Cervical Cancer
Overview
What is cervical cancer?
Cervical cancer, or cancer of the cervix, begins on the surface of the cervix. There are two main types of cancer of the cervix — squamous cell carcinomas and adenocarcinomas. About 80% to 90% are squamous cell carcinomas, while 10%-20% are adenocarcinomas.
What is the cervix?
The cervix is the lower part of the womb (uterus). The uterus has two parts — the upper part (body) where a baby grows, and the lower part (cervix). The cervix connects the body of the uterus to the vagina (birth canal).
Symptoms and Causes
What are the symptoms of cervical cancer?
Early stages of cervical cancer do not involve pain or other symptoms. The first identifiable symptoms of the disease are likely to include:
- Watery or bloody vaginal discharge which may be heavy and can have a foul odor.
- Vaginal bleeding after intercourse or exercise, between menstrual periods, or after menopause.
- Menstrual periods that may be heavier and last longer than normal.
If the cancer has spread to nearby tissues, symptoms may include:
- Difficult or painful urination, sometimes with blood in urine.
- Diarrhea, or pain or bleeding from the rectum upon defecation.
- Fatigue, loss of weight and appetite.
- A general feeling of illness.
- Dull backache or swelling in the legs.
If abnormal bleeding, vaginal discharge, or any other symptoms last more than two weeks without explanation, you should have a complete gynecological examination that includes a Pap smear.
Diagnosis and Tests
How is cervical cancer diagnosed?
Together, pelvic exams and Pap smears can detect most cases of cervical cancer. For an accurate diagnosis, your doctor will visually examine the cervix and take a tissue sample of any apparent abnormality for biopsy.
If the biopsy confirms cancer, further tests will determine whether the disease has spread (metastasized). These tests might include liver and kidney function studies; blood and urine tests; and X-rays of the bladder, rectum, bowels, and abdominal cavity. This process is called staging.
What are the stages of cervical cancer?
- Stage I: Cancer is found only in the cervix.
- Stage II: Cancer has spread beyond the cervix but has not yet spread to the pelvic wall (the tissues that line the part of the body between the hips).
- Stage III: Cancer has spread to the lower third of the vagina and may have spread to the pelvic wall and nearby lymph nodes.
- Stage IV: Cancer has spread to the bladder, rectum or other parts of the body.
Are routine pelvic exams necessary?
There is no consensus from national experts and medical societies about whether a woman needs a pelvic exam on the years that she is not due for cervical cancer screening. Some medical societies leave it up to the doctor and patient to decide whether a pelvic exam should be done, while other societies discourage a pelvic exam due to patient discomfort, and the potential for unnecessary follow-up for harmless findings. Unfortunately, a pelvic exam has never been shown to prevent cancer, especially for cancers that women worry about the most, such as ovarian cancer.
Young women age 25 and under who have engaged in sexual activity are recommended to have an annual (once yearly) screening test for chlamydia.
Management and Treatment
How is cervical cancer treated?
The treatment team for a woman with cervical cancer will include a gynecologic oncologist (doctor who specializes in cancers of women's reproductive organs). Recommended treatment for cervical cancer is based on many factors including the stage of the disease, the age of the patient and general health of the woman, and the woman's desire for future childbearing. The three main treatments for cervical cancer are radiation, chemotherapy and surgery. Some people may have a combination of treatments. Radiation or chemotherapy may be used to treat cancer that has spread beyond the pelvis (Stage IV) or cancer that has recurred.
There are two kinds of radiation treatment:
- A device loaded with radioactive pellets which is placed into the vagina near the cancer and kept in place for a certain period of time.
- An external device which beams radiation into the target areas during visits to the radiotherapist.
A variety of chemotherapeutic drugs, or combinations of them, are used. Sometimes radiation and chemotherapy are used before or after surgery.
Different kinds of surgery are used to treat for cervical cancer. Some of the most common kinds of surgery for cervical cancer include:
- Laser surgery: This surgery uses a laser beam burn off cells or to remove a small piece of tissue for study.
- Cone biopsy: A surgery in which a cone-shaped piece of tissue is removed from the cervix.
- Simple hysterectomy: This surgery involves the removal of the uterus but not the tissue next to the uterus. The vagina and the pelvic lymph nodes are not removed.
- Radical hysterectomy and pelvic lymph node dissection: With this surgery, the uterus, surrounding tissue called the parametrium, a small portion of the upper part of the vagina, and lymph nodes from the pelvis are removed.
