**7. Cervical cancer: prevention and control**

#### **7.1. The three-tier system of primary, secondary and tertiary prevention**

#### *7.1.1. Primary prevention*

HPV infection is the causal factor and it can be prevented by Health Education and Vaccination.

Health education:

genital and menstrual hygiene;

stop tobacco use;

encourage male circumcision;

condom promotion;

safe sex;

Prophylactic HPV vaccines for girls before sexual life exposure;

Two-dose vaccine.

The WHO recommends two-dose vaccine (given at 0 and 6 month or 0 and 12 month) for those starting vaccine before 15 years of age.

#### *7.1.2. Secondary prevention*

#### *7.1.2.1. Screening*

Stage III = up to 40%; Stage IV = <15%.

—CKC.

**6.1. HPV vaccination**

three-dose schedule.

*7.1.1. Primary prevention*

genital and menstrual hygiene;

encourage male circumcision;

Health education:

stop tobacco use;

condom promotion;

Two-dose vaccine.

safe sex;

Ablation: cryotherapy, laser ablation.

**5. Treatment of cervical intraepithelial neoplasia**

6 Cervical Cancer - Screening, Treatment and Prevention - Universal Protocols for Ultimate Control

Success rate of all the above modalities is 80–100%.

**6. Efforts t o prevent HPV infection**

cervical cancer in females aged 10–25 years.

The efficacy of these vaccines ranges from 0 to 80%.

**7. Cervical cancer: prevention and control**

**7.1. The three-tier system of primary, secondary and tertiary prevention**

Prophylactic HPV vaccines for girls before sexual life exposure;

Excision: loop electro excision procedure—LEEP, laser conisation, or cold knife conisation

GARDASIL is a quadrivalent vaccine against HPV types 6, 11, 16 and 18 and is given in a

CERVARIX is a bivalent vaccine against HPV types 16 and 18 for the prevention of CIN and

HPV infection is the causal factor and it can be prevented by Health Education and Vaccination.

Screening is a process in which the apparently normal population is subjected to a rapidly applied test to detect an abnormality or a disease condition.

#### *7.1.2.2. Cytology screening*

Pap smear screening of women from the age of 25 years can be implemented in the population and the resources need to be planned well to ensure success.

#### *7.1.2.3. HPV testing*

HPV testing is a highly sensitive test, but is costly and resource intensive.

#### *7.1.2.4. Visual screening*

The most successful and cost-effective methods are as follows:


#### *7.1.2.5. Colposcopy*

Colposcopy is very useful in visual inspection positive lesions to make colposcopic diagnosis, apply a directed biopsy and in guidance of LEEP.

Screen and treat policy for low-resource settings:

Most suited strategy for limited resource settings. A single visit approach has resulted in reduction of incidence rate and mortality rate due to cervical cancer in many countries.

Modalities:

VIA positive—cryotherapy;

VIA positive—colposcopy positive—cryotherapy;

VIA positive—colposcopy positive—biopsy taken—cryotherapy;

VIA positive—colposcopy positive—biopsy taken—biopsy positive—recall for treatment.

In most research settings and in some programmatic settings (e.g., mostly in Asia in countries such as India, Bangladesh and Nepal), colposcopy is used for triaging VIA positives in screen and treat policy.

Radical hysterectomy and bilateral pelvic lymphadenectomy or radiotherapy (or trach-

Introductory Chapter: Cervical Cancer - Screening, Treatment and Prevention

http://dx.doi.org/10.5772/intechopen.76907

9

Chemoradiation or radical hysterectomy and bilateral pelvic lymphadenectomy +/−

Chemoradiation or radical hysterectomy and bilateral pelvic lymphadenectomy in

Chemoradiation or radical hysterectomy and bilateral pelvic lymphadenectomy in

Stage III: Carcinoma extending onto pelvic wall; the tumour involves lower third of the vagina. All patients with hydronephrosis or nonfunctioning kidney are included unless

Stage IIIA: Involvement of lower third of the vagina; no extension of pelvic sidewall.

or rectum. Bullous oedema does not allow a case to be designated as stage IV.

Stage IIIB: Extension to pelvic sidewall and/or hydronephrosis or nonfunctioning kidney.

Stage IV: Carcinoma extends beyond true pelvic or clinically involves mucosa of bladder

Cervical cancer, though a highly prevalent cancer, is largely and effectively preventable and treatable. The great advances in science and sociology well contribute towards the global crusade to eliminate cervical cancer, especially among the underserved and unreached poor women in the world. The InTech publishers, editor and authors, dedicate this book towards

selected patients +/− adjuvant radiotherapy or chemoradiation

selected patients +/− adjuvant radiotherapy or chemoradiation

Stage II: Carcinoma extending beyond cervix but not to pelvic sidewall; carcinoma involves

electomy and pelvic lymphadenectomy). Stage IB2 Clinical lesions more than 4.0 cm in size;

adjuvant radiotherapy or chemoradiation.

vagina but not its lower third.

Stage IIA: No parametrial involvement

Stage IIB: Parametrial involvement

known to be result of other causes.

Chemoradiation or radiotherapy

Chemoradiation or radiotherapy.

Stage IVB: Spread to distant organs:

Sources: (Benedet, 2000; FIGO, 2009).

this noble mission (**Appendix A** and **B**).

