In this blog for junior doctors, Dr Sarah Louise Smyth and Mr Hooman Soleymani majd, Specialist Registrar in Obstetrics and Gynaecology, Consultant in Gynaecological Oncology and BSCCP Accredited Colposcopists, discuss aspects of cervical screening, colposcopy and cervical cancer.
Take-home points
- Human papillomavirus vaccination and primary human papillomavirus testing continue to reduce cervical cancer cases each year.
- With further research ongoing, there may be future scope to increase the intervals between screening tests and even introduce self-sampling.
- Abnormal screening test results, colposcopy referrals and (in a small number of cases) the diagnosis and treatment of cervical cancer can be a worrying and stressful time for patients. This needs to be approached with appropriate consideration and sensitivity, as there may be potentially challenging questions and, occasionally, the need to break bad news.
With recent changes to the assessment of cervical smear tests and the introduction of the human papillomavirus (HPV) vaccination, we provide an up-to-date overview on cervical health and pathways of management.
Cervical Screening
This programme has been successful in halving the number of cases of cervical cancer and reducing associated loss of life since its introduction (1).
Risk factors for abnormalities in screening test results include:
- Persistent human papillomavirus (HPV) infection
- Early onset of sexual activity and multiple sexual partners
- HIV infection
- A weakened immune system
- Smoking
- Other sexually transmitted infections
- Long-term use of the combined oral contraceptive pills
- Multiple completed pregnancies
Abnormalities of the cervix are mostly caused by high-risk strains of the human papillomavirus (HPV) – a sexually transmitted infection. The virus has been found to affect the way in which healthy cells of the cervix can develop abnormal DNA changes (mutations), allowing them to grow and multiply more quickly and with less control.
Since its launch in 2008, human papillomavirus vaccination has been available to young girls from the age of 12. Subsequently, the vaccination program has been altered to include young boys from the age of 12 as well as males who have sexual activity with males up to the age of 45. The vaccination now also helps to prevent genital warts. You can read more about the Cochrane evidence on HPV vaccination in this blog (2).
The screening program aims to detect precancerous cells of the cervix. Patients are invited every 3 years between the ages of 25 and 50 years, and every 5 years afterwards until the age of 64 years (3).
As of 2019, a change in the assessment of cervical smear tests was introduced, where samples are screened for the presence of high-risk human papillomavirus strains first.
Patients who have the high-risk virus present will have their samples assessed for abnormal cells (dyskariosis) and to what degree. This potentially increases the number of abnormal smear test results, hence increasing the number of referrals to colposcopy (a procedure used to look at the cervix, often following an abnormal smear test result) (4).
However, it also increases the detection of abnormalities in cervical cells and at an earlier stage, as well as more accurately detecting those abnormal cells with more worrying features and cervical cancers. This information has been summarised in the Cochrane Review on human papillomavirus test compared to the papanicolaou (pap) test to screen for cervical cancer (5).
Further to this, because negative results are highly likely to be truly negative, in the future it may be possible to increase the intervals between screening tests and even introduce self-sampling.
Cervical screening aims to guide us in the risk of cellular abnormalities of the cervix and cancer and subsequent management thereof. Treatment can then be offered sooner, preventing disease progression. However, there is a small risk of incorrect results. Were an abnormality to be missed, owing to the slow rate of disease progression, it would likely be picked up on a subsequent test. In contrast to this, were a result to be falsely positive, there is the possibility of unnecessary investigation and treatment (6).
In addition to this, some minor abnormalities can either progress or regress. As we cannot distinguish between these individuals there is a risk of over-diagnosis and overtreatment, For the patient, further risk can be associated with discomfort and anxiety regarding cervical smear tests and their results.
Colposcopy
A colposcopy is a procedure used to look at the cervix. Most commonly a patient will be referred to the colposcopy clinic due to an abnormal smear test result, however, there are other signs and symptoms, which could also prompt an urgent review (7).
These include (8):
- Abnormal appearance of the cervix on examination
- Abnormal vaginal bleeding or discharge
- Pelvic pain or pain during intercourse
- Bladder or bowel symptoms including blood in the urine
It’s important to remember that attending the clinic can be a difficult experience for patients, associated with high levels of anxiety with psychological consequences. As a result, clinicians and staff working in this clinic should consistently endeavour to improve this environment wherever possible (9).
In our practice, we try to improve patients’ experience by providing a thorough explanation of the colposcopy process and addressing any questions or concerns in advance. Information leaflets can also be useful in this regard. We provide a welcoming environment and private space for the patient to undress, aiming to promote modesty at all times. We also offer music or a video display of the colposcopy – involving the patient and empowering them regarding their clinical care (10).
Within the colposcopy clinic, patients will undergo examination and biopsy (sample) or removal of an area of the cervix (loop treatment) based on test results to date and specialist findings; with the aim of treating precancerous cells of the cervix (cervical intraepithelial neoplasia). These abnormal cells are once again divided according to the degree of abnormality.
