Cervical neoplasia: the case for an alternative to surgery

the case for an alternative to surgery
JANE LYTTLETON has worked in women's health centres for the last six
years and has, by forming fruitful liasons with gynaecologists, gained valuable
experience in treating a wide range of women's health disorders.
She has recently returned from her second trip to China where she worked in
the gynaecology department of The Red Cross hospital in Hangzhou, and from
London where she gave a seminar to students and practitioners of the London
School of Acupuncture and T.C.M.
She is currently a Lecturer in Acupuncture at the N.S.W. College of Natural

In these days of the routine annual Pap smear, CIN or cervical dysplasia is amore and more commonly heard label amongst young women attending myclinic. Most frequently by the time it is reported in a case history it has alreadybeen dealt with by surgical means. But sometimes a woman whose Pap smearresult is positive wishes to find an alternative treatment to surgery and TCMhas proved to be helpful in many cases.
CIN stands for cervical intraepithelial neoplasia and is a term used to describethe appearance of abnormal cells on the cervix. The degree ofabnormality is graded CIN 1 to 111, i.e. mild dysplasia through to carcinoma insitu. These cells are commonly found at the 'transformation zone' - an areausually visible near the end of the opening of the cervix. This area representsthe transformation of columnar to squamous cells as the endocervix becomesexposed to the vaginal environment, and is the area sampled when a Papsmear is taken. The area is fairly constantly in association with inflammatorycells which were shown to be part of an immune response to the transformedcells. Transition is halting in its progress with interruptions and resumptionsso that the final squamous covering is a mosaic in time as well as space. Eachburst of activity represents a period of enhanced risk of transformation of theepithelium toward neoplasia.
Because of the connotations words like neoplasia and dysplasia have, manywomen believe they have cancer or are about to get it and hence complyrapidly with the suggested surgery. In fact although CIN can indicate thepossibility of a cancer developing it does not necessarily do so - and in thosefew (probably around 2%) in which it does, the development of the conditionto malignancy is usually slow. In studies of atypical cervical cells a decade ago,it was reported that nine out of ten mild cases reverted to normalspontaneously and that only 15-30% of carcinomas in situ developed toinvasive cancer. The situation has changed somewhat in the last ten yearswith the discovery of the Human Papillomavirus {or genital wart virus)which appears to be closely linked with CIN. Forty strains of the virus havebeen isolated but only two (HPV 16 and 18) appear to be definitely associatedwith malignancy.(1) It appears now that 10% of sexually active women indeveloped nations are infected with HPV, however only 0.5-1% of these will JOURNAL OF CHINESE MEDICINE NUMBER 27 MAY 1988
develop cancer. Reports from the Centre for Disease in Atlanta and theGerman Cancer Research Institute state that cervical cancer develops only 15-30 years after infection by HPV.(2) There have however been isolated casesreported in the literature of more rapid development.(3) In Australia alldiagnosed CIN or the presence of HPV is treated surgically (hence there are nofigures for spontaneous reversal). This is by diathermy or laser whicheffectively removes (by burning) the top layers of cells of the cervix.
All considered, it seems reasonable to advise women with positive Pap smearsthat, provided they have 36 monthly repeat smears to check progress, analternative to surgery may safely be explored. I recommend 3-6 months ofacupuncture treatment and the taking of Chinese herbs along with appropriatelifestyle changes.
A positive Pap smear, while indicating something (maybe temporarily) is awryin the order and balance of the body, does not in fact indicate any obviousTCM diagnosis. This is because CIN has no symptoms of its own. It is only atan advanced stage of development of cervical cancer that symptoms such aspain and discharge will appear. From the point of view of TCM, tumours andneoplasias represent a blockage in the flow of Qi, such that a particular area oftissue is no longer nourished adequately by Qi and Blood and the controllinginfluence of the harmony of Yin and Yang no longer holds in check thedevelopment, growth and functioning of the tissue. A tumour is begunsubsequent to accumulation of Qi and Blood. Surgical treatment at this earlystage will remove the aberrant cells but will not necessarily re-establish anadequate flow of Qi and Blood in the area. Indeed it is likely that the localstagnation of the energy may be added to by the tissue trauma and scarringsubsequent to surgery. One might expect that if this were the case the dysplasiamight commonly occur in treated women. In fact statistics indicate that earlyrecurrence rates are 5 10%. t4, This has been explained by the fact that ablationof the surface of the cervix brings about tissue changes which do not encouragefurther HPV infection. One then suspects that Qi and Blood stagnation maymanifest elsewhere - and in fact this is sometimes borne out clinically, e.g.
