Cervical Cancer

Cervical cancer is the third most common gynecologic malignancy after endometrial cancer and ovarian cancer; it is the eighth most common malignancy among women in the USA. The peak incidence occurs in patients in their 40s or 50s. However, it occurs in women of all ages, including the elderly.

Human papillomavirus (HPV) is thought to play a role in the etiology of cervical cancer. Although HPV is a common component of the biologic flora of the vagina, certain subtypes may have the ability to integrate into the DNA of cervical cells and induce genetic alterations, leading to malignant transformation; HPV types 16 and 18 are present in > 75% of cervical cancers. Prevention strategies that use Pap tests for early detection of HPV types 16 and 18 are being investigated.

Cervical histopathology is classified as mild cervical dysplasia, in which abnormal cells proliferate in the lower third of the epithelium; moderate cervical dysplasia, in which abnormal cells involve the middle third of the epithelium; severe dysplasia (carcinoma in situ), in which a full thickness of epithelium contains abnormal cells; or invasive carcinoma, in which cancer cells penetrate the basement membrane and invade the stroma. About 85% of cervical cancers are squamous cell carcinomas and 15% are adenocarcinomas, although the incidence of adenocarcinomas may be increasing.

Symptoms depend on the stage of the tumor. Some patients have postcoital or postmenopausal vaginal bleeding, although many patients with premalignant or small lesions are asymptomatic. Routine Pap testing is the best screening method. Technologic advances in slide preparation and automated rescreening devices have improved the accuracy rate of the Pap test, so that it can detect about 90% of early-stage neoplasias. In elderly women with no previous history of abnormal Pap smears under routine surveillance and with no outstanding risk factors, the need for frequent Pap tests decreases. Elderly women who have had consistently normal Pap smears need to be tested only every 5 years. Those who have had cancer or dysplasia, regardless of age, should continue to undergo annual Pap tests.

If the Pap test result is positive, colposcopy-directed biopsies and endocervical curettage are used diagnostically; if biopsy results do not exclude invasive carcinoma or if the cervical transformation zone is not visible, subsequent cervical conization may be required. Conization can often be accomplished using diathermy loops under local anesthesia in an office setting.

The combined cure rate for all cervical cancers is 50 to 60%. The cure rate for early-stage cancers treated with radical hysterectomy or radiation therapy approaches 85%. Locally advanced disease is treated with radiation and chemotherapy; the 5-year survival rate in these cases is about 70%. Radiation or chemotherapy can provide palliation for patients with distant metastases; however, the prognosis in these cases is very poor.