Cervical Cancer

What Is Cervical Cancer?

The uterus (womb) is a bottle-shaped organ lying low in the female pelvis. The uterine cervix is the 4 cm long bottle-neck-like end of the uterus. While most of the uterus lies in the pelvis, the lower 2 cm of the cervix is located in the vagina, where it connects the uterus with the vagina. The canal through the cervix, the endocervical canal, is contiguous with the uterine cavity.

Cancer of the cervix occurs when the cells of the surface of cervix change in a way that leads to abnormal growth and invasion of other tissues or organs of the body.

Like all cancers, cancer of the cervix is much more likely to be cured if it is detected early and treated immediately.

  • One of the key features of cervical cancer is its slow progression from normal cervical tissue to precancerous (or dysplastic) changes in the tissue to invasive cancer.
  • The slow progression through numerous precancerous changes is very important because it provides opportunities for prevention and early detection (through Pap test) and treatment.
  • These opportunities have caused a decline in the incidence of cervical cancer over the past decades in the United States. Still, over 12,000 new cases of cervical cancer occur each year in the U.S., and over 4,000 women die each year from the disease.

Invasive cancer means that the cancer affects the deeper tissues of the cervix and may have spread to other parts of the body. This spread is called metastasis. Cervical cancers don't always spread, but those that do most often spread to the regional lymph nodes, the lungs, the liver, the bladder, the vagina, and/or the rectum.

What Are Causes and Risk Factors of Cervical Cancer?

Cervical cancer begins with abnormal changes in the cervical tissue. Infection with human papillomavirus (HPV) is the cause of almost all cervical cancers. Other known risk factors for cervical cancer include early sexual contact, multiple sexual partners, cigarette smoking, HIV infection and a weakened immune system, and taking oral contraceptives (birth control pills).

  • High-risk types of HPV, a virus whose different types cause skin warts, genital warts, and other abnormal skin and body surface disorders, have been shown to lead to many of the changes in cervical cells that may eventually lead to cancer.
  • Because HPV can be transmitted by sexual contact, early sexual contact and having multiple sexual partners have been identified as risk factors for the development of cervical lesions that may progress to cancer.
  • Cigarette smoking is another risk factor for the development of cervical cancer. The chemicals in cigarette smoke interact with the cells of the cervix, causing precancerous changes that may over time progress to cancer.
  • Oral contraceptives ("the birth control pill") may increase the risk for cervical cancer, especially in women who use oral contraceptives for longer than five years.
  • Women who have weakened immune systems, such as HIV-infected women, are also at greater risk for cervical cancer.
  • Overweight women are more likely to develop a form of cervical cancer known as adenocarcinoma.
  • Other factors that have been associated with an increased risk of cervical cancer include poverty, having three or more term pregnancies, and having a first pregnancy prior to the age of 17.
  • A family history of cervical cancer also increases a woman's risk.

HPV infection is very common and does not lead to cancer in the majority of cases. Genital infections with HPVs typically cause no symptoms and go away on their own. Sometimes, however, the infection persists. Precancerous changes or ultimately cervical cancer only arises when there is a persistent infection by one of the HPV types associated with cervical and other cancers.

What Are Cervical Cancer Symptoms and Signs?

As in many cancers, there may be no signs or symptoms of cervical cancer until it has progressed to a advanced cervical caner stages.

When Should One Seek Medical Care for Cervical Cancer?

The range of conditions that can cause vaginal bleeding are diverse, range in seriousness, and vary based on the age, fertility, and medical history of the patient.

  • Vaginal bleeding after menopause is never normal. If a woman has gone through menopause and has vaginal bleeding, she should see her health-care professional as soon as possible.
  • Very heavy bleeding during a woman's period or frequent bleeding between periods warrants evaluation by a health-care professional.
  • Bleeding after intercourse should be evaluated by a health-care professional.
  • If a woman has vaginal bleeding that is associated with weakness or feeling faint or lightheaded, or if a woman actually faints, she should go to a hospital emergency department for care.

What Specialists Treat Cervical Cancer?

Gynecologists will usually be involved in the diagnosis of cervical cancers. Gynecologic oncologists are surgical specialists trained in the care of patients with gynecologic cancers, including cervical cancer. Other specialists, including radiation oncologists, may also be involved in the care of patients with cervical cancer.

What Screening Tests and Exams Do Health-Care Professionals Use to Diagnose Cervical Cancer?

As with all cancers, early diagnosis is key to successful treatment and cure. Treating precancerous changes that affect only the surface of a small part of the cervix is much more likely to be successful than treating invasive cancer that affects a large portion of the cervix and has spread to other tissues.

