Invasive cervical cancer

Background Most common cancer of women in Africa, most common gynaecologic cancer, most common cancer of black and coloured women in SA Probably always preventable: follows on SIL lesions and share epidemiology Half of patients present in late stages 80% squamous Ca, 20% adenocarcinoma

Clinical Ages: (range !!) Symptoms: none / + smear / BLEEDING / discharge. Pain is a LATE complaint Signs: normal to cachectic. Paraneoplastic syndromes common: excessive anaemia, fever, cachexia On cervix: ulcer / exophytic / endophytic growth

Spread 1 Direct: vagina, uterus then parametria then adjacent organs: bladder, rectum, vulva 2 Lymphatic: pelvic nodes then para-aortic 3 Hematogenous: late and rare: bone, lungs, liver

Staging Necessary to diagnose extent of cancer, to decide on appropriate therapy, to suggest prognosis Staging is clinical but utilises special tests: –FBC, U&E, LFT, urine MCS –X ray chest –Ultrasound of bladder, ureters, upper abdomen and kidneys –Can do CT, MRI, Cystoscopy if needed

Staging system IA: invisible, diagnosed on cone or LLETZ IB: Visible: 4cm = IBii IIA: Cx + upper 2/3 of vagina IIB: Cx + parametria not to pelvic sidewall IIIA: Cx + entire vagina (lower 1/3) IIIB: Cx + parametria to pelvic sidewall IVA: pelvic organs: bladder, rectum IVB: distant organs

Treatment options Stage IA: LLETZ or cone is sufficient Stage IB: RHND: radical hysterectomy and pelvic node dissection Stage II, III: Radical radiotherapy to pelvis with added chemotherapy Stage IV: chemotherapy plus pelvic irradiation

Outcomes Success of treatment is determined by stage, size, type, nodal status and general condition of patient including HIV status Prognosis: 5year survival rates: –IA: =/- 100% –IB: - nodes: 85-90%; + nodes: 60-70% –II: 50-60% –III: 35-40% –IV: <10%

Control of disease Screening for precursors and treatment of HSIL Early detection of invasive CaCx Correct treatment per stage Education education education

Palliative care Reasons for death: uraemia, bleeding, infection, general cachexia, HIV, metastases When we cannot cure we still care Cannot re-operate radically in most cases, cannot re-irradiate radically, can sometimes offer chemotherapy Can relieve pain, look after normal needs, help, talk: at home, hospital, hospice