Gynecology Book

http://www.fpnotebook.com/

Cervical Cancer

Aka: Cervical Cancer, Cervical Adenocarcinoma In-Situ, Pre-invasive 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: 12,200 cases per year with 4210 deaths (2010, ACS)
      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 [PubMed]
    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 [PubMed]
    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. Cervical Adenocarcinoma-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. Cervical Adenocarcinoma-in-situ (Pre-invasive Cervical Cancer)
      1. Option 1: Hysterectomy (preferred)
      2. Option 2: Conservative management (fertility desired)
        1. Diagnostic Excision margins negative
          1. Long-term close follow-up
        2. Diagnostic Excision margins or ECC positive
          1. Re-excision (preferred) OR
          2. Re-evaluation at 6 months with HPV and cytology co-testing AND Colposcopy with ECC
      3. (2014) ASCCP Guidelines
        1. http://www.asccp.org/Guidelines-2/Management-Guidelines-2
    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 [PubMed]
  9. References
    1. Canavan (2000) Am Fam Physician 61(5):1369-76 [PubMed]
    2. Elkas (1998) Curr Opin Obstet Gynecol 10:47-50 [PubMed]
    3. Lorincz (1992) Obstet Gynecol 79:328-37 [PubMed]

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