The most important progress that has been made in early detection of cervical cancer is widespread use of the Papanicolaou test (Pap smear).

  • The Pap smear test is done as part of a regular pelvic examination.
  • Named after the pathologist who developed the test (Papanicolaou), the Pap smear is a quick, painless, and relatively inexpensive way of screening women for precancerous or cancerous changes in their cervix.
  • Cells from the surface of the cervix are collected on a slide and examined. Any abnormality found on a Pap smear mandates further evaluation.
  • Women should undergo Pap screen every three years beginning at 21 years of age.
  • Women between 30-65 should undergo co-testing with HPV and Pap smear testing every five years or Pap testing every three years.
  • HPV testing for women in their 20s is controversial as it is highly prevalent but is recommended if the Pap smear is abnormal in this age group.

Diagnosis of cervical cancer requires that a sample of cervical tissue (called a biopsy) be taken and analyzed under a microscope.

  • This tissue sample can be obtained in a number of ways.
  • A cervical biopsy is usually done by a specialist in diseases of women's reproductive and sexual organs (a gynecologist).
  • The biopsy is examined by a physician who specializes in diagnosing diseases by looking at cells and tissues under a microscope (a pathologist).

Colposcopy is a procedure similar to a pelvic examination.

  • The examination uses a type of microscope called a colposcope to inspect the cervix. The entire area of the cervix is stained with a harmless dye to make abnormal cells easier to see.
  • The colposcope magnifies the cervix by eight to 10 times, allowing easier identification of any abnormal-appearing tissue that may need biopsy.
  • This procedure can usually be done in a gynecologist's office.
  • These abnormalities may be an early step in the slow series of changes that can lead to cancer.

Sometimes a larger biopsy is needed to fully check for invasive cervical cancer.

A cone biopsy is performed in the operating room while a woman is under anesthesia.

  • A small cone-shaped sample of the cervix is removed for examination.
  • Like LEEP, cone biopsy procedures result in tissue samples in which the types of cells and how much they have spread to underlying areas can be more fully determined.

How Do Physicians Determine Cervical Cancer Staging?

Precancerous Changes

Over the years, different terms have been used to refer to abnormal changes in the cells on the surface of the cervix. These changes are now most often called squamous intraepithelial lesion (SIL). "Lesion" refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells. Changes in these cells can be divided into two categories.

  • Low-grade SIL: Early, subtle changes in the size and shape of cells that form the surface of the cervix are considered low grade.
    • These lesions may go away on their own, but over time, they may become more abnormal, eventually becoming a high-grade lesion.
    • SIL is also called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1).
    • These early changes in the cervix most often occur in women aged 25-35 years but can appear in women of any age.
  • High-grade SIL: A large number of precancerous cells, which look very different from normal cells, constitute a high-grade lesion.
    • Like low-grade SIL, these precancerous changes involve only cells on the surface of the cervix.
    • These lesions are also called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ.
    • They develop most often in women aged 30-40 years but can occur at any age.

Precancerous cells, even high-grade lesions, usually do not become cancerous and invade deeper layers of the cervix for many months, perhaps years.

A woman should ask her health-care professional if she does not understand the way the result of her Pap smear is reported.

Invasive Cancer

If abnormal cells spread deeper into the cervix or to other tissues or organs, the disease is then called cervical cancer, or invasive cervical cancer. Cervical cancer occurs most often in women aged 40 years or older, though it can be found in younger women.

If the biopsy results show invasive cancer, a series of tests will be performed, all designed to see whether the cancer has spread and, if so, how far. The extent of spread of a cancer is referred to as the stage of the cancer.

  • A chest X-ray looks for spread to the lungs.
  • Blood tests can indicate whether the liver is involved. A CT scan may be necessary if results are not definitive.
  • Special X-rays or a CT scan can be used to look at the bladder and other organs.
  • The vagina and rectum are also examined, sometimes under anesthesia.

These tests are used to "stage" the cancer.

  • By finding out how far it has spread, a health-care professional can make a reasonable guess about a woman's prognosis and the kind of treatment she will need.
  • Cervical cancer is staged from stage 0 (earliest and least severe) to stage IV (metastatic disease, advanced and the most severe).
  • Staging is based on size and depth of the cancerous lesion, as well as degree of spread.

What Is the Medical Treatment for Precancerous Cervical Lesions?

Treatment for precancerous lesions differs from that of invasive cancer. Ideally, proper management of precancerous disease prevents the patient from ever getting invasive cervical cancer.

Precancerous Lesions

Choice of treatment for a precancerous lesion of the cervix depends on a number of factors. These factors include whether the lesion is low- or high-grade, whether a woman wants to have children in the future, her age and general health, and her preference and that of her health-care professional.

