Dr Mairi Chong emphasises the need for GPs to be aware of treatment options for cervical cancer and their associated complications, as advised by SIGN
Cervical cancer prevention is currently topical with the introduction of new vaccines. Programmes for vaccination were introduced this year by the Department of Health and the Scottish Government. The incidence of cervical cancer is declining with the help of the screening programme already in place.1 Estimates show that screening in the UK saves around 5000 lives a year.2 However, prevention is not always successful, and it is important that there is a clear framework to follow that covers the diagnosis and treatment options available for patients.
The SIGN guideline on Management of cervical cancer covers presentation, referral, diagnosis, staging, and treatment of cervical cancer.1 As GPs, we are often faced with the huge emotional burden experienced by women and their families who are given the diagnosis, and the guideline contains a section on psychosocial care and support, which will assist GPs with offering information on counselling and services available.
Need for the guideline
According to the Information Service Division, in Scotland there were 295 new cases of cervical cancer in 2005,3 and 105 women died of the disease in 2007.4 The 5-year survival rate between 1997 and 2001 was 70.6%.5 These are shocking statistics in view of the use of the well established screening programme for pre-invasive disease. Only 30% of cancers, however, are found upon smear testing, as the majority of women have not participated in the screening programme.6
Presentation and referral
Cervical cancer is commonly found in women aged between 30 and 45 years,1 and the risk factors are well known: human papillomavirus, smoking, and lower socioeconomic status.
Signs and symptoms of cervical cancer are common and non-specific.
- inter-menstrual bleeding
- post-coital bleeding
- post-menopausal bleeding
- vaginal discharge (blood stained)
- pelvic pain
- abnormal appearance on examination.
Many of these signs are suggestive of Chlamydia trachomatis infection, and women with these symptoms should be tested accordingly.7 Post-menopausal bleeding may also be a presenting symptom of endometrial cancer and a pelvic examination and referral for gynaecological investigation are warranted. If there is any suspicion of malignancy, women should be referred on to gynaecology.1
A symptomatic woman whose cytology tests are negative has a significantly reduced risk of cervical cancer compared to that of a woman with positive cytology, but the risk is not zero.
Diagnosis and screening
Diagnosis is confirmed by means of histopathological examination of cervical biopsies. Staging of the cancer and lymph node involvement indicates prognosis and determines treatment.1 All patients with a positive result on biopsy will receive magnetic resonance imaging (MRI), or a post-contrast spiral computerised tomography (CT) scan if MRI is contra-indicated.
Patients with cancer frequently have a range of complex requirements and referral to an expert multidisciplinary team is recommended as a good practice point in the SIGN guideline, and will ensure they receive optimal management.
Treatment options include:
- radical surgery–if the disease is not extensive, fertility conservation may be an option
- hormone replacement therapy, which should be offered to women who lose ovarian function as a result of treatment.1
Complications of treatment
Anaemia during treatment is an indicator of poor prognosis.8 Patients with cervical carcinoma who are undergoing radiotherapy or chemotherapy should have their haemoglobin monitored, and if it falls below 12g/dl, correction should be attempted with blood transfusion or erythropoietin and iron therapy.1
The effects of late radiation on the bladder include: 1,9
- detrusor instability
Management of these effects is with hydration, bladder irrigation, antibiotics, analgesia, and referral to urology if reconstructive surgery is indicated.
Symptoms and signs of proctitis include:
- mucus discharge
Treatment with rectal sucralfate may reduce late radiation proctitis, but it is not recommended in acute episodes. Patients should be referred to secondary care for specialist opinion.
Cervical cancer may result in a number of sexual problems including loss of libido, change in sexual activity, and decreased orgasm. The guideline recommends that sexual function and concerns of women should be addressed in both primary and secondary care before treatment is initiated. In order to prevent development of vaginal stenosis as a result of radiotherapy, women should be offered a vaginal stent/dilator, and should be given support to maximise the benefit of its use.1
Lymphoedema is a possible complication of cervical cancer and may be related to the disease or treatment, and presents as a swelling of one or both lower limbs. Patients with lymphoedema should be referred early for assessment by a specialist.1 Conservative physical therapies such as compression bandaging, massage, good skin care, and exercise, all play a role in the management of this condition.10 Patients should be well informed regarding good skin care, avoiding temperature extremes, protecting limbs from sun damage or other injury, and maintaining an optimal weight.1
Complications of advanced disease
Complications of advanced disease include:
- renal failure
- malodorous discharge
Comprehensive palliative care will be required as the patient’s health declines.1
Patients should be reviewed every 4 months for at least 2 years. History taking and clinical examination should be performed to detect symptomatic and asymptomatic recurrence. A scan (CT or MRI) should be considered if recurrence is suspected, followed by whole body positron emission tomography (PET) or PET-CT if recurrent or persistent disease is demonstrated.
