Cervical cancer

Any woman with post-coital bleeding has cervical cancer until proved otherwise.

Demographics and presentation

Peak incidence in the 6th decade; 80% are squamous cell carcinoma. History: post-coital bleeding, intermenstrual bleeding, offensive vaginal discharge. Examination: ulceration or a mass on the cervix; friability (bleeds easily on contact). Investigations: co-test. Management: refer urgently to gynaecology.

About cervical cancer

The third most common gynaecological malignancy in Australia, after uterine and ovarian cancer, affecting approximately 900 women in 2016. Squamous cell carcinoma is the most common type, accounting for 70% of cases; adenocarcinoma is less common and harder to diagnose, since it starts higher in the cervix. Cervical cancer death rates in Australia have halved since the National Cervical Screening Program began in 1991. Five-year survival is 74%.

Risk factors: almost all cases are caused by persistent infection with high-risk HPV types — the biggest risk factor; smoking is the other main risk factor. HPV 16 and 18 are detected in 70–80% of Australian cervical cancer cases. About 8 in 10 women will acquire genital HPV at some point, but most never develop cervical cancer — only a few HPV types cause it, and it usually takes 10–15 years from HPV acquisition for abnormal cells to become cancerous — during this time the immune system may clear the virus, allowing regression. Taking the COCP for 5+ years is associated with a small increase in risk — but the pill also reduces the risk of ovarian and uterine cancer. Other risk factors: a weakened immune system, and in-utero exposure to diethylstilbestrol (DES).

Diagnosis

Cervical screening test, colposcopy, biopsy (may be done during colposcopy). LLETZ (large loop excision of the transformation zone, usually under local anaesthetic) is the most common method to remove tissue for examination and to treat precancerous change. A cone biopsy is used when abnormal glandular cells are present, or early-stage cancer is suspected.

Staging

• Stage I — cancer confined to the cervix.
• Stage II — spread outside the cervix to the upper two-thirds of the vagina or nearby tissue.
• Stage III — spread to the lower third of the vagina and/or the pelvic wall, possibly involving pelvic/abdominal lymph nodes or causing kidney failure.
• Stage IV — spread to the bladder or rectum (IVA), or distant spread to the lungs, liver or bones (IVB).

Management

Precancerous disease: LLETZ, cone biopsy, or laser surgery.

Surgery (choice depends on extent of spread and age): cone biopsy (very early cancers, especially in young women wanting to preserve fertility); trachelectomy (removes part/all of the cervix and part of the vagina, uterus/tubes/ovaries left in place — uncommon, used in young women with early-stage disease wanting children); total hysterectomy (uterus and cervix, often with the fallopian tubes; some premenopausal women keep their ovaries); radical hysterectomy (uterus, cervix, and surrounding soft tissue and top of the vagina — the standard operation for most surgically-treated cervical cancers); bilateral salpingectomy (both tubes, commonly recommended with an open hysterectomy); bilateral salpingo-oophorectomy (both tubes and ovaries, if spread to the ovaries is suspected or the woman is peri/postmenopausal).

Other modalities: sentinel lymph node biopsy, lymphadenectomy, radiation therapy, chemotherapy, targeted therapy (bevacizumab), palliative care.

HPV vaccination

In 2007, Australia led the world with a national publicly funded HPV vaccination program. The HPV vaccine (Gardasil) is administered through the National Immunisation Program. Vaccination ideally occurs before first sexual activity. Women who have been vaccinated still need cervical screening — the vaccine doesn’t prevent all cervical-cancer- causing HPV types. Gardasil 9 (covering HPV 6/11/16/18/31/33/45/52/58) has been the NIP vaccine since 2018, and since 6 February 2023 the routine schedule for ages 12–25 is a single dose (immunocompromised patients still need 3 doses); the catch-up program extends to age 25.