Cervical Cancer: Difference between revisions

No edit summary
No edit summary
 
(6 intermediate revisions by 3 users not shown)
Line 6: Line 6:
== Definition/Description  ==
== Definition/Description  ==
[[File:Cervical-cancer.jpg|thumb]]
[[File:Cervical-cancer.jpg|thumb]]
Cervical cancer is a type of cancer that forms within the tissues of the cervix.<ref name="One">Available at: http://www.cancer.gov/cancertopics/types/cervical. Accessed March 18, 2014.</ref>  The cervix connects the uterus with the vagina (birth canal).<ref name="One" />, <ref name="Two" />The endocervix is the portion of the cervix closest to the uterus whereas the exocervix or ectocervix is closest to the vagina.<ref name="Two">Available at: http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-what-is-cervical-cancer. Accessed March 18, 2014.</ref> The cervix is covered in two main types of cells: squamous cells found on the exocervix, and glandular cells on the endocervix.<ref name="Two" /> Squamous and glandular cells come together at the area known as the transformation zone. It is here where most cervical cancers originate.<ref name="Two" /> Gradually, the normal cells lining this area develop pre-cancerous changes that transform into cancer.<ref name="Two" /> Cervical cancer typically grows at a slow rate and presents asymptomatically.<ref name="One" /> Therefore, it is recommended to receive routine Papanicolaou (Pap) smears to test for changes in the lining of the cervix and/or the development of cancerous cells.<ref name="One" />  
[[Oncology|Carcinoma]] of the cervix is a malignancy arising from the cervix.<ref name=":0">Radiopedia Cervical Cancer Available from:https://radiopaedia.org/articles/carcinoma-of-the-cervix (last accessed 5.9.2020)</ref>   
* The cervix connects the uterus with the vagina (birth canal).<ref name="One">Available at: http://www.cancer.gov/cancertopics/types/cervical. Accessed March 18, 2014.</ref>, <ref name="Two" />
* The endocervix is the portion of the cervix closest to the uterus whereas the exocervix or ectocervix is closest to the vagina.<ref name="Two">Available at: http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-what-is-cervical-cancer. Accessed March 18, 2014.</ref>  
The cervix is covered in two main types of cells: squamous cells found on the exocervix, and glandular cells on the endocervix.<ref name="Two" />  
* Squamous and glandular cells come together at the area known as the transformation zone. It is here where most cervical cancers originate.<ref name="Two" />  
* Gradually, the normal cells lining this area develop pre-cancerous changes that transform into cancer.<ref name="Two" /> Cervical cancer typically grows at a slow rate and presents asymptomatically.<ref name="One" />  


== Prevalence ==
== Epidemiolgy ==
Cervical cancer continues to be listed among the top gynecologic cancers worldwide.
* According to current data, it is ranked fourteenth among all cancers and fourth-ranked cancer among women worldwide
* Globally, there are more than 500,000 new cases of cervical cancer annually.
* Approximately 250,000 women die of cervical cancer annually. 
* In the United States, about 4000 women die from cervical cancer annually with African Americans, Hispanics, and women in low-resource areas having higher disparities in evidenced-based care and a much higher mortality rate. The causative agent is a sexually transmitted viral infection.
* Cervical cancer mortality is higher among women who have not been screened in the last five years and those women without consistent follow-up post identification of a precancerous lesion.
* Trends continue to show that women with the highest risk of mortality may be less likely to receive a vaccination that could potentially prevent cervical cancer.<ref name=":1">Fowler JR, Jack BW. [https://www.ncbi.nlm.nih.gov/books/NBK431093/ Cancer, Cervical].2017 Available from:https://www.ncbi.nlm.nih.gov/books/NBK431093/ (last accessed 5.9.2020)</ref>
In the United States, the diagnosis of invasive stage cervical cancer has declined (75% decline since the 1960s) steadily.<ref name="Three">Ph.d. SE, Ph.d. KL. Understanding Pathophysiology. Mosby Incorporated; 2011.</ref><ref name="Four">Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. W B Saunders Company; 2012.</ref>Screening for cervical cancer has become more common due to the introduction of the Pap smear in the 1930s which made early detection possible.<ref name="Five">Reviews CT. e-Study Guide for: Pathology: Implications for the Physical Therapist by Catherine C. Goodman, ISBN 9781416031185. Cram101 Textbook Reviews; 2012.</ref> 


In the United States, cervical cancer is the fourteenth most common type of cancer found in women and the third most common gynecological malignancy.<ref name="Three">Ph.d. SE, Ph.d. KL. Understanding Pathophysiology. Mosby Incorporated; 2011.</ref>,<ref name="Four">Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. W B Saunders Company; 2012.</ref> However worldwide, cervical cancer is the most commonly found type of cancer in women.<ref name="Three" /> In the United States, the diagnosis of invasive stage cervical cancer has declined (75% decline since the 1960s) steadily.<ref name="Three" /><ref name="Four" />Screening for cervical cancer has become more common due to the introduction of the Pap smear in the 1930s which made early detection possible.<ref name="Five">Reviews CT. e-Study Guide for: Pathology: Implications for the Physical Therapist by Catherine C. Goodman, ISBN 9781416031185. Cram101 Textbook Reviews; 2012.</ref> Although cervical cancer is the most common cause of gynecological cancer-related death worldwide, mortality rates have decreased significantly in the United States (more than 45% since the early 1970s).<ref name="Four" />,<ref name="Five" />  
Cervical cancer is the most common cause of gynecological cancer-related death worldwide
* Mortality rates have decreased significantly in the United States (more than 45% since the early 1970s).<ref name="Four" />,<ref name="Five" />
* 80% to 85% of cervical cancer-related deaths occur in developing countries.<ref name="Six">Available at: http://www.rho.org/about-cervical-cancer.htm. Accessed March 18, 2014.</ref> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
* Pre-invasive carcinoma in situ (no invasion of surrounding tissues) is more common in women 30-40 years of age.<ref name="Four" /> Invasive carcinoma is more frequent in women over 40 years of age.<ref name="Four" /> Women ages 65 and over account for 25% of new cases of cervical cancer.<ref name="Five" />


