Cervical Cancer Overview

The uterine cervix is the lowest portion of a woman's uterus (womb). Most

of the uterus lies in the pelvis, but part of the cervix is located in the vagina,
where it connects the uterus with the vagina.

Cancer of the cervix occurs when the cells of the 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 and treatment. 

 These opportunities have caused the decline of cervical cancer over

the past decades in the United States.

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 thelungs, the liver, the bladder, the vagina, and/or
the rectum.
Cervical Cancer Causes

Cervical cancer begins with abnormal changes in the cervical tissue. The
risk of developing these abnormal changes has been associated with
certain factors, including previous infectionwith human
papillomavirus (HPV), early sexual contact, multiple sexual
partners, cigarette smoking, and taking oral contraceptives (birth
control pills).

Forms 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.

 Genetic material that comes from certain forms of HPV has been

found in cervical tissues that show cancerous or precancerous
changes. 

 In addition, women who have been diagnosed with HPV are more
likely to develop a cervical cancer that has genetic material matching
the strain of virus that caused the infection. 

 These findings demonstrate a strong link between the virus and

cervical cancer. 

 Because HPV can be transmitted by sexual contact, early sexual

contact and having multiple sexual partners have been identified as
strong 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 pill") may increase the risk for cervical cancer,
especially in women who use oral contraceptives for longer than 5 years.

Cervical Cancer Symptoms

As in many cancers, you may have no signs or symptoms of cervical

cancer until it has progressed to a dangerous stage.

 Cervical cancer does not usually causepain, although it may in very

advanced stages. 

 The most common symptom is abnormalvaginal bleeding. This is

any bleeding from the vagina other than during menstruation. 

 Abnormal vaginal discharge also may occur with cervical cancer.

When to Seek Medical Care

The range of conditions that can cause vaginal bleeding are diverse, range
in seriousness, and vary based on your age, fertility, and medical history.
Vaginal bleeding after menopause is never normal. If you have gone
through menopause and have vaginal bleeding, see your health care
provider as soon as possible.
Very heavy bleeding during your period or frequent bleeding between
periods warrants evaluation by your health care provider.
Bleeding after intercourse, especially after vigorous sex, does occur in
some women. If this occurs only occasionally, it is probably nothing to
worry about. Evaluation by your health care provider is advisable,
especially if the bleeding happens repeatedly.

If you have vaginal bleeding that is associated with weakness, feeling faint
or light-headed, or actual faint, go to a hospital emergency department for
care.

Exams and Tests

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 is done as part of a regularpelvic examination. 

 Named after the pathologist who developed the test, 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.
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 8-10 times, allowing easier

identification of any abnormal-appearing tissue that may need biopsy. 

 This procedure can usually be done in your 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.

 The loop electrosurgical excision procedure (LEEP) technique uses

an electrified loop of wire to take a sample of tissue from the cervix. 
 This procedure can often be performed in your gynecologist's office.

A cone biopsy is performed in the operating room while you are

under anesthesia.

 A small cone-shaped sample of your 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.

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 calledsquamous 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 2 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. 

o These lesions may go away on their own, but over time, they
may become more abnormal, eventually becoming a high-grade
lesion. 

o SIL is also called mild dysplasia or cervical intraepithelial

neoplasia 1 (CIN 1). 
 o 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. 

o Like low-grade SIL, these precancerous changes involve only

cells on the surface of the cervix. 

o These lesions are also called moderate or severe dysplasia,

CIN 2 or 3, or carcinoma in situ. 

o 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.
Some laboratories may still use an older system for describing
abnormalities. This system classifies changes into 1 of 5 groups, 1 being
the most mild changes and 5 being the most severe.

Ask you health care provider if you do not understand the way the result of
your 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.

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.

 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. 

 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, your health care providers can
make a reasonable guess about your prognosis and the kind of
treatment you will need. 

 Cervical cancer is staged from stage 0 (least severe) to stage IV

(metastatic disease, the most severe). 

 Staging is based on size and depth of the cancerous lesion, as well

as degree of spread.

Cervical Cancer Treatment

Treatment of cervical cancer is directed at preventing precancerous cells
from becoming cancerous cells.

 This is usually a step-by-step process, involving the removal of cells

or tissue to diagnose cancer and to find out how far it has invaded. 

 If the deepest cells removed by biopsy were normal, no further

treatment may be needed. 

 If the deepest cells removed by biopsy were cancerous or

precancerous, this means the cancer has invaded farther than the
biopsy. In these cases, treatment generally starts with removal of
additional tissues. As these tissues are removed, they are checked for
dysplastic change to be sure all the precancerous or cancerous cells
have been removed from the body or are otherwise destroyed.

Self-Care at Home

Self-treatment is not appropriate 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 you can do to

reduce the physical and mental stresses of your cancer and its treatment.

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

 You may lose your appetite during your 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
during the therapy. They are also better able to tolerate the side effects
of therapy. 

 Your cancer specialist (oncologist) or gynecologist may be able to

recommend a nutritionist who can provide suggestions for keeping up
your calorie and protein intake.

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

 Physical activity will also help keep your strength and energy level
up. Engage in mild physical activity that is comfortable but doesn't wear
you out. 