Colposcopy aims to diagnose cervical abnormalities with further accuracy using physical examination and pathology results to guide ongoing management.
Practitioners recognise that the process is not without risk and can be associated with pain, bleeding, infection, earlier labour when pregnant and the inability to swim, use tampons, undertake sexual activities or strenuous exercise for four weeks or more following treatment. There is no evidence to suggest that colposcopy treatment affects fertility. The colposcopist will present the risks and benefits of examination, biopsy and treatment in order to promote patient autonomy and achieve informed consent (11).
Cervical cancer
Rarely, patients will be diagnosed with cervical cancer. In the UK in 2017 there were 3152 new cases and 850 deaths (which equates to less than 1% of all cancer deaths overall).
Worldwide, cancer of the cervix is the 4th most common cancer found in women and the most common cancer found in women under the age of 35 in the United Kingdom. This amounts to 9 new cases and more than 2 deaths from cervical cancer every day, yet 99.8% of cases are preventable. Whilst survival rates continue to improve, this is steeply affected by how much the disease has already spread at the time of diagnosis (12).
Patients with a new diagnosis of cervical cancer following biopsy or loop treatment will undergo additional imaging in the form of a MRI scan to investigate the extent of the cancer, the results of which are discussed at a team meeting to plan on-going management pathways.
The extent (or stage) of the disease is based on how deep the cancer is within the cervical tissue as well as its largest dimension. This is further delineated should it have spread into the womb or other surrounding structures or organs; or even to more distant areas of the body (11).
Treatment is similarly based on this staging system. Earliest stage disease can be managed with removal of an area of the cervix alone, proceeding to complete removal of the womb and pelvic lymph nodes (part of the body’s immune system that help fight infection and disease). Removal of the ovaries and methods of fertility-sparing surgery are considered on a case-by-case basis (13,14).
For those patients with more advanced cervical cancer, chemotherapy and radiotherapy are used primarily instead to avoid multiple treatments without additional benefit. Further details regarding these treatment options can be found in the Cochrane Reviews on chemo-radiotherapy for cervical cancer: results of a meta-analysis; and nerve-sparing radical hysterectomy for early-stage cervical cancer (15).
Editor's note:
Readers may also be interested in the review Hysterectomy with radiotherapy or chemotherapy or both for women with locally advanced cervical cancer (published August 2022).
Dr Sarah Louise Smyth and Mr Hooman Soleymani majd have nothing to declare.
Dr Sarah Louise Smyth
Dr Sarah Louise Smyth BMedSci BMBS MRCOG, graduated from the University of Nottingham in 2011 with a Bachelor of Medical Sciences and later in 2013 with a Bachelor of Medicine and Bachelor of Surgery. She commenced her speciality training in the field of Obstetrics and Gynaecology within the Wessex Deanery in 2015 and later joined the Thames Valley Deanery in 2018. Sarah was admitted as a Member of the Royal College of Obstetricians and Gynaecologists in 2019. She currently works as a senior registrar in obstetrics and gynaecology, having previously worked as a clinical fellow in gynaecological oncology at Oxford University Hospitals NHS Foundation Trust. She is also an accredited colposcopist with the British Society for Colposcopy and Cervical Pathology.
Hooman Soleymani majd
Mr Hooman Soleymani majd started his Obstetrics and Gynaecology career in London, before moving to Oxford where he completed his structured postgraduate training programme. During the course of training he obtained his membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), which culminated in a Certificate of Completion of Training (CCT) in Obstetrics and Gynaecology. Mr. Soleymani majd completed a further three years of Sub-Specialty Training in Gynaecological Oncology at the Churchill Cancer Centre in Oxford. He is also a BSCCP accredited Colposcopist and trainer, as well as a member of the British Gynaecological Cancer Society (BGCS). He is an accomplished and experienced surgeon, performing numerous complex radical laparoscopic and open surgeries every year. He has a special interest in performing ultra-radical surgery for ovarian cancer; his skill set includes upper abdominal surgery, liver mobilisation and diaphragmatic reconstruction. Mr Soleymani majd also has a particular surgical interest in treating patients with Placenta Accreta Spectrum (PAS) and is a founding member of the OxPAT group.
Mr Soleymani Majd has active involvement in teaching registrars/fellows and medical students from Oxford University. He is part of an Oxford research group that has a special interest in new developments in surgical techniques in ultra-radical surgery for advanced ovarian cancer, he has published many papers and been invited to speak at a number of international congresses. He is on the editorial board of Current Problems in Cancer: Case Reports, Gynecology and Pelvic Medicine (GPM) and the Journal of Obstetrics, Gynecology and Cancer Research (JOGCR). He is also a reviewer for Cereus, BMJ case reports, European Journal of Gynaecology Oncology (EJGO) and Frontiers in Oncology. Mr Soleymani majd is an Honorary Senior Clinical Lecturer in Gynaecological Oncology surgery at Oxford University and works as a Consultant in Gynaecological Oncology at the Churchill Hospital, Oxford, and has been in post since 2016.