1 national death from cervical cancer every 15 minutes
Human papillomavirus is the only identifiable oncogenic virus in human carcinogenesis, and persistent infection with high-risk HPV types is the main cause of cervical cancer. Today’s research proves that prevention of HPV infection can prevent cervical cancer, and the absence of HPV infection can prevent cervical cancer.
The cause of cervical cancer has been clearly identified and can be detected and treated at an early stage. However, the incidence of cervical cancer in China still accounts for 30% of the annual incidence rate and 12% of the mortality rate of cervical cancer worldwide. According to statistics, one person dies of cervical cancer every 15 minutes in China, and the incidence has been on the rise and younger in the past decade.
The ways of HPV infection
Sexual intercourse and/or skin-to-skin contact in the genital tract is the most important route of HPV transmission. Infection generally occurs from microscopic trauma or laceration of the epithelium of the genital tract visible only under the microscope, mostly in the deformed zone reserve cells at the junction of the squamous and columnar epithelium of the cervix.
Cycle of HPV infection in the cervix
It takes about 8 years for cervical epithelial lesions to progress from mild, to severe until cervical cancer develops. Mild lesions detected early can return to normal, but if the infection is prolonged and severe, it can develop into cervical cancer.
Screening diagnosis requires individualized judgment
There are 15 high-risk types of HPV, among which types 16 and 18 mostly cause cervical cancer.
In 2013, WHO stipulated that HPV value >1.0ng/L is positive, but the high HPV test value does not exactly represent the severity of the lesion.
HPV testing is done to check for cervical lesions above CIN2, and if only the virus is positive it does not mean that the disease is present.
All tests are not 100% sensitive and specific and can be falsely negative. HPV causes mainly squamous and adenocarcinoma, and a few cervical cancers can be HPV negative.
Screening age
1. young women under 25 years of age have the highest rate of HPV infection, but the vast majority of infections will clear within 2 years, so the use of HPV for primary screening in this population should be avoided and HPV testing triage should be used only after liquid-based thin-layer cytometry examination reveals atypical squamous epithelial cells of undefined significance
2. persistent infection with high-risk HPV in women over 40 years of age should be taken seriously; although it generally takes 10-15 years to develop cervical cancer, about 25% of patients can develop cervical cancer within 5 years
3.Women under 30 years old use TCT primary screening and HPV triage strategy, i.e., HPV detection when ASCUS is available on TCT, and combined TCT and HPV detection is available for women over 30 years old.
There is no report on whether cervical cancer is hereditary, but it is recommended that women with family history of cervical cancer should be treated as a high-risk group and be examined strictly and regularly.
High demand for preserving uterine function, surgery becomes the first choice of treatment
Traditionally, radiotherapy was once the main mode of treatment; in recent years, with the younger incidence, the demand for preserving function after treatment has become increasingly strong, so neoadjuvant chemotherapy has come into being, and the current treatment mode prefers surgery, preoperative chemotherapy and preserving function.
1.Precise radiotherapy treatment
In recent years, various high-tech facilities have developed rapidly, and imaging examinations such as CT, MRI and PET-CT can be used to pinpoint the location before treatment, and radiation therapy can be administered after surgery.
However, the most important side effect of radiotherapy is that it inevitably damages ovaries and guidance function, and is irreversible for life.
Therefore, radiotherapy is not preferred for young patients, and this modality is mainly for advanced patients or middle-aged and elderly patients who do not need to preserve ovarian function and sexual function.
2.Surgical treatment
Precise surgery for cervical cancer is increasingly developed, and the scope of extensive hysterectomy is more accurate, and different types of surgery are given according to different stages; asymmetric type of extensive surgery can also be performed according to different conditions of the same stage.
3.Surgical route
Transabdominal surgery: the basic procedure of extensive hysterectomy and the basis of other types of surgery.
Transvaginal surgery: must have the basis of transabdominal surgery and vaginal hysterectomy.
Laparoscopic surgery: the basis of transabdominal surgery.
Robotic laparoscopic surgery: as above.
Extensive hysterectomy with preservation of reproductive function
It can be performed either transabdominally or transvaginally, removing the cervix below the endometrium and also removing the sacral ligament, the main ligament and the vagina for 2 cm each, and then anastomosing the uterine body above the endometrium and the vaginal stump.
The pregnancy and delivery rate is 37% within 12 months and 60% within two years after this procedure.
4.Neoadjuvant chemotherapy
Preoperative neoadjuvant chemotherapy reduces the size of the tumor and increases the rate of surgical resection; reduces the viability of cancer cells and reduces intraoperative dissemination and postoperative metastasis; eliminates subclinical lesions and reduces the risk of recurrence; can “reduce staging” and provides the opportunity for surgery.
Neoadjuvant chemotherapy is still controversial. Some studies have concluded that it does not increase postoperative survival rates, while it delays surgical treatment, results in acute and subacute toxic reactions, prolongs treatment cycles, and is relatively expensive.
There is no conclusive evidence in this regard, and some studies in China have also found that neoadjuvant chemotherapy can effectively prolong 5-year tumor-free survival.
Uncontrolled with high recurrence rate
New lesions found within 6 months after surgery and 3 months after radiotherapy are considered uncontrolled; new lesions found after 6 months after surgery and 3 months after radiotherapy are considered relapsed.
Uncontrolled and recurrence rates account for about 30% of all treatments, and 95% of them occur within two years after treatment; they often occur when treatment is inappropriate, treatment is not standardized, and most of them are under-treated, making treatment difficult, quality of life poor, and prognosis poor.
20-40% of cervical cancer patients are already in advanced stage when first treated and are prone to recurrence, so patients should be told the importance of regular review after treatment.
1.Recurrence site
Recurrence of vaginal stump or central recurrence of pelvic confinement occurs in 60% of patients with extensive total hysterectomy.
Among the patients treated with conventional radiotherapy, 70% of them were confined to pelvic recurrence; after the 1980s, radiotherapy equipment and technology improved, pelvic recurrence only accounted for 41% and distant 59%, and 53.3% of pelvic recurrence was in the pelvic wall.
2.Means of monitoring
The detection means of recurrence are limited: cytology, ultrasound, CT, MRI and serological examination are difficult to detect early recurrence, relatively pelvic examination is reliable, PET-CT examination can be done if necessary.
3.Treatment plan for uncontrolled and recurrence
The treatment plan selection should be decided according to the degree of uncontrolled and recurrence and the type and intensity of the last treatment, and should also be determined by considering the patient’s physical condition, psychology, family and economic situation. Radiotherapy, surgery and palliative care can be selected individually, and treatment should not be given up easily for young and middle-aged patients.
4.Surgery for patients with uncontrolled and recurrent disease after radiotherapy
For central recurrence, pelvic contouring is feasible; for “recurrence” reaching the pelvic floor or pelvic wall, expanded pelvic contouring, expanded pelvic contouring + intraoperative radiotherapy is performed.