 Rest is equally important. Get plenty of sleep each night and rest

during the day if you need to. 

 Quit smoking. 

 Avoid alcohol. You may not be able to drink alcohol with some of the
medications you are taking. Be sure to ask your health care provider.

Medical Treatment

Treatment for precancerous lesions differs from that of invasive 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 you want to have children in the future, your age and
general health, and your preference and that of your health care provider.

 If you have a low-grade lesion, you may not need further treatment,
especially if the abnormal area was completely removed during biopsy.
You should have regular Pap smears and pelvic exams. 

 When a precancerous lesion requires

treatment, cryosurgery (freezing),cauterization (burning, also
calleddiathermy), 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, you 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 you do not plan to have
children in the future.

Diagnostic procedures, such as LEEP and cone biopsy, sometimes may be

treatment 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.
Invasive cancer

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

 Treatment for invasive cervical cancer usually involves a team of

specialists. The team generally includes a gynecologic oncologist and
a radiation oncologist.

 These doctors may decide to use one treatment method or a
combination of methods.

 You 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. See For More Information to find out about clinical trials on the
Internet.

Cancerous cells typically invade surrounding tissues.

 If a biopsy shows that cancerous cells have invaded through a layer

called thebasement 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 your pelvis.

 External radiation treatments usually are given 5 days a week for 5-6
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 1-3 days, and the treatment may be
repeated several times over the course of 1-2 weeks. 
 You stay 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 used most often when the cancer has spread to other parts of
the body. Just one drug or a combination of drugs may be given.

 Anticancer drugs used to treat cervical cancer may be given via an

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 your general health, however, you may need
to stay in the hospital during treatment.

Surgery

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, her

partner, and her health care provider. 

 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, you may have pain in your
lower abdomen. The pain can be controlled by medication. 

 You may have difficulty emptying your bladder. You 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. You also may have
trouble having normal bowelmovements. 

 Your 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 4-8 weeks.

Once you have had your uterus removed, you will no longer
have menstrualperiods.

 Sexual desire and the ability to have intercourse usually are not
affected by hysterectomy. 

 On the other hand, many women have an emotionally difficult time

after this surgery. 

 Your view of your own sexuality may change. You may feel an
emotional loss because you are no longer able to have children. 

 An understanding partner is important at this time. 

 You may want to discuss these issues with your health care
provider, medical social worker, or counselor.

Follow-up
Regular pelvic examinations and Pap smears are important for every
woman. These tests are no less 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
your 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,
you should continue to have regular checkups and should report any health
problems that appear.

Prevention

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 you should have apelvic
exam and Pap smear depends on your individual situation.

 You should have your first Pap smear when you become sexually
active, no matter how old you are. 

 If you are not sexually active, you should have your first Pap smear
at age 18 years or earlier. 

 In both cases, you should have a Pap smear every year for at least
3 years. 
 If these Pap smears reveal no abnormal cells and you have few risk
factors for cervical cancer, the US Guide to Clinical Preventive Services
recommends a repeat Pap smear at least every 3 years. 

 Because a woman's risk factors may change with her lifestyle, many
medical professionals prefer that you have a Pap smear yearly through
age 65 years and older, regardless of the number of negative tests you
have had in the past. 

 If you have had precancerous changes or cancer of the cervix, your

gynecologist will recommend a schedule of follow-up examinations and
tests.

Avoidance of human papillomavirus infection is becoming increasingly

important in the prevention of precancerous and cancerous changes of the
cervix.

 Early age at first intercourse is associated with increased

risk. 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. 

 A vaccine to protect women from cervical cancer may be available in

5 years. Early tests found an experimental vaccine to be effective
against the virus responsible for half of all cases of cervical cancer. The
vaccine targets a strain of HPV. The vaccine would not be effective for
women who already have HPV.
Cigarette smoking is another risk factor for cervical cancer that can be
prevented. Quitting smoking may decrease your chances of developing
cervical cancer.

Outlook

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 stage of cervical cancer, more than 90% of women
survive at least 5 years after diagnosis. 

 Later stages of cervical cancer have a significantly worse outlook;

20% or fewer of women with stage IV cervical cancer survive 5 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 providers 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.)

Support Groups and Counseling

Living with cancer presents many new challenges for you and for your
family and friends.

 You will probably have many worries about how the cancer will
affect you and your ability to "live a normal life," that is, to care for your
family and home, to hold your job, and to continuing the friendships and
activities you enjoy. 

 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.

 Your friends and family members can be very supportive. They may
be hesitant to offer support until they see how you are coping. Don't
wait for them to bring it up. If you want to talk about your concerns, 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 you want to
 discuss your feelings and concerns about having cancer. Your
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 your concerns with others who have
been through the same thing can be remarkably reassuring. Support
groups of people with cancer may be available through the medical
center where you are receiving your treatment. The American Cancer
Society also has information about support groups all over the United
States.

Dysplasia

human papillomavirus

genital warts

invasive cervical cancer

Papanicolaou test

Pap smear

Pap test

pelvic exam

pelvic examination

precancerous changes

precancerous lesions

squamous intraepithelial lesion