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Referral and warning signs
When to refer
Referral for Colposcopy/Biopsy for any abnormal screening result or suspicious lesion. Refer ALL confirmed invasive cancer cases to specialized Gynae-Oncology centre.
Red flags
- Post-coital bleeding
- Intermenstrual bleeding
- Postmenopausal bleeding
- Suspicious cervical lesion on speculum exam
- Abnormal screening test result
Signs and symptoms
- Early stages often asymptomatic.
- Abnormal vaginal bleeding: Post-coital bleeding, Intermenstrual bleeding, Postmenopausal bleeding, Menorrhagia.
- Unusual or foul-smelling vaginal discharge (watery, mucoid, purulent, or bloody).
- Pelvic pain or pain during intercourse (dyspareunia).
- Late Stage Symptoms: Leg swelling (oedema), Flank or back pain (hydronephrosis), Urinary symptoms (frequency, haematuria, incontinence, fistula), Rectal symptoms (tenesmus, rectal bleeding, constipation, fistula), Weight loss, fatigue, anorexia.
Risk factors
- Persistent infection with high-risk Human Papillomavirus (HPV) types (esp. 16, 18) - necessary cause.
- Early onset of sexual activity.
- Multiple sexual partners.
- History of other sexually transmitted infections (e.g., Chlamydia, HSV).
- Immunosuppression (especially HIV infection - AIDS-defining illness).
- Smoking.
- Long-term use of oral contraceptives (small increased risk).
- High parity (multiple births).
- Low socioeconomic status (linked to screening access/risk factors).
- Lack of regular screening (Pap smear/VIA/HPV test).
Diagnosis
Clinical assessment
Suspect based on symptoms (abnormal bleeding - esp. post-coital, discharge) or abnormal screening test result. Speculum examination may reveal visible cervical lesion. Bimanual/rectovaginal exam assesses parametrial involvement.
Investigations
- Cervical Biopsy: Essential for diagnosis. Punch biopsy of visible lesion or colposcopy-directed biopsy.
- Screening tests: Visual Inspection with Acetic Acid (VIA) or Lugol's Iodine (VILI) - allows screen-and-treat. Pap Smear (Cytology). HPV DNA Testing.
- Colposcopy: Magnified view of cervix, guides biopsy.
- Staging Investigations: Clinical staging (FIGO). Imaging (Chest X-ray, Ultrasound, CT, MRI, PET-CT) for treatment planning/assessing extent.
- Blood tests: CBC, Renal function.
Diagnostic criteria
Histopathological confirmation from cervical biopsy.
Management
Non-pharmacological management
- Referral to specialized Gynae-Oncology centre.
- Management depends on stage.
- Pre-invasive Disease (CIN): Excisional (LEEP, Cone) or ablative procedures (cryotherapy).
- Early Stage Invasive Cancer: Surgery (Hysterectomy + nodes) OR Primary Radiotherapy.
- Locally Advanced Invasive Cancer: Primary Chemoradiotherapy (Radiation + Cisplatin + Brachytherapy).
- Metastatic Disease: Palliative Chemotherapy +/- Targeted therapy +/- Immunotherapy. Palliative radiotherapy.
Pharmacological treatment
- Chemotherapy: Cisplatin (concurrent with radiation). Carboplatin/Paclitaxel (metastatic/recurrent).
- Targeted Therapy (Bevacizumab - anti-VEGF).
- Immunotherapy (PD-1/PD-L1 inhibitors).
- Pain management, supportive care.
Monitoring
Follow-up with exams, Pap/HPV tests, imaging as needed. Monitor for treatment side effects (radiation effects, lymphoedema, menopause).
Complications
- Abnormal bleeding
- Foul discharge / Infection
- Pain
- Urinary obstruction / Hydronephrosis / Renal failure
- Rectal involvement / Fistula formation
- Vesicovaginal fistula (VVF)
- Lymphoedema
- Metastatic disease
- Complications of treatment
Prevention
- Primary Prevention: HPV Vaccination. (Girls age 10, ideally before sexual debut).
- Secondary Prevention: Screening. (VIA, VILI, Pap, HPV test).
- Safe sex practices.
- Smoking cessation.
Patient education
- Explain diagnosis, link to HPV.
- Importance of staging.
- Treatment options based on stage.
- Potential side effects.
- Importance of follow-up.
- Prevention for daughters/family (HPV vaccination).
- Screening importance.
Uganda-specific notes
Most common cancer among women in Uganda. High association with HPV and HIV. Screening primarily uses VIA ('screen-and-treat'). Access to Pap smear, colposcopy, HPV testing, radiotherapy, brachytherapy, and comprehensive surgical/oncological care limited but available at UCI/RRHs. HPV vaccination program implemented.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 12, Section 12.3.2
- National Guidelines for Prevention and Control of Cervical Cancer, MOH Uganda
(Refer to specific MOH guidelines)