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Cervical cancer
Background
Overview
Definition
Cervical cancer refers to malignant disease arising from the cervical epithelium, and principally comprises SCCs.
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Pathophysiology
Over 90% of cervical cancers are caused by infection of the cervical epithelium by a high-risk subtype of HPV, which leads to overexpression and integration of E6 and E7 viral oncogenes, resulting in transformation to CIN, squamous intraepithelial lesions, and invasive cervical carcinoma.
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Epidemiology
The incidence of cervical cancer in women is estimated at 7.4 cases per 100,000 person-years.
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Disease course
Clinical manifestations of localized disease include abnormal vaginal bleeding, menorrhagia, and dyspareunia, while more advanced disease can lead to systemic symptoms.
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Prognosis and risk of recurrence
The 5-year survival is estimated at 87% for patients with stage 1 node-negative and 73% for patients with stage 1, node-positive disease. In patients with more advanced disease (stages 2B-4A), 5-year survival with chemoradiation therapy is estimated at 70%.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of cervical cancer are prepared by our editorial team based on guidelines from the American Cancer Society (ACS 2020), the American Society for Radiation Oncology (ASTRO 2020), the U.S. Preventive Services Task Force (USPSTF 2018), the European Society of Medical Oncology (ESMO 2017), the American College of Physicians (ACP 2015), and ...
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Screening and diagnosis
Indications for screening
As per ACS 2020 guidelines:
Start cervical cancer screening at age 25 for patients with a cervix, using primary HPV testing every 5 years through age 65 (preferred). Obtain screening with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) if primary HPV testing is not available.
B
Discontinue cervical cancer screening for patients with a cervix aged > 65 years who have no history of CIN grade 2 or a more severe diagnosis within the past 25 years and have documented adequate negative prior screening in the 10-year period before age 65 years.
B
Classification and risk stratification
Risk stratification: as per ESMO 2017 guidelines, tumor risk assessment includes tumor size, stage, depth of tumor invasion, lymph node status, lymphovascular space invasion, and histological subtype. Lymph node status and the number of lymph nodes involved are the most important prognostic factors.
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Medical management
Definitive chemoradiotherapy: as per ASTRO 2020 guidelines, offer radiotherapy with concurrent platinum-based chemotherapy for definitive treatment in patients with FIGO stage IB3-IVA squamous cell or adenocarcinoma of the cervix.
A
initiate cisplatin at a dose of 40 mg/m² weekly for 5-6 cycles. ⁄
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Adjuvant chemoradiotherapy
Neoadjuvant chemotherapy
Palliative chemotherapy
Therapeutic procedures
Technical considerations for radiotherapy, intensity-modulared radiotherapy
As per ASTRO 2020 guidelines:
Perform intensity-modulated radiotherapy in patients with cervical cancer treated with postoperative radiation therapy with or without chemotherapy to decrease acute and chronic toxicity.
B
Consider performing intensity-modulated radiotherapy in patients with cervical cancer treated with definitive radiotherapy with or without chemotherapy to decrease acute and chronic toxicity.
C
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Technical considerations for radiotherapy (brachytherapy)
Surgical interventions
Indications for surgery: as per ESMO 2017 guidelines, reserve surgery only in patients with earlier stages of cervical cancer up to FIGO IIA, without risk factors necessitating adjuvant therapy, which results in a multimodal therapy without improvement of survival but increased toxicity.
A
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First-line surgical treatment
Fertility-sparing treatment
Preventative measures
Primary prevention: as per ESMO 2017 guidelines, primary prevention of cervical cancer is now possible via immunisation with highly efficacious HPV vaccines.
B
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Secondary prevention
Follow-up and surveillance
Clinical follow-up
As per ESMO 2017 guidelines:
Schedule follow-up visits during which a patient history and a complete physical examination (including a pelvic-rectal exam) should be obtained.
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Return to annual population-based general physical and pelvic examinations after 5 years of recurrence-free follow-up.
B
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Imaging follow-up