Epidemiology
In the UK, cervical cancer is the seventh most common female cancer, representing 2.5% of all cancer cases. Worldwide it represents 10% of all female cancers and 80% occur in the developing world. The average age at presentation is 35–44 years.
The decline in incidence of cervical cancer has been due to the introduction of screening programmes based on cytological cervical smear assessment.
Aetiology
Invasive cervical cancer most commonly, progresses from cervical infection by human papilloma virus (HPV) to cervical intraepithelial neoplasia (CIN) and on to invasive disease. CIN is a cytological diagnosis and describes the involvement of the epidermis:
- CIN 1: involvement of lower 1/3 of epithelium;
- CIN 2: involvement of lower 2/3 of epithelium;
- CIN 3: involvement of all layers of epithelium.
Cervical cancer develops when disease breaches the epithelial basement membrane and invades the cervical stroma. The majority of cervical cancers are squamous cell, but adenocarcinoma accounts for 15% of cases. Adenocarcinoma develops from the endocervical epithelium and most commonly affects women under 40 years of age.
The most significant causative factor is HPV, particularly HPV 16, 18, 31, 33 and 45. HPV 16 and 18 convey the highest risk of malignancy. Other risk factors include high number of sexual partners, early age at first intercourse, low socioeconomic status, non-barrier forms of contraception, cigarette smoking, prolonged use of combined oral contraceptive pill, multiparity and immunocompromised state (e.g. HIV).
Vaccination against HPV is now available in the form of Cervarix, which protects against HPV 16 and 18, and Gardasil which protects against HPV 6, 11, 16 and 18, thus it prevents many cases of genital warts as well as cervical cancer. Cervarix is now offered to 12- to 13-year-old girls in the UK.
Clinical presentation
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