Cervical Cancer
This guideline is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Diagnosis & assessment at presentation
Stages & types of cervical cancer
Presentation at the Joint Oncology Meeting
Patients requiring Wertheim hysterectomy
Management of associated problems of Ca cervix
The most common gynaecological cancer in South Africa. Most patients present with locally advanced disease & require radiotherapy with chemotherapy. Early stage is treated with hysterectomy (micro-invasive) or radical hysterectomy.
Diagnosis & assessment at presentation
- Describe the nature & extent of the lesion
- Punch biopsy (histology marked ‘Urgent’)
- Assess for metastases on history & examination
- FBC, U&E, & HIV (CD4 if positive) – not RPR or LFT
- Chest x-ray
- Ultrasound kidneys (for hydronephrosis) – if present, automatically Stage 3b
- Palpable lymph nodes must be FNA’d or biopsied
- If there is suspicion of bony metastasis (lumbosacral pain, sciatic nerve root symptoms) – X ray, bone scan
- Cystoscopy & biopsy if lower 1/3 vagina involved
- Inform the unit consultant
- Arrange a follow-up appointment in 10-14 days, for possible admission & for presentation to the weekly oncology meeting
- The differential diagnosis (other possibilities): cervical TB, schistosomiasis (may coexist with ca)
Follow up visit
- The histological report will confirm the diagnosis. Explain the diagnosis to the patient
- The patient must be properly staged: speculum, PV, PR, sonar – by an experienced person
- Stage 1B lesions need to be assessed for possible Wertheim’s hysterectomy. Other cases, for radiotherapy (DXT) +/- chemotherapy, can be presented at the Joint Oncology meeting at Charlotte Maxeke on Thursdays, as an out-patient or in-patient. Explain all this to the patient
- The Hb result needs to be 12 g/dL or more for radiotherapy – but there is a delay so give haematinics unless severely anaemic
Stages and types of cervical cancer (FIGO 2018)
- Stage 1a1: Minimal stromal invasion <3mm
- Stage 1a2: 3-5mm depth invasion
- Stage 1b: Tumour confined to the cervix larger than stage 1a2
- 1b1: <2cm diameter
- 1b2: 2-4cm diameter
- 1b3: >4cm diameter
- Stage 2a: Upper 2/3 vagina
- 2a1: <4cm diameter
- 2a2: >4cm diameter
- Stage 2b: Involvement of either or both parametria not to pelvic sidewall
- Stage 3a: Involvement of vagina lower 2/3, parametria not to sidewall
- Stage 3b: Spread to either pelvic sidewalls or hydronephrosis
- Stage 3c1 or 2:
- 1: Pelvic nodes positive
- 2: Aortic nodes positive
- Stage 4a: Mucosal involvement of bladder or rectum
- Stage 4b: Distant spread - outside the pelvis (includes inguinal nodes)
The majority, 85%, are squamous, 15% are adenocarcinomas - the incidence of which has not been reduced by cervical screening. Other rare variants exist. Squamous carcinomas & adenocarcinomas are treated the same.
Presentation at the Joint Oncology Meeting
CMAH every Thursday at 09:30. Generally, the patients do not need to attend. The patients’ files and oncology forms are taken early in the morning to CMAH.
The following must be included:
- Summary of the case in the file (for the presenter to read out) and DXT form completed
- Results of FBC, U&E, HIV (CD4 count if positive).
- ‘Hard’ copy of histology report or laboratory number
- Chest X-ray report
- Kidney ultrasound report
- Staging examination, including:
- Size of lesion
- Vaginal involvement
- Parametrial involvement
- Drawing of the lesion
- Any metastases: histology or cytology reports (glands, bladder biopsy etc.)
Patients requiring DXT (+/- chemotherapy)
- Stage Ib2 & all stage II-IV
- DXT is for 4- 6 weeks at Johannesburg Hospital
- Chemotherapy may also be used (platinum based)
- Most patients are transported daily in a hospital vehicle
- Inform patients about the treatment, in particular:
- What takes place with radiotherapy
- How long radiotherapy takes
- Side-effects & complications of radiotherapy
- Need to use vaginal dilators (if necessary)
- After completion of treatment, follow-up is at CMAH and then respective hospitals
Patients requiring Wertheim hysterectomy (radical with lymph node dissection)
- Some stage Ia2, Ib1 (occasionally Ib2) and IIa (occasionally) qualify
- Cross-match 2 units of packed cells on standby for theatre
- Consent for ‘Wertheim hysterectomy’
- Explain that further treatment, e.g. radiotherapy +/- chemo, may be necessary after the operation (histology determines: +ve margins/nodes)
- NB after catheter removal (2 days) ask for voluntary voiding plus every 4-6 hours. When 4-6 hours produces nothing voluntary voiding only
Follow up
- If excision is complete with negative nodes:
- Review at 3 months, 6-monthly twice, then annually
- At each visit, ask about general health, pain & vaginal bleeding
- Full examination, looking for evidence of metastases
- Vaginal examination at 6 months, then annually
- Pap smear at 6 months, then annually
Management of associated problems of Ca cervix
Excessive vaginal bleeding
- Catheterize the bladder
- Prepare a vaginal pack with acetone to stop the bleeding
- Soak the tip of the gauze pack with acetone
- Insert the pack through a Cusco speculum using a packing forceps or sponge holder(avoid touching normal vagina with acetone, it burns)
- Ensure that the pack is closely applied to the cervix
- Alternative: soak the pack tip with 3 vials of Cyclokapron for injection instead
- Tranexamic acid (Cyclokapron) 500 mg orally 3 times daily may be helpful
- In premenopausal patients consider incidental menorrhagia as a cause
- In desperate cases, emergency DXT, internal iliac artery ligation (at surgery) or embolisation are all options
Vesico-vaginal fistula
- This can be confirmed on cystoscopy but usually is easy to define on examination
- Take a biopsy from the edge of the fistula if possible
- If the fistula is associated with previous radiation, take a biopsy and inform the radiotherapy department, even if the biopsy is tumor-free
- Urinary diversion (ileal conduit – big operation) will be considered if there is no cancer. Consult a urologist
- Fistula is discussed in more detail in Urinary Fistula
Pain relief
- Ask regularly about pain
- Exclude specific causes & treat appropriately, e.g. urinary tract infection or constipation
- Consider lumbosacral metastases as a cause of pain (urgent DXT)
- Know the WHO stepwise approach to increase pain relief (as above)