The best and, in fact, only method of detecting asymptomatic cervical cancer involves routine annual pelvic examination, including cytologic study, of all married or parous women 30 years of age and over.

Fig. 53. Pathways of spread of cervical carcinoma.

The details of the pelvic examination, including the modified Schiller iodine test and the proper procurement of vaginal and cervical smears, is described on pp. 62 to 66 in the chapter on cancer detection. If a pelvic examination were done routinely on all women, the cancer of the cervix so discovered would be almost 100% curable.

Three questions should be dealt with here:

1. Which is better, the vaginal or cervical smear? Or should both be done?

It is our firm conviction that both vaginal and cervical smears should be taken routinely. The direct cervical smear is the best means of detecting cervical cancer, whereas the vaginal smear is the best means for detecting endometrial cancer. The combination of the two reduces the chances of missing a lesion in either site to the lowest possible level. In mass screening projects in which great numbers of women are surveyed, often by non-physicians and without benefit of a formal pelvic examination, the expediency of limiting cytology to a vaginal smear is understandable and permissible. It takes the doctor only a matter of seconds to take both smears in his office at the time of pelvic examination, and this is the recommended office procedure.

2. In the absence of abnormal findings, how often should the smear be repeated?

It is possible that in the future it may be possible to relax the recommendation of the yearly vaginal and cervical smears. Reports of large-scale screening programs involving annual examination of the same women are beginning to suggest, as has been noted previously, that carcinoma in situ and its precursors may be quite slow-moving. Thus a smear once every two years might be counted on to give ample warning of departure from normal. This, of course, would be subject to the obvious safeguards of selecting patients according to age, gynecologic history and findings, previous cytology, etc. At the present time, however, the recommendation for yearly vaginal and cervical smears remains.

3. How much cancer will be found?

The answer to this varies greatly, of course, in accordance with a number of factors, including the following:

(a) How strict one is with regard to excluding symptomatic patients from screening programs

(b) How rigid are the criteria used by the cytologist and pathologist in making the diagnosis

(c) The actual incidence of the disease in the group surveyed (e.g., a predominantly Jewish group would show a relatively low yield)

Some general statements can be made, however:

(a) The usual range of biopsy-proved carcinomas found in the general population is 4 to 6 cases per 1,000 women surveyed.

(b) The number of suspicious or cytologically abnormal cases is about double this. The long-term outlook for these lesions is unknown, but a certain suspicion of eventual development of cancer must be maintained.

(c) Thus as many as 10 to 15 cases per 1,000 or 1 to l%% of women surveyed for the first time can be expected to show significant abnormalities on cytologic smear.

(d) To this yield must be added the occasional pick-up of carcinoma of the endometrium (see below).

It cannot be emphasized too strongly that in over 50% of cases of carcinoma in situ, the only clue to the lesion lies in the vaginal or cervical cytology; i.e., the patients are asymptomatic and the cervix appears entirely normal to the naked eye.

Clinical Features Of Cancer Of The Cervix-Diagnosis. Localized Lesion

Although present concepts of the disease make it likely that Stage 0 or carcinoma in situ is the only really "localized" lesion, in recognition of traditional teaching Stage I disease will be included under this same heading.

Symptoms

1. May be asymptomatic, especially if the lesion is an in situ carcinoma.

2. Vaginal discharge. If present, this is usually scanty to moderate in amount and watery or yellow in character. Appearance of, or change in the character of, a vaginal discharge should be investigated. 3. Vaginal bleeding. This may take any of the following forms:

(a) Spotting, i.e., the appearance of very small amounts of blood either:

(1) Spontaneously or

(2) After douching or intercourse

(b) Menorrhagia or metrorrhagia, i.e., the menstrual bleeding may be prolonged or excessive, or there may be bleeding between periods.

(c) Frank hemorrhage. Occasionally this may be the presenting or only symptom of localized cervical cancer.

The fact that carcinoma of the cervix occurs mainly in immediately premenopausal or menopausal patients, when alterations in the menstrual partem and other symptoms are expected by most women, should serve to emphasize the undesirability of depending on the occurrence of symptoms to call attention to the disease. It is worth noting that pain is an uncommon "early" symptom.

Sign

1. The cervix may be entirely normal in gross appearance, and a normal iodine stain (modified Schiller test, p. 65) may be observed.

2. The cervix may be entirely normal in appearance but take the iodine stain abnormally. Any nonstaining area on the cervix must be viewed with suspicion and handled accordingly (see below).

3. The cervix may present the appearance of presumably benign "cervicitis," diffuse or relatively localized in character. Such areas may or may not take the iodine stain. An ulcerating carcinoma may simulate a simple cervical erosion or cervicitis in all respects.

4. Upon inspection and palpation the cervix may display the suspicious signs of localized lesions of the three pathologic types noted previously: ulcerative, exophytic, or nodular.

Pelvic examination should confirm the fact that clinically these lesions appear to be confined to the cervix, i.e., are actually Stage I. Evidence of further spread on physical examination indicates advanced lesions.

Advanced Lesion Symptoms

Symptoms may be minimal despite the presence of an advanced lesion. However, they are usually prominent and may take the form of the following:

1. Usually an increase in frequency and intensity of symptoms noted under the localized lesion. Hemorrhage is more likely to be prominent, and the vaginal discharge is often yellow, malodorous, and associated with secondary vulvovaginitis.

2. Pain. This may be in any one of the following forms:

(a) A relatively mild sense of pelvic pressure or discomfort

(b) A more severe, but ill-defined lumbar, pelvic, thigh, or abdominal pain or aching

(c) A severe, often intractable, type of pain due to local invasion of bone and nerve

3. Urinary symptoms. These may present in the following forms:

(a) A frequency and nocturia most commonly. These do not necessarily signify actual bladder invasion

(b) Complaints secondary to the obstruction of one or both ureters, such as fever, chills, dysuria, lumbar pain or ache

(c) Incontinent passage of urine into the vagina and other symptoms consequent to a vesicovaginal fistula

4. Rectal symptoms. These may include the following:

(a) Constipation

(b) Diarrhea

(c) Tenesmus and related complaints

(d) Incontinent passage of stool into the vagina and other symptoms related to a rectovaginal fistula.

5. Other symptoms

(a) General or nonspecific symptoms such as anorexia, weight loss, nausea and vomiting, and fever

(b) Symptoms secondary to anemia

(c) Symptoms secondary to uremia

Signs

These are described in the sections dealing with the staging of lesions and the pathways of spread (p. 156 ff.).

In general, the physical findings reflect the local effects of the spread of the disease to involve the vagina, parametrium, uterus proper, bladder, rectum, adjacent soft tissues and bone, and intra-abdominal and inguinal lymphatics.

Advanced carcinoma of the cervix usually kills by means of its local effects- especially the compromising of the urinary tract with resultant uremia-but, like any other cancer, it can metastasize widely on occasion.