A9. Cervical cancer; symptoms and diagnosis

Cervical carcinoma is a “controllable”, highly preventable cancer for three reasons:

• There is a precursor lesion (CIN) which progresses slowly to cancer (topic A7)
• There is an inexpensive and non-invasive screening test for CIN (Pap smear)
• The precursor lesion can be treated simply and effectively to prevent progression to cancer

Additionally, HPV vaccines (topic A8) are available which effectively prevent HPV-related cervical cancer. For these reasons, cervical cancer is a preventable disease which, according to the WHO, no person should die from.

There are two major types of cervical carcinoma, squamous carcinoma and adenocarcinoma. Squamous cell carcinoma accounts for 80% of cases, while adenocarcinoma accounts for the remaining 20%. Other types, including neuroendocrine type, are very rare.

For etiology, see topic A7. HPV 16 and 18 account for over 70% of cases.

Clinical features

Early cervical cancer is frequently asymptomatic. The most common symptoms are:

• Abnormal vaginal bleeding (metrorrhagia, hypermenorrhoea)
  • Especially postcoital bleeding
• Vaginal discharge
• Dyspareunia
• Pelvic pain

Diagnosis and evaluation

Cervical examination may reveal ulceration, induration, or an exophytic tumor. Biopsy is required for diagnosis.

Cervical cytology (Pap smear) should always be performed.

If physical examination shows a suspicious lesion, a punch biopsy should be taken directly from it. If no tumour is visible, colposcopy with acetic acid or Schiller test (applying iodine solution) should be used to look for suspicious areas to biopsy.

If no suspicious lesions are found or biopsy is negative but malignancy is still suspected, cervical conization can be performed and examined histologically.

If cancer is suspected, we should look for involvement of the parametrium by rectovaginal examination. Further evaluation of the parametrium can be accomplished with PET or MRI.