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Reviewed by the Faculty of Harvard Medical School

Cervical Cancer

What Is It?

The cervix is a small, donut-shaped structure, located at the top of the vagina. It is the entrance to the uterus. Cervical cancer begins with abnormal, microscopic changes in cells in the outer layer of the cervix, called the epithelium. This stage is called dysplasia. If changes continue to occur, cells may become cancerous and grow out of control.

Cervical cancer tends to grow slowly. It can remain in an early stage, confined to the cervical covering, for 2 to 10 years. Once cancer moves beyond this layer, it invades nearby tissue, including the main body of the uterus, the vagina, bladder and rectum.

Virtually all cervical cancer is caused by infection with certain types of human papilloma virus (HPV), which slowly damages the cells that line the cervix. HPV is a very common infection among sexually active women, but only a small number of women who get infected develop cervical cancer. Smokers and women who are infected with HIV are more likely to develop cervical abnormalities if they are infected with HPV.

Symptoms

In its early stages, cervical cancer does not cause any symptoms. Once it begins to spread, it may cause a blood-tinged or discolored vaginal discharge, spotting after intercourse or abnormal bleeding. These symptoms aren't unique to cervical cancer and can occur with many disorders of the female reproductive tract.

More advanced stages of cervical cancer can cause pelvic pain, appetite loss, weight loss and anemia.

Diagnosis

The diagnosis of cervical cancer usually begins with a pelvic exam. The doctor uses a speculum, an instrument that holds the walls of the vagina open to make it easier to inspect your cervix and vagina, and do a Pap test. The Pap test is a quick, painless procedure in which the doctor gently brushes the surface lining and the canal of your cervix to obtain a sample of mucus and cells. The cells are then sent to a laboratory for examination.

If the Pap test indicates irregularly shaped cells (dysplasia) or possibly cancerous cells, a gynecologist will examine your cervix and vagina with a special instrument called a colposcope and will do a biopsy to further examine the abnormal cells. A colposcope contains a magnifying lens that makes the cervix appear larger. In a biopsy, a small piece of tissue is removed from the cervix so it can be examined in a laboratory. A vinegar solution is applied to the cervix and vagina so that abnormal areas turn white temporarily. This helps the gynecologist determine where to remove tissue for the biopsy.

Another test called endocervical curettage or endocervical scraping also may be done. A thin instrument is used to take a scraping of the cells inside the inner opening of the cervix. These are cells that may be hidden from view during colposcopy. A local anesthetic is used to numb the cervix during this and other types of biopsies.

DNA testing also can be done to check for the presence of HPV infection in cervical secretions, and to determine the type of HPV. Some HPV types are more likely to cause cancer. Many doctors use this test in women with abnormal Pap smears so that women with higher risk of developing cancer can have colposcopies and biopsies earlier, while women who have a lower risk can simply have a follow-up Pap smear in a few months. Further research is underway to determine whether HPV testing provides any benefit over routine Pap smears.

Expected Duration

Cervical cancer grows slowly and can take years to invade nearby tissues. However, it will continue to grow until it is treated.

Prevention

Almost all cervical cancer is caused by infection with HPV. In June 2006, the Food and Drug Administration approved a vaccine against HPV for use in women. The currently available vaccine (several pharmaceutical companies are developing a version) targets HPV strains 6 and 11, which cause 90% of genital warts — as well as the major cervical cancer-causing strains, 16 and 18. Given as a set of three shots over six months, the vaccine will protect against only those four strains.

The Centers for Disease Control and Prevention (CDC) added the HPV vaccine to its official vaccination recommendations in July 2006. It proposed that all 11- and 12-year-old American girls get the shots, although girls as young as 9 could receive it if they're sexually active. For "catch-up," the CDC also recommends that girls and women ages 13 to 26 be vaccinated against HPV, regardless of their Pap test results. To prevent this disease, you should also have regular pelvic exams and Pap tests — at least once a year if you are 18 or older or if you are under 18 and sexually active. If your first three Pap smear tests are normal, discuss with your doctor whether you can have Pap smears less frequently.

Other steps to help prevent cervical cancer include the following:

  • Limit the number of sexual partners you have to reduce possible exposure to HPV. This also will reduce your risk of developing HIV and other sexually transmitted diseases.
  • Use condoms during vaginal intercourse to decrease your risk of HPV infection (unless you have only one uninfected sexual partner).
  • Stop smoking.

