Test Your Knowledge: Ten Questions about Cervical Cancer

Question 6. Which of the following best refl ects the evidence on conisation of the cervix (removing the abnormal portion using a diathermy loop or scalpel) for treating microinvasive carcinoma (stage Ia1)? Several randomized controlled trials (RCTs) have shown that conisation of the cervix is superior to simple hysterectomy (removal of the cervix and uterus) Consensus opinion, based on observational studies, is that conisation of the cervix is effective for treating microinvasive carcinoma (stage Ia1) Conisation of the cervix is not suitable for women who wish to preserve their fertility

Several randomized controlled trials (RCTs) have shown that conisation of the cervix is superior to simple hysterectomy (removal of the cervix and uterus) Consensus opinion, based on observational studies, is that conisation of the cervix is effective for treating microinvasive carcinoma (stage Ia1) Conisation of the cervix is not suitable for women who wish to preserve their fertility Question 7. Which of the following best refl ects the evidence on radical trachelectomy (removal of the cervix and parametrium) plus lymph node removal for treating early-stage cervical cancer?
Several RCTs have shown that the rate of recurrence free survival is lower with this treatment than with radical hysterectomy (removal of the cervix, uterus, vaginal cuff, pelvic lymph nodes, obturator lymph nodes, paracervical tissue, and parametrial tissue) The rate of operative complications is the same as with radical hysterectomy Unlike radical hysterectomy, radical trachelectomy plus lymph node removal can preserve fertility

Question 8. Which of the following best refl ects the evidence on radiotherapy versus surgery (i.e. radical hysterectomy plus lymph node removal) for earlystage cervical cancer?
There is overwhelming evidence that surgery is associated with higher rates of overall survival and disease-free survival There is overwhelming evidence that radiotherapy is associated with higher rates of overall survival and diseasefree survival One RCT found no signifi cant difference in overall survival or disease-free survival and consensus regards both treatments as likely to be benefi cial

Question 9. Which of the following best refl ects the evidence on chemoradiotherapy (chemotherapy and radiotherapy given simultaneously for a short duration of time) for treating bulky early-stage cervical cancer?
There is no evidence of any survival benefi t from adding chemotherapy to radiotherapy alone Several RCTs have found that chemoradiotherapy improves overall survival and progression-free survival compared with radiotherapy, when used either with or after hysterectomy Several RCTs have found that chemoradiotherapy improves progression-free survival but not overall survival compared with radiotherapy, when used either with or after hysterectomy

Answer 2. Most cases occur in the developing world
Almost 80% of cases occur in the developing world [1], which may partly be explained by the lack of screening programs in many developing countries [2].
Worldwide, cervical cancer is the second most common malignancy in women, after breast cancer [3].
Cervical cancer is most often diagnosed in the fi fth decade [1].

Answer 3. High socioeconomic status
Risk factors for cervical cancer include smoking, history of genital warts, low socioeconomic status, micronutrient defi ciency, HIV infection, immunosuppressive therapy, early age of sexual activity, a high total number of sexual partners, and persistent infection with oncogenic strains of human papilloma virus (HPV) [1,2].

Answer 5. Clinical examination with cystoscopy and proctoscopy
As most cases of cervical cancer occur in the developing world, staging is based on clinical examination, although improved imaging with MRI has allowed greater prediction of parametrial and pelvic lymph node involvement.However, there are no randomized controlled trials showing that the use of imaging (with CT, MRI, or positron-emission tomography) leads to better survival for women with cervical cancer [1].

Answer 6. Consensus opinion, based on observational studies, is that conisation of the cervix is effective for treating microinvasive carcinoma (stage Ia1)
A systematic review of the clinical evidence found no RCTs of conisation of the cervix versus simple hysterectomy, but concluded that that there is a consensus (based on observational studies) that conisation is effective for treating microinvasive carcinoma (stage Ia1) [1].Unlike hysterectomy, conisation of the cervix does preserve fertility.

Answer 7. Unlike radical hysterectomy, radical trachelectomy plus lymph node removal can preserve fertility
A systematic review of the clinical evidence found no RCTs of radical trachelectomy plus lymph node removal versus radical hysterectomy [1], but it did fi nd a retrospective observational study comparing these two treatments [2].The study included women with stage Ia2 or Ib tumors 2 cm or smaller without pelvic lymph node metastasis.Thirtytwo women had received radical trachelectomy plus lymph node removal and this group was compared with two groups of women who had undergone radical hysterectomy: one unmatched control group (556 women) and one control group matched for age and tumor characteristics (30 women).There was no signifi cant difference between the treatments in recurrence-free survival.The study found a signifi cantly higher rate of intraoperative complications with radical trachelectomy plus lymphadenectomy than with radical hysterectomy in unmatched controls.The conception rate in women who underwent radical trachelectomy plus lymph node removal was 37% at one year.radiotherapy in 5-year survival or disease-free survival rates [1].Consensus opinion is that both surgery and radiotherapy are likely to be benefi cial [2,3].Answer 9. Several RCTs have found that chemoradiotherapy improves overall survival and progression-free survival compared with radiotherapy, when used either with or after hysterectomy One systematic review identifi ed two RCTs comparing chemoradiotherapy versus radiotherapy alone for women with bulky early-stage cancer (in the fi rst RCT, women had stage Ib2 tumors [1]; in the second RCT, women had stage Ia2, Ib, and IIa tumors [2]).These trials found that chemoradiotherapy improves overall survival and progressionfree survival compared with radiotherapy, when used either with or after hysterectomy.

Question 2 .
Which one of the following is true about the epidemiology of cervical cancer?Most cases occur in the developing world Worldwide it is the most common malignancy in women It is most commonly diagnosed in the third decade of lifeQuestion 3. Which one of the following is not a risk factor for cervical cancer?one of the following is true about HPV infection in women?Peak prevalence is in women aged 20-30 years Infection is usually persistent HPV DNA is found in about half of squamous cervical cancersQuestion 5.The FIGO (Federation of Gynecology and Obstetrics) staging of cervical cancer, which is the internationally accepted classifi cation, is based on which of the following?Clinical examination with cystoscopy and proctoscopy Radiological examination with computed tomography (CT) and magnetic resonance imaging (MRI) Surgical examination Question 6.Which of the following best refl ects the evidence on conisation of the cervix (removing the abnormal portion using a diathermy loop or scalpel) for treating microinvasive carcinoma (stage Ia1)?

Question 10 .Answer 1 .
Approximately what proportion of women with stage IVb disease will survive for over two years?Squamous cell carcinoma About 80% of cervical cancers are of the squamous type[1].