increased period pain, PMS or decreased fertility. And if the blockage staysuncorrected it may perhaps manifest in more substantial ways e.g. tumours ofuterus or ovary, fibroids or cysts. This possibility is borne out by a retrospectivestudy done in New Zealand and reported recently in The Times and TheAustralian (October 9th 1987). The study followed nearly 1,000 women withsevere dysplasia over 28 years. Most remained well regardless of whether theyreceived treatment of not. But a small group of treated women developedcancer and despite progressively more extensive treatment (includinghysterectomy) cancers kept returning in adjacent sites like the vaginal wall. Itwas only because of the exceptionally long period of follow-ups in thesewomen that their diseases were known to be related to the original problemon the cervix which otherwise would have been described as cured.
To apply a TCM approach to the diagnosis of CIN it is appropriate firstly togather all the signs and symptoms which may indicate stagnation of Qi andBlood. In gynaecology these are many and various and represent a sizeable JOURNAL OF CHINESE MEDICINE NUMBER 27 MAY 1988
percentage of the women's health disorders seen in an acupuncture clinic. Asmany a young woman of the 60's, 70's, or 80's can attest, we have inheritedthat ancient Chinese curse, 'May you live in interesting times'. There aremany unique and profound stresses which modern day woman confronts inher everyday life. In addition to the relentless stress of crowded, noisy andpolluted city life, women juggle constantly shifting, vaguely defined andpoorly understood roles. They experience discrimination and oppression inmost societies to varying degrees and are constantly required to make personaldecisions about their life and relationships for which there are no longerrelevant parental models. (See B. Flaws, 1985 for a further discussion)( 5 ).
There are many unique and profound stresses which modern day womanconfronts in her everyday life. In addition to the relentless stress of crowded,noisy and polluted city life, women juggle constantly shifting, vaguely definedand poorly understood roles. As every practitioner trained in TCM knows, the 'Liver' is the temperamentalor emotional organ and one of its roles is to spread Qi so that it flowssmoothly without obstruction. Ongoing emotional stress is a key factor inupsetting this important role, and leads to the very common diagnosis inwomen of 'Liver Qi Stagnation'. The term 'Gan' or Liver includes in itsfunctional sphere aspects of the uterus, the thoracocostal region, the eyes,nails, base of the throat and top of the head. A breakdown in the patency of Qiof the Liver channel or organ can produce symptoms in any of these areas.
The classics of Chinese medicine point out that 'the power granted by theLiver is the capacity for control' and that 'the emotion anger damages theLiver'.(6) These two points are particularly relevant in the light of modernfeminism which represents a struggle through which women attempt to gaincontrol over their lives and inevitably feel some degree of anger, resentmentor frustration when confronting the injustices of patriarchal society. In thislight, Liver Qi Stagnation seems almost inevitable for the thinking woman ofthe 80's, and it presents a clinical challenge as it manifests more and morefrequently in gynaecological symptoms. A case in point.even after fourdecades of Pap smear screening there appears to be an increase in mortality inyoung women with cervical cancer. This is especially apparent in countrieslike Canada where screening has been most comprehensive.(7) This may bedue to an increase in HPV infection in the aftermath of the freer sexual moresof the 60's and 70's. It is also conceivable that the increase in CIN parallels theincrease seen in all other gynaecological disorders attributable to Liver QiStagnation, such as premenstrual syndrome, period disorders, some types ofinfertility and so on.
Relevant to mention at this point is the vastly increased use of certain sorts ofdrugs by women for period cramps, and their effect in general and on cervicalhealth in particular. Non steroidal anti-inflammatory drugs have been usedextensively in the past few years for the treatment of arthritis and relateddisorders. With the discovery of the role of prostaglandins in menstrualcramps, this group of drugs began to be given to women sufferingdysmenorrhoea. They proved to be very effective pain killers and theproducers of anti arthritic drugs started marketing them intensively for use in JOURNAL OF CHINESE MEDICINE NUMBER 27 MAY 1988
dysmenorrhoea. Now Naproxen (Naprosyn, Synflex), Indomethacin (Indocid),Ibuprofen (Brufen, Apsifen, Fenbid) and Diclofenac Sodium (Voltarol) areprescribed by doctors for dysmenorrhoea but the extent of their use is farsuperseded by over the counter drugs such as Ponstan (Mefenamic Acid),Naprogesic (Naproxin), and Aspirin which work by the same mechanism.
