Cervical Cancer: From Diagnosis to Concurrent Chemoradiation

A 52-year-old postmenopausal woman presented with vaginal bleeding of three months' duration. The bleeding was irregular but heavy whenever it occurred, accompanied by a foul-smelling vaginal discharge and pelvic pain for one month. Her obstetric history was unremarkable, with full-term deliveries and her last child born 20 years earlier. She had no history of oral contraceptive use and had not been undergoing regular cervical screening.

What the examination found

Abdominal examination was normal. A per speculum examination told a different story: a friable growth on the cervix that bled on touch, soaking the gauze used during the exam. The cervix itself was hard and indurated, and on a per rectal examination, the parametrium, the tissue surrounding the cervix, was also indurated, suggesting local extension beyond the cervix itself.

A punch biopsy of the cervix confirmed squamous cell carcinoma, which Dr. Raizada noted is a very common cancer in both India and much of Africa. Her haemoglobin was low, a direct consequence of the bleeding, but other laboratory values, including renal function, were normal, and there was no hydronephrosis.

Staging: MRI defines the extent, and the stage

An MRI showed the lesion extending from the cervix into the upper vagina, with parametrial involvement, but no involvement of the rectum or bladder. This combination of findings staged the disease as Stage IIB cervical cancer.

Treatment: concurrent chemoradiation, then brachytherapy

The standard treatment for Stage IIB cervical cancer is concurrent chemoradiation: five weeks of external beam radiotherapy delivered alongside weekly chemotherapy. Once external radiation is complete, intracavitary radiotherapy, also called vaginal brachytherapy, is added. Identified and treated at this stage, Dr. Raizada noted, cervical cancer has a good cure rate, which makes the timing of diagnosis the single most important variable in the outcome.

The workup before treatment starts

Before concurrent chemoradiation begins, staging investigations establish the exact extent of disease, commonly using a PET scan to check involvement of the bladder, rectum, parametrium and lymph nodes. A pre-chemotherapy fitness workup follows: kidney function testing, including glomerular filtration rate, and audiometry, since some chemotherapy agents used in this regimen can affect hearing. Only once fitness is confirmed does weekly chemotherapy begin alongside radiation, with potential radiation side effects explained to the patient in advance.

On imaging choice specifically, Dr. Raizada's guidance was that MRI of the pelvis is excellent for assessing local tumour extent and pelvic structures, but comprehensive staging also requires evaluating the chest and upper abdomen, which is better done on CT. In practice this usually means CT of the thorax combined with CT of the abdomen and pelvis with contrast, or alternatively MRI of the abdomen and pelvis with contrast combined with a CT of the chest, chosen based on institutional protocol and, where there is diagnostic uncertainty, on the fact that the chest is generally better evaluated on CT while the pelvis is better evaluated on MRI.

HPV: the cause, and why prevention starts years before any of this

Cervical cancer is associated with poor personal hygiene and multiple sexual partners, but its strongest association by far is with human papillomavirus, a viral infection. Because HPV is an infection, preventing the infection prevents the cancer. HPV is most commonly linked to cervical cancer, but it also causes vulval and vaginal cancer in women, penile cancer in men, anal cancer in both sexes, and certain head and neck cancers, including oropharyngeal cancer.

Because it is a preventable cancer, Dr. Raizada urged every clinician on the call to raise screening and vaccination with every patient they see. For women aged 21 to 29, a Pap smear every 3 years is recommended. From 30 onward, Pap smear combined with HPV testing every 5 years replaces the earlier schedule. Screening overall runs from 21 to 65 years of age.

The next article in this series covers HPV vaccination in full: who needs it, the dosing schedule by age, and why vaccination never replaces screening.