Detecting cervical cancer early dramatically increases your chances of survival. If the disease is discovered and treated early, 99 women out of 100 survive. If it isn't diagnosed until it reaches the most advanced stage, only 7 women in 100 will survive.

Because of Pap-smear testing, cervical cancer is far more likely to be diagnosed at the noninvasive stage than at the invasive stage. From 1955 to 1992, increased Pap-smear testing led to a drop of almost 75% in the death rate from cervical cancer.

Treatment

How far the cancer has spread is called the cancer's stage. The treatment depends on the stage.
  • Stage 0 cancer is confined to the superficial layer. This includes dysplasia and carcinoma in situ, a cancer confined to the cervix epithelium.
  • Stage I cancer is confined to the cervix.
  • Stage II cancer extends beyond the cervix, but not to the pelvic wall or into the lower portion of the vagina.
  • Stage III cancer extends into the pelvic wall, the lower portion of the vagina or the ureters (the tubes that connect the kidneys to the bladder).
  • Stage IV cancer extends beyond the pelvis or involves the bladder, the rectum or both.

When recommending treatments for Stage 0 or Stage I cancer, your doctor also will consider whether you want to have children. When Stage 0 or Stage I cervical cancer is diagnosed during pregnancy, it may be possible to postpone treatment until after delivery. A woman with Stage I cancer who still wants to have children usually is treated with one of the following:

  • Laser surgery, in which the superficial tissue layer is heated and vaporized
  • Cryosurgery, in which the tissue to be removed is frozen
  • Conization, surgical removal of a cone of cervical tissue
  • Loop electrosurgical excision procedure (LEEP), in which low-voltage, high-frequency radio waves are run through a thin loop of wire, which is used as a cutting device to remove the abnormal cells from the cervix

After these procedures, a Pap test should be done about every four months for one year and every six months for a second year to check for abnormal cells.

Conization may be done for Stage I cancer in women who plan to become pregnant. For women who don't plan to become pregnant, the treatment for minimally invasive cancers in Stage I usually is a total hysterectomy (removal of uterus and cervix). This procedure removes the cancer and prevents it from coming back. The ovaries remain in place so hormone function remains normal. Larger Stage I and Stage II cancers require either a radical hysterectomy (removal of the uterus, cervix, as well as the ovaries, fallopian tubes and regional lymph nodes in the pelvis) or radiation therapy along with chemotherapy. The choice between surgery and radiation therapy depends in part on the age and health of the woman and also a woman's concerns about the potential side effects or complications.

Stage III and stage IV cancer must be treated with radiation. Studies have shown that combining chemotherapy with radiation therapy helps to improve survival in these later stages.

When To Call A Professional

Report any of the following symptoms to your doctor:
  • Abdominal pain
  • Weight loss
  • An unusual discharge from the vagina
  • Blood spots or light bleeding outside the time of your normal period
  • Significant pain or bleeding during sex

Remember that these symptoms don't necessarily mean that you have cancer. For women with advanced cervical cancer, significant vaginal bleeding could indicate that the cancer has broken into nearby blood vessels, such as an artery. This requires immediate medical attention at the hospital.

Prognosis

Survival depends on the stage at which the cancer is discovered and treated. The percentage of patients who survive five years or more at each stage is:

  • Stage 0 — 99% to 100%
  • Stage I — 85% to 95%
  • Stage II — 65% to 70%
  • Stage III and early stage IV — 40% to 50%
  • Late stage IV — Below 10% to 15%
Additional Info

National Cancer Institute (NCI)
Public Inquiries Office
Suite 3036A
6116 Executie Blvd., MSC 8322
Bethesda, MD 20892-8322
Toll-Free: 1-800-422-6237
TTY: 1-800-332-8615
http://www.nci.nih.gov/

American Cancer Society (ACS)
1599 Clifton Rd., NE
Atlanta, GA 30329-4251
Toll-Free: 1-800-227-2345
TTY: 1-866-228-4327
http://www.cancer.org/

Cancer Research Institute
681 Fifth Ave.
New York, NY 10022-4209
Toll-Free: 1-800-992-2623
Fax: 212-832-9376
E-Mail: info@cancerresearch.org
http://www.cancerresearch.org/

Last updated August 2, 2008




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