Carcinoma of the cervix at Muhimbili National Hospital, Tanzania: Diagnosis and Therapeutic Implication of the Small Cell Type

Abstract

Carcinoma of the cervix is the most common malignancy worldwide after breast cancer, majority occurring in developing countries. One histological type of cervical cancer, known as small cell carcinoma (SMCC) is relatively rare but more aggressive when it occurs, posing problems in management. It is established that human papillomavirus (HPV) is the etiological agent for squamous intraepithelial lesions (SIL) and cervical cancer. Recently there have been suggestions that cervical cancer occurs more often in HIV infected women. Immunosuppression, caused by human immunodeficiency virus (HIV) infection, which in the terminal stages causes acquired immunodeficiency syndrome (AIDS), leads to persistence of HPV and therefore increased risk of SIL and cancer. Information on the association of HIV infection and cervical cancer is rare in Tanzania. Likewise the frequency of small cell carcinoma, and whether it has any association with HIV infection is lacking. In order to plan the management of cervical cancer and particularly SMCC, it is important to know its magnitude and also interaction with HIV infection. For this ressoan a prospective study was carried out at Muhimbili National Hospital. Results show that 86.2% clinically diagnosed patients were histologically confirmed as cervical cancer while 13.8% were non-cancerous lesions. Mean age of cervical cancer was 49.6 years, similar to what has been reported before. A geographical variation in the distribution of cervical cancer in Tanzania was noted which may be a result of different socio-cultural factors in the different zones. Sexual related risk factors for cervical cancer were identified as mean age at first exposure to sexual intercourse, marriage and vi

pregnancy below 19 years. Polygamy and unstable marital status were noted as risk factors although there was no statistically significant difference (p<0.70). The number of pregnancies as a risk factor for cervical cancer were only significant when they were seven and above (p<O.OI). Majority (90%) of patients were diagnosed when the disease was in late stages, an indication of poor prognosis. Histologically, squamous cell carcinoma (SCC) was the most common (86.5%). SMCC accounted for 10.9% of all cervical cancer and neuroendocrine carcinoma (NE) for 38.1 % of all SMCC. Out of 42 patients with cervical cancer, 61.9% had demonstrable HPV and out of these 10 (23.8%) and 16 (38.1%) were small cell and non-small cell carcinomas respectively. The mean age and clinical stage of small cell carcinoma were slightly higher than that of non small cell carcinoma although there was no statistically significant difference irrespective ofHPV serostatus (p<0.90). Severe immunodeficiency caused by HIV was associated with advanced clinical stages of cervical cancer (p<0.002), but non of the SMCC was associated with HIV infection. It is concluded that cervix cancer is a major problem in women especially those in active age groups. Sexually related factors besides HPV are risk factors involved in the pathogenesis of the disease. Preventive measures directed against these risk factors and early diagnosis of cervix cancer are recommended in order to reduce to a minimum the incidence and burden of the disease at national level.

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