  • If a woman has a low-grade lesion, she may not need further treatment, especially if the abnormal area was completely removed during biopsy. She should have regular Pap smears and pelvic exams.
  • When a precancerous lesion requires treatment, cryosurgery (freezing), cauterization (burning, also called diathermy), or laser surgery may be used to destroy the abnormal area without harming nearby healthy tissue.
  • Abnormal tissue also can be removed by LEEP or conization.
  • Treatment for precancerous lesions may cause cramping or other pain, bleeding, or a watery vaginal discharge.

In some cases, a woman may choose to have a hysterectomy for precancerous changes, particularly if abnormal cells are found inside the opening of the cervix. This surgery is more likely to be done if a woman does not plan to have children in the future.

Diagnostic procedures, such as LEEP and cone biopsy, sometimes may be used as treatments as well.

  • Both of these procedures involve taking away some of the cervical tissue for evaluation.
  • If that evaluation finds that there were indeed abnormal cells but that those abnormal cells did not extend as far as the level where the tissue was cut, only follow-up may be needed.
  • If there is uncertainty about whether all of the precancerous cells have been removed using a LEEP or cone biopsy procedure, then further treatments may be required.

Cryocautery may be used in some cases.

  • In this procedure, a steel instrument is cooled to subzero temperatures by immersion in liquid nitrogen or a similar liquid.
  • This ultracooled instrument is then applied to the surface of the cervix.
  • The cells are frozen, and they eventually die and are sloughed off, to be replaced by new cervical cells.

Tissue may also be removed by laser ablation.

  • A laser beam is applied to either specific areas of cervical tissue or a whole layer of tissue at the surface of the cervix.
  • The laser destroys these cells, leaving healthy cells in their place.

The success of cryocautery or laser ablation procedures is determined by a follow-up examination and Pap smear.

What Is the Medical Treatment for Invasive Cervical Cancer?

The most widely used treatments for cervical cancer are surgery and radiation therapy. Chemotherapy or biological therapy is sometimes used.

  • The treatment team may decide to use one treatment method or a combination of methods.
  • A woman may choose to take part in a clinical trial (research study) to evaluate new treatment methods. Such studies are designed to improve cancer treatment. Participating in a clinical trial has both benefits and risks. Participation in clinical trials is always voluntary.

Cancerous cells typically invade surrounding tissues.

  • If a biopsy shows that cancerous cells have invaded through a layer called the basement membrane, which separates the surface layers of the cervix from other underlying layers, surgery is usually required.
  • The extent of the surgery varies, depending on the stage of the cancer.

Radiation therapy (also called radiotherapy) is also used to fight cervical cancer at some stages.

  • Radiation therapy uses high-energy rays to damage cancer cells and stop them from growing.
  • Like surgery, radiation therapy is local therapy; the radiation affects cancer cells only in the treated area.
  • Radiation may be applied externally or internally. Some women receive both kinds.

External radiation comes from a large machine, which aims a beam of radiation at the pelvis.

  • External radiation treatments usually are given five days a week for five to six weeks. At the end of that time, an extra dose of radiation called a "boost" may be applied to the tumor site.
  • Each treatment takes only a few minutes.
  • Because of safety concerns and expense of equipment, radiation therapy generally is offered only at certain large medical centers or hospitals.

Internal or implant radiation comes from a capsule containing radioactive material which is placed directly in the cervix.

  • The implant puts cancer-killing rays close to the tumor while sparing most of the healthy tissue around it.
  • It is usually left in place for one to three days, and the treatment may be repeated several times over the course of one to two weeks.
  • A woman stays in the hospital while the implants are in place.

Chemotherapy is the use of powerful drugs to kill cancer cells. In cervical cancer, it is sometimes used in combination with radiation therapy in high-risk patients, or may be used alone when the cancer has spread to other parts of the body. Just one drug or a combination of drugs may be given. Chemotherapy regimens are constantly changing, and a woman should discuss the best treatment options with her physician. Targeted biological treatments may also be used with chemotherapy.

  • Anticancer drugs used to treat cervical cancer may be given via an intravenous (IV) line or by mouth.
  • Either way, chemotherapy is systemic treatment, meaning that the drugs flow through the body in the bloodstream. They can kill cancer cells anywhere in the body.
  • Chemotherapy is given in cycles. Each cycle comprises a period of intensive treatment followed by a recovery period. Treatment usually consists of several cycles.
  • Most patients have chemotherapy as an outpatient (in an outpatient clinic at the hospital, at the doctor's office, or at home). Depending on which drugs are given and a woman's general health, however, she may need to stay in the hospital during treatment.

