Cervical cancer is a leading cause of cancer deaths among females in Malawi, especially in those aged 15-44 years, primarily linked to HPV infection. The document details the pathophysiology, risk factors, and various management and prevention strategies, including vaccination and screening methods. Key classifications for diagnosis are provided, alongside recommended interventions and investigations for effective patient management.

1. CERVICAL CANCER
CHN

2. Outline
• Epidemiology
• Pathophysiology
• Risk factors
• Presentation
• Investigations
• Staging
• Management
• Prevention
• Screening methods

3. Epidemiology
• About 2314 cervical cancer deaths occur
annually in Malawi (2012 estimations) (1)
• Cervical cancer ranks as first cause of female
cancer deaths(1)
• Cervical cancer is the first leading cause of
cancer deaths in Malawi aged between 15-44
years in Malawi (1)

4. Pathophysiology of cervical cancer

5. Pathophysiology continued…
• Ectocervix covered by squamous stratified
epithelium
• Canal of cervix lined by columnar epithelium;
one cell thick
• The two meet at Squamocolumnar Junction
(SCJ)
• Position of SCJ varies; lying in cervical os during
infancy but rolls onto ectocervix in puberty,
exposing it to delicate acid environment of
vagina ---> squamous cell metaplasia

6. Pathophysiology continued…
• Transformation zone

7. PATHOPHYSIOLOGY continued…
• Dysplasia
–Metaplasia can be interrupted by other factors
such as HPV infection coupled with other risk
factors  dysplastic epithelium
–Dysplastic epithelium has immature cells with
large nuclei, variable size and shape; and
actively dividing
• Dysplasias referred to as Cervical
Intraepithelial Neoplasia (CIN)- histological
diagnosis.

8. AETIOLOGY OF CERVICAL CANCER
• Human Papilloma Virus (HPV), types 16,18, 33,
35, 45, 52, 58 associated and proven to cause
cervical cancer
• HPV-DNA detected in 95% to 100% of adequate
specimens of cervical cancer, supporting the
claim that HPV is the necessary cause. (J Natl
Cancer Inst Monogr. 2003;(31):3-13)

9. TYPES OF CERVICAL CANCERS
• Two main types of cervical cancer:
–Squamous cell carcinoma: most common
–Adenocarcinoma
–Adenosquamous
–Small cell undifferentiated

10. Risk factors
• HPV infection; necessary but not sufficient
cause
• Other factors:
–Smoking
–Tobacco smoking,
–High parity
–Sex with multiple partners, early sexual debut,
promiscuous partner
–Long-term hormonal contraceptive use
–Co-infection with HIV
–Immunosuppresion
–Genetic

11. Presentation
• Abnormal vaginal bleeding (postcoital,
intermenstrual, postmenopausal or
menorrhagia)
• Vaginal discharge, sometimes
malodorous.
• Symptoms and signs of anaemia
• Dysuria

12. Physical Exam
• General exam
• Pelvic mass
• Bimanual palpation
• Speculum exam
• Rectal exam

13. Pretreatment and staging interventions
• Bimanual pelvic examination
• Speculum examination.
• Colposcopy, endocervical curettage, hysteroscopy.
• Conisation of the cervix is regarded as a clinical
examination.
• Cystoscopy or proctoscopy (confirmed by biopsy)
• Intravenous urography.
• X-ray examination of the lungs and skeleton.
• Other investigations;
• full blood count, urea and electrolytes and liver function tests
• computerised tomography scan

14. MAKING THE DIAGNOSIS
• A tissue biopsy is required to confirm
malignancy and to identify the histological type
of tumour.
• Endocervical curettage (ECC) should be
done as well, to detect any lesions that may be in
the endocervical canal.

