CERVICAL CANCER OVERVIEW
An estimated 12,170 new cases of invasive cervical cancer were anticipated in 2012 in the United States, with 4220 deaths projected.
75% to 80% are squamous cell carcinomas.
Since the advent of cytologic screening in the 1940s, the incidence of cervical cancer has been decreasing; however, a steady increase in the incidence of preinvasive disease of the cervix has occurred.
- Associated risk factors include race, early age at first coitus, multiple sexual partners, multiparity, lower socioeconomic standing, cigarette smoking, history of sexually transmitted diseases, immunosuppression, and oral contraceptive use.
- Strong association with human papillomavirus (HPV).
- HPV serotypes 16, 18, 31, 33, 45, and 56 account for more than 80% of all invasive cervical cancers.
- Screening for cervical cancer historically has been done with the Papanicolaou (Pap) smear and pelvic examination.
- Testing for DNA of high-risk oncogenic HPV may be used to triage atypical smears and to reduce the frequency of cytologic screening.
- Biopsies should be performed of gross lesions.
- Patients without gross lesions but with abnormal cytology should undergo colposcopy with directed biopsies and endocervical curettage (ECC) or brushing.
- Once a diagnosis of cancer is made, the patient requires a complete history and physical examination, including bimanual and rectovaginal examination, as well as supraclavicular and groin lymph node examination.
- Cervical cancer is staged clinically, not surgically.
- Assignment of stage of disease may be influenced by findings from chest and skeletal radiography, excretory urography (intravenous pyelogram [IVP]), barium enema, cystoscopy, and proctoscopy.
- Results of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), or other imaging modalities do not influence assignment of International Federation of Obstetrics and Gynecology (FIGO) stage, but may be important in directing therapy.
- High-grade dysplasia or carcinoma in situ may be treated with excisional cone biopsy (i.e., cervical conization performed with loop electrosurgical excision procedure [LEEP], or cold-knife).
- Stage Ia1 (microinvasive cervical cancer with depth of invasion 3 mm or less and 7 mm in width or less) without lymphovascular invasion is managed with conservative surgery (i.e., excisional conization or extrafascial hysterectomy).
- Stage Ia2 lesions (invasion of more than 3 mm depth, and lesion up to 7 mm wide) or Ia1 lesions with lymphovascular invasion are managed with modified radical hysterectomy or a radical trachelectomy.
- Stage Ib lesions and stage IIa lesions may be managed with radical hysterectomy or radiation therapy with equivalent probability of cure but different morbidities. Selected surgical patients with adverse risk factors may benefit from adjuvant postoperative radiation or chemoradiation.
- Patients with stages IIb to IVa generally are treated with radiation therapy with concurrent chemotherapy.
- Disease that recurs centrally in the pelvis after radiation may be treated with radical exenterative surgery.
- Locally recurrent disease after surgery is generally treated with radiation therapy or chemoradiation.