Cervical cancer and vaginal cancer

A lesson for the developing nations Posted by Ahmad Azizov on February 20, 2021

Cervical cancer

Worldwide there are about half a million new cases of cervical cancer and about half of these patients end up passing. Developing nations are especially vulnerable to this condition because of the lack of effective screening tools. The median age of a patient who gets cervical cancer is in the early 50s. Early signs of this disease are limited to postcoital bleeding with more advanced stages presenting with menorrhagia and irregular uterine bleeding. Some non-specific signs include pelvic and leg pain, deep vein thrombosis, weight loss, appetite loss, etc. 

Risk factors 

The most important risk factor for cervical cancer is HPV (types 16, 18, 31 and 45). Sexual intercourse is an independent risk factor as well as transmitting HPV. Additionally, these patients also tend to be from low socioeconomic backgrounds with early age of coitus and multiple sexual partners. 

Screening and prevention measures 

Pap smears are the most effective screening tool in the developed nations and can reduce the mortality from cervical cancer by 90%. HPV vaccines are a very preventative measure. On physical exam, some of these lesions can be seen as ulcerative and barred shaped lesions but if the lesion is beyond the cervix, spotting it on physical exam in the office becomes difficult. 

In Ontario, the screening guidelines are as the following. Read more here

A Pap test is recommended every three years for:

  • women 21 years old and older who are or have been sexually active
  • transgender men who have a cervix, who are 21 years old and older, and who are or have been sexually active

Women 70 years old and older can stop having Pap tests if they have had three or more normal Pap test results in the past 10 years.

Pathology

  • Squamous cell carcinoma 
    • Most common type of cervical cancer - 75-80%
    • Pap smear is excellent at picking these up 
  • Adenocarcinoma 
    • Increasing incidence in younger women 
    • More difficult to pick up 

Staging/Treatment 

Staging of cervical cancer is done clinically. Even though the primary mode of spread is direct extension, as the tumour size increases hematological and lymphatic spread becomes more likely. 

  • Stage 1a
    • Commonly diagnosed with cone biopsy 
    • Simple hysterectomy might be employed if there are no high-risk features 
  • Stage 1b-1
    • At this stage, lesions can be spotted on a physical exam 
    • Radical hysterectomy will be required 
    • Can be done open or laparoscopically 
  • Stage 1b-2 - to stage 4a
    • Will require staging under anesthesia 
    • Imaging, cystoscopy and proctoscopy might be required 
    • These stages will require chemoradiation as well as radical hysterectomy 
    • More advanced stages will only require chemoradiation because a safe operation is not possible
  • Stage 4b
    • Palliative stage and palliative treatment 

There are additional therapies that can be employed 

  • Adjuvant therapy
    • Postoperative chemoradiation for high-risk features (deep lesions or lymph node involvement) 
  • Recurrent disease
    • If recurrence is after surgery alone, radiation is recommended
    • If recurrence is after radiation, removal of the pelvic organs involved is the only curable option 
  • Palliation 
    • These patients are quite sick with distant metastasis 
    • Palliative chemotherapy can be employed as well as pain control (opiates) 
  • Symptom management 
    • Often bilateral kidney failure due to ureter obstruction 
    • Fistulas between vagina and bladder as well as between vagina and bowels 

Prognosis

Lymph node involvement is the most deterministic factor in the mortality of cervical cancer patients. Having said that the use of pap smear in early detection has resulted in many of the patients being diagnosed at stage 1, for which the 5 year mortality is 10-20% with treatment. 

Vaginal cancer

The incidence of vaginal cancer is much lower at around 2700 in the USA annually. Most of these are caused by the extensions of cervical cancer or are secondary metastasis from other gynecological cancers. The staging of vaginal cancers is similar to cervical cancer. 

Pathology 

  • Squamous cell carcinoma 
    • Most common type of vaginalcancer - 85-90%
    • Pap smear is excellent at picking these up 
  • Adenocarcinoma 
    • Makes up 5% of the vaginal cancers
  • Clear cell vaginal adenocarcinoma 
    • Largely limited to the historical use of diethylstilbestrol (DES) in 1960s

Treatment

treatment of vaginal cancers is down primarily via radiation because surgical management often causes too much anatomic distortion. 

All information provided on this website is for educational purposes and does not constitute any medical advice. Please speak to you doctor before changing your diet, activity or medications. 


Written by
Ahmad Azizov Member since April 2020
Interested in vascular surgery, surgery, endovascular procedure

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