Cervical Cancer

Key facts

• Pap screening decreases mortality by 70%  
• 50% of diagnosis occur in women who have never been screened  
• HPV 16 and 18 confer the highest risk  
• 95% of cases are associated with HPV infection  
• 90% are SCC, 10% are adenocarcinoma, 1-2% are clear cell  
• Mean age of CIN is 15-20 yrs younger than invasive disease  
• Prognostic factors include: LN metastasis, tumor size, stage, uterine extension, and hemoglobin <100.  
• Risk of pelvic LN involvement for stage I, II and III disease is 15%, 30% and 45% respectively

Epidemiology

Cancer of the uterine cervix is the ninth most common cancer in BC women with an incidence rate of 9.8 per 100,000. Over 80% of all cervical cancer cases are squamous cell carcinomas arising in the ectocervix with further 17% being adenocarcinoma or adenosquamous carcinoma arising in the endocervical canal. The incidence rate has been steadily falling for several decades with an average annual rate of decline of about 2%. Cervical cancer responds well to treatments, resulting in a 5-year relative survival of about 74%.

HPV Role

Human papillomaviruses (HPV) infection, particularly with one of several particular virus subtypes, is the major factor causally associated with cervical cancer. There is evidence of positive relationships between cervical cancer risk and early age of first marriage, early age of pregnancy, greater number of sexual partners, as well as early age of first intercourse. The relationship with lifetime number of sexual partners appears weakened when HPV infection is taken into account.

Smoking

Higher risks of cervical cancer have been observed for long-term or high-intensity smokers. However, in many recent studies, the effect of smoking has practically disappeared when HPV infection is taken into consideration.

Prevention

Screening

PAP smear screening has dramatically increased the incidence of cervical cancer due to early detection and decreased the mortality by a great deal.

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Types of curative-intent surgery

Removal of cervix, small rim of vaginal cuff, and outside of puborectalis fascia Modified radical hysterectomy — removal of parametria and paracervical tissue medial to ureters (cardinal and ureterosacral ligaments) and vaginal cuff 1-2cm Extended radical hysterectomy — removal of superior vesicular artery, part of ureter and bladder, and more vaginal cuff

Adjuvant CRT

Indications for RT or CRT

Post Operative Radiotherapy

• Lymphovascular invasion 
• 1/3 or more stromal invasion 
• 4 cm+ tumor size

Post Operative CRT

• Positive Margin 
• Positive Lymph Node 
• Parametrial or greater extension

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