Are There Home Remedies for Cervical Cancer?

Self-treatment is not appropriate as the sole or only treatment for cancer under most circumstances. Without medical treatment, the cancer will continue to grow and spread. Eventually vital body organs will not be able to function properly because the cancer will take their oxygen and nutrients, crowd them out, or injure them. The result is very often death.

Although self-treatment is inappropriate, there are things a woman can do to reduce the physical and mental stresses of cancer and its treatment.

Maintaining good nutrition is one of the best things a woman can do.

  • A woman may lose her appetite during treatment.
  • Common side effects of chemotherapy, such as nausea, vomiting, and sores inside the mouth, can make eating difficult.
  • However, people who eat well, taking in enough calories and protein, will have an easier time keeping their strength and energy up during the therapy. They are also better able to tolerate the side effects of therapy.
  • A cancer specialist (oncologist) or gynecologist may be able to recommend a nutritionist who can provide suggestions for keeping up calorie and protein intake.
  • Acupuncture might help with the nausea secondary to chemotherapy.

The following lifestyle changes may help keep a woman stronger and more comfortable during treatment:

  • Physical activity will also help keep strength and energy level up. A woman should engage in mild physical activity that is comfortable but doesn't wear her out.
  • Rest is equally important. A woman should get plenty of sleep each night and rest during the day if she needs to.
  • A woman should quit smoking.
  • A woman should avoid alcohol. She may not be able to drink alcohol with some of the medications she is taking. She should ask her health-care professional if she has any concerns about diet and lifestyle changes.

What Forms of Surgery Treat Cervical Cancer?

Surgery removes cancerous tissue in or near the cervix.

  • If the cancer is only on the surface of the cervix, the cancerous cells may be removed or destroyed by using methods similar to those used to treat precancerous lesions.
  • If the disease has invaded deeper layers of the cervix but has not spread beyond the cervix, an operation may remove the tumor but leave the uterus and the ovaries.
  • If the disease has spread into the uterus, hysterectomy is usually necessary.
  • Hysterectomy is also sometimes done to prevent spread of the cancer.

Hysterectomy is surgical removal of the entire uterus, including the cervix; sometimes the ovaries and fallopian tubes also are removed. In addition, lymph nodes near the uterus may be removed to check for spread of the cancer.

Hysterectomy is major surgery.

  • The decision to have a hysterectomy is made by a woman and her health-care professional.
  • Whether hysterectomy is necessary depends on the individual circumstances.
  • In invasive disease, a hysterectomy is usually recommended.
  • Some women who do not plan to have children in the future may choose to undergo hysterectomy for preventive reasons. Other women who do plan to have children may wish to preserve their reproductive organs even if this increases their risk somewhat.

Hysterectomy requires a considerable recovery period.

  • For a few days after the operation, a woman may have pain in her lower abdomen. The pain can be controlled by medication.
  • A woman may have difficulty emptying her bladder. She may need to have a thin, plastic tube called a catheter inserted into the bladder to drain the urine for a few days after surgery. She also may have trouble having normal bowel movements.
  • A woman's activities should be limited for a period of time after the surgery to allow healing to take place. Normal activities, including sexual intercourse, usually can be resumed in four to eight weeks.

Once a woman has had her uterus removed, she will no longer have menstrual periods or be able to have children.

  • Sexual desire and the ability to have intercourse usually are not affected by hysterectomy.
  • A woman's view of her own sexuality may change. She may feel an emotional loss because she is no longer able to have children.
  • A woman may want to discuss these issues with her health-care professional, a social worker, or counselor. Support groups are available as well.

Is Follow-up Necessary After Treatment of Cervical Cancer?

Regular pelvic examinations and Pap smears are important for every woman. These tests are even more important for a woman who has been treated for precancerous changes or for cancer of the cervix.

  • Follow-up care should include a full pelvic examination, Pap smear, and other tests as indicated on a regular schedule recommended by the gynecologist.
  • These precautions are necessary to allow early detection should the cancer return.

Cancer treatment may cause side effects many years later. For this reason, a woman should continue to have regular checkups and should report any health problems that appear.

Is It Possible to Prevent Cervical Cancer?

The key to preventing invasive cervical cancer is to detect any cell changes early, before they become cancerous. Regular pelvic examinations and Pap smears are the best way to do this. How often a woman should have a pelvic exam and Pap smear depends on her individual situation.

  • Women between the ages of 21-30 should have Pap tests every three years.
  • Women over age 30 may opt to have HPV and Pap co-testing every five years or a Pap test alone every three years.
  • If a woman has had precancerous changes or cancer of the cervix, her gynecologist will recommend a schedule of follow-up examinations and tests.
  • Women who have had the HPV vaccine (see below) should still have Pap tests.

