Cervical Cancer

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Cervical cancer is a malignant tumour that arises from the cells of the cervix, which is the lower part of the uterus that connects to the vagina. It is primarily caused by persistent infection with high-risk types of human papillomavirus (HPV).

Aetiology

Cervical cancer develops when the normal cells in the cervix become abnormal and grow uncontrollably. The primary cause is infection with high-risk HPV, particularly types 16 and 18, which are responsible for the majority of cases. Other contributing factors include:

• HPV Infection: The most significant risk factor, particularly with persistent high-risk HPV types.
• Smoking: Increases the risk by damaging the DNA of cervix cells and affecting the immune system’s ability to clear HPV infections.
• Immunosuppression: Conditions that weaken the immune system, such as HIV, increase susceptibility to HPV infections and cervical cancer.
• Long-term Use of Oral Contraceptives: Prolonged use (more than five years) may slightly increase the risk.
• Multiple Full-term Pregnancies: Having many children has been linked to an increased risk of cervical cancer, potentially due to hormonal changes and increased exposure to HPV during sexual activity.
• Early Sexual Activity: Starting sexual activity at a young age increases the risk of HPV infection.

Risk Factors

Several factors increase the risk of developing cervical cancer:

• Persistent HPV Infection: The most significant risk factor for cervical cancer.
• Smoking: Doubles the risk of cervical cancer compared to non-smokers.
• Immunosuppression: Weakened immune systems are less able to fight off HPV infections.
• Family History: A history of cervical cancer in close relatives may slightly increase risk.
• Long-term Oral Contraceptive Use: Usage over five years is associated with a slightly increased risk.
• Multiple Sexual Partners: Increases the likelihood of HPV infection.
• Early Sexual Activity: Increases exposure to HPV.

Clinical Presentation

Cervical cancer may be asymptomatic in the early stages, which is why regular screening is crucial. When symptoms do occur, they may include:

• Abnormal Vaginal Bleeding: This could include bleeding between periods, after sexual intercourse, or postmenopausal bleeding.
• Unusual Vaginal Discharge: May be watery, bloody, or have a foul odour.
• Pelvic Pain: Especially during intercourse.
• Advanced Disease Symptoms: These can include difficulty urinating or defecating, leg swelling, or kidney failure due to ureteric obstruction.

Investigations

The following investigations are crucial for diagnosing cervical cancer:

• Cervical Screening (Smear Test): Detects precancerous changes in cervical cells. It is offered to women aged 25 to 64 in the UK.
• HPV Testing: Conducted alongside the smear test to check for the presence of high-risk HPV types.
• Colposcopy: A detailed examination of the cervix using a colposcope if abnormal cells are detected during screening.
• Biopsy: During a colposcopy, a small tissue sample may be taken from the cervix to check for cancerous cells.
• Imaging: MRI, CT, or PET scans may be used to determine the extent of cancer spread if a diagnosis is confirmed.
• Cystoscopy or Proctoscopy: May be performed to check if the cancer has spread to the bladder or rectum in advanced cases.

Management

The treatment of cervical cancer depends on the stage of the disease, the patient’s overall health, and preferences:

Primary Care Management

As a Physician Associate, your role is vital in the early detection of cervical abnormalities through routine screening and timely referral to secondary care if cancer is suspected. Patient education about the importance of regular cervical screening is also crucial.

Secondary Care Management

Treatment in secondary care may involve:

• Surgery:
  • Conization: Removal of a cone-shaped section of abnormal tissue from the cervix.
  • Hysterectomy: Removal of the uterus and cervix, often performed in early-stage cervical cancer.
  • Radical Hysterectomy: Removal of the uterus, cervix, part of the vagina, and surrounding tissues, including pelvic lymph nodes, in more advanced cases.
• Radiotherapy: Often used in combination with surgery or as the primary treatment in more advanced stages.
• Chemotherapy: May be combined with radiotherapy (chemoradiation) or used to treat advanced cervical cancer.
• Targeted Therapy: For some patients, drugs that target specific cancer cell mechanisms may be used alongside other treatments.

When to Refer

Immediate referral to a gynaecologist or oncology specialist is needed in the following situations:

• Abnormal findings on cervical screening tests, particularly high-grade changes or positive high-risk HPV tests.
• Suspicious symptoms such as unexplained vaginal bleeding, especially in postmenopausal women, or abnormal vaginal discharge.
• Persistent symptoms that do not resolve with standard treatment.

References

1. NHS (2024) Cervical Cancer. Available at: https://www.nhs.uk/conditions/cervical-cancer/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Cervical Cancer: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng12 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Prevention and Early Detection of Cervical Cancer. Available at: https://www.bmj.com/content/345/bmj.e5359 (Accessed: 26 August 2024).
4. Jo’s Cervical Cancer Trust (2024) Cervical Cancer: Information and Support. Available at: https://www.jostrust.org.uk/ (Accessed: 26 August 2024).

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