Each year, more than 300 women with endometrial, cervical, ovarian and other cancers of the female reproductive system receive treatment from Cleveland Clinic gynecologic oncologists, who collaborate closely with Clinic gynecologic pathologists, medical and radiation oncologists, and radiologists. Membership in the Gynecologic Oncology Group offers patients access to investigational treatments through more than 40 ongoing clinical trials. Additional cancer research studies offer patients access to the latest treatments under investigation.
What is cervical cancer?
Cancer of the uterine cervix - also called cervical cancer - is the second most common cancer among women worldwide. The disease afflicts 493,000 women worldwide each year and kills some 273,000. Despite the dramatic decrease in cervical cancer in United States, the American Cancer Society estimates that 10,370 new cases were diagnosed in 2005, of whom 3,710 women died.
Eighty-five percent are squamous cell from the outside of the cervix, 10% are adenocarcinomas from the inside of the cervix, and 5% are adenosquamous, clear cell, small cell, verrucous, etc. Epidemiologic and clinical data demonstrate that human papillomaviruses (HPV), especially HPV-16 and HPV-18, play at least a major if not a necessary role in the etiology of cervical cancer. However, investigators recognize that HPV is not enough to induce cervical cancer and that a multifactorial etiology is most likely.
HPV can be found in a large proportion of patients with cervical cancer, approaching 100%, but is not yet found in every patient with disease. Other risk factors include multiple sexual partners, herpes simplex virus type 2 infections, cigarette smoking, multiparity vaginal douching, nutrition, and use of oral contraceptives.
Symptoms of Cervical Cancer
The most common symptom is vaginal bleeding (following intercourse or between menses) and vaginal discharge. However, precancerous changes of the cervix (abnormal pap smears, dysplasia, precancer) usually do not cause pain or any symptoms. Therefore, it is very important that all women be screened by a pelvic exam and a Pap test since precancerous changes are usually asymptomatic.
The Pap smear is the best screening tool. Up to 50% of women newly diagnosed with cervical cancer have never had a Pap smear.
The Pap test, or Pap smear - is a way to check for abnormal cells from the cervix and the vagina. This test can find precancerous changes or cancer of the cervix or vagina.
American Cancer Society Recommendations for Pap smears:
- Women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse, but no later than 21 years of age. Screening should be done every year with the regular Pap test or every 1-2 years using the newer liquid-based Pap test.
- Beginning at age 30, women who have had 3 normal Pap test results in a row may get screened every 2 to 3 years with either the conventional (regular) or liquid-based 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 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 10 years may choose to 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) may also choose to stop having cervical cancer screening, unless the surgery was done as a treatment for cervical cancer or precancer. Women who have had a hysterectomy without removal of the cervix should continue to follow the guidelines above.
Colposcopy is a widely used method to check the cervix for abnormal areas after an abnormal pap smear. A vinegar-like solution is applied to the cervix and then using an instrument much like a microscope (called a colposcope) the physician looks closely at the cervix for abnormal areas. The physician may remove a small amount of cervical tissue (Cervical Biopsy) for examination by a pathologist.
Endocervical Curettage (ECC) is used to inspect inside the opening of the cervix, an area that cannot be seen during colposcopy. A small curette (spoon-shaped instrument) is used to scrape tissue from inside the cervical opening.
LEEP is another method used to do a biopsy is called loop electrosurgical excision procedure (LEEP) and can be used for further evaluation of or treatment of abnormal pap smears and biopsies.This procedure is usually performed in the office using local anesthesia. It is performed with an electric wire loop connected to a generator. The loop is used to biopsy, or remove, a thin, round piece of tissue. When abnormal cells are believed to be up in the cervical canal or are of the adenocarcinoma type, a larger biopsy called a Cone Biopsy may be necessary. Cone biopsy of the cervix allows the pathologist to see whether the abnormal cells have invaded the tissue beneath the surface of the cervix up in the canal. The procedure usually requires general anesthesia and is done in the hospital as a minor outpatient surgery.
If cancer is detected a more extensive evaluation is necessary:
- Complete history and physical examination (Pelvic and Rectal examinations).
- Biopsy-proven evidence of carcinoma (Pap and /or ECC, LEEP, Cone biopsy).
- Chest x-ray
- Laboratory studies: CBC, chemistry panel, and liver functions tests.
- CT (computed tomography) scan or IVP (intravenous pyelogram) "kidney dye study."
Cervical cancer is staged clinically based on the above evaluation.
- IA - Cancer confined to the cervix and diagnosed only by microscopy.
- IB - Cancer confined to the cervix and clinically visible or greater than 7mm
- IIA - Cancer extends to the upper 2/3 of the vagina.
- IIB - Cancer extends to the parametrial tissue (Tissue next to the uterus and cervix)
- IIIA - Cancer extends to the lower 1/3 of the vagina
- IIIB - Cancer extends to the pelvic side wall or causes dilation of the kidney and its drainage system (hydronephrosis) or nonfunctioning kidney.
- IVA - Cancer extends to the adjacent organs (Bladder and/or rectum)
- IVB - Cancer with metastasis (spread) to distant organs.
Conization, or simple hysterectomy (removal of the uterus and cervix) is the treatment choice for stage IA cervical cancer without vascular invasion (under the microscope the cancer is not invading into blood vessels).
Surgery can be performed up to stage IIA with equivalent efficacy compared with radiation. Surgery has the advantage of sparing the ovaries from radiation (ovarian function) in premenopausal patients. A Radical hysterectomy (complete surgical removal of the uterus, upper vagina, parametrium with pelvic lymph nodes) is performed.
For young women who wish to preserve their fertility potential, Radical trachelectomy (Surgical removal of the cervix, upper vagina and surrounding tissues, and pelvic lymph nodes) can be performed in place of a radical hysterectomy. The body of the uterus and the ovaries are not removed. This procedure is usually reserved for women with small lesions (< 2cm) with no or minimal vascular-space invasion.
Locally advanced cervical cancer
In recent years, cisplatin-based chemotherapy given along with radiation (Chemoradiation) has emerged as the new standard of care for treating locally advanced cervical cancer (stage IIb and above). This combination has improved response rates and survival compared to prior therapy with radiation alone. Radiation treatments are given as several weeks of daily external radiation treatments that are "aimed" at the pelvis and sometimes the lymph nodes in the lower abdomen. This is followed by a few treatments with internal radiation therapy that is inserted directly into the uterus and cervix. During the external radiation chemotherapy is typically given 1 day a week as outpatient therapy.
What is the follow-up after treatment for cervical cancer?
Following treatment for cervical cancer, close surveillance is recommended. A typical follow-up schedule is visits every 3 months for 1 year, every 4 months for the second year, every 6 months for the next three years, then annually thereafter. Screening for recurrence consists of reviewing patient history, a physical exam, and pap smear at each visit. Chest x-rays are done yearly. Occasionally, laboratory blood tests will be done twice a year, depending on the type of therapy used and stage of the cancer. CT and/ or PET (positron emission tomography) scans are used based on symptoms or findings from the above tests.