvic Radiation Therapy
   5. Stage 4
      1. Chemotherapy
      2. Pelvic Radiation Therapy
7. Prognosis
   1. Carcinoma-in-situ (Preinvasive): 99% cure rate
   2. Stage 1: 75-80% cure rate
   3. Stage 2: 50-55% cure rate
   4. Stage 3: 30-35% cure rate
   5. Stage 4: 10% cure rate
8. Prevention
   1. See Pap Smear
   2. Bivalent HPV 16/18 Vaccine
      1. Harper (2004) Lancet 364:1757-65
9. References
   1. Canavan (2000) Am Fam Physician 61(5):1369-76
   2. Elkas (1998) Curr Opin Obstet Gynecol 10:47-50
   3. Lorincz (1992) Obstet Gynecol 79:328-37