<br>In the United States, approximately 11,000 women are diagnosed with cervical cancer and 3,700 women die due to the disease each year.<ref name="Five" /> Worldwide, nearly 500,000 women are diagnosed with cervical cancer annually.<ref name="Six">Available at: http://www.rho.org/about-cervical-cancer.htm. Accessed March 18, 2014.</ref> The disease accounts for 288,000 deaths per year.<ref name="Five" />  
== Etiology ==
[[File:Nci-vol-11920-72.gif|thumb|219x219px]]Current literature reports that Human papillomavirus (HPV) is found in the majority of sexually active people at some point during their life. There are more than 130 types of known HPV with 20 HPV types identified as cancer-related.
* HPV-related cervical dysplasia rates are only known in women since men are not screened outside of research protocols.  
* HPV 16 and 18 are the most commonly found HPV in invasive cervical cancer.  
* Population-based HPV prevalence studies show that the greatest prevalence of high-risk HPV occurs in the young adult period before 25 years of life and cervical cancer death peaks in the middle age period of 40 to 50 years of life<ref name=":1" />.


&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
== Risk Factors ==
 
* human papillomavirus (HPV) 16 and 18 infections
&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 80% to 85% of cervical cancer-related deaths occur in developing countries.<ref name="Six" /> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
* multiple sexual partners or a male partner with multiple previous or current sexual partners
 
* young age at first intercourse
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
* high parity
 
* immunosuppression
Pre-invasive carcinoma in situ (no invasion of surrounding tissues) is more common in women 30-40 years of age.<ref name="Four" /> Invasive carcinoma is more frequent in women over 40 years of age.<ref name="Four" /> Women ages 65 and over account for 25% of new cases of cervical cancer.<ref name="Five" />  
* certain HLA subtypes
* oral contraceptives
* nicotine/[[Smoking Cessation and Brief Intervention|smoking]] <ref name=":0" />


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
 
Presenting symptoms include:
*May be asymptomatic (early stages)<ref name="Four" />
* vaginal bleeding
*Painful intercourse or pain after intercourse<ref name="Four" />
* vaginal discharge
*Unexplained or unexpected bleeding (after intercourse or between menstrual periods)<ref name="Three" />,<ref name="Four" />
* subclinical: an abnormal cervical cancer screening test<ref name=":0" />
*Watery, foul-smelling vaginal discharge (serosanguineous or yellowish color)<ref name="Three" />,<ref name="Four" />
[[File:Stages2.jpg|right|frameless|656x656px]]  
*Pelvic, epigastric, or low back pain (with large lesions)<ref name="Three" />,<ref name="Five" />
*Hemiparesis, headache (cancer recurrence with brain metastases)<ref name="Four" />
*Bowel and bladder problems (later stages)<ref name="Five" />
[[File:The development of cervical cancer.jpg|thumb|462x462px]]
[[Image:Stages2.jpg|816x466px]]  


== Clinical Staging for Cervical Cancer  ==
== Clinical Staging for Cervical Cancer  ==


Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, based on clinical examination rather than surgical findings<ref name="Five" />. For premalignant dysplastic changes, cervical intraepithelial neoplasia (CIN) grading is used.<br>
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, based on clinical examination rather than surgical findings<ref name="Five" />. Revised FIGO staging of cervical carcinoma 2018
 
<nowiki>*</nowiki>If the woman is treated surgically, the pathology report can be used to provide a separate pathologic stage; this does not replace the original clinical stage. 
 
{| cellspacing="1" cellpadding="1" border="1" style="width: 832px; height: 399px;"
|-
| '''Stage'''
| <br>
| <br>
| '''Characteristics'''
|-
| 0
| <br>
| <br>
| Full-thickness involvement of the epithelium (surface) without invasion into the stroma (support structure); carcinoma in situ (CIN grades 1, 2, or 3 are assigned)
|-
| I
| <br>
| <br>
| Invaded the cervix but has not spread any further
|-
| <br>
| IA
| <br>
| Small enough it can only be diagnosed by microscopy; there are no visible lesions
|-
| <br>
| <br>
| IA1
| Area of invasion is less than 3 millimeters (1/8-inch) deep and less than 7 millimeters (1/4-inch) wide
|-
| <br>
| <br>
| IA2
| Area of invasion is between 3 and 5 millimeters (about 1/5-inch) with horizontal spread of 7 millimeters or less
|-
| <br>
| IB
| <br>
| Visible lesion or a microscopic lesion with more than 5 millimeters of depth or horizontal spread of more than 7 millimeters; has spread into connective tissue of the cervix
|-
| <br>
| <br>
| IB1
| Visible lesion 4 centimeters or less in greatest dimension
|-
| <br>
| <br>
| IB2
| Visible lesion more than 4 centimeters
|-
| II
| <br>
| <br>
| Invades beyond cervix to upper 1/3 of the vagina only
|-
| <br>
| IIA
| <br>
| Without parametrial (tissue next to the cervix) invasion
|-
| <br>
| IIB
| <br>
| With parametrial invasion
|-
| III
| <br>
| <br>
| Extends to pelvic wall or lower 1/3 of the vagina
|-
| <br>
| IIIA
| <br>
| Involves lower 1/3 of vagina but not the pelvic wall
|-
| <br>
| IIIB
| <br>
| Extends to pelvic wall and/or blocks urine flow to the bladder; may have spread to pelvic lymph nodes
|-
| IV
| <br>
| <br>
| Extends beyond the true pelvis
|-
| <br>
| IVA
| <br>
| Invades mucosa of bladder or rectum and/or extends beyond true pelvis
|-
| <br>
| IVB
| <br>
| Distant metastasis to other organs (beyond the pelvis) such as lungs
|}
 
