Cervical Cancer
Epidemiology and Etiology
Cervical cancer death rates have declined by approximately 80% since 1930 because of the widespread implementation of screening programs, accounting for an estimated 13,800 new cases and 4290 deaths in the US in 2020.1 In countries that lack screening and prevention programs, cervical cancer is the second most common cancer in women.
HPV infection is detected in gt;99% of tumors, most commonly HPV-16 and -18. Other risk factors include early onset of sexual activity, multiple sexual partners, high-risk partners, history of sexually transmitted illness, and chronic immunosuppression.Screening and Prevention
The 2018 USPSTF recommends screening for cervical cancer with cervical cytology every 3 years for women aged 21-29. For women aged 30-65, screening options include cervical cytology alone every 3 years, high-risk HPV (hrHPV) testing alone every 5 years, or combined cytology and hrHPV every 5 years. Women younger than 21 or older than 65 with adequate prior screening and women who have undergone hysterectomy do not need screening.25 HPV vaccines include the bivalent vaccine (Cervarix) which targets HPV 16 and 18; the quadrivalent vaccine (Gardasil) which targets HPV 16, 18, 6, and 11; and the 9-valent vaccine (Gardasil-9) which targets HPV 16, 18, 6, 11, 31, 33, 45, 52, and 58. Vaccination should ideally start before the onset of sexual activity and is recommended for both sexes by 11-12 years old.
Pathology
The most common histologies are squamous cell carcinoma (75%-85%) and adenocarcinoma (15%- 25%).
Clinical Presentation
Patients with early stage lesions are commonly asymptomatic and diagnosed incidentally on Pap smear, which underscores the importance of screening. Symptoms observed at presentation may include irregular or heavy vaginal bleeding or postcoital bleeding, usually occurring in patients without Pap smear for several years.
Patients with advanced disease may present with back pain, hematochezia, or vaginal passage of urine or stool due to fistula formation from invasive cancer.Diagnostic Testing
Diagnosis is obtained through colposcopy with cervical cytology and biopsy. A cone biopsy is recommended in women without gross cervical lesions or with microinvasive disease to define the depth of the lesion. Clinical examination in conjunction with imaging, such as chest radiograph, CT, PET CT, and pelvic MRI, may be used to assess International Federation of Gynecology and Obstetrics (FIGO) stage, as indicated.
Staging
Staging is based on the FIGO system. In general, stage I disease is confined to the cervix. Stage II disease invades beyond the uterus but does not extend into the lower third of the vagina or the pelvic wall. Stage III involves the lower third of the vagina, the pelvic wall, the pelvic/para-aortic lymph nodes and/or causes hydroureter. Stage IV disease extends beyond the pelvis.
TREATMENT
Patients with early stage disease may be treated with fertility sparing resection, hysterectomy, or radiation therapy. Chemoradiation can be used in locally advanced tumors and as adjuvant therapy in high-risk patients following hysterectomy. Metastatic disease is treated with chemotherapy, most commonly a platinum (cisplatin or carboplatin) alone or in combination with paclitaxel with or without bevacizumab. Immunotherapy may be considered in those with PD-L1 positive or with MSI-high tumors who progress after platinum-based chemotherapy.26