Cervical cancer continues to be listed among the top gynecologic cancers worldwide. According to current data, it is ranked fourteenth among all cancers. Cervical cancer intervention focuses on primary and secondary prevention. Primary prevention and screening is the best method to decrease the burden of cervical cancer and to decrease mortality. In the United States and other developing countries, most screening and diagnostic efforts are directed towards early identification of high-risk human papillomavirus (HPV) lesions through HPV testing and Pap smears. Although HPV testing is not recommended in women younger than 30 years of age, low-risk younger women should begin screening with Pap tests at age 21 and continue until age 65, according to the United States Preventive Services Task Force recommendations. Since cervical cancer is a sexually transmitted infection, it is a preventable disease. Targeted education, screening, and intervention can reduce the burden of disease. Like many diseases and cancers, disparities exists in screening rates, early diagnosis, and timely treatment. Screening rates tend to be less in low socioeconomic and low resource areas with ethnic and age variations. Studies show that women with obesity and chronic disease may also have lower rates of cervical and breast cancer screening. A study on ethnic minority women in the United Kingdom reports several barriers to screening including lack of awareness, fear, embarrassment and shame, and low perceived risk. One study reviewing the barriers for Haitian women revealed socioeconomic barriers, language barriers, and limited understanding of health and disease. In the United States, cervical cancer mortality is disproportionately higher for African American women. Since 2006, vaccination has been available for prevention of cervical cancer. Vaccination can improve cancer death rates in underdeveloped countries where resources may not be available for routine screening and in populations with higher mortality rates.
Current literature reports that Human Papillomavirus (HPV) is found in the majority of sexually active people at some point during their life. There are more than 130 types of known HPV with 20 HPV types identified as cancer-related. HPV-related cervical dysplasia rates are only known in women since men are not screened outside of research protocols. HPV 16 and 18 are the most commonly found HPV in invasive cervical cancer. Population-based HPV prevalence studies show that the greatest prevalence of high-risk HPV occurs in the young adult period before 25 years of life and cervical cancer death peaks in the middle age period of 40 to 50 years of life. Studies have shown that HPV-related cervical disease in women younger than 25 years old is largely self-limiting. However, those with co-infection may be less likely to have spontaneous clearance and progress to cancer. Risks factors for HPV and cervical cancer include age at first intercourse, multiple sexual partners, smoking, herpes simplex, HIV, and oral contraceptive use. HPV is transmitted by skin to skin contact including during sexual intercourse, hand to genital organ contact, and oral sex.
Globally, there are more than 500,000 new cases of cervical cancer annually. Approximately 250,000 women die of cervical cancer annually. In the United States, about 4000 women die from cervical cancer annually with African Americans and women in low-resource areas having a much higher mortality rate. HPV, the causative agent, is a sexually-transmitted viral infection. Cervical cancer mortality is higher among women who have not been screened in the last five years and those women without consistent follow-up post identification of a pre-cancerous lesion. Trends continue to show that women with the highest risk of mortality may be less likely to receive a vaccination that could potentially prevent cervical cancer.
HPV is the causative agent in cervical cancer. More than 75 percent of cases are due to high-risk HPV 16 and 18. Although there are more than a half million cases of HPV identified annually, most are low-grade infections and will spontaneously resolve within two years. Progression of high-grade lesions and cancer are seen in the presence of other carcinogenic factors such as listed above.
The patient with cervical cancer is usually asymptomatic in early stages. The history and physical must include sexual history including the age of first sexual encounter. Sexual history includes questions about postcoital bleeding and pain during intercourse. The history includes questioning about previous sexually transmitted infections, the number of lifetime partners, previous history of HPV infection, history of human immunodeficiency virus, use of tobacco, and whether the patient has had a previous vaccination against HPV. Women should be asked about menstrual patterns and any abnormal bleeding, persistent vaginal discharges, irritations, or known cervical lesions. The physical exam must include a full evaluation of the external and internal genitalia. In women with cervical cancer, the exam findings might include a friable cervix, lesions, erosions, or bleeding with examination and fixed adnexa.
According to the United States Preventative Services Task Force (USPTF), Pap screening is recommended beginning at age 21 years of age. HPV testing begins at age 30 in conjunction with Pap smear cytology. Screening is recommended every three years for women with continued normal screening and those low risk for cervical cancer. For women over 30 years of age, cytology can be every five years with HPV testing. Level A or women with low-risk status and consistent normal screenings can discontinue cervical cancer cytology and HPV testing at age 65. Women who have had a total abdominal hysterectomy including removal of the cervix for benign disease do not require further screening.
Pre-cancerous lesions are managed conservatively for those women younger than 25 years. The majority of abnormal findings in women younger than 25 are low-risk cervical dysplasia and will resolve spontaneously. Colonoscopy evaluates persistent, abnormal cytology or lesions suspected to be greater than low risk. These are managed according to findings. Low-risk lesions may be watched and reevaluated more frequently, and high-risk lesions are treated based on size, location, and staging. Cryotherapy or excision is done to manage pre-cancerous lesions that are limited in size and depth. Conization, laser or Loop Electrosurgical Excision Procedure (LEEP) are used in managing those lesions that include the endocervical canal and are more extensive. If cancer is diagnosed, the next step in management is staging to determine further treatment. Staging is based on findings and results from examination, tissue findings, imaging, and reported signs and symptoms. Grading is based on size and depth of cancer and signs of spread to other organs. Treatment of early-stage disease includes a radical hysterectomy. For women who desire pregnancy with early stage disease, conization may be the initial treatment. Chemotherapy and radiation are usually the next steps in treatment after hysterectomy to slow growth of cancer.
Primary prevention includes vaccination with Gardasil or Cervarix to prevent cervical cancer. Gardasil is a quadrivalent vaccine that prevents not only cervical cancer but also prevents genital warts. The recommended age for vaccination is from nine to 26 years old for both females and males. Health promotion aimed at vaccination can have a major impact on cervical cancer mortality in women in low resource areas and those who are in high-risk ethnic groups.