Clinical problems in stage 0 (intraepithelial) cancer of the cervix.

Abstract A report is given of 275 patients with intraepithelial (Stage 0) squamous-cell cancer of the cervix or cervical stump, who have had diagnosis and treatment in our clinic during the past eight and one-half years. An attempt is made, by the use of descriptive tables, to place Stage 0 cancer in its proper perspective in the entire problem of malignancies of the female generative tract, as these malignancies are seen by our group. From this small series, we can draw no valid conclusions. This series is simply the basis for consideration of an attempt to formulate how properly to manage the problem of Stage 0 cancer. A review of the clinical material, as shown in the various tables, adds little noteworthy data to those of the 1952 report. Although the figures are not of statistical value, Table I shows that the incidence of intraepithelial cancer in the gynecologic patients was 0.58 per cent and in the obstetric patients the incidence was 0.57 per cent. No significant alterations are found for age (Tables III and IV), for race and economic status, for marital status, or parity (Tables V, VI, and VII). Table VIII shows clearly that Stage 0 cancers were found in cervices and in cervical stumps in which no clinical manifestations of disease were apparent to the examiners. If evidences of disease were present, they were in no way pathognomonic of Stage 0 cancer. A comparison of treatment Tables IX, X, and XI in the original report of 1952 with treatment Tables X and XI in this present report shows among the clinicians of our department a definite trend to vaginal hysterectomy with conservation of the ovaries in our younger age groups. The majority feels that vaginal hysterectomy with removal of an adequate vaginal cuff is the operation of choice. It should be noted in Table X that of 237 gynecologic patients with intraepithelial cancer of the cervix, 57 are being followed with no further definitive treatments than multiple punch biopsies for 7 patients and cold-knife cone biopsies for 50 patients. Discrepancies between the total figures for certain categories in the treatment Table X in this report and those in the treatment Tables IX and X in the original 1952 report are due to elimination from this series of a number of patients treated and followed elsewhere (uncontrolled and lost). Table XI shows that of 38 obstetric patients with intraepithelial cancer of the cervix, 10 have received no more definitive treatments than multiple punch biopsies and 11 no more definitive treatments than cold-knife conizations. The figures in Tables X and XI state a calculated risk we have assumed in following these patients who have not had definitive treatment. Another expression of this assumed risk is found in Table XII which shows that 7 gynecologic patients with Stage 0 cancer of the cervix were permitted to become pregnant one or more times before definitive treatments were given. It is important to note that only one of these 7 patients has continued to show genital smear atypicalities. This patient had multiple biopsies only and not cervical conization. Table XIII gives the data on the 11 patients, in a total of 38 obstetric patients who had Stage 0 cancer, who became pregnant after the diagnosis was established. Of these 11 patients, but 3 at the present time had had definitive operative treatment. Eight patients are being followed. One obese, hypertensive patient died following vaginal hysterectomy. No other significant complications occurred as a result of operations for diagnosis or treatment of Stage 0 cancer. Resuturing of the cervix for hemostasis was done in several patients who continued to bleed following cold-knife conization. Routine soundings control the problem of cervical stenosis. One patient, of the 275 patients, had a depressive psychosis prior to diagnosis and definitive therapy and committed suicide despite psychiatric care. It is not felt that the diagnosis and treatment hastened her action. No patient in this series has developed drug addiction. In the discussion, an effort is made to show some of the problems of Stage 0 cancer as they involve many of the specialists of hospital technical practice as well as those of our own service. A short summary is given of the clinical records of two patients in whom invasive squamous-cell cancer of the vagina was demonstrated years after definitive diagnosis and hysterectomy for intraepithelial cancer of the cervix. These two patients are subjects for many varied speculations. To our knowledge none of the patients who are being followed without definitive treatment has developed invasive squamous-cell cancer of the cervix. The follow-up is an important feature in the study of Stage 0 cancer of the cervix or of the cervical stump. It is essential that all patients whether they have had conservative or definitive treatment be followed with adequate diagnostic techniques. Heavy obligations are assumed by anyone who elects to treat the lesion whether by conservative or definitive therapeutic methods. The “pooling” of data from many clinics must be expedited in order to clarify the confusion which now exists in criteria both for diagnosis and for the methods of treatment. Data are presented on the number of follow-up visits and the duration of the follow-up periods for 60 of 75 patients who have Stage 0 cancer and who have had but multiple punch biopsies and cold-knife cervical conizations. The number of follow-up visits per patient ranges from 1 to 14, totaling 289 for the 60 patients. The duration of the follow-up periods ranged from 2 months to 6 years. No patient in this series who has had definitive treatment for Stage 0 cancer of the cervix continues to show atypicalities in genital smears. Three gynecologic and 2 obstetric patients who had multiple punch biopsies or coldknife cervical conizations of the cervix have persistent cytologic atypiae. The two obstetric patients have recently delivered and 2 of the gynecologic patients desire further pregnancies. The third gynecologic patient is 74 years of age and has severe cardiac disease. It is important that two groups of patients in this series be followed closely for academic as well as for clinical reasons. The first group is comprised of those patients who had microscopic foci of invasion found in tissue specimens subjected to multiple block sectioning. There were 7 of these patients, 6 gynecologic and one obstetric. To date, none of these patients has clinical evidence of invasive cancer. The second group is comprised of those patients who have not yet had definitive treatment. Patient 4 in Table XII is an outstanding example in this category. Faithful in follow-ups and with understanding, she refuses further diagnostic or treatment procedures. The diagnostic multiple punch biopsies were made just four years ago. The patient remains adamant in her intention to have another child. Periodic infertility on the husband's part has increased the difficulty of the situation.