Advanced Cervical Cancer after Untreated CIN

Figure 1. The patient first presented with a preneoplastic lesion, but never received treatment.

Summary
A case is presented of advanced uterine cervical cancer in a Peruvian woman who failed to receive treatment for previously diagnosed cervical intraepithelial neoplasia (CIN).

Case Report
A 35 year-old female of low socioeconomic background coming from a small village far from the capital, gravida 6, para 5, first coitus at age of 15, with a history of multiple sexual partners, presented with a Pap smear suggestive of CIN III ( HSIL). Repeat cytology performed on arrival at the triage clinic was consistent with HSIL. Colposcopy performed next day at the dysplasia clinic showed an area of thick, acetowhite epithelium with a punctation pattern, extending up into the cervical canal (Fig. 1). Colposcopically directed biopsy reported two weeks later was consistent with CIN III; endocervical curettage was negative.

Figure 2. Lost to follow-up, the patient returned five years later with invasive cancer.

Because of endocervical involvement, the patient was scheduled for cold knife conization to be performed as an inpatient procedure three weeks later due to the great demand for hospital beds. In the meantime, she ran out of money and was unable to stay in the capital any longer. She was lost to follow-up for five years. In May 2002, she presented again with episodes of heavy vaginal bleeding and pain referred to the flank. Physical examination revealed a 4.5 x 3.5 cms. exophytic cervical mass (Fig. 2) extending into both parametria, reaching the right pelvic wall, corresponding to a mid-differentiated, squamous cell carcinoma, clinical stage IIIb. She received external pelvic radiotherapy with a 60 Cobalt machine to a total of 5,000 cGy, followed by intracavitary radium brachytherapy, reaching an overall tumor dose of 9000 cGy. Follow-up at six months revealed persistence of unresectable disease at the cervix and parametria. She was referred to the medical oncologist for consideration of chemotherapy, but financial limitations prevented her from being treated. She was lost to follow-up again, with persistent disease.

Discussion
Cancer of the uterine cervix is the most prevalent female malignancy in the majority of developing countries. Worldwide, it is estimated that 500,000 new cases are diagnosed each year, 80% of these in the developing world, and that half of these patients will die. Although in Lima, the capital of Peru, female cancer figures are changing, with breast carcinoma displacing cervical cancer to the second position in incidence¹, in the rest of the country, as represented by the Trujillo Cancer Registry², cervical carcinoma is the primary cause of cancer-related mortality in women. It is a real public health problem affecting women of reproductive age with heavy family commitments, like the present case. It is a compound picture, involving mainly socio-cultural and economic aspects that prevent women from being screened and treated at an early, curable stage of disease. The same factors also account for patients being denied access to modern standards of advanced disease management, such as chemoradiation and radiotherapy using a linear accelerator.

Our patient exemplifies very well the difficulties that face most of the developing world´s women in accessing health care and, specifically, oncologic care. Although she had a Pap smear, she was not able to benefit either from treatment for early disease or from chemoradiation at a later stage. In this setting, the offer of early detection and cancer treatment is scarce. Until a more definitive solution (HPV vaccines) arrives, we are convinced that the most cost-effective strategy to decrease the incidence and mortality of the cervical cancer is to reinforce secondary prevention. Classic, cytology-based screening programs have been successful in achieving that goal in industrialized countries, but they have almost uniformly failed in the developing world. Furthermore, as occurred with our patient, less than 30% of women with a positive Pap smear receive treatment in Perú. ³ They are lost in the course of the expensive and time-consuming diagnostic workup. So, alternative diagnostic and therapeutic approaches, better tailored to our needs and resources, are urgently needed in order to avoid patients being lost to follow-up. Secondary prevention based on visual inspection⁴ and single session management³, using outpatient cryosurgery or electrosurgical loop excision (LEEP) as therapeutic modalities, are promising strategies currently being tested in some protocols and awaiting final validation and wider dissemination in low resource settings.

Carlos L. Santos
Instituto de Enfermedades Neoplásicas “Eduardo Cáceres Graziani”, Departamento de Ginecología, Lima, Perú.

REFERENCES

¹ Metropolitan Lima Cancer Registry 1990 – 1993. Centro de Investigación en Cancer Maes–Heller Vol II : 30, agosto 1998.

² Cancer Incidence in Five Continents. Vol VII. IARC Scientific Publications No 143, Lyon: 124-125-128-129, 1997.

³ Carlos Santos, M.D. et al. One Session Management of Cervical Intraepithelial Neoplasia: A Solution for Developing Countries. Gynecologic Oncology 61: 11-15, April 1996.

⁴ R. Sankaranarayanan, et al. Visual Inspection of the Uterine Cervix after the Application of Acetic Acid in the Detection of Cervical Carcinoma and its Precursors. Cancer 83: 2150–6, 1998.