Cervical cancer remains a major public health concern globally, particularly in developing countries where screening and vaccination programs are limited. This article provides an in-depth overview of cervical cancer, exploring its etiology, pathophysiology, epidemiology, clinical presentation, diagnostic approaches, treatment modalities, and prevention strategies, aligned with current international medical literature.
Introduction
Cervical cancer originates in the epithelial lining of the cervix and is primarily associated with persistent infection by oncogenic types of the Human Papillomavirus (HPV). It is the fourth most common cancer among women worldwide, with approximately 600,000 new cases and 340,000 deaths annually, according to the World Health Organization (WHO, 2023). The burden is disproportionately higher in low- and middle-income countries due to inadequate screening and vaccination coverage.
Pathophysiology
The development of cervical cancer follows a well-documented sequence known as the Cervical Intraepithelial Neoplasia (CIN)–Carcinoma pathway. Persistent HPV infection—particularly with high-risk strains such as HPV-16 and HPV-18—leads to genetic mutations in cervical epithelial cells. The viral oncoproteins E6 and E7 inactivate tumor suppressor genes p53 and Rb, respectively, resulting in uncontrolled cellular proliferation, dysplasia, and eventual carcinoma formation.
Two major histological types are recognized:
1. Squamous Cell Carcinoma (SCC) – accounting for nearly 70–80% of cases.
2. Adenocarcinoma – representing 20–25% of cases and often associated with HPV-18.
Etiology and Risk Factors
The primary etiological agent is persistent high-risk HPV infection, transmitted through sexual contact. However, several cofactors increase susceptibility, including:
– Early onset of sexual activity and multiple sexual partners
– Immunosuppression (e.g., HIV infection)
– Long-term use of oral contraceptives
– Cigarette smoking
– Multiparity and poor genital hygiene
– Co-infection with other sexually transmitted diseases
Epidemiology
Globally, cervical cancer incidence rates are highest in Sub-Saharan Africa, South Asia, and Latin America. According to GLOBOCAN (2022), the age-standardized incidence rate in developing countries is nearly three times higher than in developed nations. In Bangladesh, cervical cancer ranks as the second most common malignancy in women, following breast cancer.
Clinical Manifestations
Cervical cancer is often asymptomatic in its early stages. As the disease progresses, patients may experience:
– Irregular or post-coital vaginal bleeding
– Foul-smelling or blood-stained vaginal discharge
– Pelvic or lower abdominal pain
– Dyspareunia (pain during intercourse)
– Advanced disease may cause hematuria, rectal bleeding, or leg swelling due to lymphatic obstruction.
Diagnostic Evaluation
Accurate and early diagnosis is essential for effective management. Recommended diagnostic procedures include:
1. Pap Smear (Papanicolaou Test): Detects premalignant or malignant changes in cervical cells.
2. HPV DNA Testing: Identifies high-risk viral strains responsible for oncogenesis.
3. Colposcopy: Allows magnified visualization of abnormal cervical epithelium.
4. Cervical Biopsy: Confirms diagnosis and identifies histological type.
5. Endocervical Curettage (ECC): Used when lesions extend into the cervical canal.
6. Imaging (Ultrasound, MRI, CT, PET): Determines disease staging and metastasis.
Staging (FIGO 2023 Classification)
Cervical cancer staging follows the FIGO (International Federation of Gynecology and Obstetrics) guidelines:
– Stage I: Disease confined to the cervix
– Stage II: Spread beyond cervix but not to the pelvic wall
– Stage III: Extension to pelvic wall and/or lower vagina
– Stage IV: Involvement of bladder, rectum, or distant organs
Treatment Modalities
Treatment depends on stage, histological type, and patient condition.
– Surgical Management: Early-stage cancers (IA–IIA) are treated via radical hysterectomy with pelvic lymphadenectomy.
– Radiotherapy: Used for locally advanced disease, either alone or in combination with chemotherapy.
– Chemotherapy: Cisplatin-based regimens remain standard for concurrent chemoradiation therapy.
– Targeted and Immunotherapy: For metastatic disease, agents like pembrolizumab show promising outcomes.
Prevention Strategies
1. Primary Prevention (HPV Vaccination):
– WHO recommends vaccination for girls aged 9–14 years before sexual debut.
– Available vaccines include bivalent (Cervarix), quadrivalent (Gardasil), and nonavalent (Gardasil-9) formulations.
2. Secondary Prevention (Screening):
– Regular Pap smear and HPV co-testing every 3–5 years for women aged 25–65.
– Visual Inspection with Acetic Acid (VIA) in low-resource settings.
3. Tertiary Prevention:
– Early detection and treatment of precancerous lesions using cryotherapy, LEEP (Loop Electrosurgical Excision Procedure), or cold knife conization.
Global Health Initiatives
The WHO Global Strategy (2020) aims to eliminate cervical cancer as a public health problem through the 90–70–90 targets by 2030:
– 90% of girls fully vaccinated with HPV vaccine by age 15.
– 70% of women screened by age 35 and again by 45.
– 90% of women with cervical disease treated effectively.
Conclusion
Cervical cancer remains both a preventable and curable malignancy when addressed through vaccination, regular screening, and timely intervention. Collaborative international efforts focusing on HPV immunization, awareness, and equitable access to healthcare are critical to reducing its global burden. The integration of modern diagnostic tools, molecular testing, and public health education represents the path forward toward achieving the WHO’s vision of a cervical cancer–free future.