Despite their effectiveness in stopping the pain from Qi and Blood Stagnationin the short term, they do not in fact remove the underlying cause of theblockage and in the long term the stagnation may be worse. This is borne outby the appearance of side effects after long term use or in sensitive individuals.
These are mostly symptoms indicative of Liver Qi Stagnation and Liverinvading Stomach and Spleen viz. epigastric pain, abdominal pain, bloating,dyspepsia, diverticulitis, diarrhoea, heartburn, nausea, constipation,headaches, dizziness, tinnitus sobering evidence indicates that these drugs may potentiate the developmentof neoplasias if they are used in the presence of inflammation. (9) As describedearlier, the transformation zone of the cervix is associated with inflammatorycells. And it is interesting to note that cervical neoplasia is anothermanifestation of the very same imbalance for which the pain killers are beingtaken in the first place, i.e. Qi Stagnation. In the clinic the first part of a casehistory examines all the details of the menstrual cycle - its regularity, the typeand nature of the flow, the presence and nature of any pain, and theemotional and physical symptoms before the period. I will then ask sensitivelyabout the woman's life situation, including home circumstances, type of work,hours spent working, relationships, demands made upon her in various roles,(mother, sister, lover, wife, partner, employer, employee, house cleaner, cook,accountant and so on). Frequently, but not always, a picture emerges typical ofLiver Qi Stagnation with ample evidence to indicate that emotional stress is atits root. The case history must then be expanded in whichever way is relevantto the individual patient. For example as a result of Liver Qi Stagnation somewomen may have developed blood stagnation manifesting the symptoms ofendometriosis, or the Liver Qi may have invaded the Spleen causing gastro-intestinal tract disturbances or the appearance of Damp or Blood deficientsymptoms. With time and further stagnation, Heat may accumulate. Thus theramifications of Liver Qi which does not flow smoothly can be manifold. Ofcourse any treatment that attempts to undo the stagnation and its manyrepercussions would be ineffectual or at best temporary in its effect if theunderlying cause is not also addressed. To this end any of the many techniqueswhich calm the mind are appropriate. The regular daily practice of Tai Qi, QiGong, yoga, or meditation help to still a worried mind and reduce the effects ofstress. Some women may find an hour of gardening, piano playing, bushwalking or swimming just as therapeutic. Whichever technique is employed,it is its regular daily application which is important. In the first months oftreatment of CIN the use of guided imagery has been found very useful bymany patients. This takes a form similar to meditation but it is seeded withhealing images and gives the woman direct experience of her own power indirecting her recovery. Another important lifestyle factor to be explored withwomen with CIN is overwork. In many cases seen in my clinic the conditionof Liver Qi Stagnation is not only contributed to by stress but also by adeficiency of Qi. Of course plentiful Qi is less likely to become blocked or JOURNAL OF CHINESE MEDICINE NUMBER 27 MAY 1988
stagnate than is a weak Qi flow. It is a common case for the modern daywoman to run her stores of Qi low from overwork and irregular eatingpatterns over the years of juggling career and home demands. Next to consideris the diet itself, although in cases of Liver Qi Stagnation it is the regularity ofeating, the daily routine, which is more important than what is eaten.
However if the picture is more complicatedthan simple Liver Qi Stagnation and the Spleen is involved then dietaryconsiderations are more important. Then of course excesses of sweet andgreasy foods must be avoided. If the woman suffers from symptoms of PMS,particularly swollen sore breasts, then coffee is best omitted. I usuallyadminister acupuncture once weekly throughout the month and morefrequently in the week before the period if indicated by premenstrualsymptoms or dysmenorrhoea. Points are chosen according to the diagnosisand typically include points to tonify and move the Qi and Blood. In cases ofsimple Qi Stagnation acupuncture may be used on its own, however if there isdeficiency of Qi or Blood, herbs will be employed.
