Cervical cancer is the 3rd most prevalent gynecologic cancer in the United States and the 4th most common cancer in women overall (Beckman’s ch 47). Cervical cancer has decreased more than 50% in the past three decades in the United States due to screening evaluations (Practice Bulletin 168). This cancer is caused by human papillomavirus infection. Infection with this virus can be transient or persistent (Practice Bulletin 140, 168). Persistent infection for more than 1 year leads to a higher risk of high-grade cervical cancer (Practice Bulletin 140). In addition, if HPV infection is identified in women older than 30 years, it is more likely to be a persistent infection rather than an initial infection which leads to a higher probability of cervical cancer (Practice Bulletin 168).
There are many different subtypes of HPV with types 16 and 18, known as the high risk subtypes, leading to the majority of cervical cancers. Many HPV infections are cleared by the host’s immune cells and do not cause transition to neoplastic cells (Beckman’s ch 47). Therefore, only a small percentage of infections transition into cancer (Practice Bulletin 168). However, there are some risk factors the increase the risk of neoplasia including immunosuppression, smoking, a young age of first intercourse, and having more than one sexual partner (Beckman’s ch 47, Practice Bulletin 140).
Cervical cancer is classified based on the Bethesda system which organizes neoplasia into squamous and glandular types. The squamous cell type is further divided into cervical intraepithelial neoplasia (CIN 1, 2, and 3) subtypes (Beckman’s ch 47, Practice Bulletin 168). Precursors of cancer are adenocarcinoma in situ and CIN 3 (Practice Bulletin 140). Squamous cell carcinomas make up about 80% of cervical cancers and adenocarcinomas are far less common making up only 15% of cervical carcinomas (Beckman’s ch 47).
Patients may have a variety of symptoms leading to evaluation of cervical cancer, or they may have no symptoms or not recognize the symptoms they are experiencing. For our patient, her only symptom was a couple of episodes of post-menopausal bleeding. Other symptoms a patient may experience include watery discharge, spotting, and postcoital bleeding (Beckman’s ch 47). Most times patients are asymptomatic and cervical cancer is identified from abnormal pap smears. Therefore, patients should be screened for cervical cancer regularly. The goal is to evaluate between true cancer precursor and benign lesions (Practice Bulletin 140). There are specific screening recommendations supported by various societies. For our patient, who is 64 years old, the recommendation is to have both cytology and HPV testing every 5 years or screening with cytology every 3 years. Screening is no longer performed after the age of 65 if the patient has had 3 negative cytology reports in a row, or 2 negative cotest results in a row in the last 10 years (Beckman’s ch 2, Practice Bulletin 168). However, if a woman, like our patient, has a finding of adenocarcinoma in situ, they should continue with screening for a total of 20 years after the adenocarcinoma regresses or is treated (Beckman’s ch 2, Practice Bulletin 168). In order to identify adenocarcinoma, the best testing is cotesting because cytology alone has not been found to be as effective (Practice Bulletin 168).
When a patient has abnormal findings from a cervical cytology test, they should be further evaluated to rule out invasive cancers. Next, there should be an evaluation for the grade and spread of the lesion. This can first be done with colposcopy and biopsy. Acetic acid can be used to assist in visualizing abnormal lesions. The neoplastic cells will take up more acetic acid and appear white, indicating the areas to be biopsied (Beckman’s ch 47). The physician could also do colposcopy and endocervical curettage and take four random cervical biopsies if acetic acid does not show obvious lesions to biopsy (Practice Bulletin 140). In addition to colposcopy, HPV DNA testing can also be done, especially in women with atypical glandular cells (Beckman’s ch 47).
Abnormalities of glandular cells, such as adenocarcinoma in situ, are rare when compared to squamous cell abnormalities. If a woman has any abnormalities, they should be evaluated with colposcopy, HPV DNA testing, and endocervical curettage (Practice Bulletin 140). If the woman, like our patient, is over 35 years old, they should also have the endometrial lining biopsied (Beckman’s ch 47). Because adenocarcinoma in situ is difficult to visualize on colposcopy, it is recommended to do a procedure, such as cone knife conization, to diagnose invasive disease (Practice Bulletin 140).
There are several methods to remove the abnormal cervical tissue. These include cold knife conization, as performed in our patient, LEEP (large loop excision of the transformation zone), laser conization, and electrosurgical needle conization. For glandular cell abnormalities, a cold knife conization should be done as damage may occur in the techniques using cautery leading to difficulties in assessing the margins of the specimen (Beckman’s ch 47, Practice Bulletin 140). Cold knife conization is the technique that provides the best and most accurate view of the margins. If the pathology after the procedure does not have negative margins, it may be necessary to proceed with a hysterectomy.
Management and treatment of patients with cervical cancer is similar whether they have squamous cell or adenocarcinoma. It is based on staging of the disease and whether or not it is invasive. If it is invasive, the patient should have a hysterectomy with lymph node dissection or radiation (Beckman’s ch 47). This is particularly recommended for adenocarcinoma, especially if the patient is done with childbearing (Practice Bulletin 140). If the cancer is invasive, but is identified early, surgery alone is recommended, however, if it is more advanced then the patient could have chemotherapy and radiation.
HPV can be prevented through various methods including sexual abstinence, vaccination with the HPV vaccine, barrier protection, regular exams and screening, and limiting the number of sexual partners. The HPV vaccine is very effective with the quadrivalent type preventing 91% of new HPV cases and 100% of persistent infection (Beckman’s ch 47). The vaccine can be administered to boys and girls regardless of previous HPV exposure. The recommended age of vaccination in females is 9-26 years (Practice Bulletin 168). Even patients who have received the vaccination should still undergo screening recommendations (Practice Bulletin 168).
There are many benefits and risks of widespread screening of cervical cancer in females. Benefits include a decrease of disease prevalence and cancer prevention. However, more screening may identify more abnormal lesions and lead to invasive and expensive workups. Additionally, it positive screening results can cause anxiety for women (Practice Bulletin 168). In women who have undergone menopause, there are more false positive cytology screenings which may be due to vaginal atrophy (Practice Bulletin 168). Having a false positive result leads to unnecessary anxiety in women and again, more procedures and expenses. In our patient, it caused her to have a second procedure under anesthesia and many questions and anxiety about how she contracted HPV and what will happen if the conization does not have negative margins. On a positive note, our patient also started advocating to her family and encouraging her grandkids to receive the HPV vaccine.