Management of cervical cancer
Scope of the guidance
This item is based on the SIGN guideline that covers the
presentation, referral, diagnosis, staging and treatment of
cervical cancer.
Source
Scottish Intercollegiate Guidelines Network. Management of
cervical cancer: a national clinical guideline 99.
Scotland: SIGN, 2007.
www.sign.ac.uk/pdf/sign99.pdf
Key Points
1. Background
- Despite an established cervical cancer screening programme
there are around 2,800 cases of cervical cancer each year in the UK
and approximately 1,000 women die from the disease. It is the
second most common female cancer worldwide and is now ranked
11th most frequent type of female cancer in the UK.
- Only one-third of cervical cancers are
detected by screening – the majority are in women who have never
had a smear test or have not been regularly screened.
- Cervical cancer commonly occurs in women aged
30-45 years old. So surgical treatment may need to be managed to
conserve fertility.
- Risk factors for cervical cancer include:
human papillomavirus (HPV) infection, early onset of sexual
activity, multiple sexual partners, smoking, low socio-economic
status and immunosuppressive therapy. It is still not known
whether long-term use of the oral contraceptive pill (OCP) is a
risk factor for developing cervical cancer, as it is difficult to
separate OCP use and HPV infection status in research studies (see
Smith et al. in Further
Reading).
- HPV subtypes 16 and 18 are the cause of
approximately 70% of cervical cancer.
2. Cervical screening
- reduces not only the incidence of cervical
cancer (by detecting pre-cancerous changes known as cervical
intraepithelial neoplasia (CIN) but also the number of women
presenting in advanced stages of the disease.
- is estimated to save approximately 5,000
lives per year in the UK.
- is taken up by around 80% of eligible
women.
- is currently offered to women at three-yearly
intervals between the ages of 25 and 49 years, and at five-yearly
intervals between the ages of 50 and 64 years in England. Different
age ranges and frequencies are advised in the devolved nations as
Table 1 shows.
Table 1 Age range and frequency of recommended
screening intevals across UK
| Country |
Age Range (years) |
Recommended
screening intervals
|
| England |
25-64 |
3 yearly age 25-49
5 yearly age 50-64
screen >65 years if
abnormal tests recently
or have not been screened
since age 50 years old
|
| Northern Ireland |
25-65 |
5 yearly |
| Scotland |
20-60 |
3 yearly |
| Wales |
20-64 |
3 yearly |
3. Vaccination
- Two vaccines (cervarix and gardasil) have
been shown to be effective in young women prior to HPV exposure for
prophylaxis.
- HPV vaccines will be introduced for girls
aged around 12-13 years old, starting in September 2008. This will
be a course of three vaccinations over six months.
4. Symptoms and Signs
- Symptoms / signs of cervical cancer are
common and non-specific:
o inter-menstrual bleeding
o post-coital bleeding
o post-menopausal bleeding
o abnormal appearance of the
cervix or suspicion of malignancy
o blood stained vaginal
discharge
o pelvic pain
5. Differential diagnosis
- Many of the symptoms / signs listed above are
found in chlamydia trachomatis infection, which is much commoner
than cervical cancer. So, testing for chlamydia infection is
key in any diagnostic work-up, especially in pre-menopausal
women.
- Post-menopausal bleeding may be the
presenting symptom of endometrial cancer, but could also indicate
cervical cancer.
6. Diagnosis
- Diagnosis of cervical cancer is made by
analysis of biopsy samples. The suspected tumour is usually
first surgically excised; then analysed by a histopathologist. The
pathology report should include:
o Tumour and size
o Extent of tumour
o Depth and pattern of
invasion
o Lymphovascular space
invasion
o Status of resection margins
and lymph nodes
o Presence of pre-invasive
disease
- The pathology report should indicate the
degree of risk of the woman developing metastatic disease.
7. Staging - looking for cancer spread
- Staging is described using an international
staging score known as the FIGO stage (International Federation of
Gynaecology and Obstetrics).
- A magnesium resonance imaging (MRI) scan is
best for staging patients with confirmed cervical cancer from their
biopsy.
- A computerised tomography (CT) scan is used
as an alternative for patients who cannot have an MRI scan.
- A positron emission tomography (PET) scan is
usually used for patients who are not suitable for surgery, to look
for metastatic spread.
- Routine cystoscopy and sigmoidoscopy is not
needed, unless other imaging cannot rule out bladder or bowel
involvement.
8. Treatment
o Radical hysterectomy (removal
of uterus, cervix, parametrial tissues and upper vagina) is the
surgery of choice for early stage disease.
o Surgery for early stage
disease aims to conserve the ovaries and thus avoid the effects of
an early menopause; though if conserving fertility is an issue,
then alternative operations can be considered.
-
Treatment during pregnancy:
o Pregnant women with any stage
of cervical cancer earlier than 16 weeks gestation should be
treated immediately.
o Pregnant women beyond 16
weeks gestation could have their treatment delayed until the baby
can be delivered safely.
-
Chemoradiotherapy / radiotherapy:
o Radiotherapy may be as
effective as radical surgery in early stage disease, and is less
likely to cause complications.
o Chemoradiotherapy is normally
offered instead of surgery for women with later stage disease,
because of the high risk that some of the cancer would be left
behind with surgery.
o Any patient who has radical
radiotherapy should also have chemotherapy if they are fit
enough.
o Anyone who has had surgery
where positive lymph nodes have been found should have
chemoradiotherapy.
o During radiotherapy or
chemoradiotherapy, monitor haemoglobin levels as anaemia can
occur.
-
Hormone replacement therapy:
o is recommended for women of
pre-menopausal age who have lost ovarian function due to treatment
for their cancer.
9. Complications of treatment
o loss of libido, vaginal
dryness, bleeding, stenosis, dyspareunia, atrophic vaginitis and
pain; you could offer patients support sessions: relaxation,
emotional support and care and personalised information about their
disease and treatment.
o swelling of one or both lower
limbs
o restricts activities and
affects quality of life
o if a patient has symptoms
suggestive of lymphoedema then referral to a specialist is
recommended.
10. Follow-up
- Patients should be followed up every four
months for at least two years to check for recurrence of the
disease.
- Follow-up should include history taking and
examination, but there is no need for repeat smears if the patient
is asymptomatic.
- If you suspect recurrent disease, an MRI or
CT scan should be done to look for evidence of recurrence.
- Patients should be offered psychological
support once the diagnosis is made, and throughout the treatment
and management of their disease.
- Give patients information about local support
services.
Practical tips for the busy GP >>
EGP 1. May 2008