Current direction in the prevention of cervical cancer

Cervical screening seems to benefit a minor part of the world female population, and yet women who benefit from it still prove its weaknesses. The fact that these genital lesions are the consequence of a chronic genital infection with HPV opens new and extraordinary opportunities for prevention through vaccination. The highest efficacy is demonstrated in young women naive to the virus types associated with the vaccines. The effectiveness of HPV vaccines are limited by two factors: all genital cancers and precancerous lesions are not induced exclusively by HPV types 16 and 18, and the optimal benefit is demonstrated in adolescents and young women before they have encountered these viruses. Vaccination and screening act complementarily and synergistically, and constitute to date the new standards of disease prevention.     

Quality of life in cervical cancer survivors: patient and provider perspectives on common complications of cervical cancer and treatment

Objective

This study's objective was to quantify the impact (utility) of common complications of early cervical cancer treatment on quality of life (QOL). Utilities assigned by survivors were compared to those assigned by providers.

Methods

30 survivors of early cervical cancer identified from our Tumor Registry and 10 gynecologic oncology providers were interviewed. Participants evaluated complications (health states) using the standard gamble (SG) and visual analogue scale (VAS). Each participant was randomly assigned to rate 5 of 13 health states. Mixed-effects linear models were used to generate confidence intervals for utility means, and evaluate the effect of group (survivors versus providers). Higher utilities indicate the health state is closer to perfect health.

Results

Survivors and providers mean ages were similar (44 and 40). Mean time from diagnosis was 6.7 years. 28 of 30 survivors had no evidence of disease. 56% of survivors had complications. Using SG, providers consistently assigned utilities 7% higher than survivors (p = 0.035) for all health states except “ileostomy”, which survivors rated higher than providers. Survivors assigned the lowest utility to small bowel obstruction (SBO) (fixable without an ostomy) and ureteral obstruction (UO). Survivors rated SBO 16% and UO 21% lower than providers. Personal history of complications or higher stage did not have a consistent effect on QOL adjustments.

Discussion

Providers assign higher utilities than survivors to health states. Providers and survivors diverge on which complications impact QOL the most. Data on patient preferences should be considered when weighing treatment options with similar survival but different associated complications.     

Current controversies in cervical cerclage

Cervical incompetence is defined as the inability to support a full-term pregnancy because of a functional or structural defect of the cervix. It is characterized clinically by acute, painless dilatation of the cervix usually in the mid-trimester culminating in prolapse and/or premature rupture of the membranes with resultant preterm and often previable delivery. Cervical cerclage has become the mainstay for the management of cervical incompetence, but remains one the more controversial surgical interventions in obstetrics. This article reviews the current state of the literature as regards the indications, contraindications, and techniques of cervical cerclage. This article also focuses in detail on 4 areas of controversy, namely transabdominal cerclage, cervical cerclage for a short cervix, the management of cerclage after preterm premature rupture of the membranes, and the utility of a second (salvage) cerclage.     

Conservative management of cervical cancer: Current status and obstetrical implications

Recent advances in screening and early diagnosis have decreased cervical cancer incidence and mortality rates in high-resource settings. The postponement of childbearing, combined with an increased number of cervical cancer survivors, has yielded new paradigms in patient care. In recent years, radical surgery has been challenged as the standard of care for early-stage cervical cancer owing to its significant morbidity and fertility impairment. Attention has been directed to assessing more conservative procedures that can reduce treatment-induced morbidity without compromising oncologic safety and reproductive potential of patients with early-stage disease. In those with more advanced disease, neoadjuvant chemotherapy followed by conservative surgery has also been considered. These conservative treatment modalities including cervical conization, simple trachelectomy, and simple hysterectomy have been studied in various settings. In this chapter, we discuss the role of conservative surgery in the management of cervical cancer and the resulting obstetrical outcomes.     

宫颈癌保留生育功能的现状及反思

随着宫颈癌筛查技术的规范与普及,越来越多年轻的宫颈癌患者在早期被发现,大多数生育年龄的宫颈癌患者有强烈的保留生育功能意愿。文章对宫颈癌患者行保留生育功能手术的适应证、手术方式、安全性及妊娠结局、相关争议等做一概述。     

Current Jewish perspectives on maternal identity

Infertility counseling is a specialized field that will continue to grow in coming years as the impact of infertility and its treatment is documented more in terms of emotional, physical, social and life consequences. We report here on more recent developments in halakha (Jewish law and ethics) that are of importance to Orthodox Jewish infertile couple considering donor gametes or surrogacy. Counselors should anticipate issues that may arise in the future and assist couples in their efforts to address them. Good medical practice values the importance of understanding the patient’s individual concerns and values, including the complex psychological, sociological and cultural context in which they experience their infertility. Good counseling anticipates and addresses future problems about which patients might not currently be aware, and requires up-to-date authoritative information.     

Current status and future perspectives in male contraception

Contraception is a crucial human right for its role on health, development and quality of life. Since the introduction of hormonal female contraception the burden of family planning has fallen mostly on women. The few methods of family planning available for men--namely condoms, vasectomy, periodic abstinence and withdrawal--are hundred year old in concept, are based on preindustrial practices and have low efficacy or are difficult to reverse. In spite of the shortcomings of currently available male contraceptives, 1/3 of the couples that use contraception worldwide rely on male methods suggesting that development of a safe, effective, reversible and affordable contraceptive method for men would meet a critical need. Recent surveys have shown that men want to know more about reproductive health and want to support their partner more actively. In recent decades, there have been exceptional advances in the development of safer and more effective contraceptives. Currently, several methods of contraception for men are under development. This paper summarises the efforts performed over the past decades to develop an effective, safe and reversible male contraceptive.     

