How not to miss - cervical cancer
Gynaecological oncologists Dr Adeola Olaitan and Professor Martin Widschwendter on the key signs and pitfalls for making this tricky diagnosis
Worst outcomes if missed
- Death – more than 85% of women with a stage I cervical cancer – a stage where the invasive cancer is confined to the cervix – survive the first five years, whereas only 60 to 75% of women who present with stage II cervical cancer are alive five years after diagnosis. Survival rates decrease rapidly to between 30 and 40% for women with stage III cancers and less than 15% for women with stage IV cancers.
- Infertility, bowel and bladder damage, and sexual dysfunction – early diagnosis, ideally before the cells breach the basement membrane and gain access to blood and lymph vessels, allows for fertility-preserving treatment. Diagnosis of the disease at more advanced stages requires a radical hysterectomy, chemotherapy or radiotherapy with substantial sequelae including infertility, damage to bowels and bladder, fistulation and sexual dysfunction.
Despite the success of the NHS cervical screening programme, 3,300 women are diagnosed with cervical cancer every year and three women a day die of this disease.
Symptoms and signs
Screening saves 5,000 lives a year but – as with all screening tests – there is a small false negative rate.
It is important for GPs to be aware of the symptoms and signs of cervical cancer, so that women can be diagnosed early while curative treatment is still possible.
A key symptom is abnormal vaginal bleeding and, in particular, postcoital bleeding. Cervical cancer is also associated with inter-menstrual and post-menopausal bleeding. Persistent offensive vaginal discharge is another symptom.
Pain during sex, back pain, abdominal pain, incontinence and weight loss are symptoms of more advanced disease. Cervical cancer is a disease of younger women – it is the most common cancer in women under 35 years old. The key questions to ask and pitfalls to avoid are listed in the boxes below.
- Postcoital bleeding and offensive discharge in a young woman will most commonly be caused by a sexually transmitted infection such as chlamydia or a bacterial vaginosis (mainly infection with Gardnerella vaginalis, presenting with a typical fish-like odour).
- Benign cervical polyps can also cause bleeding after sexual intercourse.
- Intermenstrual bleeding may be because of hormonal causes or poor compliance with the combined oral contraceptive pill.
It is important that cervical cancer is excluded in women presenting with these symptoms before they are attributed to benign causes.
Don’t be misled by a recent negative smear because – although rare – interval cancers can occur, as can false negatives.
The first and most important step is to examine the patient and visualise the cervix. If the cervix is clinically normal, it is appropriate to take swabs to exclude an infection. Visualisation of the cervix will also enable the GP to exclude benign cervical polyps.
If the cervix is abnormal in appearance, friable or with an exophytic or destructive lesion and contact bleeding, referral to a specialist under the two-week rule is indicated. Don’t take a cytology sample if there is a suspicion of cervical malignancy – cytology is only for screening in an asymptomatic population.
Five key questions
- When did the abnormal bleeding start?
- What triggered the abnormal bleeding? (For example, sexual intercourse, exercise, poor compliance with hormonal medication)
- Is there an associated offensive discharge?
- Is there pain with intercourse or at any other time?
- Is there a history of previous abnormal smears?
Five red herrings
- A recent normal cervical smear – interval cancers and false negatives can occur
- Patients who are outside the screening age bracket – under 25 or over 65
- The patient is not currently sexually active
- Ectropions or polyps - these can coexist with malignancy
- A normal pelvic ultrasound – an ultrasound scan cannot diagnose cervical cancer.
Dr Adeola Olaitan and Professor Martin Widschwendter are gynaecological oncologists at University College London Hospital. Professor Widschwendter is also the Head of the UCL Women’s Cancer Department.
A key component in the successful development of the UCL Department of Women’s Cancer has been their relationship with The Eve Appeal. In addition to providing seed funding, core infrastructure funding and project funding, The Eve Appeal is dedicated to improving public awareness of all gynaecological cancers. Much research remains to be done for women-specific cancers and the kind of support provided by The Eve Appeal is vital.
Patient Information materials are available to all GP surgeries/health clinics from www.eveappeal.org.uk or by calling 020 7605 0100.
- Yu C, Chiu C, McCormack M and Olaitan A. Delayed Diagnosis of Cervical Cancer in Young Women. Journal of Obstetrics and Gynaecology, 2005; 25:367–70
- Sasieni P, Adams J and Cuzick J. Benefit of cervical screening at different ages: evidence from the UK audit of screening histories. British Journal of Cancer, 2003;89:88–93
- Peto J, Gilham C, Fletcher O and Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. The Lancet, 2004;364(9430):249–56