In 2018, there will be an estimated 13,240 new patients diagnosed with invasive cervical cancer and 4170 deaths from cervical cancer in the United States. The mean age of diagnosis in the United States is 48 years. During the last 30 years, cervical cancer incidence and deaths in developed countries have decreased by more than 50%, primarily because of screening and preventive treatment. It remains the second most common cause of mortality from cancer in women worldwide, with more than 260,000 women dying each year of cervical cancer. More than 85% of deaths are in less developed countries.
Human papillomavirus (HPV) is the causative agent in most patients and can be detected in 99.7% of cervical cancers. Risk factors include sexual habits associated with a higher risk of acquiring HPV, such as earlier onset of sexual activity and several partners. Immunosuppression, including HIV infection, low socioeconomic status, and oral contraceptive use are additional risk factors. Cigarette smoking increases the risk of squamous cell carcinoma of the cervix. Squamous cell carcinoma is the histologic type in 69% of cervical cancers, with adenocarcinoma accounting for 25%. HPV vaccination decreases the incidence of cervical dysplasia and cervical cancer. Cervical cancer screening and HPV vaccination are covered in MKSAP 18 General Internal Medicine.
Early cervical cancer is frequently asymptomatic. The most common symptoms are abnormal or heavy vaginal bleeding or vaginal discharge. Pelvic or back pain and bowel or bladder symptoms are presentations of advanced disease. Diagnosis is made by direct biopsy of a visible lesion, colposcopy, or cone biopsy (conization). Current guidelines for staging studies recommend a complete blood count, liver chemistry tests, kidney function studies, and imaging studies for moderate-risk and high-risk stage cancers. Chest radiography, CT or PET-CT scan, and MRI can be added as indicated. Cystoscopy and proctoscopy are optional. HIV testing should be considered. Cervical cancer staging and treatment are described in Table 44. For patients with tumors 2 cm in size or smaller that are confined to the cervix and with no lymph node involvement, fertility-sparing surgeries such as conization (only for stage IA) or radical trachelectomy are options. Vaginal radical trachelectomy involves removal of the cervix with conservation of the uterus. A permanent cerclage is placed in the uterine isthmus.
Patients with disease confined to the cervix who have tumors 2 cm or less in size and no node involvement can be treated by limited surgery that preserves fertility such as radical trachelectomy, which removes the cervix with conservation of the uterus. For high-risk disease, adding weekly cisplatin-based chemotherapy to radiation decreases the risk of recurrence by 34% and improves overall survival. Adding the anti–vascular endothelial growth factor monoclonal antibody bevacizumab to chemotherapy improves overall survival in patients with distant metastases.
The 5-year relative survival for all stages of cervical cancer is 67.5%. The anatomic stage is the most important predictor of prognosis. Ninety percent of patients with localized disease survive 5 years. The 5-year survival rate drops to 58% for patients with regional disease and 17% for patients with disease extending outside of the true pelvis or involving the bladder or rectum.
Surveillance is recommended to monitor for recurrences that are potentially curable. Guidelines recommend doing a history and physical examination every 3 to 6 months for 2 years, every 6 to 12 months during years 3 to 5, and then annually based on the risk of recurrence. Annual vaginal cytology, cervical cytology, or both is recommended. Imaging and laboratory studies are recommended only if indicated based on symptoms or findings on examination that are suspicious for recurrence.