I have chosen three interesting case histories, all with relatively goodoutcomes but not necessarily straightforward in their response to treatment. Ithink that they are representative of women being brought face to face withrather serious consequences of Qi imbalance by the typical lifestyle of a youngwoman in the 80's.
Shirley, a 39 year old woman, is a legal secretary whose career direction was
most uncertain when she first consulted me in March 198 7. Her Pap smear
had first shown CIN 1 and HPV infection in June 1986. She had had it treated
with radical diathermy followed by a D. and C. A follow up Pap smear in
February 19 8 7 revealed that abnormal cells were still present. Examination
with a colposcope (a telescope type of instrument used to magnify the
appearance of the cervix surface) however, was unable to locate them and the
assumption was made that the abnormality must exist further up the os out of
reach of the diathermy. Shirley was recommended to have a cone biopsy. This
is a surgical procedure rather more complicated than the diathermy, removing
as it does a sizeable wedge from the cervix. A hospital stay of 5 days is required
and the procedure runs the risk of haemorrhage and future complications
with fertility and then with the ability of the cervix to hold a pregnancy.
Although fertility, and pregnancy were not issues for Shirley she was reluctant
to have the surgery without first getting a second opinion. We balanced the
risks of holding off the surgery with the risks the surgery itself presented and
decided on an upper limit of three months before the next Pap smear. On first
consultation the following picture emerged:
Signs and symptoms of Liver Qi Stagnation were evident in the week before
the period. These included sore nipples, depression, tearfulness, shaking,
clumsiness and irritability. The Qi Stagnation contributed to the Blood
Stagnation evident during the period viz. heavy flow of dark blood with large
clots, severe cramping, brown discharge before and after the period. Plenty of
symptoms seemed to indicate that the obstruction of Liver Qi had damagedthe Spleen, (Liver invades Spleen). She was prone to nausea, loose stools andbelching, felt full after eating, and before a period experienced abdominalbloating, constipation and sweet cravings. The diagnosis of Liver QiStagnation complicated by Blood Stagnation and Spleen Qi deficiency wasmade. Underlying this was a Kidney and Heart Yin Xu constitution asevidenced by restless sleep with dreams, a tendency to be anxious andoverwrought, frequency of urination, nocturia and a history of nocturnalenuresis into early adulthood.
Her treatment was based primarily on the principle of moving the Liver Qiand secondarily on strengthening the Spleen, Kidney and Heart. Main pointsincluded: Taichong LIV-3Ligou LIV-5Neiguan P-6Shenmen HE-7Zusanli ST-36Sanyinjiao SP-6Zhongwan REN-12Qihai REN-4Guanyuan REN-4Geshu BL- 17Ganshu BL-18Shenshu BL-2 3 Yinxu (an extra point 0.5 cun posterior to Sanyinjiao SP-6 used in thetreatment of cervical inflammation. (10) Points were chosen according to the time of the cycle and her pulse picture.
Shirley had two treatments prior to her first period. This began slowly with abrown discharge but the subsequent flow was much improved with smallerclots and no pain.
Shirley had three treatments before this period. Her premenstrual symptomsall cleared except for the tearfulness. The period still began with a browndischarge but was followed by a good flow, considerably reduced in quantitywith very little clotting and slight cramping.
Three treatments and no premenstrual symptoms were experienced this cycle,and the period started with a fresh red flow from the start. Shirleyexperienced a few cramps on the first night of the period.
It appeared that the Blood Stagnation and virtually all the Qi Stagnation hadcleared and so a Pap smear was done. The result was negative i.e., noabnormal cells were found. However the report stated that no endocervicalcells were present on the slide. The examination of cells from the endocervixwas particularly important in Shirley's case since it had been assumed that thiswas the origin of the abnormal cells appearing on the previous smear. At thispoint more symptoms which indicated all was not entirely well with the Qisuddenly developed.
Shirley started experiencing severe abdominal pain on the right side. Thismimicked appendicitis but did not test positive at McBurney's point. Shebecame very constipated and her tongue showed signs of full Heat. She wasnot only very stressed at work at this time but was fighting off (unsuccessfully)a bad case of the flu. During this cycle she had four treatments and tookChinese herbs which addressed the Qi Stagnation and the Heat.
When her next period came, once again the brown discharge preceded theflow and she experienced some menstrual cramps. The right sided abdominalpain persisted on and off, but responded well to massage.