== Associated Co-morbidities  ==
 
Cervical cancer is associated with and may be the manifestation of human papillomavirus (HPV).<ref name="Five" /> 
 
== Medications  ==
 
=== Drugs Approved to Prevent Cervical Cancer ===
*Cervarix (Recombinant HPV Bivalent Vaccine)<ref name="One" />
*Gardasil (Recombinant HPV Quadrivalent Vaccine)
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -Gardasil protects against two strains of HPV that cause cervical cancer.<ref name="Five" /> The vaccine is administered to females between the ages of 9 and 26.<ref name="Five" /> The vaccination is especially important for women who do not have access to regular cervical cancer screenings.<ref name="Five" /><br>
 
=== Drugs Approved to Treat Cervical Cancer ===
'''''*'''''Systemic chemotherapy involves injecting or orally administering cancer-treating drugs.<ref name="Seven">Available at: http://www.cancer.org/treatment/treatmentsandsideeffects/treatmenttypes/chemotherapy/chemotherapyprinciplesanin-depthdiscussionofthetechniquesanditsroleintreatment/chemotherapy-principles-types-of-chemo-drugs. Accessed March 19, 2014.</ref> These drugs then enter the bloodstream, and travel throughout the body, reaching areas of cancerous growth.<ref name="Seven" />Chemotherapy can work in the following ways:<ref name="One" /><ref name="Eight">Available at: http://www.cancerresearchuk.org/cancer-help/about-cancer/treatment/chemotherapy/about/how-chemotherapy-works. Accessed March 18, 2014.</ref>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -Cure the cancer<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -Shrink the cancer<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -Relieve symptoms<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -Prolong life span by controlling cancer or putting it into remission <br>
 
Chemotherapy is often delivered in cycles.<ref name="Seven" /> Periods of treatment are followed by periods of recovery.<ref name="Seven" /><br>
 
*Blenoxane (Bleomycin)-mixture of cytotoxic glycopeptide antibiotics;<span style="font-style: italic;"> </span>''Side effects- pulmonary fibrosis, hypotension, mental confusion, fever, chills and wheezing.<ref name="Nine">Available at: http://www.rxlist.com/script/main/hp.asp. Accessed March 19, 2014.</ref>''
*Cisplatin*-sterile aqueous solution that contains sodium chloride in water for injection; ''Side effects- renal toxicity, nausea and vomitting, myelo-suppression, ototoxicity, facial edema, bronchoconstriction, tachycardia, hypotension<ref name="Nine" />''
*Hycamtin (Topotecan Hydrochloride)- antitumor drug with topoisomerase 1-inhibitory activity<ref name="Nine" />
*Platinol (Cisplatin)
*Platinol-AQ (Cisplatin)
*Topotecan Hydrochloride (Hycamtin)
*Carboplatin
*Paclitaxel* (Taxol)- nonaqueous solution with antitumor activity; ''Side effects- anaphylaxis, dyspnea, hypotension, angioedema, urticaria (hives)<ref name="Nine" />''
*Gemcitabine (Gemzar)-nucleoside metabolic inhibitor that exhibits antitumor activity; ''Side effects- pallor, easy bruising or bleeding, unusual weakness, decreased urination, nausea, upper stomach pain, dark urine, clay-colored stools, jaundice, chest pain, pain spreading to arm or shoulder, diaphoresis, signs of allergic reaction<ref name="Nine" />''


&nbsp;*Currently, Cisplatin is the most effective single chemotherapy drug for recurrent disease.<ref name="Twelve">Cervical cancer. The Lancet. 2003;361(9376):2217.</ref> When administered with paclitaxel, the combination is more effective than cisplatin alone (in terms of response rate and survival).<ref name="Twelve" />
FIGO no longer includes Stage 0 (Tis)


===Drug Combinations Used in Cervical Cancer===
I: confined to cervix uteri (extension to the corpus should be disregarded)
*Gemcitabine-Cisplatin<ref name="One" />


== Diagnostic Tests/Lab Tests/Lab Values  ==
II: beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall


Medical professionals who are able to diagnose cervical cancer include''':<ref name="Green">Available at: http://www.webmd.com/cancer/cervical-cancer/cervical-cancer-when-to-call-a-doctor. Accessed March 19, 2014.</ref><br>'''
III: 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


*Gynecologists
IV: carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum<ref name=":0" />
*Obstetricians
*Family physicians
*Nurse practitioner
*Physican assistants
*Internists


=== Screening Tests ===
== Treatment and prognosis ==
[[File:Figure 28 02 08.jpg|thumb|479x479px]]
Prognosis is affected by many factors which include:
A Pap smear, also referred to as a Pap test, tests cervical cells for abnormal changes.<ref name="Purple">Available at: http://www.womenshealth.gov/publications/our-publications/fact-sheet/pap-test.html. Accessed March 20, 2014.</ref> It is these abnormal cellular changes that can lead to cervical cancer if left untreated.<ref name="Purple" /> Cervical cancer is highly preventable, given that regular Pap smears are performed.<ref name="Purple" /> It is recommended that women receive annual Pap smears beginning three years after the onset of vaginal intercourse but no later than 21 years of age.<ref name="Five" /> Women aged 70 and older, with an intact cervix, are no longer required to recevie Pap smears if they have had no positive test results within the last 10 years.<ref name="Five" /> Women who do not have a cervix (ex. hysterectomy), as well as no history of abnormal Pap results or cervical cancer can discontinue annual Pap smears.<ref name="Purple" /> However, some medical professionals support routine Pap smears regardless of age, presence of cervix, or past negative test results.<ref name="Five" /> '''Even if not currently sexually active, or protected sex is being practiced, regular Pap smears should still be performed.'''<ref name="Purple" />  
* tumour stage
* the volume of the primary mass
* histologic grade
Five-year survival rates vary between 92% for stage I disease and 17% for stage IV disease<ref name=":0" />


