Epidemiology and pathogenesis of cervical cancer

The majority of the estimated incidence of 471,000 new cases for invasive cervical cancer (CX) and 215,000 cancer deaths occurs in the developing countries. For Germany the CX accounts at 8th position of all cancers in women in 1997 with 5,800 newly diagnosed cases. But, every fourth woman between 25th- and 35th-year of life has been affected by CX. This counts at the upper third of the incidence in the European Union (EU). The estimated loss of live-years for women affected by CX is about nine years. The lethality for all stages of invasive cervical cancer is about 30%. For the last two decades stagnation of the reduction of mortality by CX has been reported for EU and the USA, especially affecting woman up to 35th-year of life. The percentage of this age group of all primary operative treated CX at the Leipzig University Hospital between 1979 and 1999 was 26.2%, with a mean age of 43.4 +/- 11.1 years. Improved screening for CX in the western countries and a change in environmental factors have been caused an increase of cervical precancerous (CIN-) lesions. The frequency of CIN-lesions has been estimated to be 100-times higher than the incidence of invasive cancer (21.1) in Germany. The pathogenesis of CX is multistage and CIN I and II represent highly regressive lesions, whereas CIN III requires therapeutic intervention, caused by high progression rate. The Bethesda-classification of low und high grade squamous intraepithelial lesions (SIL) cannot be recommended for biopsies or conisation specimens. Dsyplastic lesions of endocervical columnar epithelium should not be graded, the only general accepted lesion represents the adenocarcinoma in situ (ACIS). Both, CIN and ACIS represents proliferative active lesions, caused by infection with HPV. But the detection of morphologic alterations, associated with HPV, like koilocytes, are inverse correlated with the grade of the CIN-lesion.     

Epidemiology of cervical cancer: study of a prison population

The occurrence of cervical cancer among 511 inmates of the Detroit H ouse of Correction was investigated. 30% of the women were prostitutes, 82.6% had trichomonas infestation, 15.5% had syphilis, and 5.3% had gonorrhea. 3.7% of the women were diagnosed as having cancer of the cervix, a rate that was 4 times higher than in a matched control group. Sexual activity of the prisoners, on the average, began 2.8 years earlier than it did for controls. It is concluded that the initiation of coitus at an early age and promiscuity are the primary etiologic factors associated with cervical cancer.     

Epidemiology of breast cancer

Breast cancer is the most frequent malignant tumor worldwide. In recent years there has been observed an increase in its frequency, especially in developing countries, as Mexico, where mortality is arriving to the first cause of death in females. This is, in part, due to a delayed diagnosis, most frequently done in locally advances stages with a low cure rate. This is a review of all risk factors: age, sex, personal and familial history, genetic syndromes, associated breast disease, geographic distribution, body structure and environmental, hormonal, reproductive and dietary factors. It is concluded that breast cancer is a public health problem in developed and developing countries, and the best methods to drop mortality for breast cancer is the wide use of screening mammography in women at risk, in order to find cancers at initial stages and offer the adequate treatment.     

Epidemiology of endometrial cancer

Endometrial cancer is the commonest gynaecological cancer mostly affecting women in the post-menopausal age group. Rates vary worldwide and are highest in white women in Western populations. Some risk factors are related to reproduction, such as early age at menarche, late age at menopause and nulliparity, while others are more directly oestrogen-related, for example, conditions such as the polycystic ovarian syndrome. Use of unopposed oestrogen replacement therapy is associated with an increased risk, and use of the combined oral contraceptive pill is associated with a decreased risk. The relationship between tamoxifen and endometrial cancer is not established. Obesity, diabetes and hypertension increase the risk of endometrial cancer while smoking, low-fat diets and physical exercise appear to decrease the risk; all of these possibly exert their effects by various indirect influences on oestrogen levels, thus influencing the level of stimulation of the target endometrial epithelium.     

Epidemiology of endometrial cancer

Endometrial cancer is the commonest gynaecological cancer mostly affecting women in the postmenopausal age group. Rates vary around the world but are highest in white women in Western populations. Some risk factors are related to reproduction such as early age at menarche, late age at menopause and nulliparity. Others are more directly oestrogen-related, such as use of unopposed oestrogen replacement therapy which is associated with an increased risk, and use of the combined oral contraceptive pill, associated with a decreased risk. Obesity, diabetes and hypertension increase the risk of endometrial cancer while smoking, low-fat diets and physical exercise appear to decrease the risk, and all of these possibly exert their effects by various indirect influences on oestrogen levels, thus influencing the level of stimulation of the target endometrial epithelium. From a histological and molecular pathology perspective, at least two major types of endometrial tumours can be distinguished. The proportion of type II tumours is reported to range from 20 to 50%. Few epidemiological studies have distinguished between these two tumour types, and these studies have included relatively small numbers of type II tumours. There is evidence that endocrine and nutritional lifestyle factors affect the risk of type I but not type II tumours, with age being the only identified risk factor for type II cancer.     

Endometrial cancer. Epidemiology

In evaluating these trends in the East-West comparison, one notes that the epidemiologic features connoting high risk are similar in both cultures; while they are more common in the West, they are more strongly associated in the East. Clearly, a prospective interview method of obtaining reproductive data will be more informative for such a crosscultural study with greater numbers lending better support. In summary, there exists a grouping of reproductive phenomena fairly common in Western societies that are related to higher risk for endometrial cancer, and we have noted similar characteristics in Eastern women who have developed this disease, while control groups in Eastern societies where this disease is uncommon have a low profile for such attributes in comparison to the West.     

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.     

Invasive cervical cancer

In this review, the aetiology of cervical cancer is discussed plus HPV vaccination, diagnosis, imaging techniques, the new FIGO staging and management with surgical options for stage 1a1-1b2 and non-surgical options for stage 1b3-3b cervical cancer. Palliative treatments and exenterative surgery are included.     

Prevention of cervical cancer

This article reviews the burden of cervical cancer in South Africa and shows that it remains the most common cancer among South African women, particularly women with least access to cervical cancer screening. It explains the rationale behind the South African cervical cancer screening policy, which is to offer all asymptomatic women three free cervical smears in a lifetime, beginning at age 30, 10 years apart. Further, it illustrates that cervical cancer screening offers unique opportunities for prevention at both the primary and secondary levels. The causal association of human papillomavirus infection of the cervix and the possibility for vaccination against the virus is discussed. The history of screening in South Africa and why it has failed to make a major impact to date on the morbidity and mortality of cervical cancer is also discussed. Finally, possible alternative approaches to cervical cytology for the prevention of cervical cancer are briefly reviewed.