Cervical Cancer Overview

OBS/GYN

CARCINOMA OF THE CERVIX

Cervical cancer remains a major global public
health problem affecting predominantly middleaged women in low-resourced countries
especially in sub-saharan Africa

Approximately 570 000 cases of cervical cancer

and 311 000 deaths from the disease occur
annually worldwide..

Cervical cancer is the third most common cancer

in women, ranking after breast cancer and lung
cancer .

Commonest genital tract Cancer among women

and the leading cause of cancer-related death in
women in many African countries

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Cervical Cancer: A Major Public Health Concern

Cervical cancer remains a significant global health challenge, particularly affecting middle-aged women
in low-resource countries, with Sub-Saharan Africa being one of the most impacted regions.

Key Facts:

Annually, approximately 570,000 new cases of cervical cancer are reported worldwide.
The disease leads to about 311,000 deaths each year.
Cervical cancer is the third most common cancer in women, following breast and lung cancer.
It is the most prevalent genital tract cancer in women and a leading cause of cancer-related
deaths in many African countries.

With timely screening, early detection, and vaccination against HPV, the burden of cervical cancer can be
significantly reduced.

Classification

1. Squamous cell carcinoma: 80%

2.Adenocarcinoma : 15%
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 3. Adenosquamous

4. Small cell carcinoma

5. Glassy cell carcinoma

6. Melanoma

7. Lymphoma

Exophytic: grows out of the cervix

Endophytic: Eats up the cervix

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Classification of Cervical Cancer

Cervical cancer is classified based on the type of cells involved. The two most common types are
squamous cell carcinoma and adenocarcinoma, but rarer variants also exist.

Major Types:

1. Squamous Cell Carcinoma (80%) – The most common type, arising from the squamous cells lining
the cervix.
2. Adenocarcinoma (15%) – Develops from the glandular cells of the cervix.
3. Adenosquamous Carcinoma – Contains both squamous and glandular cancerous cells.
4. Small Cell Carcinoma – A rare but aggressive type.
5. Glassy Cell Carcinoma – A rare variant with a poor prognosis.
6. Melanoma – Extremely rare, arising from pigment-producing cells.
7. Lymphoma – Cancer of the lymphatic system that can involve the cervix.

Growth Patterns:

Exophytic – Grows outward from the cervix, forming a visible mass.

Endophytic – Invades inward, destroying cervical tissue.

Early detection through screening (Pap smear, HPV testing) is crucial for better outcomes.

Pathogenesis
It is globally agreed that carcinoma of
the cervix is associated with infection
with the human papiloma virus.
Virtually all sexually active female are
exposed to the human papilloma virus.
The development from infection to
invasive cervical carcinoma takes

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 several years and involves an interplay
of multiple environmental, lifestyle,
socioeconomic and pharmacological
factors.

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Pathogenesis of Cervical Cancer

Cervical cancer is strongly linked to human papillomavirus (HPV) infection, which is considered the
primary cause. Almost all sexually active women are exposed to HPV at some point in their lives, but only
a small percentage develop cervical cancer.

Progression from HPV Infection to Cancer:

1. HPV Infection – High-risk HPV types (especially HPV 16 and 18) infect cervical cells.
2. Persistent Infection – In some women, the immune system fails to clear the virus, leading to
chronic infection.
3. Cellular Changes (Cervical Intraepithelial Neoplasia - CIN) – HPV disrupts normal cell growth,
causing precancerous changes in the cervix.
4. Invasive Cancer – Over several years, if left untreated, these precancerous changes can progress
to invasive cervical cancer.

Risk Factors Influencing Progression:

Environmental – Poor hygiene, pollution.

Lifestyle – Early sexual activity, multiple sexual partners, smoking.
Socioeconomic – Limited access to screening and healthcare.
Pharmacological – Prolonged use of immunosuppressive drugs.

Regular Pap smears, HPV vaccination, and early treatment of precancerous lesions can prevent the
progression to cervical cancer.

Pathogeensis..
Currently, over 150 different serotypes of HPV
have been recognized and cloned.More than
90% of all cervical cancers are caused by 8 HPV
types; 16,18,31,33,35,45,52 and 58. Three types
- 16,18 and 45 are implicated in 94% of cervical
adenocarcinomas. When the viral genomes get
integrated into human genome in the immature
transformation zone of the cervix, they evade
apoptosis due to loss of suppressor genes TP53
and RB and cause damage to the DNA, leading to
the unregulated proliferation of cells and
malignant transformation

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Pathogenesis of Cervical Cancer

Cervical cancer develops primarily due to persistent infection with high-risk human papillomavirus
(HPV) types.

