SYNTHESIS ON CERVICAL CANCER

Cervical cancer is a neoplasm in the cervix. It is the second most common cancer
among women (next to Breast Cancer), but the most common neoplasm in the female genital
tract. Its 5-year survival rate is approximately 44% with a mortality rate of 1 in 10,000.
Pathophysiology
Cervical cancer is a long term outcome of persistent infection of the lower genital tract
with one of about 15 high risk HPV types
There are several risk factors in the development of cervical cancer which were
discussed thoroughly yesterday.
Risk Factors for Cervical Cancer
1. HIV infection
HPV is said to be the necessary cause of cervical cancer. High risk oncogenic types of
HPV are HPV 16, 18, 31, 33, 35, 45, 51, 52, 56.

2. Multiparity (> 7 pregnancies)

Those with higher parity has 4x relative risk for developing cervical cancer. Aside from
the fact that pregnancy renders a woman to be in immunocompromised state, child birth
causes both physical and mechanical trauma to the cervix causing dysplasia which are
pre-malignant cells and may eventually transform to malignant cells.

3. Long term OCP use from more than 5 years

The use of OCP does not directly causes cervical cancer, however, Estradiol, a
component of OCP which increases viral expression.

4. Smoking
Nicotine, a content of cigarette smoke, contributes to the development of cervical
cancer in 2 ways. First, in decreses the Langerhan cells present in the urogenital tract
which act as resident macrophage and antigen presenting cell which confers immunity
to HPV. Also, nicotine has a direct mutagenic effect.

5. Co-infection with Chlamydia and Gonorrhea

Present of other sexually transmitted infections confers a high risk behavior and thus
higher risk of exposure to HPV hence contributing to the development of cervical
cancer.

6. Early age of intercourse

During the pre-pubertal years the endocervix which contains the squamocolumnar
junction/transformation zone. This exposes to trauma which may lead to cell dysplasia.
We also discussed the three types of Transformation zone
 Type I – Pre-pubertal: The transformation zone is fully ectocervical
Type II-Reproductive age: The transformation zone is halfway
Type II – Menopausal: The transformation zone is at the endocervix

7. Low socioeconomic status

Those with low socioeconomic status have limited access to health care service such as
HPV vaccine and education.

Prevention of Cervical Cancer

In order to prevent cervical cancer, patient education on having a healthy lifestyle,
balanced diet, exercise should be done. More importantly, HPV vaccination confers good
protection against the disease. There are 3 available vaccines in the market such as:
Bivalent: HPV 16 and 18
Quadrivalent:HPV 6, 11, 16, 18
Nonavalent: HPV 6, 11, 16, 18, 31, 33, 35, 45, 51, 52, 56
It is important to explain to our patient that the vaccine does not confer total protection
from the disease since it only covers certain HPV strains, and there are other strains that may
possibly cause the disease.
Aside from vaccination, we can also do secondary intervention in the form of Pap smear
with HPV co-testing or in low resource setting, through VIA.

Diagnosis/Staging of Cervical Cancer

The staging of cervical cancer is clinical.
2018 FIGO Staging
Stage I. The carcinoma is strictly confined to the cervix.
Stage IA. Carcinoma is diagnosed microscopically with maximum depth of <5mm.
IA1. Stromal invasion is <3mm
 IA2. Stromal invasion >3mm but less than 5mm
Stage IB Deepest invasoin of >5mm
IB1. Stromal invasion of >5mm in depth but <2cm in greatest dimension
IB2. Greatest dimension of > 2 cm but less than 4 cm
IB3. Greatest dimension of > 4cm
Stage II. The carcinoma invades beyond the cervix but not to the lower third of the vagina or
pelvic side wall
Stage IIA. There is involvement of upper third of vagina but NO PARAMETRIAL
involvement
IIA1. Lesion is <4cm
IIA2. Lesion is >4cm
Stage IIB. There is PARAMETRIAL INVOLVEMENT
Stage III. The carcinoma invaded the lower third of the vagina, or causes hydronephrosis, or
involved the pelvic side wall and the pelvic or paraaortic lymph node
Stage IIIA. Involves the lower third of the vagina
Stage IIIB. Involves the pelvic side wall and/or causes hydronephrosis or nonfunctioning
kidney
Stage IIIC. With pelvic, paraaortic lymph node involvement (may note if R or P)
IIIC1. Pelvic lymph node involvement
IIIC2. Para-aortic lymph node involvement
Stage IV. Metastases beyond the true pelvis or has involved the mucosa of the bladder
or rectum
Stage IVA. Metastases to adjacent pelvic organs
Stage IVA. Metastases to distant pelvic organs
Management
The primary treatment for cervical cancer is concurrent chemotherapy and complete
radiotherapy. The main use of the chemotherapy is to sensitize the cells for radiotherapy.
Surgical management (RHBSO) can only be offered up to Stage IIA1.