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
== Screening Tests ==
 
Cervical cancer screening is one of the best cancer prevention achievements. However, there continue to be women who are not compliant with screening recommendations. Many die from this preventable cancer due to inadequate screening. Public health efforts are available to increase access to screening with appropriate follow-up<ref>Mansour T, Limaiem F. Cancer, cervical screening. InStatPearls [Internet] 2019 Jan 4. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK537348/ (accessed5.9.2020)</ref>[[File:Figure 28 02 08.jpg|thumb|479x479px]]
<br>
* According to the United States Preventative Services Task Force (USPTF), Pap screening is recommended beginning at age 21 years of age.  
 
* HPV testing begins at age 30 in conjunction with Pap smear cytology.
=== Diagnostic Tests ===
* Screening is recommended every three years for women with continued normal screening and those low risk for cervical cancer.
 
* For women over 30 years of age, cytology can be every five years with HPV testing.
==== Imaging<ref name="Black" /> ====
* Level A recommendation or women with low-risk status and consistent normal screenings can discontinue cervical cancer cytology and HPV testing at age 65.
''*Tumor must be at least stage 1b or greater to be seen on a radiograph.''<br>
* Women who have had a total abdominal hysterectomy including removal of the cervix for benign disease do not require further screening<ref name=":1" />
 
*Magnetic resonance imaging (MRI)- imaging modality of choice for depicting primary tumor<br>  
*Ultrasound- tumor appears as a hypoechoic (dark) cervical mass; should not be used as a primary diagnostic tool<br>
*Computed tomography (CT)-used to assess disease in more advanced stages and/or monitor distant metastasis<br>
*Positron emission tomography (PET)-CT- imaging modality of choice for staging cervical cancer<br>
 
==== Biopsy<ref name="Two" /> ====
*Colposcopic
*Endocervical curettage (scraping)
*Cone
 
== Etiology/Causes  ==
[[File:Nci-vol-11920-72.gif|thumb|219x219px]]
The presence of HPV is a common feature in the majority of individuals diagnosed with cervical cancer.<ref name="Five" /> Clinical studies show that the transference of HPV during unprotected sexual intercourse is the primary cause of cervical cancer.<ref name="Five" /> The disease can spread through local extension and through the lymphatic system to the retroperitoneal lymph nodes.<ref name="Four" />
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
 
<br>
 
=== Risk Factors<ref name="Four" />,<ref name="Five" /> ===
*Early age at first sexual intercourse (17 years or younger)
*Early age at first pregnancy
*Tobacco use, including exposure to passive smoke
*Low socioeconomic status (lack of screening)
*History of any sexually transmitted disease (STD), especially HPV and human immunodeficiency virus (HIV)
*History of multiple sex partners (five or more)
*History of childhood sexual abuse
*Intimate partner abuse
*Women whose mothers used the drug diethylstilbestrol (DES) during pregnancy
*Hormonal contraceptive use
*Ethnic background- African-American women experience a 72% higher incidence compared with Caucasian women
*High parity (number of births)
*Alcohol and drug use (impaired decision making)


== Systemic Involvement  ==
== Systemic Involvement  ==
 
* Cervical cancer affects the female reproductive system.  
Cervical cancer affects the female reproductive system.  
* Pressure from tumor on neighboring structures can affect the urinary system and gastrointestinal system (bowel).<ref name="Five" />
 
* Metastasis has been known to occur to the central nervous system (CNS), pulmonary system, urinary system (bladder), gastrointestinal system (rectum), retroperitoneal lymph nodes, paracervical lymphatics and parametrial lymphatics.<ref name="Four" />
Pressure from tumor on neighboring structures can affect the urinary system and gastrointestinal system (bowel).<ref name="Five" />  
 
Metastasis has been known to occur to the central nervous system (CNS), pulmonary system, urinary system (bladder), gastrointestinal system (rectum), retroperitoneal lymph nodes, paracervical lymphatics and parametrial lymphatics.<ref name="Four" />  


== Medical Management  ==
== Medical Management  ==
Precancerous lesions are managed conservatively for those women younger than 25 years.
* The majority of abnormal findings in women younger than 25 are low-risk cervical dysplasia and will resolve spontaneously.
Colposcopy evaluates persistent, abnormal cytology or lesions suspected to be greater than low risk. These are managed according to findings.
* Low-risk lesions may be watched and reevaluated more frequently
* High-risk lesions are treated based on size, location, and staging.
* Cryotherapy or excision is done to manage pre-cancerous lesions that are limited in size and depth.
* Conization, laser or Loop Electrosurgical Excision Procedure (LEEP) are used in managing those lesions that include the endocervical canal and are more extensive.
* LEEP may provide better visualization of the squamocolumnar junction and provide the benefit of less bleeding in the outpatient setting. 
If cancer is diagnosed, the next step in management is staging (see above) to determine further treatment.
* Treatment of early-stage disease includes a radical hysterectomy.
* For women who desire pregnancy with early-stage disease, conization may be the initial treatment.
* [[Chemotherapy Side Effects and Syndromes|Chemotherapy]] and [[Radiation Side Effects and Syndromes|radiation]] are usually the next steps in treatment after hysterectomy to slow the growth of cancer<ref name=":1" />


The treatment of cervical cancer varies depending on clinical staging. <br>
== Physiotherapy Management  ==
 