Key Facts About HPV and Cervical Cancer:

Over 150 HPV serotypes have been identified.

8 high-risk HPV types (16, 18, 31, 33, 35, 45, 52, 58) cause more than 90% of cervical cancers.
HPV 16, 18, and 45 are responsible for 94% of cervical adenocarcinomas.

Mechanism of Cancer Development:

1. HPV Infection in the Transformation Zone – The virus infects immature cervical cells, integrating
its genome into the host DNA.
2. Evasion of Apoptosis – The viral proteins E6 and E7 inactivate tumor suppressor genes TP53 and
RB, preventing normal cell death.
3. DNA Damage and Uncontrolled Cell Growth – Loss of these tumor suppressors leads to genetic
instability, uncontrolled cell division, and eventually malignant transformation.

Regular HPV vaccination, screening (Pap smear, HPV DNA test), and early treatment of
precancerous lesions are key strategies for prevention.

Aetiology /Riskfactors
Several risk factors of cervical cancer have been
described and these include:
1. Low socioeconomic status;
2. Tobacco smoking (twofold);
3. Prolonged use of oral contraceptives (2.5‐fold)
4. Early onset of sexual intercourse (13years)
5. Multiple sexual partners (of woman or of the
partner);
6. Other sexually transmitted infections (e.g. herpes
simplex virus, Chlamydia) and bacterial vaginosis
might influence HPV persistence and the probability
of progression of HPV infection to dyskaryosis;
7. Immunocompromise, including HIV (fivefold).

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Etiology and Risk Factors of Cervical Cancer

Several factors increase the risk of developing cervical cancer, primarily by promoting persistent HPV
infection and its progression to malignancy.

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Key Risk Factors:

1. Low Socioeconomic Status – Limited access to healthcare and screening.

2. Tobacco Smoking – Doubles the risk by weakening immune defenses against HPV.
3. Prolonged Use of Oral Contraceptives – Increases risk by 2.5 times due to hormonal influences
on cervical cells.
4. Early Onset of Sexual Activity (<13 years) – Higher exposure to HPV at a vulnerable age.
5. Multiple Sexual Partners – Increases the likelihood of HPV infection, including exposure to a
partner with multiple sexual contacts.
6. Other Sexually Transmitted Infections (STIs) – Infections like herpes simplex virus, Chlamydia,
and bacterial vaginosis can prolong HPV persistence and enhance its cancer-causing potential.
7. Immunocompromise (e.g., HIV/AIDS) – Fivefold increase in risk due to weakened immune
surveillance against HPV.

Prevention Strategies:

HPV Vaccination before sexual debut.

Regular Cervical Screening (Pap smear, HPV DNA test).
Safe Sexual Practices (condom use, limiting partners).
Smoking Cessation and managing co-existing STIs.

Staging

Cervical cancer is still staged clinically using the

International Federation of Gynaecology and
Obstetrics (FIGO, 2022) system

Stage I The carcinoma is strictly confined to the

cervix (extension to the corpus should be
disregarded)

Stage Ia Invasive carcinoma which can be diagnosed

only by microscopy, with deepest invasion ≤5mm,
measured from the base of the epithelium

Stage Ia1 Measured stromal invasion of ≤3.0mm in

depth

Stage Ia2 Measured stromal invasion of >3.0mm and

not >5.0mm

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Staging of Cervical Cancer (FIGO 2022)

Cervical cancer is clinically staged using the International Federation of Gynecology and Obstetrics
(FIGO) system.

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Stage I: Cancer Confined to the Cervix

Stage Ia – Microscopic invasive carcinoma (not visible to the naked eye).

Stage Ia1 – Stromal invasion ≤3.0 mm in depth.
Stage Ia2 – Stromal invasion between 3.1 mm and 5.0 mm in depth.

The staging system helps guide treatment decisions and prognosis assessment.

