Cervical Cancer Flashcards
Cervical Cancer
Etiology & Risk Factors
Cervical Cancer
- a squamous cell carcinoma: 3rd most common cancer
- almost exculsively (99%) cause by HPV infections: sexually transmitted disease from penis–>vaginal intercourse
- strains 16 &18 are most often causing cancer
- lower SES, black and hispanic pop. highest rates becuase LACK of screening
Risk Factors
HPV: 16 & 18 : 100% of cervical cancer is due to HPV
- immunosuppresed state (HIV, long term steroids, organ transplant)
- coinfectec with other STI (decrease immune response)
- multiple sex partners, early age of having sex
- nutritional deficiency
- cigarette smoking
- genetics
- lack of pap’s and screenings
HPV
- 100% cervical
- high rates of anal cancer & oropharyngeal
- highest prevelence in 20-24 year olds
HPV Specifics
straings
clearance
transitent and persistant
HPV:human papilloma virus
- most common STI: 20 million people infected
- about 2/3 of those sexually active will aquired a strain of HPV: most peopple will clear infection (we have vaccine!!)
- types 6 & 11 = warts
- types 16 & 18 = cancer
Clearance
- average: people with HPV will clear the infection within two years
- 90% of people will clear it: it will sit dormant and not bother them
- 10% of people will struggle with HPV to clear it, and have abnormal pap results/cervical dysplasia throughout their life: so they got it at some point, kinda cleared it, came back, causing abnoraml cells etc.
- can reawaken in thise 10% and therefore later in life develop abnormal pap results: at points when maybe the immune system is low
Transient infection
- get infected, mild abnormality, pt. will clear it
Persistant
- infected, attempted to clear
- progression to cancer leions and invasion to cancer
- cannot regress at this point
HPV
how to prevent
vaccinations
Prevention
- abstinence : but still can potentially spread in genital-genital contact
- condoms: can still persist with condome use!!
- HPV vaccine: 100% efficacy with vaccine
Vaccine: gardasil-9
Gardasil 9 : covers 6,11, 16, 18, 31, 33, 45, 52 & 58
gardasil 4: on the market
cervarix: bivalenet on the market
Who should get it
- ages 11-12 should get 2 doses 6-12 months apart
- can start as early as 9
if starting ages 15-26: need 3 doses
0 months, 2 months, 6 months
weak immune system = 3 doses
not recommened for those over the age of 26 : because its assumed you “already have it” and your body has done its thing
Cervical Cancer
etiology & type of cancer
Symptoms
Cervical Cancer: types
Squamous cell carcinoma
can be adenocarcinoma: rarely though
rates of CC: highest is in ther 40-44 year old groung, rates climb from 30- to 40
Screening for Cervical Cancer
- cervical cancer is going to occur in those who have not been screening in past 10 years or had routine paps
Symptoms
- ususally early on: asymptomatic
- causes of atypia or dysplasia are found via pap smear
- late stages: post-cotial bleeding: even spoting is a concern
- irregular brown discahrge or heavy bleeding = late stage
- bladder or rectal dysfunction, abd pain are sigsn of mets
Cervical Cancer Screening
what are you sampling (where)
ACS guidelines
ACOG guidelines
Cervical Cancer Screening
yearly cervical cytology screening = pap smear
- goal = cytological screening to sample transformation zone at the squamo-columnar junction
ACS Guidelines
first PAP : age 25
then, pap every 5 years: using hrHPV testing alone
if you cannoy do hrHPV testing alone, then…
- co-test hrHPV + cytology Q5years
- cytology alone Q3years
ACOG Guidelines
first PAP: age 21
ages 21-29: pap with cervical screening (cytology ALONE) Q3years
ages 30-65:
- pap with cytology alone Q3 years
- pap with co-testing: cytology +hrHPV Q5years
Cervical Cancer Screening
for those over 65
for those s/p hysterectomy
when to stop?
ACS: can stop over 65 if theyve had a test within 10 yeras and no abnormal
ACOG: can stop over 65 if theyve had 3 consectuvie cytology normal or 2 cotesting normal
s/p hysterectomy
- uspstf: dont screen if they dont have hx. high grade precancerous lesion
- ACS: dont screen unless thye had hyspterecomty because of cervical cancer
Cervical Cancer Screening: what is theres an abnormal
- hpv unknown
- hpv +
- hpv + with 16/18
- 2 unsat. paps
refer to the asccp for what to do with abnormal pap results
HPV unknown: repeat cytology in 2-4 months
HPV + : repeat pap OR do colposcopy
HPV + with 16/18: do coloposcopy
2 unsatisfactory paps: do colposcopy
Cytology of pap smear
Grading via…
traditional methods
what is CIN/CIS
Tradtional Grading
- normal
- metaplasia
- inflammation
- minial atypia
- mild dysplasia: (CIN I)
- moderate dysplasia: (CIN II)
- severe dysplasia: (CINS II/CIS)
- invasive carcinoma
CIN: ceverical intraepitheial neoplasia
when you see a CIN report: you will be doing something, like excision
CIN: HPV (16/18) driven neoplasias in the cervix: pre-cancerous lesions
CIN I: cells affecting 1/3 thickness
CIN II: superfiscial cytoplasmic maturation 1/3-2/3 thickeness
CIN III: full thickness atypia; highest risk and progression to invasive squamous cell carcinoma
CIN
Treatment
CIN
Treatments: surgical excision: treatment of choice
EXCEPT: women who are pregnant: < 25 with CIN II : we will wait as body may clear it
takes approx. 2-10 years for the carcinoma to penetrate the basement membrane and become invasive: but we like to excise before then
CIS
what is it
CIS: carcinoma in situ
this is cancer: but it has not spread, yet
Preinvasive stage of cancer: can also be seen as CIN III, stage O cancer
what is it
- squamous cell carcinoma in the intraepithelial cells of teh cervic but not in nearby tissues
**ususally treated
Bethesda Cervical Cancer Grading Scale
Bethesda Scale
normal: normal cells
Inflammation/reactive cellular changes
ASC-US
- atypical sqamous cells of undetermined significance
- usually, these regress spontaneously
ASC-H
- atpical sqamous cells- cannot rule out HIGH-grade lesions
- these are watched closely
ASC-G
- Atypical glanddular cells
LGSIL
- low grade squamous intraepitheial lesions
- correlated with CIN I
HGSIL
- high-grade squamous intereiptheial lesions
- colposcopy with biopsy if needed
Management of LGSIL
Low grade sqamous intraepitheial lesions (LGSIL)
- what to do = depends on hx. and age
Colposcopy
- looks at cells under cuper magnification to determine the extention of abnormalities through or outside the transformation zone
- uses acetic acid: turns the abnormal cells become white
- punch biopsy and endocervical curettage are done to get get cells
Management of HGSIL
High grade squamous interepitheial lesions (HGSIL)
excision or ablastion of the abnormal cells and entire transformation zone
abaltive: cryotherpy, co2 laser
excisions: loop (LEEP), conization (take cone shaped cut out if CIN III)
Follow up pap and testing/monitring for cerivcal cancer
pregnancy?
what if conization fails
Testing
- follow up with co-testing/hpv + cytology usually at …
- 6 months
- every yearfor 3 years
- then every 3 years
CIN is not treated in pregnancy: posposted but colposcopy and biopsy can and SHOULD be done
failed conization
- move to doing a TAH
- can do radiation, chemo etc. if severely invasive
Prognosis
- odler women = worse
- but early and noninvasice = good prognosis in 90%