'''Recommended Treatment Based on Clinical Staging for Cancer of the Cervix'''<ref name="Three" />
 
{| cellspacing="1" cellpadding="1" border="1" style="width: 826px; height: 186px;"
|-
| '''Stage'''<br>
| '''Treatment'''<br>
|-
| 0<br>
| Cryosurgery, laser surgery, loop electrosurgical excision procedure (LEEP), electrocautery<br>
|-
| I<br>
| LEEP, laser surgery, conization, cryosurgery, radiation without surgery, total hyterectomy with or without bilateral pelvic lymphadenectomy<br>
|-
| II<br>
| Radiation, radical hysterectomy and pelvic lymphadenectomy often followed by radiation<br>
|-
| III<br>
| Radiation with external beam or implant(s) with or without hydroxyurea <br>
|-
| IV<br>
| Radiation with external beam or implant(s) with or without hydroxyurea, chemotherapy (cisplatin or ifosfamide with distant site involvement)<br>
|}
 
Recent findings have shown that women staged with CIN&nbsp;2 or 3 may not require immediate treatment, as the abnormality may regress naturally.<ref name="Five" /><br>
 
Previous research has shown that cisplatin-based chemotherapy combined with radiation has increased survival rates in women with locally advanced cervical cancer.<ref name="Five" />
 
Recently, new research has been conducted to determine the effectiveness of concurrent cisplatin-based chemotherapy with an epidermal growth factor receptor inhibitor (E).<ref name="Red">Nogueira-rodrigues A, Moralez G, Grazziotin R, et al. Phase 2 trial of erlotinib combined with cisplatin and radiotherapy in patients with locally advanced cervical cancer. Cancer. 2014;</ref> Epidermal growth factor receptor (EGFR) is commonly overexpressed in cervical cancer; therefore, the inhibitor, which has antitumor effects, acts to decrease the expression of EGFR.<ref name="Red" /> The results of this study suggest that treatment with E combined with cisplatin-based chemotherapy has been shown to work against a locally advanced cervical cancer.<ref name="Red" />
 
== Physiotherapy Management (Current Best Evidence) ==
[[File:Cervical cancer.jpg|thumb]]
[[File:Cervical cancer.jpg|thumb]]


The primary role of physical therapy associated with cervical cancer is education. Physiotherapists should be an advocate to their patients to stay regular with Pap smears and to practice other preventative measures (physical examinations, vaccines, protected sex). It is important for physiotherapists to gather a thorough patient history, including questions that encompass issues such as vaginal bleeding, GI or genitourinary function, location of pain and discomfort, and pre-existing comorbidities.<ref name="Five" /> If issues of concern are found during the evaluation, physiotherapists should refer the patient to their primary care physician for further testing.  
The primary role of physical therapy associated with cervical cancer is education. Physiotherapists should be an advocate to their patients to stay regular with Pap smears and to practice other preventative measures (physical examinations, vaccines, protected sex). It is important for physiotherapists to gather a thorough patient history, including questions that encompass issues such as vaginal bleeding, GI or genitourinary function, location of pain and discomfort, and pre-existing comorbidities.<ref name="Five" /> If issues of concern are found during the evaluation, physiotherapists should refer the patient to their primary care physician for further testing.  


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
The main risk factors of lower limb lymphadema are BMI , FIGO stage, age , radiotherapy, lymphynode dissection and the number of lymph nodes removed. These risk factors should be considered while treating the patients of cervical cancer.<ref>Hu H, Fu M, Huang X, Huang J, Gao J. Risk factors for lower extremity lymphedema after cervical cancer treatment: a systematic review and meta-analysis. Translational cancer research. 2022 Jun;11(6):1713.</ref>Prophylactic complex physiotherapy treatment was associated with lower rates of lymphedema and better patient reported symptom scores based on Gynecologic Cancer Lymphedema Questionnaire.<ref>Daggez M, Koyuncu EG, Kocabaş R, Yener C. Prophylactic complex physiotherapy in gynecologic cancer survivors: patient-reported outcomes based on a lymphedema questionnaire. International Journal of Gynecologic Cancer. 2023 Dec 1;33(12).</ref>
 
Compresssion therapy is the gold standard therapy for lymphadema of lowerlimb. It reduces the volume of the limb and it is also considered to be fast acting.<ref>BORDEA MP, EL-BSAT R, PREDESCU C, DANCIU R, VOINEA S, BORDEA C. REHABILITATION AFTER LOWER LIMB LYMPHOEDEMA IN GYNAECOLOGICAL MALIGNANCIES–THE ROLE OF PHYSIOTHERAPY.</ref>Patients can be taught to tighten the compression system if its gets loose with time. For stage two lymphadema, the sub-bandage pressure of 45 mm Hg should be provided. For intolerant patients it should be between 15 to 25 mm Hg.


physiotherapists should look for signs and symptoms of metastasis in women with a previous history of cervical cancer. Lymph node palpation is an important component of the examination due to the high rate of metastasis to this location.<ref name="Five" /> Questions that address possible warning signs of metastasis (ex. rapid weight loss, night pain/sweats, vaginal bleeding, fatigue, frequent infections) should be included in patient history.<ref name="Four" /> If issues of concern are found during the evaluation, physiotherapists should refer the patient to their primary care physician for further testing. <br>
Physiotherapists should look for signs and symptoms of metastasis in women with a previous history of cervical cancer. Lymph node palpation is an important component of the examination due to the high rate of metastasis to this location.<ref name="Five" /> Questions that address possible warning signs of metastasis (ex. rapid weight loss, night pain/sweats, vaginal bleeding, fatigue, frequent infections) should be included in patient history.<ref name="Four" /> If issues of concern are found during the evaluation, physiotherapists should refer the patient to their primary care physician for further testing.