Staging

Stage Ib Clinically visible lesions limited to the cervix uteri or

preclinical cancers greater than stage Ia*

Stage Ib1 Clinically visible lesion >5mm in depth of stromal

invasion and <2cm in greatest dimension

Stage Ib2 Clinically visible lesion >2.0cm but <4cm in

greatest dimension

Stage 1b3 Invasive carcinoma, > or= 4cm in greatest

dimension

Stage II Cervical carcinoma invades beyond the uterus, but

not to the pelvic wall or to the lower third of the vagina

Stage IIa Without parametrial invasion

Stage IIa1 Clinically visible lesion ≤4cm in greatest dimension

Stage IIa2 Clinically visible lesion >4cm in greatest

dimension

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Staging of Cervical Cancer (FIGO 2022)

Stage Ib: Visible Lesions Confined to the Cervix

Stage Ib1 – Clinically visible lesion with stromal invasion >5mm, but less than 2 cm in greatest
dimension.
Stage Ib2 – Lesion between 2.0 cm and 4 cm in greatest dimension.
Stage Ib3 – Lesion ≥4 cm in greatest dimension.

Stage II: Cancer Extends Beyond the Uterus

The tumor invades beyond the cervix but does not reach the pelvic wall or lower third of the
vagina.

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Stage IIa: No Parametrial Invasion

Stage IIa1 – Clinically visible lesion ≤4 cm in greatest dimension.

Stage IIa2 – Clinically visible lesion >4 cm in greatest dimension.

Staging helps in determining the extent of disease and plays a key role in treatment planning.

Stage IIb With obvious parametrial invasion

Stage III The tumour extends to the pelvic wall and/or involves lower
third of the vagina and/or causes hydronephrosis or non‐functioning
kidney†
Stage IIIa Tumour involves lower third of the vagina, with no
extension to the pelvic wall
Stage IIIb Extension onto the pelvic wall and/or hydronephrosis or
non‐functioning kidney
Stage 111c Involvement of pelvic and/or para-aortic lymph nodes
irrespective of the tumour size and extent.
Stage 111c1 Pelvic lymph node metastasis only
Stage111c2 Para-aortic node metastasis
Stage IV The carcinoma has extended beyond the true pelvis or has
involved (biopsy proven) the mucosa of the bladder or rectum. A
bullous oedema, as such, does not permit a case to be allotted to
stage IV
Stage IVa Spread of the growth to adjacent organs
Stage IVb Spread to distant organs

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Staging of Cervical Cancer (FIGO 2022)

Stage IIb: Parametrial Invasion

Stage IIb – The tumor shows obvious invasion into the parametrium (tissues around the cervix).

Stage III: Tumor Involves Pelvic Structures

Stage IIIa – The tumor invades the lower third of the vagina, with no extension to the pelvic wall.
Stage IIIb – The tumor extends to the pelvic wall and/or causes hydronephrosis (swelling of the
kidney) or non-functioning kidney.
Stage IIIc – Involvement of pelvic and/or para-aortic lymph nodes, regardless of tumor size or
extent.
Stage IIIc1 – Pelvic lymph node metastasis only.
Stage IIIc2 – Para-aortic lymph node metastasis.

Stage IV: Cancer Extends Beyond the Pelvis

The tumor extends beyond the true pelvis or involves bladder/rectal mucosa (biopsy proven). A
simple bullous edema does not qualify as stage IV.

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 Stage IVa – Spread to adjacent organs (e.g., bladder, rectum).

Stage IVb – Spread to distant organs (e.g., lungs, liver).

This staging system helps assess the extent of the disease, which is crucial for planning treatment
options and evaluating prognosis.

The American Joint Committee on cancer (AJCC) TNM staging

system is another staging system which is based on 3 key pieces of
information:
T – indicates how far the primary tumour has grown into the cervix
and nearby tissues
N – indicates any cancer spread to lymph nodes near the cervix
M – indicates if the cancer has spread to distant sites
Thus;
T0 – no evidence of a primary tumour
TX – primary tumour cannot be assessed due to lack of information
N0 – no regional lymph node spread
N1 – cancer has spread to nearby lymph node
NX – regional nodes cannot be assessed due to lack of information
M0 – no spread to distant sites
M1 – distant metastasis

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AJCC TNM Staging System for Cervical Cancer

The American Joint Committee on Cancer (AJCC) TNM staging system classifies cervical cancer based
on three key factors:

T (Tumor) – Describes the size and extent of the primary tumor.

N (Nodes) – Indicates whether the cancer has spread to nearby lymph nodes.
M (Metastasis) – Shows whether the cancer has spread to distant organs.

TNM Categories:

Tumor (T):

T0 – No evidence of a primary tumor.

TX – Primary tumor cannot be assessed due to lack of information.

Nodes (N):

N0 – No spread to regional lymph nodes.

N1 – Cancer has spread to nearby lymph nodes.
NX – Regional lymph nodes cannot be assessed.

Metastasis (M):

M0 – No distant spread.

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 M1 – Cancer has metastasized to distant organs.

