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Cervical Cancer

Definition

Cervical cancer is cancer that starts in the cervix, the lower part of the uterus (womb) that opens at the top of the vagina.

Alternative Names

Cancer - cervix

Causes

Worldwide, cervical cancer is the third most common type of cancer in women. It is much less common in the United States because of the routine use of Pap smears.

Cervical cancers start in the cells on the surface of the cervix. There are two types of cells on the cervix's surface: squamous and columnar. Most cervical cancers are from squamous cells.

Cervical cancer usually develops very slowly. It starts as a precancerous condition called dysplasia. This precancerous condition can be detected by a Pap smear and is 100% treatable. That is why it is so important for women to get regular Pap smears. Most women who are diagnosed with cervical cancer today have not had regular Pap smears or they have not followed up on abnormal Pap smear results.

Undetected precancerous changes can develop into cervical cancer and spread to the bladder, intestines, lungs, and liver. It can take years for precancerous changes to turn into cervical cancer. Patients with cervical cancer do not usually have problems until the cancer is advanced and has spread.

Almost all cervical cancers are caused by HPV (human papilloma virus). HPV is a common virus that is spread through sexual intercourse. There are many different types of HPV. Some strains lead to cervical cancer. (Other strains may cause genital warts, while others do not cause any problems at all.)

Risk factors for cervical cancer include:

  • Having sex at an early age
  • Multiple sexual partners
  • Poor economic status (may not be able to afford regular Pap smears)
  • Sexual partners who have multiple partners or who participate in high-risk sexual activities
  • Women whose mothers took the drug DES (diethylstilbestrol) during pregnancy in the early 1960s to prevent miscarriage
  • Weakened immune system

Symptoms

Most of the time, early cervical cancer has no symptoms. Symptoms that may occur can include:

  • Abnormal vaginal bleeding between periods, after intercourse, or after menopause
  • Any bleeding after menopause
  • Continuous vaginal discharge, which may be pale, watery, pink, brown, bloody, or foul-smelling
  • Periods become heavier and last longer than usual

Symptoms of advanced cervical cancer may include:

  • Back pain
  • Bone fractures
  • Fatigue
  • Heavy bleeding from the vagina
  • Leaking of urine or feces from the vagina
  • Leg pain
  • Loss of appetite
  • Pelvic pain
  • Single swollen leg
  • Weight loss

Exams and Tests

Precancerous changes of the cervix and cervical cancer cannot be seen with the naked eye. Special tests and tools are needed to spot such conditions.

  • Pap smears screen for precancers and cancer, but do not make a final diagnosis.
  • If abnormal changes are found, the cervix is usually examined under magnification. This is called colposcopy. Pieces of tissue are surgically removed (biopsied) during this procedure and sent to a laboratory for examination.

Other tests may include:

  • Endocervical curettage (ECC) to examine the opening of the cervix
  • Cone biopsy

If the woman is diagnosed with cervical cancer, the health care provider will order more tests to determine how far the cancer has spread. This is called staging. Tests may include:

Treatment

Treatment of cervical cancer depends on:

  • The stage of the cancer
  • The size and shape of the tumor
  • The woman's age and general health
  • Her desire to have children in the future

Early cervical cancer can be cured by removing or destroying the precancerous or cancerous tissue. There are various surgical ways to do this without removing the uterus or damaging the cervix, so that a woman can still have children in the future.

Types of surgery for early cervical cancer include:

  • Loop electrosurgical excision procedure (LEEP) -- uses electricity to remove abnormal tissue
  • Cryotherapy -- freezes abnormal cells
  • Laser therapy -- uses light to burn abnormal tissue

A hysterectomy (removal of the uterus but not the ovaries) is not often performed for cervical cancer that has not spread. It may be done in women who have repeated LEEP procedures.

Treatment for more advanced cervical cancer may include:

  • Radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina.
  • Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed.

Radiation may be used to treat cancer that has spread beyond the pelvis, or cancer that has returned. Radiation therapy is either external or internal.

  • Internal radiation therapy uses a device filled with radioactive material, which is placed inside the woman's vagina next to the cervical cancer. The device is removed when she goes home.
  • External radiation therapy beams radiation from a large machine onto the body where the cancer is located. It is similar to an x-ray.

Chemotherapy uses drugs to kill cancer. Some of the drugs used for cervical cancer chemotherapy include 5-FU, cisplatin, carboplatin, ifosfamide, paclitaxel, and cyclophosphamide. Sometimes radiation and chemotherapy are used before or after surgery.

Support Groups

National Cervical Cancer Coalition - http://www.nccc-online.org/

Outlook (Prognosis)

Many factors influence the outcome of cervical cancer. These include:

  • The type of cancer
  • The stage of the disease
  • The woman's age and general physical condition

Pre-cancerous conditions are completely curable when followed up and treated properly. The chance of being alive in 5 years (5-year survival rate) for cancer that has spread to the inside of the cervix walls but not outside the cervix area is 92%.

The 5-year survival rate falls steadily as the cancer spreads into other areas.

Possible Complications

  • Some types of cervical cancer do not respond well to treatment.
  • The cancer may come back (recur) after treatment.
  • Women who have treatment to save the uterus have a high risk of the cancer coming back (recurrence). 
  • Surgery and radiation can cause problems with sexual, bowel, and bladder function.

When to Contact a Medical Professional

Call your health care provider if you:

  • Are a sexually active woman who has not had a Pap smear in the past year
  • Are at least 20 years old and have never had a pelvic examination and Pap smear
  • Think your mother may have taken DES when she was pregnant with you
  • Have not had regular Pap smears (ask your health care provider how often you should have one performed)

Prevention

A vaccine to prevent cervical cancer is now available. In June 2006, the U.S. Food and Drug Administration approved the vaccine called Gardasil, which prevents infection against the two types of HPV responsible for most cervical cancer cases.

Studies have shown that the vaccine appears to prevent early-stage cervical cancer and precancerous lesions. Gardasil is the first approved vaccine targeted specifically to prevent any type of cancer.

Practicing safe sex (using condoms) also reduces your risk of HPV and other sexually transmitted diseases. HPV infection causes genital warts. These may be barely visible or several inches wide. If a woman sees warts on her partner's genitals, she should avoid intercourse with that person.

To further reduce the risk of cervical cancer, women should limit their number of sexual partners and avoid partners who participate in high-risk sexual activities.

Getting regular Pap smears can help detect precancerous changes, which can be treated before they turn into cervical cancer. Pap smears effectively spot such changes, but they must be done regularly. Annual pelvic examinations, including a pap smear, should start when a woman becomes sexually active, or by the age of 20 in a nonsexually active woman.

See also: Physical exam frequency

If you smoke, quit. Cigarette smoking is associated with an increased risk of cervical cancer.

References

Kahn JA. HPV vaccination for the prevention of cervical intraepithelial neoplasia. N Engl J Med. 2009 Jul 16;361(3):271-8.

Noller KL. Intraepithelial neoplasia of the lower genital tract (cervix, vulva): Etiology, screening, diagnostic techniques, management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 28.

National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: Cervical Cancer Screening. v.1.2011.

Smith RA, Cokkinides V, Brooks D, Saslow D, Brawley OW. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2010;60:99-119.

NCCN Clinical Practical Guidelines in Oncology: Cervical cancer. V.1.2010. National Comprehensive Cancer Network, Inc. Available at www.nccn.org. Accessed December 28, 2009.