In its earliest stages, the disease is curable by removing the cancerous tissue. In other cases, a simple hysterectomy or a radical hysterectomy can be performed.
Prevention
What are the risk factors for cervical cancer?
In many cases, cervical cancer can be linked with known risk factors for the disease. Some risk factors can be avoided, while others cannot. Some risk factors include:
- An irregular screening history: Women who have not regularly had a Pap test (smear) are at increased risk of cervical cancer.
- HPV Infection: Some types of human papillomavirus (HPV) are transmitted sexually and can infect the cervix. Cervical infection with HPV is the primary risk factor for cervical cancer. However, only a very small percentage of women infected with untreated HPV will develop cervical cancer.
- Sexual History: Females who begin having sexual intercourse before the age of 16 and females who have had many sexual partners are at a higher risk of HPV infection and developing cervical cancer. The prevention of sexually transmitted diseases reduces the risk of cervical cancer.
- Smoking: Cigarette smoking is associated with an increased risk of cervical cancer.
- HIV Infection: Women who have been infected with HIV have a higher-than-average risk of developing cervical cancer.
Can cervical cancer be prevented?
Women can take some measures to prevent cervical cancer. Receiving regular gynecological exams and getting Pap tests are the most important steps that women can take toward the prevention of cervical cancer. See the "risk factors" section for additional cervical cancer prevention tips.
The American College of Obstetricians and Gynecologists recommends the following Pap test guidelines:
- All women should begin cervical cancer screening when they are 21 years old. Screening should be done every 3 years in women with no history of abnormal Paps. More frequent screening may be needed if any abnormal cells are found or if HPV is present.
- Beginning at age 30, women who have had 3 normal Pap test results in a row should be screened every 5 years with both a Pap smear test AND a screening test for - high risk type - HPV infection. Another acceptable option is to be screened every 3 years with only the Pap test. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, or a weakened immune system due to organ transplant, chemotherapy, or chronic steroid use should continue to be screened annually.
- Women 65-70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 20 years should stop having cervical cancer screening. Women with a history of cervical cancer, DES exposure before birth, HIV infection or a weakened immune system should continue to have screening as long as they are in good health.
- Women who have had a total hysterectomy (removal of the uterus and cervix) should also stop having cervical cancer screening, unless they have a history of cervical cancer or precancer. Women who have had a hysterectomy without removal of the cervix should continue to follow the guidelines above.
What are the recommendations for cervical cancer screening?
National societies agree on the following recommendations:
- Cervical cancer screening should begin at age 21 years, regardless of sexual history.
- For women aged 21 to 29 years, screening is recommended every 3 years with only a Pap test (no HPV test).
- For women 30 years and older, co-testing with Pap and HPV should be done every 5 years, or Pap test alone every 3 years.
- Routine Pap testing should be discontinued (stopped) in women who have had a total hysterectomy for benign conditions and who have no history of CIN (cervical intraepithelial neoplasia) grade 2 or higher.
- Cervical cancer screening can be discontinued at age 65 in women who have 2 consecutive normal co-test results or 3 consecutive normal Pap test results in the past 10 years, with the most recent normal test performed in the past 5 years.
- Women who have been adequately treated for CIN grade 2 or higher will need to continue screening for 20 years, even if it takes them past the age of 65.
The above recommendations do NOT apply to women who have HIV, are immunocompromised (have a weak immune system), have a history of DES in utero exposure, and have not been adequately screened.
It is important to remember that a diagnostic Pap test may be done earlier if a woman is having new problems, such as unusual bleeding.
Also, women being followed for an abnormal Pap test or who have been treated for an abnormal Pap test will have a different scheduled follow-up than what is noted above.
What is the cervical cancer vaccine?
The cervical cancer vaccine, called Gardasil®, is approved for girls and women ages 9 to 26 and protects against the development of cervical cancer. The vaccine, which also protects against genital warts (and also has been approved for boys for this purpose), works by triggering the body's immune system to attack certain human papillomavirus (HPV) types, which have been linked to many cases of cervical cancer. It is best to get the vaccine before the start of sexual activity. The vaccine consists of a series of 3 shots, with shot 2 coming 2 months after the first, and shot 3 coming 6 months after the first.
Outlook / Prognosis
What are the survival rates for cervical cancer?
In women with invasive cervical cancer that is caught at the earliest stage, the 5-year relative survival rate is over 90%. The overall 5-year relative survival rate for cervical cancer is about 68%. The rate takes into account all stages of the cancer combined.
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