This system provides a detailed and structured approach to staging, helping guide treatment
decisions and prognosis evaluation.

Clinical features

The most common symptom of cervical

cancer is abnormal vaginal bleeding or
discharge.

Abnormal bleeding may take the form of

post-coital spotting, intermenstrual
bleeding or heavy menstrual bleeding.

Vaginal discharge at times foul smelling

and may occur with advanced and
necrotic cancers.

Pelvic pain may result from locally

advanced disease or tumour necrosis

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Clinical Features of Cervical Cancer

The most common symptom of cervical cancer is abnormal vaginal bleeding or discharge. Symptoms
may vary depending on the stage of the disease.

Key Symptoms:

Abnormal Vaginal Bleeding:

Post-coital spotting (bleeding after intercourse).
Intermenstrual bleeding (bleeding between periods).
Heavy or prolonged menstrual bleeding.
Vaginal Discharge:
May be foul-smelling, especially in advanced or necrotic tumors.
Pelvic Pain:
Can occur due to tumor invasion or necrosis in locally advanced disease.

Early detection through regular screening (Pap smear, HPV testing) is essential, as cervical cancer may
remain asymptomatic in its early stages.

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 Clinical features cont'd:
Extension to the pelvic side walls may
cause sciatic pain or back pain associated
with hydronephrosis.

Metastatic involvement of the iliac and

para aortic lymph nodes can extend into
the lumbosacral nerve roots and also
present as lumbosacral pain.

Bladder or rectal invasion by advanced

stage disease may produce urinary or
rectal symptoms example haematuria.

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Additional Clinical Features of Cervical Cancer

As cervical cancer progresses, symptoms may arise due to local extension or metastatic spread.

Signs of Local Extension:

Pelvic Side Wall Involvement:

Sciatic pain or back pain, often due to hydronephrosis from ureteral obstruction.
Lymph Node Metastasis (Iliac & Para-aortic Nodes):
Involvement of lumbosacral nerve roots may cause lumbosacral pain.
Bladder or Rectal Invasion:
Urinary symptoms, such as haematuria (blood in urine).
Rectal symptoms, including pain or bleeding during defecation.

These symptoms indicate advanced disease, highlighting the importance of early screening and
diagnosis.

Clinical features..

Physical Findings:

Cervical cancer most commonly appear as

an exophytic cervical mass that bleeds on
contact.

With endophytic tumours, the endocervical

canal and the external cervix may appear
normal, but on bimanual examination feels
like a firm, indurated mass, often called a
barrel-shaped cervix.

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Physical Findings in Cervical Cancer

During a physical examination, cervical cancer may present in different forms depending on its growth
pattern.

Common Findings:

Exophytic Tumors:
Appear as a visible cervical mass.
Bleeds easily on contact during examination.
Endophytic Tumors:
The cervix may appear normal, but the tumor grows within the endocervical canal.
On bimanual examination, the cervix feels firm, indurated, and may take on a barrel-
shaped appearance.

A thorough pelvic exam, along with Pap smear, HPV testing, and biopsy, is essential for early
detection and diagnosis.

Mode of spread
1.Direct invasion to the upper vagina,
bladder, endometrium and rectum.
2. Lymphatic spread to the sacral,
paraortic, obturator, internal iliac and
external iliac nodes.
3. Haematogenous spread to the lungs,
liver and bones
4. Transcoelomic to the pouch of douglas

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Modes of Spread of Cervical Cancer

Cervical cancer can spread through multiple pathways as the disease progresses.

1. Direct Invasion:

Spreads locally to nearby structures, including:

Upper vagina
Bladder
Endometrium
Rectum

2. Lymphatic Spread:

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 Cancer cells travel through lymphatic channels to regional lymph nodes, such as:
Sacral nodes
Para-aortic nodes
Obturator nodes
Internal iliac nodes
External iliac nodes

3. Hematogenous Spread:

Cancer cells enter the bloodstream and metastasize to distant organs, including:
Lungs
Liver
Bones

4. Transcoelomic Spread:

Rarely, cancer spreads through the peritoneal cavity to the Pouch of Douglas.

Understanding these pathways helps guide staging, treatment planning, and prognosis assessment.

Investigations

FBCand differentials

SE/U/Cr

LFT

Urinalysis

CXR

Skeletal survey x-ray

IVU

CT-Abdomen and pelvic

MRI

Cystoscopy

Proctoscopy

Cervical biopsy

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Investigations for Cervical Cancer

A range of tests is conducted to confirm the diagnosis, assess disease extent, and plan treatment.

