Cervical cancer

Overview

•Most common gynaecological cancer in women under 35 in the UK

•Caused by persistent high-risk HPV (hrHPV) infection - >99% of cases are HPV-positive; types 16 and 18 account for ~70%

•HPV transmitted via skin-to-skin genital contact including oral sex - lesbian and bisexual women are NOT exempt from screening

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Women in same-sex relationships should undergo cervical screening as normal - HPV is transmitted via genital contact and oral sex, not exclusively penetrative heterosexual intercourse. Uptake amongst lesbian women is ~10 times worse than the general population, sometimes due to incorrect healthcare advice.

Presentation

•Post-coital bleeding - most classic symptom; cervical cancer until proven otherwise

•Intermenstrual bleeding

•Postmenopausal bleeding

•Offensive/blood-stained vaginal discharge

•Pelvic pain - suggests locally advanced disease

•Asymptomatic - most common in early disease; detected on screening

Investigations

🥇 First-line

•cervical smear (LBC with primary hrHPV testing) - screens asymptomatic women

•Colposcopy: magnified direct visualisation with acetic acid and Lugol's iodine; allows targeted biopsy

🏆 Gold standard

•colposcopic-directed biopsy - histological confirmation of CIN grade or invasive carcinoma

•Staging: MRI pelvis (local extent/parametrial invasion); CT chest/abdomen/pelvis (distant metastases); PET-CT (selected cases)

Management

•CIN1: observe (may regress spontaneously)

•CIN2/CIN3: large loop excision of the transformation zone (LLETZ) - diagnostic and therapeutic

•Stage IA1 (fertility-sparing): cone biopsy with clear margins

•Stage IA (definitive): simple or modified radical hysterectomy

•Stage IB1/IIA1: radical hysterectomy (Wertheim's) with pelvic lymph node dissection

•Stage IB2/IIA2 or locally advanced (IIB-IVA): concurrent chemoradiotherapy - EBRT + brachytherapy with cisplatin

•Stage IVB (metastatic): palliative chemotherapy - cisplatin + paclitaxel ± bevacizumab

Prevention

•HPV vaccination: Gardasil 9 (nonavalent - covers types 6, 11, 16, 18, 31, 33, 45, 52, 58; ~90% of cervical cancers) - offered to all boys and girls aged 12-13; two doses ≥6 months apart

•Catch-up vaccination available up to age 25

Cervical Screening Programme

•Primary hrHPV testing via liquid-based cytology (LBC)

•Ages 25-49: invited every 3 years; ages 50-64: every 5 years

•hrHPV negative → routine recall

•hrHPV positive → cytology assessed on same sample → if abnormal cytology, refer to colposcopy

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Two consecutive inadequate smear samples = refer to colposcopy. Do not attempt a third smear in primary care. Requesting hrHPV testing on an inadequate sample is futile.