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Cervical cancer update: The latest on screening & management

The Journal of Family Practice. 2021 December;70(10):499-505,509 | doi: 10.12788/jfp.0316
December 8, 2021|Family Medicine
Linda Speer, MD;Shirley Bodi, MD
Author and Disclosure Information

Department of Family Medicine, University of Toledo College of Medicine and Life Sciences, OH
Linda.speer@utoledo.edu

The authors reported no potential conflict of interest relevant to this article.

Here are updated guidelines for prevention, testing, and treatment. Elimination of causative HPV continues to hold center stage in the global effort to curb disease.

PRACTICE RECOMMENDATIONS

› Encourage eligible patients to be vaccinated against human papillomavirus (HPV) because the vaccine is highly effective for preventing cervical dysplasia, especially when given to patients previously unexposed to the virus. A

› Screen for cervical disease with either cytology plus HPV testing or primary HPV testing with secondary triage for cytology; both protocols are more accurate than screening with cervical cytology alone, and allow you to widen the screening interval. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

The World Health Organization estimates that, in 2020, worldwide, there were 604,000 new cases of uterine cervical cancer and approximately 342,000 deaths, 84% of which occurred in developing countries.1 In the United States, as of 2018, the lifetime risk of death from cervical cancer was 2.2 for every 100,000, with a mean age of 50 years at diagnosis.2

In this article, we summarize recent updates in the epidemiology, prevention, and treatment of cervical cancer. We emphasize recent information of value to family physicians, including updates in clinical guidelines and other pertinent national recommendations.

Spotlight continues to shine on HPV

It has been known for several decades that cervical cancer is caused by human papillomavirus (HPV). Of more than 100 known HPV types, 14 or 15 are classified as carcinogenic. HPV 16 is the most common oncogenic type, causing more than 60% of cases of cervical cancer3,4; HPV 18 is second, causing 16.5% of cases—taken together, the 2 types account for more than 75% of cervical cancers.

HPV is the most common sexually transmitted infection, with as many as 80% of sexually active people becoming infected during their lifetime, generally before 50 years of age.5 HPV also causes other anogenital and oropharyngeal cancers; however, worldwide, more than 80% of HPV-associated cancers are cervical.6 Risk factors for cervical cancer are listed in TABLE 1.7 Cervical cancer is less common when partners are circumcised.7

Table of variables associated with cervical cancer
Table 1: Variables associated with cervical cancer

Most cases of HPV infection clear in 1 or 2 years. In approximately 1% of untreated cases, cancer develops. Once infection progresses to high-grade dysplasia (ie, cervical intraepithelial neoplasia [CIN] 3), further progression to invasive cervical cancer occurs in approximately 30% of untreated cases.8 Patients who develop cervical cancer generally test positive for a high-risk HPV genotype for at least 3 to 5 years before infection progresses to cancer.9

At least 70% of cervical cancers are squamous cell carcinoma (SCC); 20% to 25% are adenocarcinoma (ADC); and < 3% to 5% are adenosquamous carcinoma.10 Almost 100% of cervical SCCs are HPV+, as are 86% of cervical ADCs. The most common reason for HPV-negative status in patients with cervical cancer is false-negative testing because of inadequate methods.

Primary prevention through vaccination

HPV vaccination was introduced in 2006 in the United States for girls,a and for boysa in 2011. The primary reason for vaccinating boys is to reduce the rates of HPV-related anal and oropharyngeal cancer. The only available HPV vaccine in the United States is Gardasil 9 (9-valent vaccine, recombinant; Merck), which provides coverage for 7 high-risk HPV types that account for approximately 90% of cervical cancers and 2 types (6 and 11) that are the principal causes of condylomata acuminata (genital warts). Future generations of prophylactic vaccines are expected to cover additional strains.

Continue to: Vaccine studies...

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