Women who have a current diagnosis of cervical cancer can benefit from physical therapy services. Physical therapy provides symptom relief by addressing impairments such as fatigue, muscle weakness, and management of pain.<ref name="Four" />  
Women who have a current diagnosis of cervical cancer can benefit from physical therapy services. Physical therapy provides symptom relief by addressing impairments such as fatigue, muscle weakness, and management of pain.<ref name="Four" />  
Line 295: Line 132:
In an outpatient setting, it is recommended for physiotherapists to monitor vital signs and rate of perceived exertion (RPE) during exercise when working with patients with cancer.<ref name="Four" />
In an outpatient setting, it is recommended for physiotherapists to monitor vital signs and rate of perceived exertion (RPE) during exercise when working with patients with cancer.<ref name="Four" />


=== Local Vaginal Treatment of the Cervix'''<ref name="Four" />''' ===
Research suggest that pelvic floor muscle training prior to radiation therapy for cervical cancer is an important measure to protect the strength of pelvic floor muscles and to prevent incontinence. <ref>Sacomori C, Araya-Castro P, Diaz-Guerrero P, Ferrada IA, Martínez-Varas AC, Zomkowski K. Pre-rehabilitation of the pelvic floor before radiation therapy for cervical cancer: a pilot study. International urogynecology journal. 2020 Nov;31:2411-8.</ref>
*Escharotic treatment- This plant and mineral-based extract is applied to the surface of the cervix. It contains proteolytic properties that dissolve the top layer of cervical cells, which are affected by the HPV&nbsp;virus.
*Vaginal suppository treatment- Vag pak acts to enhance the immune system and rid cervical cells of infection.


== Differential Diagnosis  ==
== Differential Diagnosis  ==
 
Benign Conditions<ref name="Ten">Available at: http://oncolex.org/en/Gynecological-cancer/Diagnoses/Cervical-cancer/Background/DifferentialDiagnoses. Accessed March 19, 2014.</ref><ref name="Black">Available at: http://radiopaedia.org/articles/carcinoma-of-the-cervix. Accessed March 19, 2014.</ref>
=== Benign Conditions<ref name="Ten">Available at: http://oncolex.org/en/Gynecological-cancer/Diagnoses/Cervical-cancer/Background/DifferentialDiagnoses. Accessed March 19, 2014.</ref><ref name="Black">Available at: http://radiopaedia.org/articles/carcinoma-of-the-cervix. Accessed March 19, 2014.</ref> ===
*Polyps  
*Polyps  
*Cervical conditions (infections, polyps, myomas)  
*Cervical conditions (infections, polyps, myomas)  
*Iatrogenic (birth control pills, HRT, IUD)  
*Iatrogenic (birth control pills, HRT, IUD)  
*Cervical ectopic pregnancy (consider with women of childbearing age)<br>
*Cervical ectopic pregnancy (consider with women of childbearing age)<br>
 
Malignant Conditions'''<ref name="Ten" /><ref name="Black" />'''
=== Malignant Conditions'''<ref name="Ten" /><ref name="Black" />''' ===
*Endometrial cancer with cervical invasion  
*Endometrial cancer with cervical invasion  
*Other cervical malignant condition (sarcoma, lymphoma, metastasis)  
*Other cervical malignant condition (sarcoma, lymphoma, metastasis)  
*Invasion of the cervix from other organs in proximity:
*Invasion of the cervix from other organs in proximity:
**Bladder cancer
**Bladder cancer
**Rectal cancer
**[[Colorectal Cancer|Rectal cancer]]
**Vaginal cancer
**Vaginal cancer
**Uterine cancer
**Uterine cancer
== Resources    ==
'''National Institue of Cancer''', Cervical Cancer: http://www.cancer.gov/<br>
'''American Cancer Society''', Cervical Cancer: http://www.cancer.org/<br>
'''NC&nbsp;Cervical Cancer Resource Directory''': http://www.ccresourcedirectory.org/
== References  ==
== References  ==
<references />&nbsp;  
<references />&nbsp;  
Line 334: Line 159:
[[Category:Pelvis - Conditions]]
[[Category:Pelvis - Conditions]]
[[Category:Oncology]]
[[Category:Oncology]]
[[Category:Genetic Disorders]]

Latest revision as of 12:12, 31 January 2024

Original Editors - Anna Marie Usery & Stephanie Wilton from Bellarmine University's Pathophysiology of Complex Patient Problems project. Rewan Elsayed Elkanafany

Top Contributors - Anna Usery, Stephanie Wilton, Kim Jackson, Nupur Smit Shah, Rewan Elsayed Elkanafany, Elaine Lonnemann, WikiSysop, Lucinda hampton, Wendy Walker, Vidya Acharya and Manisha Shrestha  

Definition/Description[edit | edit source]

Cervical-cancer.jpg

Carcinoma of the cervix is a malignancy arising from the cervix.[1]

  • The cervix connects the uterus with the vagina (birth canal).[2], [3]
  • The endocervix is the portion of the cervix closest to the uterus whereas the exocervix or ectocervix is closest to the vagina.[3]

The cervix is covered in two main types of cells: squamous cells found on the exocervix, and glandular cells on the endocervix.[3]

  • Squamous and glandular cells come together at the area known as the transformation zone. It is here where most cervical cancers originate.[3]
  • Gradually, the normal cells lining this area develop pre-cancerous changes that transform into cancer.[3] Cervical cancer typically grows at a slow rate and presents asymptomatically.[2]

Epidemiolgy[edit | edit source]

Cervical cancer continues to be listed among the top gynecologic cancers worldwide.

