Cervical Cancer

Johan Kurnianda

Divisio nof Hematology-Medical Oncology

Department of Internal Medicine/
Tulip Integrated Cancer Clinic
Dr.Sardjito Hospital/Gadjah Mada University
Yogyakarta
 Cervix
 Lower part of the uterus
 Connects the body of the
uterus to the vagina
(birth canal)

Source: American Cancer Society

 Cervical Cancer
 Begins in the lining of the cervix

 Cells change from normal to pre-cancer

(dysplasia) and then to cancer

Source: American Cancer Society

 Three Types
 Squamous cell Carcinomas
– Cancer of flat epithelial cell
– 80% to 90%
 Adenocarcinomas
– Cancer arising from glandular epithelium
– 10% - 20%
 Mixed carcinoma
– Features both types
Source: American Cancer Society
 Statistics
 10,520 new cases in the U.S. this year
 3,900 will die
 50% are diagnosed between ages 35 and 55.
 20% at the age of 65 or over.
 Rarely occurs in women younger than 20
 Noninvasive is four times more common
 74% decrease in deaths between 1955 and 1992 in
the U.S.
 Death rate continuous to decline by 2% a year
Source: American Cancer Society
 Cervical Cancer
Magnitude of the Problem: -
 500,000 new cases identified each year
 80% of the new cases occur in developing
countries
 At least 200,000 women die of cervical
cancer each year
 Cervical cancer is the third most common
cancer worldwide
 YET - Cervical cancer is a preventable
disease
04:08 PM 6
 Lifetime Probability of Developing Cancer, by
Site, Women, US, 1998-2000

Site Risk
All sites 1 in 3
Breast 1 in 7
Lung & bronchus 1 in 17
Colon & rectum 1 in 18
Uterine corpus 1 in 38
Non-Hodgkin lymphoma 1 in 57
Ovary 1 in 59
Pancreas 1 in 83
Melanoma 1 in 82
Urinary bladder 1 in 91
Uterine cervix 1 in 128

Source:DevCan: Probability of Developing or Dying of Cancer Software, Version 5.1 Statistical Research and Applications
Branch, NCI, 2003. http://srab.cancer.gov/devcan
 Signs and Symptoms
 Vaginal bleeding

 Menstrual bleeding is longer and heavier than usual

 Bleeding after menopause or increased vaginal discharge

 Bleeding following intercourse or pelvic exam

 Pain during intercourse

Source: American Cancer Society

 Risk Factors
 Human papillomavirus infection (HPV) – Primary factor
– HPV 16, HPV 18, HPV 31, HPV 33, HPV 45
– 50% are caused by HPV 16 AND 18
 Sexual behavior
 Smoking
 HIV infection
 Chlamydia infection
 Diet
 Oral contraceptives
 Multiple pregnancies
 Low socioeconomic status
 Diethylstilbestrol (DES)
 Family history

Source: American Cancer Society

 Prevention
 Avoiding the risk factors
– Especially HPV
– Help for low-income women (NBCCEDP)
 Having the Pap Test
– 3 years after first vaginal intercourse or by age 21.
– Have test annually

Source: American Cancer Society

 Diagnosis
 Cervical Cytology (Pap Test)
– Cells are removed from the cervix and
examined under the microscope.
– Can detect epithelial cell abnormalities
 Atypical squamous cells
 Squamous intraepithelial lesions
 Squamous cell carcinoma (likely to be invasive)

Source: American Cancer Society

 Diagnosis
 Additional testing
– Colposcopy
 Cervix is viewed through a colposcope and the
surface of the cervix can be seen close and clear.
– Cervical Biopsies
 Colposcopic biopsy – removal of small section of
the abnormal area of the surface.
 Endocervical curettage – removing some tissue
lining from the endocervical canal.
 Cone biopsy – cone-shaped piece of tissue is
removed from the cervix
 Staging
 FIGO System (International Federation Of Gynecology and Obstetrics)
 Has five stages – 0 to 4
– Stage 0 Carcinoma in situ
– Stage 1 Invaded cervix, but has not spread.
– Stage 2 Has spread to nearby areas, not leaving pelvic area.
– Stage 3 Cancer has spread to the lower part of the vagina.
– Stage 4 Cancer has spread to nearby organs; metastasis.

Source: American Cancer Society

 Survival Rate
 5-year survival rate is 92% for earliest stage

 71% for all stages combined

Source: American Cancer Society

 Treatment
 Surgery
– Preinvasive cervical cancer
 Cryosurgery
 Laser surgery
 Conization
– Invasive cervical cancer
 Simple hysterectomy
– Removal of the body of the uterus and cervix.
 Radical hysterectomy and pelvic lymph node dissection
– Removal of entire uterus, surrounding tissue, upper part of the vagina,
and lymph nodes from the cervix.
 Radiation

 Chemotherapy

Source: American Cancer Society

 http://clinicaloptions.com

Cisplatin Plus Paclitaxel Improves Response Rates and

Progression-Free Survival in Women With Stage IVB,
Persistent, or Recurrent Squamous Cell Cervical
Carcinoma Compared With Cisplatin Alone

Moore DH, Blessing JA, McQuellon

RP, et al.
J Clin Oncol. 2004;22:3113-3119.

http://clinicaloptions.com/on
co
 Background and Rationale

 There is no standard systemic therapy for women

with nonresectable advanced, persistent, or recurrent
squamous cell cervical cancer
– Single-agent cisplatin has produced 20% to 30% response
rate
 Phase 2 data indicate objective response rate (RR)
46% with paclitaxel/cisplatin vs 17% with cisplatin
alone
 Current randomized phase 3 trial compares
paclitaxel/cisplatin with cisplatin alone
http://clinicaloptions.com/on
co
 Summary of Study Design
Quality of life (QoL) and tumor
measured after each cycle

Cisplatin (50 mg/m2)

Day 1 of a 21-day cycle
6 cycles total
Patients with stage IVB, N = 134
recurrent, or persistent
squamous cell cervical
cancer Cisplatin (50 mg/m2)/Paclitaxel (135 mg/m2) **
(N = 264*) Day 1 of a 21-day cycle
6 cycles total
N = 130

*280 patients enrolled; 16 ineligible (8 from each arm) N = 264 for intent-to-treat analysis
**Paclitaxel given as a 24-hour infusion followed immediately by cisplatin.

http://clinicaloptions.com/on
co
 Patient Characteristics
Characteristic Cisplatin Cisplatin/Paclitaxel (n
(n = 134) = 130)
Median age, yrs (range) 46.0 (22-84) 48.5 (21-77)
Median time from diagnosis to study 434 436
entry, days
GOG performance status
0 64 59
1 59 54
2 11 17
Disease grade
1 5 8
2 90 78
3 38 42
Not specified 1 2

http://clinicaloptions.com/onco
 Main Findings
Clinical Outcomes Cisplatin Cisplatin/ Paclitaxel P Value
(n = 134) (n = 130)
Complete response (CR), % 6 15

Partial response (PR), % 13 21

PR + CR (%) 19 36 .002
Median progression-free survival, 2.8 4.8 < .001
mos
Median overall survival, mos 8.8 9.7 ns

http://clinicaloptions.com/on
co
 What’s new in cervical cancer
research and treatment?
 HPV test

 HPV vaccine

 Radical trachelectomy procedure

 Other clinical trials

Source: American Cancer Society