1. Laboratory Tests:

Full Blood Count (FBC) and Differentials – To check for anemia, infection, or other abnormalities.
Serum Electrolytes, Urea, and Creatinine (SE/U/Cr) – Evaluates kidney function, especially in
cases of ureteric obstruction.
Liver Function Tests (LFTs) – Assesses liver involvement or metastasis.
Urinalysis – Detects hematuria or urinary tract infections.

2. Imaging Studies:

Chest X-ray (CXR) – Screens for lung metastases.

Skeletal Survey X-ray – Identifies bone metastases.
Intravenous Urography (IVU) – Assesses urinary tract involvement and hydronephrosis.
CT Abdomen and Pelvis – Evaluates tumor spread to lymph nodes and distant organs.
MRI Pelvis – Provides detailed soft tissue imaging for local staging.

3. Endoscopic Examinations:

Cystoscopy – Examines bladder invasion.

Proctoscopy – Assesses rectal involvement.

4. Confirmatory Test:

Cervical Biopsy – Gold standard for diagnosis, confirming malignancy and histological type.

These investigations help determine tumor stage, metastasis, and treatment strategy.

Treatment…

Treatment depends on the stage of the

disease and the age and fitness of the patient.

The management of cervical cancer generally

involves a multidisciplinary approach involving
the gynaecologists, surgeons, radiologists,
radiotherapist, pathologist and nurses.

Treatment options for invasive cervical cancer

are as follows:
1. Surgery
2. Radiotherapy
3. Chemotherapy
4. Combination therapy

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Treatment of Cervical Cancer

Management depends on the stage of the disease, as well as the age and overall health of the
patient. A multidisciplinary team involving gynecologists, surgeons, radiologists, radiotherapists,
pathologists, and nurses is essential for optimal care.

Treatment Options:

1. Surgery – Preferred for early-stage disease (Stage I and some Stage II cases).
Conization – For very early-stage cancer (Stage IA1).
Simple or Radical Hysterectomy – Removes the cervix and uterus, with or without lymph
node dissection.
2. Radiotherapy – Used alone or in combination with chemotherapy for locally advanced disease.
External Beam Radiotherapy (EBRT) – Targets the tumor and surrounding areas.
Brachytherapy – Internal radiation directly to the cervix.
3. Chemotherapy – Often used with radiation (chemoradiation) or for advanced/metastatic disease.
Drugs like Cisplatin and Paclitaxel are commonly used.
4. Combination Therapy – A mix of surgery, radiotherapy, and chemotherapy, depending on the
cancer stage and patient’s condition.

Early detection through screening and HPV vaccination remains the most effective strategy for
preventing cervical cancer.

Treatment…

Stage 1A1: surgery is preferred

 Total abdominal hysterectomy
 Radical hysterectomy and
 Conization
• Stages 1A2; 1B or 11A
 Surgery (Radical vaginal trachelectomy with pelvic lymph node
dissection is appropriate for fertility preservation in women with
stage 1A2 disease and those with stage 1B1 disease whose lesions
are less than or equal to 2cm; Weitheims hysterectomy or Schautas
operation is done in stage 1B)
 Radiotherapy (Combined external beam radiation with
brachytherapy and radical hysterectomy and bilateral pelvic
lymphadenectomy for patients with stage 1B or 11A disease).
 Chemotherapy and radiotherapy (Chemoradiation) [cisplatin-based
chemotherapy with radiation for stage 1a to 11A patients who have
specific high-risk features such as positive lymph nodes and
parametrial involvement].

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Treatment of Cervical Cancer by Stage

Management is based on the stage of the disease, with options including surgery, radiotherapy,
chemotherapy, or a combination of these.

Stage IA1: Surgery is Preferred

Total Abdominal Hysterectomy (TAH) – Removal of the uterus and cervix.

Radical Hysterectomy – Removal of the uterus, cervix, and part of the surrounding tissues.
Conization – An option for women who wish to preserve fertility.

Stage IA2, IB, and IIA:

1. Surgery:
Radical Vaginal Trachelectomy with Pelvic Lymph Node Dissection – For fertility
preservation in Stage IA2 and small (≤2 cm) Stage IB1 tumors.
Wertheim’s Hysterectomy or Schauta’s Operation – Used in Stage IB cases.
2. Radiotherapy:
External Beam Radiation Therapy (EBRT) + Brachytherapy – Used alone or after surgery.
Radical Hysterectomy + Bilateral Pelvic Lymphadenectomy – Can be combined with
radiation for Stage IB and IIA.
3. Chemoradiation (Cisplatin-Based Therapy + Radiation):
Recommended for patients with high-risk features (e.g., positive lymph nodes,
parametrial involvement).