  • According to current data, it is ranked fourteenth among all cancers and fourth-ranked cancer among women worldwide
  • Globally, there are more than 500,000 new cases of cervical cancer annually.
  • Approximately 250,000 women die of cervical cancer annually. 
  • In the United States, about 4000 women die from cervical cancer annually with African Americans, Hispanics, and women in low-resource areas having higher disparities in evidenced-based care and a much higher mortality rate. The causative agent is a sexually transmitted viral infection.
  • Cervical cancer mortality is higher among women who have not been screened in the last five years and those women without consistent follow-up post identification of a precancerous lesion.
  • Trends continue to show that women with the highest risk of mortality may be less likely to receive a vaccination that could potentially prevent cervical cancer.[4]

In the United States, the diagnosis of invasive stage cervical cancer has declined (75% decline since the 1960s) steadily.[5][6]Screening for cervical cancer has become more common due to the introduction of the Pap smear in the 1930s which made early detection possible.[7]

Cervical cancer is the most common cause of gynecological cancer-related death worldwide

  • Mortality rates have decreased significantly in the United States (more than 45% since the early 1970s).[6],[7]
  • 80% to 85% of cervical cancer-related deaths occur in developing countries.[8]                  
  • Pre-invasive carcinoma in situ (no invasion of surrounding tissues) is more common in women 30-40 years of age.[6] Invasive carcinoma is more frequent in women over 40 years of age.[6] Women ages 65 and over account for 25% of new cases of cervical cancer.[7]

Etiology[edit | edit source]

Nci-vol-11920-72.gif

Current literature reports that Human papillomavirus (HPV) is found in the majority of sexually active people at some point during their life. There are more than 130 types of known HPV with 20 HPV types identified as cancer-related.

  • HPV-related cervical dysplasia rates are only known in women since men are not screened outside of research protocols.
  • HPV 16 and 18 are the most commonly found HPV in invasive cervical cancer.
  • Population-based HPV prevalence studies show that the greatest prevalence of high-risk HPV occurs in the young adult period before 25 years of life and cervical cancer death peaks in the middle age period of 40 to 50 years of life[4].

Risk Factors[edit | edit source]

  • human papillomavirus (HPV) 16 and 18 infections
  • multiple sexual partners or a male partner with multiple previous or current sexual partners
  • young age at first intercourse
  • high parity
  • immunosuppression
  • certain HLA subtypes
  • oral contraceptives
  • nicotine/smoking [1]

Characteristics/Clinical Presentation[edit | edit source]

Presenting symptoms include:

  • vaginal bleeding
  • vaginal discharge
  • subclinical: an abnormal cervical cancer screening test[1]
Stages2.jpg

Clinical Staging for Cervical Cancer[edit | edit source]

Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, based on clinical examination rather than surgical findings[7]. Revised FIGO staging of cervical carcinoma 2018

FIGO no longer includes Stage 0 (Tis)

I: confined to cervix uteri (extension to the corpus should be disregarded)

II: beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall

III: 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

IV: carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum[1]

Treatment and prognosis[edit | edit source]

Prognosis is affected by many factors which include:

  • tumour stage
  • the volume of the primary mass
  • histologic grade

Five-year survival rates vary between 92% for stage I disease and 17% for stage IV disease[1]

Screening Tests[edit | edit source]

Cervical cancer screening is one of the best cancer prevention achievements. However, there continue to be women who are not compliant with screening recommendations. Many die from this preventable cancer due to inadequate screening. Public health efforts are available to increase access to screening with appropriate follow-up[9]

Figure 28 02 08.jpg
  • According to the United States Preventative Services Task Force (USPTF), Pap screening is recommended beginning at age 21 years of age.
  • HPV testing begins at age 30 in conjunction with Pap smear cytology.
  • Screening is recommended every three years for women with continued normal screening and those low risk for cervical cancer.
  • For women over 30 years of age, cytology can be every five years with HPV testing.
  • Level A recommendation or women with low-risk status and consistent normal screenings can discontinue cervical cancer cytology and HPV testing at age 65.
  • Women who have had a total abdominal hysterectomy including removal of the cervix for benign disease do not require further screening[4]

Systemic Involvement[edit | edit source]

  • Cervical cancer affects the female reproductive system.
  • Pressure from tumor on neighboring structures can affect the urinary system and gastrointestinal system (bowel).[7]
  • Metastasis has been known to occur to the central nervous system (CNS), pulmonary system, urinary system (bladder), gastrointestinal system (rectum), retroperitoneal lymph nodes, paracervical lymphatics and parametrial lymphatics.[6]

Medical Management[edit | edit source]

Precancerous lesions are managed conservatively for those women younger than 25 years.

  • The majority of abnormal findings in women younger than 25 are low-risk cervical dysplasia and will resolve spontaneously.

Colposcopy evaluates persistent, abnormal cytology or lesions suspected to be greater than low risk. These are managed according to findings.

  • Low-risk lesions may be watched and reevaluated more frequently
  • High-risk lesions are treated based on size, location, and staging.
  • Cryotherapy or excision is done to manage pre-cancerous lesions that are limited in size and depth.
  • Conization, laser or Loop Electrosurgical Excision Procedure (LEEP) are used in managing those lesions that include the endocervical canal and are more extensive.
  • LEEP may provide better visualization of the squamocolumnar junction and provide the benefit of less bleeding in the outpatient setting.

If cancer is diagnosed, the next step in management is staging (see above) to determine further treatment.

  • Treatment of early-stage disease includes a radical hysterectomy.
  • For women who desire pregnancy with early-stage disease, conization may be the initial treatment.
  • Chemotherapy and radiation are usually the next steps in treatment after hysterectomy to slow the growth of cancer[4]

Physiotherapy Management[edit | edit source]

Cervical cancer.jpg

The primary role of physical therapy associated with cervical cancer is education. Physiotherapists should be an advocate to their patients to stay regular with Pap smears and to practice other preventative measures (physical examinations, vaccines, protected sex). It is important for physiotherapists to gather a thorough patient history, including questions that encompass issues such as vaginal bleeding, GI or genitourinary function, location of pain and discomfort, and pre-existing comorbidities.[7] If issues of concern are found during the evaluation, physiotherapists should refer the patient to their primary care physician for further testing.

