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Today’s Q&A workshop summary is with Stewart Massad, MD, Professor of Obstetrics and Gynecology, Division of Gynecologic Oncology, Washington University School of Medicine.
Q: At what point in the process does a cervical cancer patient see the gynecologic oncologist?
A: This depends on the training and comfort level of the clinician. All women requiring radical therapy (generally, stage IA2 and above) should be seen by someone with special expertise in cervical cancer management, usually a gynecologic oncologist. Stage IA1 cervical cancers without lymphovascular space invasion can be managed with conization using scalpel or loop or with simple hysterectomy. Ablational treatments are contraindicated. However...(read more)
Q: Should I be worried if my pap smear comes back abnormal? Does this mean I have cervical cancer?
A: A Pap test is a screening test for cervical cancer. For the most common abnormalities (ASC-US and LSIL), the risk of cervical cancer is about 1/1000, rising with age and smoking. You should be worried enough to get prompt assessment (generally within 6-8 weeks), but you are unlikely to have cervical cancer... (read more)
Q: If atypical squamous cells (ASC) are found in my pap smear, how is the risk level of cervical cancer determined?
A: There are two types of ASC, and management differs.For women with ASC of undetermined significance (ASC-US), most centers in the US determine risk for cervical cancer using a test for oncogenic/high risk human papillomavirus (HPV). HPVs are the viruses that cause cervical cancer. However, more than 80% of sexually active women will have an HPV infection at some point, and 90% will clear spontaneously on immune recognition of the virus, so having HPV does not prompt treatment. Low risk HPV types are not associated with cervical cancer, and there’s no role for testing for these types. Women with ASC-US and high-risk HPV are at increased risk for cervical precancer, and are at long-term risk for cervical cancer, though few have cancer at the time of their abnormal Pap. Women with ASC-US who are HPV+ need colposcopy to inspect the cervix, with biopsy of any abnormality. The biopsy then.. (read more)
Q: What does it mean if I have a normal Pap test, but a positive HPV test?
A: This means that you are infected with HPV. Only high-risk types of HPV should be tested for. A positive test for high-risk HPV means that risk for developing cancer over one’s lifetime is elevated, though immediate risk is low. Women who are Pap- but HPV+ should have both tests repeated in a year. Two types of HPV (types 16 and 18) carry highest cancer risk, and an alternative is to test for these types. If either is present, colposcopy is indicated to assess for precancer or even rare cancers. Women who... (read more)
Q: What are the treatment options if high-grade squamous intraepithelial lesions (HSILs) are found during cervical cancer screening?
A: reatment with a loop electrosurgical excision procedure (LEEP) can be done for all women with HSIL. This involves removing the surface of the cervix with an electrified wire, usually as an office procedure with intracervical anesthetic. Risks of LEEP include bleeding (sometimes delayed 5-10 days), injury to surrounding organs, and infection. One concerning complication is an increased risk for preterm delivery in subsequent pregnancies, especially after deep or repeated LEEPs, though this risk has not been found in all studies; most women with LEEP who conceive deliver at term, and most preterm deliveries are at 34-36 weeks gestation and do well, though extreme prematurity also appears to be increased... (read more)
Q: What are the options for doing a biopsy for cervical cancer? How do you decide which type of biopsy to perform?
A: When a clinician sees a cervical mass, biopsy can be done immediately using forceps designed for that purpose. When cervical cancer is suspected on the basis of colposcopy or Pap, biopsy is directed to the most abnormal areas of the cervix using colposcopic biopsy forceps. If biopsy is negative or shows only microinvasive cancer, then conization using scalpel or wire is indicated to fully assess the cervix. LEEP conization can be done as an office procedure, while scalpel conization is usually done under general anesthesia in an operating room... (read more)
Q: If metastatic cervical cancer is diagnosed, what are the next steps?
A: In the US, previously untreated metastatic cervical cancer is assessed using pelvic exam and imaging. CT scan, usually supplemented by PET scanning, is the most common imaging test. These scans assess for sites of metastasis other than those initially suspected. Staging in this manner determines therapy. When metastases are only regional (restricted to the pelvis and occasionally to the pelvis and groin or para-aortic lymph nodes), radiotherapy is standard, supplemented with cisplatin chemotherapy as a radiation booster. Radiation must include both external and internal sources. For the latter, radiation instruments are inserted temporarily into the uterus, cervix, and vagina, then loaded with radio-isotopes to provide intense dosing directly into the cancer. Surgery is... (read more)
Q: For metastatic cervical cancer, what factors determine if surgery is a recommended treatment?
A: This is addressed here... (read more)
http://link.talkabouthealth.com/view/4c617cd4b61807701edfefceztpp.1/492f2591
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