Topotecan in cervical cancer

Recurrent and advanced cervical cancers are associated with high mortality and a lack of effective treatment options, especially for women who are poor candidates for surgery or radiation therapy. The broad clinical effectiveness and manageable toxicity of topotecan in other human malignancies as well as promising recent study results suggest that it is highly effective in treating cervical tumors. We therefore conducted a systematic review on the studies using topotecan in cervical cancer. Seven phase I-III clinical trials using topotecan, both as a single agent and in combination with cisplatin or paclitaxel, in patients with recurrent or advanced carcinoma of the cervix were reviewed. Data from two studies in which topotecan was used in combination with radiotherapy for induction therapy were also evaluated. Although single-agent cisplatin-based chemoradiotherapy is the standard of care for high-risk or locally advanced cervical cancer, topotecan, when used concurrently with cisplatin and/or radiation therapy, produces high objective response rates and prolonged survival. Gynecologic Oncology Group (GOG) Protocol 179 for the first time showed significantly improved overall survival and progression-free survival in a combination therapy for advanced cervical cancer compared to cisplatin alone. Recent data suggest that topotecan, when used concurrently with cisplatin, may be the new standard of care for the management of recurrent or advanced cervical cancer. Ongoing phase III studies (GOG-204, AGO-Zervix-1) will compare this combination with other cisplatin-containing and cisplatin-free combinations. Moreover, further evaluation of topotecan appears to be warranted in conjunction with radiotherapy and in the neoadjuvant setting as well as in combination with novel biologic agents.     

Angiogenesis in cervical cancer

Angiogenesis is a factor of spread and metastatization. This fact has been established for many malignancies, but the data concerning cervical cancer are rather conflicting. In a study including 42 patients affected by cervical cancer stages IB to IVA, the authors assess the mean capillary density and the correlations between this parameter and the other anatomoclinical parameters: the VEGF expression, tumoral oxygenation and the data obtained from dynamic MRI. The histologic assessment of the capillary density and the data obtained by dynamic MRI enable us at the same time to quantify the tumoral angiogenesis and establish the prognosis. The two methods could be used routinely as markers of prognosis. VGEF surely plays a role in angiogenesis linked with cervical cancer growth, but its regulation is not definitively clear at the moment. The impact of tumoral oxygenation (whose place as a prognostic marker is clearly established) on tumoral angiogenesis and vessels' permeability as well as its control is currently not clearly established. Further studies on larger populations are necessary.     

Current aspects of cervical screening

The cervical screening programme in the UK has had a long and complicated gestation. It was unplanned and has been unloved, and, initially, not surprisingly, failed to thrive. It was then taken in hand, given firm guidance and began to improve. It continues to suffer from misunderstanding and the effects of the poor handling in the past, but with careful supervision and monitoring it is beginning to be recognized as one of the most successful medical screening programmes in the world.     

Human papillomavirus infection and cervical neoplasia: new perspectives

This review addresses several problems associated with human papillomavirus (HPV) infection of the cervix and lower female genital tract. These include the definition of HPV infection and its distinction from HPV-associated neoplasia, the distinction of HPV infection from reactive epithelial changes induced by other infections, and the transmission of HPV infection via the male partner. The available evidence indicates that there are two distinct intraepithelial processes in the cervix associated with HPV. One is the classical condyloma and its counterpart in immature epithelium, atypical immature metaplasia. The other is intraepithelial neoplasia, which, like classical infection, may be mature [cervical intraepithelial neoplasia (CIN) with koilocytosis] or immature (high grade CIN or carcinoma in situ). Molecular hybridization studies indicate that HPVs 6 and 11 are most commonly detected in the former, whereas HPVs 16 and 18 DNA are most common in the latter and in invasive cancer. From the clinical standpoint the most important distinction is between HPV-related disease (condyloma or CIN) and reactive changes associated with other pathogens, such as Chlamydia. The former should be removed from the cervix, whereas the latter should be treated medically or followed. It is stressed that therapy should not hinge upon the histological distinction of HPV infection from neoplasia and that all lesions should be removed, by conservative means if possible. This is underscored by the fact that a high proportion of CIN lesions contain areas identical to condyloma and that lesions with deep endocervical canal involvement, including those with features suggesting condyloma, should be treated by cone biopsy to exclude the presence of invasive cancer. Histological classifications for nonneoplastic, HPV-infected, and neoplastic epithelium are proposed. The management of the male partner is still unsettled. However, a large proportion of male partners of these patients have penile lesions and should be included in diagnostic and therapeutic protocols of women with genital HPV infections or neoplasms.     

Sentinel lymph node (SLN) concept in cervical cancer: Current limitations and unanswered questions

Sentinel lymph node (SLN) biopsy has been increasingly used in the management of early-stages cervical cancer instead of systematic pelvic lymph node dissection (PLND). The aim of this article is to give a critical overview of key aspects related to this concept, such as a necessity for reliable detection of micrometastases (MIC) in SLN and the requirements for SLN pathologic ultrastaging, low accuracy of intraoperative detection of SLN involvement, and still a limited evidence of oncological safety of the replacement of PLND by SLN biopsy only in ≥IB1 tumours due to unknown risk of MIC in non-SLN pelvic lymph nodes in patients with negative SLN, and absence of any prospective evidence.     

Invasive cervical cancer

Cervical cancer is the second most common cancer in women worldwide and is the leading cause of death in women in sub-Saharan Africa. In this review, the aetiology of cervical cancer is discussed plus HPV vaccination, diagnosis, imaging techniques, FIGO staging and management with surgical options for stage 1a1–1b1 and non-surgical options for stage 1b2–3b cervical cancer. Palliative treatments and exenterative surgery are included.