Cervical Cancer

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Clinical Description

  • Cervical cancer is the third most common malignancy in women worldwide, and it remains a leading cause of cancer-related death for women in developing countries including Malawi. Human papillomavirus (HPV) infection must be present for cervical cancer to occur.

 

Clinical Features 

SIGNS AND SYMPTOMS

  • Physical symptoms of cervical cancer may include the following:
    • Asymptomatic (diagnosed during routine screening)
    • Symptomatic (advanced disease)
    • Abnormal vaginal bleeding (In between menstrual cycle, postmenopausal)
    • Vaginal discomfort
    • Malodorous discharge
    • Dysuria
    • Early Disease: erosion of cervix or changes of chronic cervicitis
    • Late/advanced disease: Ulcerative or fungating cervical lesion on speculum examination

INVESTIGATIONS

  • Punch biopsy for histology
  • Screening for any woman of reproductive age group above 25 years using VIA, Pap smear or HPV DNA (in research setting for now).
  • HIV positive patients are advised to be screened once they reach reproductive age.
  • Speculum and cervical punch biopsy for histological analysis.
  • Speculum examination before any antibiotic course for women presenting with abnormal vaginal bleeding or foul-smelling discharge.

Treatment 

Immunization

  • Vaccination with HPV vaccine is recommended in girls between 9 to 14 years.

Surgery

  • Fertility sparing (Trachelectomy in stage I cancer).
  • Forms of radical hysterectomy with lymph node dissection:
    • Wertheim-Meigs
    • Wertheim-modification
    • Total mesometrial resection
    • Exenteration (for locally advanced disease or pelvic recurrences)

Radiotherapy

  • If no LND was done, to be considered for Radiotherapy.
  • Radio-chemotherapy plus brachytherapy.
  • Palliative radiotherapy if advanced disease.

PHARMACOLOGICAL TREATMENT 

  • Chemotherapy regimens to be given at TERTIARY hospitals. Neoadjuvant chemotherapy where access to radiotherapy is limited.
  • Combination is better than monotherapy
    • Paclitaxel, Cisplatin, Fluorouracil, Carboplatin, Bevacizumab are drugs of choice
  • Palliative care is critical in providing pain control with morphine (see section on pain control), controlling bleeding, and providing end of life care.
  • Consider discussing with Oncology team for palliative chemotherapy in the following patients:
    • PV bleeding
    • Intractable pain on optimal analgesia
    • Symptomatic metastatic disease

Note: Assessment needs to be done at a tertiary institution with close discussions between Gynae-oncologists, Urologists, Pathologists, Radiologists, Oncologists and Palliative care team to jointly stage and decide on treatment.