Over the next couple of weeks and during the course of three treatments theabdominal pain subsided. There was no recurrence of premenstrual symptomsbut the period still began with a brown discharge and some cramps at night,indicating some degree of Qi Stagnation remained. We decided to push on foranother month.
Four treatments in this cycle saw the end of the abdominal pain and a periodwith a bright red flow and a few cramps. At this stage another Pap smear wasperformed which showed that all was still clear. Shirley decided to discontinuetreatment confident that her Qi was moving well.
In addition to regular acupuncture treatments Shirley took up yoga which shepractised regularly, did several sessions of guided imagery, and in cycle 2 shetook Xiao Yao San in a patent form. Her diet remained unchanged (it wasvegetarian) but she reduced her coffee and alcohol intake.
Janet (2 6 years) came to the clinic on the recommendation of her shiatsupractitioner after her Pap smear showed the presence of wart virus andcellular changes. She had a colposcopy and the result of the punch biopsytaken at this time revealed changes classified as CIN 11. Her doctorrecommended radical diathermy but she chose to pursue gentler forms oftherapy first.
In the months before I saw Janet there had been many major changes in herlife. She had recently moved to Sydney decided to stop full time nursing andthere had been a sudden death in the family. Her relationship was feeling thepressure somewhat and as a result of all these factors her energy was very low.
Physically the following symptoms were apparent: there was tension in theupper back which was a recent problem, she was having difficulty sleepingand dreamed a lot. Her periods were regular and the flow was clear with nopain, however she experienced irritability just before her period andsometimes her breasts were sore. She tended to get thoracocostal distentionand a knotted feeling in the stomach when she was tense or upset. Sometimesovulation caused abdominal pain for a couple of days. Pulse: thin and wiry.
Tongue: pale and swollen with a white coating The diagnosis of Liver QiStagnation was clearly suggested by her symptoms and her life changes. Inaddition there was evidence (from the tongue and the lack of energy) of Qi andBlood deficiency, although it was not clear whether this preceded the Liver QiStagnation or was a result of it. She was treated accordingly with points tomove the Liver Qi and strengthen the body. For the first 3 cycles, treatmentsaveraged only one per month since Janet was frequently out of Sydney. Overthis time however she began to sleep better, her energy improved and thecolour of her tongue became ahealthy pink. Three treatments were achievedin the fourth cycle when Janet returned to Sydney and to work. The stress ofcity life, work and relationship demands meant the constant, though lowgrade persistence of symptoms like premenstrual breast soreness, someirritability and restless sleep.
Two treatments in the fifth cycle began to improve these symptoms andalthough the presence of minor signs of Liver Qi Stagnation persisted it wasdecided it was time to do another Pap smear. The result arrived early in thesixth cycle and showed no sign of any abnormal cells.
In addition to the acupuncture treatment described above, Janet took Xiao YaoSan in a patent form when she was away from Sydney in the first couple ofcycles and she followed a Macrobiotic diet throughout the time of treatment.
Janet will continue to have acupuncture every month while any signs ofStagnation persist and intends to continue the Macrobiotic diet.
Frieda (25 years) first consulted me a year ago, at which time she had haddiagnosed cervical dysplasia (CIN 1 ) for a year. It was associated with HPV JOURNAL OF CHINESE MEDICINE NUMBER 27 MAY 1988
infection. She lived in a permanent and monogamous relationship, wasvegetarian and lived the precarious existence of an actress.
Her case was very straightforward indicating simple Liver Qi Stagnation. Hersymptoms included premenstrual volatility and irritability, cramps before andduring the period, dark blood at the start and finish of the period but no clots.
She suffered chronic neck pain and right shoulder pain.
Points used during her treatments were similar to those used above, againtaking note of the time of the cycle, the pulses, and in this case the areas ofpain in the neck and shoulders.
Four treatments were completed before the first period with encouragingresults. The period began with a bright red flow from the start and pain wasmuch reduced. She suffered a little depression before the period.
After another four treatments the period flow remained bright red from thestart and there was very little pain. The neck and shoulders remained aproblem.
All was not to be plain sailing however. Frieda had another four treatments inthis cycle which concentrated more on the neck and shoulder pain. Her periodwas a day late and when it started there was a return of the sluggish dark flowand strong menstrual cramps. This retrograde step may have been related tothe ingestion of Cold food or the fact that Frieda had been skiing, but we werenever sure. In view of the reoccurrence of the Qi Stagnation we decided todelay the scheduled Pap smear.
