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Cervical cancer

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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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 U.S. Preventive Services Task Force (USPSTF 2018), the European Society of Medical Oncology (ESMO 2017), and the Canadian Task Force on Preventive Health Care (CTFPHC 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per USPSTF 2018 guidelines, screen for cervical cancer every 3 years with cervical cytology alone in women 21-29 years of age.
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2.Classification and risk stratification

Risk stratification: tumour risk assessment includes tumour size, stage, depth of tumour invasion, lymph node status, lymphovascular space invasion, and histological subtype. Lymph node status and the number of lymph nodes involved as the most important prognostic factors.

3.Medical management

Chemoradiation therapy: administer chemoradiation therapy as the standard care for patients with bulky IB2-IVA disease, as it has demonstrated an improvement in both disease-free survival and overall survival over standard radiation therapy/hydroxyurea.
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  • Adjuvant chemoradiation therapy

  • Neoadjuvant chemotherapy

  • Palliative chemotherapy

4.Surgical interventions

Indications for surgery: 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.
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  • First-line surgical treatment

  • Fertility-sparing treatment

5.Preventative measures

Primary prevention: primary prevention of cervical cancer is now possible via immunisation with highly efficacious HPV vaccines.
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  • Secondary prevention

6.Follow-up and surveillance

Serial clinical assessment
Schedule follow-up visits during which a patient history and a complete physical examination (including a pelvic-rectal exam) should be obtained.
Return to annual population-based general physical and pelvic examinations after 5 years of recurrence-free follow-up.
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  • Serial imaging assessment