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Cervical Cancer

Carcinoma of the cervix continues to occur, although the incidence is clearly decreasing; what we are talking about are predominantly squamous cell carcinomas which are the most common variety, accounting for approximately 80% of all cervical cancers, adenocarcinoma represents approximately 20%, other cell types are much less common. There are currently approximately 14,000 cases a year, and the clinical spectrum is changing.

At the present time in the United States, approximately one-half of the cases of invasive carcinoma of the cervix are advanced at the time of diagnosis. What is the cause of death? It is either uncontrolled disease in the pelvis, or distant metastasis and I will come back to these issues. The pattern of spread is something you are familiar with, and something we want to keep in mind.

The diagnosis typically relies on the biopsy of any gross lesion of the cervix. Workup of an abnormal PAP smear in a number of cases will lead to the diagnosis of an invasive cancer of the cervix, and this will include colposcopy and biopsy or cone biopsy. As a reminder, the cervix is grossly abnormal as in this case, the first thing to do is to biopsy here, this lesion is not approached by doing a PAP smear, and again, maybe with decreasing incidents of cervical cancer.

Let’s move on to the larger carcinomas of the cervix, stage IB and stage IIA. Here we have basically two treatment options; the treatment of choice in cervical cancer as a disease as a whole as you know, is radiation therapy. In these particular stages, there may be a choice in selective cases between radical hysterectomy and bilateral pelvic lymphadenectomy, this can be done vaginally or abdominally, and radiation therapy with external radiation of the whole pelvis and brachytherapy. The bottom line is simple, they are comparable local control and survival rates with both modalities. So how does one choose? Well it’s basically based, and I try to sympathize it here on a number of points such as institutional preference, physician preference and training, tumor characteristics and here, the size of the tumor appears to be an important determinant.

With radiation therapy, adverse effects can occur within six months, from six months to a year or after a year, in which case they are called late adverse effects which are of concern in young patients and include intestinal dysfunction which can be protracted fistulas. In patient’s who undergo a radical hysterectomy, we have learned there are a number of factors that can be found that will affect prognosis, and they are, the presence of positive pelvic lymph nodes, positive margins, parametrial extension.

The problem here is that you can see there is also a significant rate of complications, and I should point out that those are severe complications, those are not just minor complications occurring anywhere from 3 to 30% in those patient’s. The message I want to share with you here is that if at all possible, we would prefer to stay out of this kind of situation where patient’s are subjected to two radical treatment modalities; one is surgery, another radiation therapy.

There was indeed a significant advantage to the chemotherapy and radiation therapy arm in that progression free survival was significantly longer and overall survival 88% versus 77% were significantly better in the patient’s treated with concurrent radiation and chemotherapy.

I want to go on and talk a little bit about a difficult treatment category where the exact treatment remains to be determined. This graph shows you how with increasing tumor size, whether or not lymph nodes are present that are positive, like in the upper curve or negative, one can see that the recurrence rate constantly goes up either with positive pelvic lymph nodes, negative pelvic lymph nodes and function of the size of the tumor. This is in patient’s who had radical hysterectomy and pelvic lymphadenectomy for treatment. The same is true for patient’s with stage IB carcinoma of the cervix.