The main risk factors of lower limb lymphadema are BMI , FIGO stage, age , radiotherapy, lymphynode dissection and the number of lymph nodes removed. These risk factors should be considered while treating the patients of cervical cancer.[10]Prophylactic complex physiotherapy treatment was associated with lower rates of lymphedema and better patient reported symptom scores based on Gynecologic Cancer Lymphedema Questionnaire.[11]

Compresssion therapy is the gold standard therapy for lymphadema of lowerlimb. It reduces the volume of the limb and it is also considered to be fast acting.[12]Patients can be taught to tighten the compression system if its gets loose with time. For stage two lymphadema, the sub-bandage pressure of 45 mm Hg should be provided. For intolerant patients it should be between 15 to 25 mm Hg.

Physiotherapists should look for signs and symptoms of metastasis in women with a previous history of cervical cancer. Lymph node palpation is an important component of the examination due to the high rate of metastasis to this location.[7] Questions that address possible warning signs of metastasis (ex. rapid weight loss, night pain/sweats, vaginal bleeding, fatigue, frequent infections) should be included in patient history.[6] If issues of concern are found during the evaluation, physiotherapists should refer the patient to their primary care physician for further testing.

Women who have a current diagnosis of cervical cancer can benefit from physical therapy services. Physical therapy provides symptom relief by addressing impairments such as fatigue, muscle weakness, and management of pain.[6]

While treating patients with cancer, it is important for physiotherapists to review hematological values.[6] Aerobic exercise is contraindicated for patients receiving chemotherapy treatments when lab values are as follows:[6]

Platelet count <50,000/mm3
Hemoglobin <10g/dL
White blood cell count <3,000/mm3
Absolute granulocytes <2,500/mm3

In an outpatient setting, it is recommended for physiotherapists to monitor vital signs and rate of perceived exertion (RPE) during exercise when working with patients with cancer.[6]

Research suggest that pelvic floor muscle training prior to radiation therapy for cervical cancer is an important measure to protect the strength of pelvic floor muscles and to prevent incontinence. [13]

Differential Diagnosis[edit | edit source]

Benign Conditions[14][15]

  • Polyps
  • Cervical conditions (infections, polyps, myomas)
  • Iatrogenic (birth control pills, HRT, IUD)
  • Cervical ectopic pregnancy (consider with women of childbearing age)

Malignant Conditions[14][15]

  • Endometrial cancer with cervical invasion
  • Other cervical malignant condition (sarcoma, lymphoma, metastasis)
  • Invasion of the cervix from other organs in proximity:

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Radiopedia Cervical Cancer Available from:https://radiopaedia.org/articles/carcinoma-of-the-cervix (last accessed 5.9.2020)
  2. ↑ 2.0 2.1 Available at: http://www.cancer.gov/cancertopics/types/cervical. Accessed March 18, 2014.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Available at: http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-what-is-cervical-cancer. Accessed March 18, 2014.
  4. ↑ 4.0 4.1 4.2 4.3 Fowler JR, Jack BW. Cancer, Cervical.2017 Available from:https://www.ncbi.nlm.nih.gov/books/NBK431093/ (last accessed 5.9.2020)
  5. ↑ Ph.d. SE, Ph.d. KL. Understanding Pathophysiology. Mosby Incorporated; 2011.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. W B Saunders Company; 2012.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 Reviews CT. e-Study Guide for: Pathology: Implications for the Physical Therapist by Catherine C. Goodman, ISBN 9781416031185. Cram101 Textbook Reviews; 2012.
  8. ↑ Available at: http://www.rho.org/about-cervical-cancer.htm. Accessed March 18, 2014.
  9. ↑ Mansour T, Limaiem F. Cancer, cervical screening. InStatPearls [Internet] 2019 Jan 4. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK537348/ (accessed5.9.2020)
  10. ↑ Hu H, Fu M, Huang X, Huang J, Gao J. Risk factors for lower extremity lymphedema after cervical cancer treatment: a systematic review and meta-analysis. Translational cancer research. 2022 Jun;11(6):1713.
  11. ↑ Daggez M, Koyuncu EG, Kocabaş R, Yener C. Prophylactic complex physiotherapy in gynecologic cancer survivors: patient-reported outcomes based on a lymphedema questionnaire. International Journal of Gynecologic Cancer. 2023 Dec 1;33(12).
  12. ↑ BORDEA MP, EL-BSAT R, PREDESCU C, DANCIU R, VOINEA S, BORDEA C. REHABILITATION AFTER LOWER LIMB LYMPHOEDEMA IN GYNAECOLOGICAL MALIGNANCIES–THE ROLE OF PHYSIOTHERAPY.
  13. ↑ Sacomori C, Araya-Castro P, Diaz-Guerrero P, Ferrada IA, Martínez-Varas AC, Zomkowski K. Pre-rehabilitation of the pelvic floor before radiation therapy for cervical cancer: a pilot study. International urogynecology journal. 2020 Nov;31:2411-8.
  14. ↑ 14.0 14.1 Available at: http://oncolex.org/en/Gynecological-cancer/Diagnoses/Cervical-cancer/Background/DifferentialDiagnoses. Accessed March 19, 2014.
  15. ↑ 15.0 15.1 Available at: http://radiopaedia.org/articles/carcinoma-of-the-cervix. Accessed March 19, 2014.

 


Retrieved from "https://www.physio-pedia.com/index.php?title=Cervical_Cancer&oldid=349628"