Cervical cancer is caused by HPV infection and develops in the lining of the cervix. It ranges from early stage cancers contained within the cervix to late stages that spread beyond the cervix. Symptoms can include abnormal bleeding or discharge. Diagnosis involves tests like Pap smears, biopsies, and imaging. Treatment options depend on the stage and include surgery, radiation, chemotherapy, or a combination. Regular screening and HPV vaccination can help prevent cervical cancer.

1. CERVICAL CANCER
Prepared By:
Khusbu Lama
BSC Nursing 4th year
Nobel college

2. Anatomy

5. INTRODUCTION
• Cervical cancer is the growth of abnormal cells in the lining of
the cervix.
• The most common cervical cancer is squamous cell carcinoma,
accounting for 70% of cases
• Adenocarcinoma is less common and more difficult to diagnose
because it starts higher in the cervix.
• Cervical cancer is an entirely preventable disease as the different
screening, diagnostic and therapeutic procedure are effective.
(DC Dutta)

6. Definition
• Cervical cancer is malignant neoplasm of the cervix or cervical area. It
may be present with vaginal bleeding but symptoms maybe absent
until the cancer is in its advanced stages. (Anupama Tamrakar)

7. Incidence
• fourth most common cancer in women.(WHO)
• In 2018, an estimated 570 000 women were diagnosed with
cervical cancer worldwide. (WHO)
• A total of 3,254 cervical cancer cases were registered in Nepal
during 2012 to 2017. (September 2019 Nepalese Journal of
Cancer)
• The most common age group was 45-59 years (44.6%) followed
by 60-74 years (29.4%) and 30-44 years (21.1%). (September
2019 Nepalese Journal of Cancer)

8. Cause
• Long-lasting infection with certain types of human
papillomavirus (HPV) is the main cause of cervical cancer.

9. Risk factors/co factors that can be changed
(American cancer society)
1. Sexual history
• sexually active (especially younger than 18 years old)
• Multiple sexual partners
2. Smoking
• Researchers believe that smoking damage the DNA of
• makes the immune system less effective in fighting HPV

10. 3. Having a weakened immune system
• Human immunodeficiency virus (HIV)
• Drugs used in auto immune diseases: corticosteroid (prednisone) cytotoxic drugs
(azathioprine and cyclophosphamide)
• 4. Chlamydia infection
• Certain studies show that the Chlamydia bacteria may help HPV grow and live
on in the cervix
5. Long-term use of oral contraceptives (birth control pills)

11. 6. Multiple full-term pregnancies
• 3 or more full-term pregnancies
• increased exposure to HPV infection with sexual activity
• studies have pointed to hormonal changes and weaker immune systems
7. Young age at first full-term pregnancy
• younger than 20 years
• 8. Economic status
• may not get screened or treated for cervical pre-cancers.

12. 9. A diet low in fruits and vegetables
NOTE:
• Intrauterine device ( IUD) use may lower the risk

13. Risk factors that cannot be changed
1. Diethylstilbestrol (DES)
• DES is a hormonal drug that was given to some women between 1938 and
1971 to prevent miscarriage.
• Women whose mothers took DES (when pregnant with them) develop clear-
cell adenocarcinoma of the vagina or cervix
• There is about 1 case of vaginal or cervical clear-cell adenocarcinoma in every
1,000 women
2. Family history

14. Signs and Symptoms (common)
• Early cervical cancers and pre-cancers are asymptomatic.
• Begin after the cancer becomes larger and grows into nearby tissue.
1. Abnormal vaginal bleeding
• Postcoital bleeding
• Postmenopausal bleeding
• Metrorrhagia, or Menorrhagia
• Bleeding after douching

16. 2. An unusual discharge from the vagina
• contain some blood
• occur between periods or after menopause.
3. Dyspareunia
4. Pain in the pelvic region

17. Signs and symptoms (more advanced)
• Excessive Fatigue
• Edema or pain of lower extremities
• Lower back pain
• Dysuria
• Frequent micturition
• Problem in bowel movement

18. Types of cervical cancer
1. Squamous cell carcinomas:
• Most (up to 9 out of 10)
• begin in the transformation zone (where the exocervix joins the
endocervix)
2. Adenocarcinomas
• develops from the columnar epithelial cells of the endocervix.
3. Less commonly, adenosquamous carcinomas or mixed carcinomas

19. OTHER TYPES
• Melanoma
• Sarcoma
• and lymphoma

20. DIAGNOSIS
1. Medical history and physical exam
• personal and family medical history: related to risk factors and symptoms of
cervical cancer
• A complete physical exam
• pelvic exam and Pap test: every 3 yrs (21-65 years)
2. Colposcopy
• if Pap test result shows abnormal cells
• Using weak solution of acetic acid (similar to vinegar) for better visualization

22. 3. Cervical biopsies
a) Colposcopic biopsy
• a small (about 1/8-inch) section of the abnormal area
b) Endocervical curettage (endocervical scraping)
• If colposcopy does not show any abnormal areas
• The curette or brush is used to scrape the inside of the canal to remove some of
the tissue

24. c) Cone biopsy
• also known as conization
• removes a cone-shaped piece of tissue from the cervix
• The tissue removed in the cone includes the transformation zone ( where
cervical pre-cancers and cancers starts).
• The methods commonly used are:
a) Loop electrosurgical excision procedure (LEEP) also called the large loop
excision of the transformation zone (LLETZ),
b) The cold knife cone biopsy.