Key Considerations:

Fertility Preservation is possible in selected early-stage cases.

Multimodal Therapy is used in advanced or high-risk cases to improve outcomes.
Regular Follow-ups are essential after treatment to monitor for recurrence.

Early detection through HPV screening and vaccination remains the best preventive strategy.

Treatment..

Stage 11B; 111 or 1VA: Chemotherapy and

radiotherapy – cisplatin-based chemoradiation

Stage 1VB
 Palliative management/ terminal care –
supportive care and symptom management
 Radiotherapy for control of bleeding and pain
 System Chemotherapy for disseminated
disease (cisplatin, paclitaxel, carboplatin,

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 docetaxel, bevacizumab).

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Treatment of Cervical Cancer by Stage (Continued)

Stage IIB, III, and IVA:

Chemoradiation (Cisplatin-Based Therapy + Radiotherapy):

Standard treatment for locally advanced disease.
Combines external beam radiotherapy (EBRT) with brachytherapy to improve survival.

Stage IVB (Distant Metastatic Disease):

Palliative Management:
Focuses on symptom relief and quality of life.
Radiotherapy:
Used for bleeding control and pain relief in advanced cases.
Systemic Chemotherapy:
Drugs such as Cisplatin, Paclitaxel, Carboplatin, Docetaxel, and Bevacizumab are used for
widespread disease to slow progression and relieve symptoms.

In advanced cases, palliative care is crucial for pain management, psychological support, and
improving the patient’s comfort.

Prognosis

1.
2.
3.
4.
5.
6.
The prognosis depends on the following
Stage of the lesion at initial therapy
Histological subtype – endocervical tumour is
diagnosed late and grows faster
Depth of tumour invasion – when <1cm, less lymph
nodes are involved and improved survival is observed
Lymph node involvement – pelvic and paraaortic
lymph node involvement are associated with reduced
survival
Tumour size – more than 4cm is associated with more
lymph node metastasis and poor survival
Histological grade – well differentiated squamous cell
carcinoma grows slowly and metastases occur late,
than the poorly differentiated type.

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Prognosis of Cervical Cancer

The prognosis of cervical cancer depends on several factors, including:

1. Stage at Diagnosis:
Early-stage disease (Stage I) has a better prognosis with high survival rates.
Advanced-stage disease (Stage III–IV) has a poorer prognosis due to higher chances of
metastasis.
2. Histological Subtype:
Endocervical adenocarcinomas tend to be diagnosed late and grow more aggressively.
Squamous cell carcinoma is the most common type and generally has a better prognosis if
detected early.
3. Depth of Tumor Invasion:
Tumors with <1 cm invasion have a lower risk of lymph node involvement and better
survival outcomes.
4. Lymph Node Involvement:
Pelvic and para-aortic lymph node metastasis is associated with lower survival rates and
increased disease spread.
5. Tumor Size:
Tumors >4 cm are more likely to have lymph node metastasis and worse survival
outcomes.
6. Histological Grade:
Well-differentiated squamous cell carcinoma grows slowly and metastasizes late, leading
to better survival.
Poorly differentiated tumors are more aggressive with a higher risk of early metastasis.

Key Takeaway:

Early detection and treatment significantly improve survival rates. Regular screening (Pap smears,
HPV testing) and HPV vaccination are crucial for prevention and early diagnosis.

Prevention

1. Primary prevention: HPV vaccination of

girls between the ages of 9-14 years.
Measures to promote healthy lifestyles
and reduce risky sexual behaviour:
Health information and warnings about
tobacco use
Sex education tailored to age and culture
Male circumcision

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 Interventions to reduce infection with
HPV (VACCINATION)

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Prevention of Cervical Cancer

Cervical cancer is largely preventable through vaccination, lifestyle modifications, and regular
screening.

1. Primary Prevention (Preventing HPV Infection)

HPV Vaccination:
Recommended for girls aged 9–14 years before sexual debut.
Protects against high-risk HPV types that cause cervical cancer.
Lifestyle Modifications:
Avoid tobacco use – smoking increases the risk of persistent HPV infection.
Safe sexual practices – limiting multiple partners and using protection can reduce HPV
transmission.
Sex education – age-appropriate and culturally sensitive education about sexual health.
Male circumcision – has been shown to lower HPV transmission rates.

