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Cervical Screening and Cancer

The most common type of cervical cancer are squamous cell carcinomas (80%). Adenocarcinomas are 2nd. The pre-malignant condition of this is called Cervical Intraepithelial Neoplasia (CIN).


It's very strongly associated with HPV infection, particularly strain types 16 and 18.


Risk factors:

  • Increased risk of HPV – No vaccination, Multiple sexual partners, Lack of protection

  • Non-engagement with cervical screening - Late detection of any dysplastic changes

  • Smoking

  • Immunosuppression e.g. HIV

  • COCP use for 5+ years

  • Increased number of full-term pregnancies


Presentation

Most asymptomatic and picked up on screening. Can present with:

  • Abnormal uterine bleeding (Intermenstrual, Postcoital, Postmenopausal)

  • Vaginal discharge

  • Pelvic pain

  • Dyspareunia

  • O/E - Ulceration, Inflammation, Bleeding, Visible tumour


Cervical Screening

Cervical smear offered to women:

  • Every 3 years if 25-49 years

  • Every 5 years if 50-64 years

  • Every year if HIV +ve


Investigations

  • Colposcopy – Get biopsy (via LLETZ – excision of transition zone)

  • Staging CT CAP

  • FIGO Staging

    • Stage 1 – Confined to cervix – 5 year survival ~ 98%

    • Stage 2 – Invades uterus or upper 2/3 of vagina

    • Stage 3 – Invades pelvic wall or lower 1/3 of vagina

    • Stage 4 – Invades bladder, rectum or beyond pelvis – 5 year ~ 15%

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“Positive visual inspection with acetic acid of the cervix for CIN-1 (photo by cervicography)” © Haeok Lee1,2*, Mary Sue Makin3, Jasintha T Mtengezo4,5 and Address Malata6 CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/)

Management

  • CIN and Early Stage 1A – LLETZ or Cone biopsy

  • Stage 1B – 2A – Radical hysterectomy and removal of local lymph nodes with chemoradiotherapy

  • Stage 2B – 4A – Chemoradiotherapy

  • Stage 4B – Combination of everything, but leaning more towards Palliative



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