Carcinoma of the cervix

Dr Nirasha Chiranjan, a radiation oncologist, revises the epidemiology, risk factors, clinical manifestations and diagnosis of carcinoma of the cervix.

South Africa has a high incidence of carcinoma of the cervix and it is a leading cause of cancer mortality. of all gynaecological cancers, 

cervical cancer is the focus of the most government public policy work and active intervention. This is largely because cervical cancer is the only gynaecological cancer that can be detected in a precancerous stage through population screening. 

In nations that run organised screening programmes, cervical cancer screening has been one of the great public health successes of the 20^th century. 

Almost all cervical cancers are caused by human papillomavirus (HPV). Experts believe that HPV vaccines may eliminate cervical cancer within the next few decades. 

In SA, there are currently two vaccines registered for the prevention of HPV-related disease: a quadrivalent vaccine and a bivalent vaccine. Both vaccines are intended for prophylactic use, before the onset of sexual activity and exposure to HPV. 

The bivalent vaccine is approved for both girls and boys from the age of nine in South Africa and is available at most retail pharmacies and school-based vaccination programmes.

Epidemiology 

Cervical cancer accounted for an estimated 604 000 new cancer cases and 342 000 deaths worldwide¹ and was the fourth most common cancer in females worldwide.² 

The majority of cervical cancer cases are from resource limited countries like those in Africa and Central America.³ 

Global incidence and mortality rates depend upon the presence of screening programmes for cervical precancer and cancer and HPV vaccination, which are most likely to be available in resource-rich countries. 

Data suggests that Pap smear screening in conjunction with HPV vaccination can greatly reduce the incidence of cervical cancer in resource-limited settings. 

Risk factors^4-5 

• Human papillomavirus (HPV) 
• Cigarette smoking 
• Immunosuppression (HIV infection)
• Low socio-economic status (limited access to healthcare and screening programmes) 
• Genetics 

Clinical manifestations⁶

• Early cervical cancer is frequently asymptomatic, underscoring the importance of screening.
• Irregular or heavy vaginal bleeding 
• Pelvic or lower back pain 
• Bowel or urinary symptoms 
• Poor appetite and weight loss 
• Bone pain 
• Swelling of one of the lower limbs
• Vaginal discharge 

Diagnosis 

• Pap smear and HPV testing. Cervical cytology is the principal method for cervical cancer screening. 
• Histologic evaluation of a cervical biopsy and colposcopy (procedure to closely examine cervix, vagina and vulva for signs of disease). 
• Full medical history and physical examination: Pelvic examination – rectovaginal examination with assessment of tumour size and vaginal or parametrial involvement.
• Imaging: CT scan/PET CT/MRI scan for determination of locoregional extent and distant metastases.

Take home message

• Vaccinate early

HPV vaccination at ages 9 and over. 

• Get screened regularly

Pap smear test starting at age 21.

Pap smear and HPV co-testing starting at age 30. 

• Spread awareness in your community

Encourage more women to be aware of the signs and symptoms of the disease and preventive strategies. 

Early detection can lead to more effective treatment and better long-term outcomes.

References:

1. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries.AU Sung H et al: CA Cancer J Clin. 2021;71(3):209. Epub 2021 Feb
2. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries .Bray CA Cancer J Clin. 2018;68(6):394. Epub 2018 Sep 12.
3. WHO/ICO Information Center of HPV and Cervical Cancer (HPV Information Center). Human Papillomavirus and Related Cancers in the World. Summary Report 2010
4. Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies.AU International Collaboration of Epidemiological Studies of Cervical Cancer Int J Cancer. 2007;120(4):885.
5. Recent trends in racial and regional disparities in cervical cancer incidence and mortality in United States.AU Yoo W, Kim S, Huh WK, Dilley S, Coughlin SS, Partridge EE, Chung Y, Dicks V, Lee JK, Bae S 2017;12(2):e0172548. Epub 2017 Feb 24.
6. DiSaia PJ, Creasman WT. Invasive cervical cancer. In: Clinical Gynecologic Oncology, 7th ed., Mosby Elsevier, Philadelphia 2007. p.55.

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