The prognosis for patients with recurrent disease is 6 months to 2 years. All options should be discussed carefully with the patient, her family, and the multidisciplinary team. There are several options for treatment. These options may include:1
- salvage surgery
- palliative treatment.
Psychological support should be offered from diagnosis throughout the treatment. Information on local support groups and services should be made available to patients, carers, and families. Common issues that it is important to discuss may involve psychological problems relating to body image. Women may find difficulty in forming new relationships post-diagnosis.
Physical issues where more practical help may be necessary include those relating to bowel function, fertility, incontinence, malodour, etc. These all need to be discussed, and as a matter of best practice a management plan for each should be developed.
The guideline also mentions other more practical issues, such as financial concerns and childcare. Social services can help with funding.
Finally, survival issues are often the most difficult to discuss, but may well be of prime importance to a mother who is perhaps feeling guilty for leaving a family behind.
The new SIGN guideline on Management of cervical cancer will improve consistency of care for patients with the disease, by clarifying points regarding care. There are now clear guidelines to follow when a patient presents to her GP. Referral, diagnosis, and care pathways are now more transparent for the whole multidisciplinary team. Although management options are likely to be discussed by specialist clinicians, it is important for GPs to be aware of the general options and the complications associated with each method of treatment.
The SIGN guideline stresses the importance of psychosocial support. This is an area in which GPs can really make a difference, by not being afraid to ask difficult questions, and by being aware of the support that can be offered locally to women and their families.
written by Dr David Jenner, NHS Alliance PBC Lead
- The incidence of cervical cancer should fall with the introduction of the human papillomavirus vaccine programme
- PBC consortia should aim to support the delivery of the vaccine to those female patients who are hard to reach or who fail to attend the school-based programme in England
- Similarly, PBC consortia should work to promote screening of cervical cancer to those most at risk and least likely to attend for screening
- Suspicious symptoms or signs should prompt urgent referral under the 2-week wait rule to ensure rapid diagnosis
- Commissioners should ensure the availability of psychosocial support and palliative care services for patients with cervical cancer
- Scottish Intercollegiate Guidelines Network. Management of cervical cancer. A national clinical guideline. SIGN 99. Edinburgh: SIGN, 2008.
- Peto J, Gilham C, Fletcher O, Matthews F. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004; 364 (9430): 249–256.
- Information Service Division. Cancer of cervix uteri. (ICD-10 C53); Scotland: trends in incidence 1980–2005. Edinburgh: The Division. www.isdscotland.org/isd/
- Information Services Division. Cancer of cervix uteri. (ICD-10 C53); Scotland: trends in mortality 1985–2007. Edinburgh: The Division. www.isdscotland.org/isd/
- Information Services Division. Cancer of cervix uteri. (ICD-9 180; ICD-10 C53); Scotland: Trends in survival by age group and period of diagnosis. Edinburgh: The Division. www.isdscotland.org/isd/
- Information Services Division. Carcinoma in situ of cervix uteri (ICD-10 D06) Scotland: trends in incidence 1980–2005. Edinburgh: The Division; 2007. www.isdscotland.org/isd/
- Scottish Intercollegiate Guidelines Network. Management of genital Chlamydia trachomatis infection. SIGN 42. Edinburgh: SIGN, 2000.
- Girinski T, Pejovic-Lenfant M, Bourhis J et al. Prognostic value of hemoglobin concentration and blood transfusions in advanced carcinoma of cervix treated by radiation therapy: results of a retrospective study of 386 patients. Int J Radiat Oncol Biol Phys 1989; 16 (1): 37–42.
- Parkin D, Davis J, Symonds R. Long-term bladder symptomatology following radiotherapy for cervical carcinoma. Radiother Oncol 1987; 9 (3): 195–199.
- Lymphoedema Framework. Best practice for the management of lymphoedema. International consensus. London: MEP Ltd, 2006.G