Doctors Revision

Oncology

Cervical Cancer

Malignant neoplasm arising from the cervix (the lower, narrow part of the uterus). Strongly associated with persistent infection by high-risk types of Human Papillomavirus (HPV). Largely preventable through HPV vaccination and screening.

Also known as: Cancer of the Cervix

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Referral and warning signs

When to refer

Referral for Colposcopy/Biopsy for any abnormal screening result or suspicious lesion. Refer ALL confirmed invasive cancer cases to specialized Gynae-Oncology centre.

Red flags

  • Post-coital bleeding
  • Intermenstrual bleeding
  • Postmenopausal bleeding
  • Suspicious cervical lesion on speculum exam
  • Abnormal screening test result

Signs and symptoms

  • Early stages often asymptomatic.
  • Abnormal vaginal bleeding: Post-coital bleeding, Intermenstrual bleeding, Postmenopausal bleeding, Menorrhagia.
  • Unusual or foul-smelling vaginal discharge (watery, mucoid, purulent, or bloody).
  • Pelvic pain or pain during intercourse (dyspareunia).
  • Late Stage Symptoms: Leg swelling (oedema), Flank or back pain (hydronephrosis), Urinary symptoms (frequency, haematuria, incontinence, fistula), Rectal symptoms (tenesmus, rectal bleeding, constipation, fistula), Weight loss, fatigue, anorexia.

Risk factors

  • Persistent infection with high-risk Human Papillomavirus (HPV) types (esp. 16, 18) - necessary cause.
  • Early onset of sexual activity.
  • Multiple sexual partners.
  • History of other sexually transmitted infections (e.g., Chlamydia, HSV).
  • Immunosuppression (especially HIV infection - AIDS-defining illness).
  • Smoking.
  • Long-term use of oral contraceptives (small increased risk).
  • High parity (multiple births).
  • Low socioeconomic status (linked to screening access/risk factors).
  • Lack of regular screening (Pap smear/VIA/HPV test).

Diagnosis

Clinical assessment

Suspect based on symptoms (abnormal bleeding - esp. post-coital, discharge) or abnormal screening test result. Speculum examination may reveal visible cervical lesion. Bimanual/rectovaginal exam assesses parametrial involvement.

Investigations

  • Cervical Biopsy: Essential for diagnosis. Punch biopsy of visible lesion or colposcopy-directed biopsy.
  • Screening tests: Visual Inspection with Acetic Acid (VIA) or Lugol's Iodine (VILI) - allows screen-and-treat. Pap Smear (Cytology). HPV DNA Testing.
  • Colposcopy: Magnified view of cervix, guides biopsy.
  • Staging Investigations: Clinical staging (FIGO). Imaging (Chest X-ray, Ultrasound, CT, MRI, PET-CT) for treatment planning/assessing extent.
  • Blood tests: CBC, Renal function.

Diagnostic criteria

Histopathological confirmation from cervical biopsy.

Management

Non-pharmacological management

  • Referral to specialized Gynae-Oncology centre.
  • Management depends on stage.
  • Pre-invasive Disease (CIN): Excisional (LEEP, Cone) or ablative procedures (cryotherapy).
  • Early Stage Invasive Cancer: Surgery (Hysterectomy + nodes) OR Primary Radiotherapy.
  • Locally Advanced Invasive Cancer: Primary Chemoradiotherapy (Radiation + Cisplatin + Brachytherapy).
  • Metastatic Disease: Palliative Chemotherapy +/- Targeted therapy +/- Immunotherapy. Palliative radiotherapy.

Pharmacological treatment

  • Chemotherapy: Cisplatin (concurrent with radiation). Carboplatin/Paclitaxel (metastatic/recurrent).
  • Targeted Therapy (Bevacizumab - anti-VEGF).
  • Immunotherapy (PD-1/PD-L1 inhibitors).
  • Pain management, supportive care.

Monitoring

Follow-up with exams, Pap/HPV tests, imaging as needed. Monitor for treatment side effects (radiation effects, lymphoedema, menopause).

Complications

  • Abnormal bleeding
  • Foul discharge / Infection
  • Pain
  • Urinary obstruction / Hydronephrosis / Renal failure
  • Rectal involvement / Fistula formation
  • Vesicovaginal fistula (VVF)
  • Lymphoedema
  • Metastatic disease
  • Complications of treatment

Prevention

  • Primary Prevention: HPV Vaccination. (Girls age 10, ideally before sexual debut).
  • Secondary Prevention: Screening. (VIA, VILI, Pap, HPV test).
  • Safe sex practices.
  • Smoking cessation.

Patient education

  • Explain diagnosis, link to HPV.
  • Importance of staging.
  • Treatment options based on stage.
  • Potential side effects.
  • Importance of follow-up.
  • Prevention for daughters/family (HPV vaccination).
  • Screening importance.

Uganda-specific notes

Most common cancer among women in Uganda. High association with HPV and HIV. Screening primarily uses VIA ('screen-and-treat'). Access to Pap smear, colposcopy, HPV testing, radiotherapy, brachytherapy, and comprehensive surgical/oncological care limited but available at UCI/RRHs. HPV vaccination program implemented.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 12, Section 12.3.2

  • National Guidelines for Prevention and Control of Cervical Cancer, MOH Uganda

    (Refer to specific MOH guidelines)

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