Avoidance of human papillomavirus (HPV) infection is becoming increasingly important in the prevention of precancerous and cancerous changes of the cervix.

  • Early age at first intercourse is associated with an increased risk of cervical cancer. Abstinence is recommended as one way to prevent the transmission of HPV.
  • Likewise, barrier protection, such as condom use, may prevent HPV infection, although this has not yet been fully studied.

Two HPV vaccines have been approved for the prevention of HPV infection. Both vaccines are given in three doses over a six-month period.

Gardasil is a vaccine that targets four different types of HPV. It is approved for use in females for the prevention of cervical cancer, and some vulvar and vaginal cancers, caused by HPV types 16 and 18, and for use in males and females for the prevention of anal cancer and precancerous anal lesions caused by HPV types 16 and 18. Gardasil is also approved for the prevention of genital warts caused by HPV types 6 and 11. The vaccine is approved for these uses in females and males ages 9-26. Gardasil-9 is a newer form of the vaccine that targets nine different types of HPV.

The Cervarix vaccine targets two HPV types: 16 and 18, which are the types associated with the majority of cervical cancers. The FDA has approved Cervarix for use in females aged 9-25 for the prevention of cervical cancer caused by HPV types 16 and 18.

Cigarette smoking is another risk factor for cervical cancer that can be prevented. Quitting smoking may decrease one's chances of developing cervical cancer.

What Is the Prognosis of Cervical Cancer?

When precancerous or early cancerous changes are found and treated, the survival rate is close to 100%. The prognosis for invasive cervical cancer depends on the stage of the cancer when it is found.

The stage of a cancer is a measure of how far it has progressed, namely, what other organs or tissues have been invaded.

  • For the earliest stages of cervical cancer (0, IA), more than 90% of women survive at least five years after diagnosis.
  • Later stages of cervical cancer have a significantly worse outlook; 20% or fewer of women with stage IV (that has spread to distant sites in the body) cervical cancer survive five years.

These statistics are the reason that prevention is stressed in this disease.

  • Most women diagnosed with precancerous changes in the cervix are in their 20s and 30s.
  • The average age for true cervical cancer to be diagnosed is in the mid-50s.
  • This difference in the age at which precancerous changes are most frequently diagnosed and the age at which cancer is diagnosed highlights the slow progression of this disease and the reason why it can be prevented if adequate steps are taken.

Health-care professionals who treat cancer often use the term "remission" rather than "cure." Although many women with cervical cancer recover completely, medical professionals sometimes avoid the word "cure" because the disease can recur. (The return of cancer is called a recurrence.)

Cervical Cancer Support Groups and Counseling

Living with cervical cancer presents many new challenges for a woman and for her family and friends.

  • Patients diagnosed with cancer have many worries about how the cancer will affect their ability to "live a normal life," that is, to care for her family and home, to hold a job, and to continue the friendships and activities that she enjoys.
  • Many people feel anxious and depressed. Some people feel angry and resentful; others feel helpless and defeated.

For most people with cancer, talking about their feelings and concerns helps.

  • Friends and family members can be very supportive. They may be hesitant to offer support until they see how the woman is coping. A woman should not wait for them to bring it up. If she wants to talk about her concerns, she should let them know.
  • Some people don't want to "burden" their loved ones, or they prefer talking about their concerns with a more neutral professional. A social worker, counselor, or member of the clergy can be helpful if a woman wants to discuss her feelings and concerns about having cancer. A gynecologist or oncologist should be able to recommend someone.
  • Many people with cancer are helped profoundly by talking to other people who have cancer. Sharing one's concerns with others who have been through the same thing can be remarkably reassuring. Support groups for people with cancer may be available through the medical center where a woman is receiving her treatment. The American Cancer Society also has information about support groups all over the United States.
Reviewed on 11/20/2017

REFERENCES:

Boardman, Cecelia H. "Cervical Cancer." Medscape.com. May 31, 2016. <http://emedicine.medscape.com/article/253513-overview>.

United States. National Cancer Institute. "Cervical Cancer." <http://www.cancer.gov/cancertopics/types/cervical>.

United States. National Cancer Institute. "Human Papillomavirus (HPV) Vaccines." Feb. 19, 2015. <http://www.cancer.gov/cancertopics/factsheet/prevention/HPV-vaccine>.

United States. National Cancer Institute. "Pap and HPV Testing." Sept. 9, 2014. <http://www.cancer.gov/cancertopics/types/cervical/pap-hpv-testing-fact-sheet>.

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