2. Secondary Prevention (Early Detection and Treatment of Precancerous Lesions)

Regular Screening:
Pap smear (cytology test) – detects precancerous changes.
HPV DNA testing – identifies high-risk HPV strains before cancer develops.
Early Treatment of Precancerous Lesions:
Methods include cryotherapy, loop electrosurgical excision procedure (LEEP), and
conization.

Key Message:

HPV vaccination, routine screening, and lifestyle modifications are the most effective ways to
prevent cervical cancer and reduce mortality rates.

Primary prevention
Vacccines currently available are
cervarix and gardasil. Cervarix is only
girls between the ages of 9-26years.
but gardasil is for boys and girls.
All are given in 3doses

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Primary Prevention of Cervical Cancer

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HPV Vaccines Available:

1. Cervarix – Protects against HPV types 16 and 18 (high-risk strains).

Recommended for girls aged 9–26 years.
2. Gardasil – Protects against HPV types 6, 11, 16, and 18.
Approved for both boys and girls.

Vaccination Schedule:

Administered in 3 doses over a period of 6 months:

First dose – At the chosen date.
Second dose – 1–2 months after the first dose.
Third dose – 6 months after the first dose.

Key Takeaway:

HPV vaccination is most effective when given before sexual activity begins. It plays a crucial role in
preventing cervical cancer and other HPV-related diseases.

Secondary prevention

The principal goal of secondary prevention is

to reduce cervical cancer incidence and
mortality by identifying and treating women
with precancerous lesions.
• There are 4 different types of screening tests
HPV DNA testing for high-risk HPV types
Visual inspection with Acetic Acid (VIA)
Visual inspection with Lugol’
s iodine (VILI)
Conventional (Pap) test and Liquid-based
cytology (LBC)

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Secondary Prevention of Cervical Cancer

The main goal of secondary prevention is to detect and treat precancerous lesions early to reduce
cervical cancer incidence and mortality.

Screening Methods:

1. HPV DNA Testing

Detects high-risk HPV types before cellular changes occur.
More sensitive than other screening methods.
2. Visual Inspection with Acetic Acid (VIA)
A simple, cost-effective method where acetic acid (vinegar) is applied to the cervix.

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 Precancerous lesions turn white when exposed to acetic acid.
3. Visual Inspection with Lugol’s Iodine (VILI)
Uses iodine solution to stain normal cervical tissue.
Abnormal areas appear unstained or yellow, indicating potential precancerous changes.
4. Pap Smear and Liquid-Based Cytology (LBC)
Pap Smear: Examines cervical cells for abnormalities.
Liquid-Based Cytology (LBC): A modern version of the Pap test with improved accuracy.

Key Takeaway:

Regular screening and early treatment of precancerous lesions significantly reduce the risk of
developing cervical cancer.

Secondary Prevention

The traditional Pap technique involves direct

transfer of the cervical cells to a microscope
slide for evaluation.

In liquid-based cytology, the collected cells are

released into a vial of liquid preservative that is
then used in the cytology lab to produce a slide
for microscopic evaluation of the cells.

The sensitivity in detecting abnormality is about

60% while the specificity is above 90%

When abnormal cells are detected on the smears,

further confirmatory diagnostic testing in the
form of colposcopy is performed

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Secondary Prevention of Cervical Cancer

Pap Smear vs. Liquid-Based Cytology (LBC):

1. Traditional Pap Smear:

Cervical cells are directly transferred onto a microscope slide for evaluation.
2. Liquid-Based Cytology (LBC):
Collected cells are placed in a liquid preservative before processing.
Provides a cleaner, more accurate sample for microscopic examination.

Sensitivity and Specificity:

Sensitivity: ~60% (ability to detect abnormalities).

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 Specificity: >90% (ability to correctly identify normal cases).

Follow-Up for Abnormal Results:

Colposcopy is performed for a closer examination if abnormal cells are detected.

Key Takeaway:

Regular screening with Pap smears or LBC, followed by colposcopy if needed, helps in the early
detection and treatment of precancerous changes, reducing cervical cancer risk.

Secondary prevention

1.
2.
3.
4.
Screening alone does not lead to decrease
in incidence and mortality from cervical
cancer but adequate treatment and follow
up of detected cases through the following
Ablative (1 and 2) and Excisional (3 and 4)
methods:
Cryotherapy
Thermal Ablation
LEEP/LLETZ
Cold knife cone biopsy

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Secondary Prevention of Cervical Cancer

Screening alone is not enough to reduce cervical cancer incidence and mortality. Proper treatment and
follow-up of detected cases are essential.