**8. Conclusion**

Stage IVA: Spread of growth to adjacent organs:

Palliative chemotherapy or radiotherapy.

Criteria to provide cryotherapy:


#### LEEP:

Ideal to treat CIN 3 lesions and large lesions.

*7.1.3. Tertiary prevention*

The diagnosis and management of invasive cervical cancer is called tertiary prevention.

*7.1.4. Carcinoma of the cervix uteri management according to FIGO staging system*

*7.1.4.1. Stage description standard treatment*

Stage 0: Carcinoma in situ, preinvasive carcinoma.

LEEP, conisation.

Stage I: Invasive carcinoma strictly confined to the cervix.

Stage IA: Invasive carcinoma identified microscopically (all macroscopically visible lesions, even with superficial invasion, should be assigned to stage IB):

Stage IA1: Measured invasion of stroma 3.0 mm or less in depth and 7.0 mm or less in horizontal spread;

Simple hysterectomy or trachelectomy, conisation in selected cases.

Stage IA2: Measured invasion of stroma more than 3.0 mm but not greater than 5.0 mm in depth and 7.0 mm or less in horizontal spread;

Simple or radical hysterectomy and bilateral pelvic lymphadenectomy (or trachelectomy and pelvic lymphadenectomy) depending on local or regional guidelines.

Stage IB: Clinically visible lesion confined to cervix or microscopic lesion greater than stage IA2:

Stage IB1 Clinical lesions of 4.0 cm or less in size;

Radical hysterectomy and bilateral pelvic lymphadenectomy or radiotherapy (or trachelectomy and pelvic lymphadenectomy).

Stage IB2 Clinical lesions more than 4.0 cm in size;

Chemoradiation or radical hysterectomy and bilateral pelvic lymphadenectomy +/− adjuvant radiotherapy or chemoradiation.

Stage II: Carcinoma extending beyond cervix but not to pelvic sidewall; carcinoma involves vagina but not its lower third.

Stage IIA: No parametrial involvement

Criteria to provide cryotherapy:

**6.** no doubt of invasive cancer.

*7.1.3. Tertiary prevention*

LEEP, conisation.

horizontal spread;

stage IA2:

LEEP:

**1.** less than 75% of TZ is involved;

**2.** lesion does not extend to endocervical canal or vagina;

8 Cervical Cancer - Screening, Treatment and Prevention - Universal Protocols for Ultimate Control

The diagnosis and management of invasive cervical cancer is called tertiary prevention.

Stage IA: Invasive carcinoma identified microscopically (all macroscopically visible lesions,

Stage IA2: Measured invasion of stroma more than 3.0 mm but not greater than 5.0 mm in

Simple or radical hysterectomy and bilateral pelvic lymphadenectomy (or trachelectomy and pelvic lymphadenectomy) depending on local or regional guidelines.

Stage IB: Clinically visible lesion confined to cervix or microscopic lesion greater than

Stage IA1: Measured invasion of stroma 3.0 mm or less in depth and 7.0 mm or less in

*7.1.4. Carcinoma of the cervix uteri management according to FIGO staging system*

**3.** no extension of the lesion onto the vaginal walls;

**4.** lesion adequately covered by cryoprobe; **5.** entire squamocolumnar junction is visible;

Ideal to treat CIN 3 lesions and large lesions.

*7.1.4.1. Stage description standard treatment*

Stage 0: Carcinoma in situ, preinvasive carcinoma.

Stage I: Invasive carcinoma strictly confined to the cervix.

depth and 7.0 mm or less in horizontal spread;

Stage IB1 Clinical lesions of 4.0 cm or less in size;

even with superficial invasion, should be assigned to stage IB):

Simple hysterectomy or trachelectomy, conisation in selected cases.

Chemoradiation or radical hysterectomy and bilateral pelvic lymphadenectomy in selected patients +/− adjuvant radiotherapy or chemoradiation

Stage IIB: Parametrial involvement

Chemoradiation or radical hysterectomy and bilateral pelvic lymphadenectomy in selected patients +/− adjuvant radiotherapy or chemoradiation

Stage III: Carcinoma extending onto pelvic wall; the tumour involves lower third of the vagina. All patients with hydronephrosis or nonfunctioning kidney are included unless known to be result of other causes.

Stage IIIA: Involvement of lower third of the vagina; no extension of pelvic sidewall.

Stage IIIB: Extension to pelvic sidewall and/or hydronephrosis or nonfunctioning kidney.

Chemoradiation or radiotherapy

Stage IV: Carcinoma extends beyond true pelvic or clinically involves mucosa of bladder or rectum. Bullous oedema does not allow a case to be designated as stage IV.

Stage IVA: Spread of growth to adjacent organs:

Chemoradiation or radiotherapy.

Stage IVB: Spread to distant organs:

Palliative chemotherapy or radiotherapy.

Sources: (Benedet, 2000; FIGO, 2009).

#### **8. Conclusion**

Cervical cancer, though a highly prevalent cancer, is largely and effectively preventable and treatable. The great advances in science and sociology well contribute towards the global crusade to eliminate cervical cancer, especially among the underserved and unreached poor women in the world. The InTech publishers, editor and authors, dedicate this book towards this noble mission (**Appendix A** and **B**).