15. FIGO CLASSIFICATION OF CERVICAL CANCER
• Stage 0: Pre- invasive carcinoma
• Stage I: Carcinoma confined to cervix
– Ia: microscopically identified, depth <5mm and <7mm wide
• Ia1: invasion < 3mm and < 7mm wide
• Ia2: Invasion >3cm < 7mm wide
– Ib: Confined to cervix, lesion greater than Ia
• Ib1:lesion < 4cm
• Ib2: lesion >4cm
• Stage II: Carcinoma beyond cervix
– IIa: involving vagina but not lower third,
• IIa1: 4cm or less
• IIa2: > 4cm
– IIb: infiltrating parametrium but not pelvic side wall

16. FIGO classification continued…
• Stage III: Involving lower third of vagina
and extending to pelvic wall side
–IIIa: Lower third involved
–IIIb: extending to pelvic wall,
hydronephrosis/nonfunctioning kidneys
• Stage IV: Involving other organs
–IVa: Mucosa of bladder or rectum; extension
beyond true pelvis
–IVb: Distant organs

17. Management of cervical dysplasia
• Ablative methods
–Cryotherapy,
–Electrocautery.
–Laser ablation
• Excional methods
–LEEP
–cone biopsy
–hysterectomy
–Radical hysterectomy plus BLND
Bishop A, et al. Program for Appropriate Technology in Health. 1995

20. Prevention of cervical cancer
• Primary
• Delay of age of sexual intercourse.
• Use of barrier methods of contraception _x0001_
• Bilat
• ral monogamy
• Vacci
• ation
•
• Seco
ary
• Educa
• ion for cervical screening to target under-screened populations.
• Impro
• ement of sensitivity and specificity of screening for the precursors

21. Vaccination Programs
• Gardasil vaccine
– is a quadrivalent vaccine; protects against HPV 6,11, 16 and 18
– Was lincensed in Malawi in 2009
– Not yet administered in the country
– Approved for use in females and males aged between 9 and 26
• Cervarix vaccine:
– Bivalent vaccine: protects against 2 HPV types 16 and 18
– Given in 3 doses over a period of 6 months
– Recommended of use in females between 10 and 25 years

22. CERVICAL
SCREENING
METHODS

23. What is ‘screening’?
• Definition:
–‘the systematic application of a test or enquiry
to identify individuals in a defined population
who are at sufficient risk of a specific disorder,
but have not sought medical attention on
account of symptoms, to enable them to
benefit from further investigation or direct
preventive action’

24. Criteria for a good screening Program
• Affordable
• Sensitive
• Specific
• Acceptable (socially and morally)
• Time and resource factors taken into account: Is
screening going to make any difference

25. Screening methods
• Visual inspection with acetic acid (VIA)
• Visual inspection with acetic acid magnification
• Visual inspection with Lugol’s iodine
• Pap smear
• Human Papilloma Virus DNA
• Speculoscopy
–Inspection with chemiluminiscent light & a low
power magnification following application of
acetic acid
• Cervicography
–Photographs taken by a 35mm specialised

26. 1.Visual inspection with acetic acid
• Promising approach in resource limited
settings
• Application of 3-5% dilute acetic acid on
the cervix
• Detection of opaque acetowhite stain
constitutes a positive test
–Reversible coagulation of intracellular proteins
• Possible results;
–Positive
–

27. VIA Positive

28. 2.Visual inspection with lugol’s iodine
(vili)
• Similar to Schiller iodine test of 1930s
• VILI findings depend on interaction between iodine &
glycogen
• Glycogen abundant in normal, mature squamous
epithelium
– Little or no glycogen in abnormal epithelium
• A dark mahogany brown cervix equates a negative test
• Colourless, pale or mustard yellow cervix equates a
positive test

29. Negative VILI

31. 4. Cytology
• Convetional
–Pap smear
• Liquid based
• Cytology + hpv dna testing
–Uses hybrid capture 2 kit to detect high risk
HPV Serotypes in cervical sample

33. References
• Msyamboza et al. “Burden of cancer in Malawi;
common types, incidence and trends: National
population-based cancer registry”BMC Research
Notes 2012, 5:149
• Mishra G. “An overview of prevention and early
detection of cervical cancer”
• WHO cervical cancer prevention pilot project in 6
African countries
• Handbook of Gynaecology Management. Sylvia
K. Rosevear.
• Clinical gynaecology, TF Kruger, MH Botha