The next period after a month of weekly treatments was again a good fresh redflow with minimal pain. Frieda avoided all cold drinks and foods before thisperiod.
A Pap smear was performed at this time and no abnormal cells were detected.
A colposcopy confirmed this finding.
Frieda decided to continue treatment for her neck and shoulders, but the nextmonth produced many other symptoms for consideration besides these. Shedeveloped herpes genitalia (caught she suspected from the speculum in thecolposcopy clinic) and shortly afterwards a digestive complaint characterised byepigastric discomfort and burping. Stress played a large part in the aetiology of JOURNAL OF CHINESE MEDICINE NUMBER 27 MAY 1988
these disorders. Despite three treatments in this cycle her period flow was darkand sluggish, and she used pain killers to pre-empt the anticipated periodpain.
Two treatments in the next month helped to produce a period with a fresh redflow once again although there was still some pain.
Subsequent treatments became more and more sporadic as her careerprevented regular visits.
It is a strange anomaly of such an intensive screening programme whichhunts out infected cervices and cauterizes them to eradicate the infection, thatnever a thought is given to the source of the infection. Almost twelve months later a routine Pap smear showed evidence of arecurrence of the HPV infection. This raises a couple of interesting questions.
Since Frieda had remained monogamous all this time it might be assumedthat she had been reinfected by her (also monogamous) partner. It is a strangeanomaly of such an intensive screening programme which hunts out infectedcervices and cauterizes them to eradicate the infection, that never a thought isgiven to the source of the infection. One suggestion made in a medicalnewspaper makes such investigation of the male partner sound as simple as abottle of vinegar and a magnifying glass. Perhaps infected women should takethe initiative and hunt out the source of their HPV infection themselves. Theother possibility is that although no sign of the infection remained aftertreatment when Frieda was tested with a Pap smear and colposcopy, the virusmay have remained in a dormant or unexpressed form or was not completelyeradicated. In the following year there continued to be some evidence ofStagnation in the area, i.e. Frieda still experienced some pain with her periodsand she used Ponstan to control this, especially when she had a show to doand it would not be done to walk on stage clasping a hot water bottle to herbelly. In light of the above mentioned findings regarding non steroidal anti-inflammatory drugs, it is also possible that Ponstan contributed to therecurrence of the CIN.
Frieda intends to have another course of treatment and is confident of gettinganother clear Pap smear result in a few months. The aim of treatment will beto eradicate the Liver Qi Stagnation altogether. I suspect that more lifestylechanges may be necessary but I find myself wondering if it is possible for ayoung woman struggling to make it in theatre (or any other profession),worrying about her next job (or if she has one), wondering where and whenshe can fit children into this lifestyle, faced with serious questions about herown health, and all those other endless decisions associated with modern citylife in the 80's to ever be free of Liver Qi Stagnation.
zur Hausen H. 'The Role of Human Papillomviruses and Herpes Viruses in the Development of Cancer of the Cervix and its Precursors'. In Ludwig K. eds. 'Proceedings of the X 1 th World Conference of Gynaecology and Obstetrics', Berlin: Springer Verlag,1986.
zur Hausen H. 'Report from the International Cancer Congress' (1986)in ‘AustralianDoctor’ , 19thJune 1987.
International Review, Australian Doctor, 20th March, 1987.
Flaws, Bob 'Premenstrual Syndrome: Its Differential Diagnosis and Treatment ‘Am.Jnl of Acupuncture (1985),13,3,205-222 Nei Jing, p.118 - transl. Ilza Veith, Univ.of California Press, Berkeley 1972.
Charmichael JA, Clarke DH, Moher B et al, 'Cervical Cancer in Women Aged 34 and Younger' American Journal Obstetrics end Gynaecology (1986) 154,264-269.
Kearney, R 'New Developments in the Clinical Use of Fatty Acids' Report given at the 2nd Adv. Nutrition '87 Seminar (Bioglan), Sydney, Australia.
Proceedings of the International Conference on Acupuncture and Moxibustion, Beijing (1979).

Source: http://www.whitepineinstitute.org/GMP2009/GMP_resources/GMP8_resources/cancer/cervical_neoplasia.pdf


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