Fatal Cervical Cancer Secondary to Untreated Dysplasia

Abstract and Introduction

Abstract

Introduction: Well-documented cases of untreated cervical intra-epithelial dysplasia resulting in fatal progression of invasive cervical cancer are scarce because of a long pre-invasive state, the availability of cervical cytology screening programs, and the efficacy of the treatment of both pre-invasive and early-stage invasive lesions.
Case presentation: We present a well-documented case of a 29-year-old Caucasian woman who was found, through routine conventional cervical cytology screening, to have pathologic Papanicolaou (Pap) grade III D lesions (squamous cell abnormalities). She subsequently died as a result of human papillomavirus type 18-associated cervical cancer after she refused all recommended curative therapeutic procedures over a period of 13 years.
Conclusion: This case clearly demonstrates a caveat against the promotion and use of complementary alternative medicine as pseudo-immunologic approaches outside evidence-based medicine paths. It also demonstrates the impact of the individualized demands in diagnosis, treatment and palliative care of patients with advanced cancer express their will to refuse evidence-based treatment recommendations.

Introduction

Cases of intra-epithelial disease of the cervix are almost entirely attributable to human papillomavirus (HPV) infection. A minority of women exposed to HPV develop a persistent infection that affects the squamocolumnar junction where the ectocervix and endocervix meet. Within that junction, dynamic changes of the epithelium occur due to puberty, pregnancy, menopause and hormonal stimulation. The epithelium is vulnerable to noxae associated with smoking, contraceptive use and infection with other sexually transmitted diseases. Alterations of the epithelium are assessed by conventional cervical cytology screening and are scored according to either the Bethesda or the Papanicolaou system. The occurrence of reactive changes and/or cell abnormalities triggers either repetitions of the cytology screening to exclude temporary alterations or a cervical biopsy for histological diagnosis of cervical intra-epithelial neoplasia and cervical cancer. With the advent of HPV vaccination^[1] and HPV screening^[2] to identify women at risk of lesions with atypical or malignant cells prior to clinical manifestation, in current clinical practice a patient's HPV status should play a central role in the prevention of HPV-associated diseases.^[3]

Invasive cervical cancer has a long pre-invasive state, and cervical cytology screening programs are available. Moreover, HPV vaccination has been shown to be a successful tool of primary prevention,^[1] and treatment of pre-invasive lesions is effective. Invasive cancer is considered a preventable cancer in the so-called highly developed Western countries.^[3] Consequently, invasive cancer of the cervix has become increasingly infrequent in this part of the world, but it remains a significant health problem in underdeveloped countries, where meticulous documentation of fatal courses of the disease plays a minor role. Thus, our knowledge of the lead time between dysplasia and the development of invasive cancer as well as progression from early-stage to metastasized cancer largely derives from extrapolating information from studies and textbooks, but very few case reports.

Herein we report a rather rare, yet well-documented case of a 29-year-old woman who, during the course of her disease, accepted multiple diagnostic procedures but refused any curative treatment beginning with the first assessment of cervical dysplasia and early-stage invasive cancer 10 years later. She finally refused to accept any interventional medical strategies, except for palliative care, at the stage of locally progressed and metastasized cervical cancer.

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