Treatment Methods for Precancerous Lesions:

These are categorized into Ablative and Excisional techniques:

Ablative Methods (Destroy Abnormal Tissue):

1. Cryotherapy – Uses extreme cold (liquid nitrogen) to freeze and destroy abnormal cervical cells.
2. Thermal Ablation – Uses heat to destroy precancerous tissue.

Excisional Methods (Remove Abnormal Tissue):

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 3. LEEP/LLETZ (Loop Electrosurgical Excision Procedure/Large Loop Excision of the
Transformation Zone) – Uses a wire loop heated with electrical current to remove affected tissue.
4. Cold Knife Cone Biopsy – A surgical procedure where a cone-shaped piece of the cervix is
removed for further examination.

Key Takeaway:

Early detection, appropriate treatment, and regular follow-up of precancerous lesions are crucial in
preventing cervical cancer progression.

Tertiary prevention

Timely assessment and referral of women with

suspected or confirmed cervical cancer are
crucial to save lives and preventing disability.

Comprehensive management of invasive

cervical cancer requires well-equipped health
facility with appropriately qualified health
providers and access to pathology, medical
imaging, surgical, radiotherapy and
chemotherapy services.

Palliative care should be integrated into the

treatment plan and provided throughout the
course of the disease

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Tertiary Prevention of Cervical Cancer

Timely assessment, referral, and comprehensive management are essential to improve survival and
quality of life in women with suspected or confirmed cervical cancer.

Key Components of Tertiary Prevention:

1. Early Referral and Diagnosis

Prompt evaluation and referral to specialized centers for staging and treatment.
2. Comprehensive Cancer Management
Requires well-equipped healthcare facilities with:
Pathology and medical imaging services.
Surgical expertise for tumor removal.
Radiotherapy and chemotherapy for advanced disease.
3. Palliative Care Integration
Pain relief and symptom management throughout the disease course.
Emotional and psychological support for patients and families.

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Key Takeaway:

A multidisciplinary approach with timely intervention, specialized treatment, and supportive care
improves outcomes and enhances the quality of life for women with invasive cervical cancer.

The global 90-70-90 strategy

The Global ‘90-70-90’

strategy towards eliminating
cervical cancer as a public health problem was adopted by
the World Health Assembly (WHA) in 2020. It plans to
achieve a threshold of 4 cases per 100 000 women-years
by 2120

By 2030, the following

‘90-70-90’ targets must be met for
countries to be on the path towards cervical cancer
elimination:
 90% of girls fully vaccinated with HPV vaccine by age 15
years.
 70% of women are screened with a high-performance test
by 35 years of age and again by 45 years of age
 90% of women identified with cervical disease receive
treatment (90% of women with precancer treated, and
90% of women with invasive cancer managed).

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The Global 90-70-90 Strategy for Cervical Cancer Elimination

Adopted by the World Health Assembly (WHA) in 2020, this strategy aims to eliminate cervical cancer
as a public health problem by reducing cases to fewer than 4 per 100,000 women-years by 2120.

Targets to Achieve by 2030:

To stay on track, countries must meet the following 90-70-90 goals:

1. 90% of girls fully vaccinated against HPV by age 15.

2. 70% of women screened with a high-performance test by age 35 and again at 45.
3. 90% of women with cervical disease receive treatment, including:
90% of women with precancerous lesions treated.
90% of women with invasive cancer properly managed.

Key Takeaway:

Achieving these targets will put the world on the path to eliminating cervical cancer, preventing
millions of deaths, and ensuring better health outcomes for women globally.

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 Conclusion

Cervical cancer is a global public health

problem but predominantly in LMICs

It arises as a complication of a sexually

transmitted infection that is almost 100%
vaccine preventable

The natural life cycle of HPV infection in the

epithelium of the cervix provides an
opportunity for detection of premalignant
disease that can be identified by screening
tests and treated before progression to
invasive cancer.

Together we can

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Conclusion

Cervical cancer remains a major global health challenge, particularly in low- and middle-income
countries (LMICs).

It develops as a complication of HPV infection, a sexually transmitted virus that is almost

entirely preventable through vaccination.
The natural course of HPV infection provides a unique opportunity for early detection through
screening programs.
Timely diagnosis and treatment of precancerous lesions can prevent progression to invasive
cancer.

By strengthening HPV vaccination, screening, and treatment programs, we can work together to
eliminate cervical cancer as a public health threat.

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