25. • Loop electrosurgical procedure (LEEP, LLETZ): using thin
wire loop heated by electricity and acts as a small knife
• Cold knife cone biopsy: using scalpel or a laser (either a
general anesthesia, or a spinal or epidural anesthesia).

28. For people with cervical cancer
• If a biopsy shows that cancer is present, below tests are done to
see if and how far the cancer has spread.
a) Cystoscopy,
b) proctoscopy,
c) and examination under anesthesia: pelvic examination

31. 4. Imaging studies
• Chest x-ray
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET scan)
• PET/CT scan(combined)
• Intravenous urography

32. Cervical Cancer Stages: FIGO
(International Federation of Gynecology
and Obstetrics) 2018
The International Journal of Gynecology
& Obstetrics

33. Stage I:
The carcinoma is strictly confined to the cervix uteri
IA: Invasive carcinoma that can be diagnosed only by microscopy, with
maximum depth of invasion <5 mm
• ○IA1: Measured stromal invasion <3 mm in depth
• ○IA2 :Measured stromal invasion ≥3 mm and <5 mm in depth
•IB: Invasive carcinoma with measured deepest invasion ≥5 mm (greater than
stage IA), lesion limited to the cervix uteri
• ○IB1 : ≥5 mm depth of stromal invasion and <2 cm in greatest dimension
• ○IB2 : ≥2 cm and <4 cm in greatest dimension
• ○IB3 : ≥4 cm in greatest dimension

34. Stage II:
The carcinoma invades beyond the uterus, but has not extended onto the lower
third of the vagina or to the pelvic wall
•IIA: Involvement limited to the upper two‐thirds of the vagina without
parametrial involvement
• ○IIA1: Invasive carcinoma <4 cm in greatest dimension
• ○IIA2: Invasive carcinoma ≥4 cm in greatest dimension
•IIB: With parametrial involvement but not up to the pelvic wall

35. Stage III:
The carcinoma involves the lower third of the vagina and/or extends to the
pelvic wall and/or causes hydronephrosis or non‐functioning kidney and/or
involves pelvic and/or paraaortic lymph nodes
•IIIA: Carcinoma involves the lower third of the vagina, with no extension to
the pelvic wall
•IIIB: Extension to the pelvic wall and/or hydronephrosis or non‐functioning
kidney
•IIIC : Involvement of pelvic and/or paraaortic lymph nodes, irrespective of
tumor size and extent
•○IIIC1: Pelvic lymph node metastasis only
• ○IIIC2: Paraaortic lymph node metastasis

37. Stage IV:
The carcinoma has extended beyond the true pelvis or has involved (biopsy
proven) the mucosa of the bladder or rectum.
•IVA Spread of the growth to adjacent organs
•IVB Spread to distant organs

38. TREATMENTS
Early stages
1. Cryosurgery
• used to treat cervical intraepithelial neoplasia (CIN)- precancerous
lesion
2. Conization

40. 3. Laser ablation

41. Surgery for invasive cervical cancer/ advanced
stages
1. Radiation therapy
• External beam radiation therapy (EBRT)
• Brachytherapy(internal radiation therapy): intracavitary brachytherapy
2. EBRT combined with chemotherapy (concurrent chemoradiation)
• low dose of the chemo drug called cisplatin is used
• The radiation treatments are given 5 days a week for about 5 weeks.
• The chemotherapy is given at scheduled times during the radiation.
• If the cancer has not spread to distant areas, brachytherapy may also be
given after the concurrent chemoradiation is complete.

43. 3. Hysterectomy (simple or radical)
4. Trachelectomy
• removes the cervix and the upper part of the vagina but not the body
of the uterus
• permanent "purse-string" stitch inside the uterine cavity to keep the
opening of the uterus closed
• Risk of miscarriage

45. Pelvic exenteration

47. Prevention

48. Primary prevention
1. Identifying high risk female
2. Sexual behavior
3. Prophylactic HPV vaccine: The ACS recommends:
• between the ages of 9 and 12.
• age 13 through 26 who have not been vaccinated, or who haven’t gotten
all their doses, should get the vaccine as soon as possible.
• Vaccination of young adults will not prevent as many cancers as
vaccination of children and teens.
• The ACS does not recommend HPV vaccination for persons older than 26
years

49. 4. Use of condom
5. Removal of cervix during hysterectomy

50. Secondary prevention
• Even when the invasive cervical cancer is detected, it is so early that a
85-100% 5 year survival rate could be achieved.

51. COMPLICATIONS
1. Hemorrhage
2. Frequent attacks of pain due to pyelitis, pyelonephritis and
hydronephrosis
3. Pyometra
4. Vesicovaginal fistula
5. Rectovaginal fistula

52. References
1. Dutta, D.C.,Konar, H.(2018). Textbook of Gynecology.(9th Edition). Jaypee Brothers Medical Private Ltd.
2. Tamrakar, A.(2014). Textbook of Gynecology.(1stEdition). Jaypee Brothers Medical Private Ltd.
3. Retrieved from https://www.cdc.gov/std/bv/default.htm
4. Retrieved from https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)
5. Retrieved from https://www.medicalnewstoday.com/articles/184622
6. Retrieved from https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention.html