Cervical Cancer

The Cervix

The cervix is part of a woman's reproductive system. It is the lower, narrow part of the uterus (womb). The uterus is a hollow, pear-shaped organ in the lower abdomen. The cervix connects the uterus to the vagina. The vagina leads to the outside of the body.

The cervical canal is a passageway. Blood flows from the uterus through the canal into the vagina during a woman's menstrual period. The cervix also produces mucus. The mucus helps sperm move from the vagina into the uterus. During pregnancy, the cervix is tightly closed to help keep the baby inside the uterus. During childbirth, the cervix dilates (opens) to allow the baby to pass through the vagina.

Risk Factors

Doctors cannot always explain why one woman develops cervical cancer and another does not. However, we do know that a woman with certain risk factors may be more likely than others to develop cervical cancer. A risk factor is something that may increase the chance of developing a disease.

Studies have found a number of factors that may increase the risk of cervical cancer. These factors may act together to increase the risk even more:

• Human papillomaviruses (HPVs): HPV infection is the main risk factor for cervical cancer. HPV is a group of viruses that can infect the cervix. HPV infections are very common. These viruses can be passed from person to person through sexual contact. Most adults have been infected with HPV at some time in their lives. Some types of HPV can cause changes to cells in the cervix. These changes can lead to genital warts, cancer, and other problems. Doctors may check for HPV even if there are no warts or other symptoms.

If a woman has an HPV infection, her doctor can discuss ways to avoid infecting other people. The Pap test can detect cell changes in the cervix caused by HPV. Treatment of these cell changes can prevent cervical cancer. There are several treatment methods, including freezing or burning the infected tissue. Sometimes medicine also helps.

• Lack of regular Pap tests: Cervical cancer is more common among women who do not have regular Pap tests. The Pap test helps doctors find precancerous cells. Treating precancerous cervical changes often prevents cancer.
• Weakened immune system (the body's natural defense system): Women with HIV (the virus that causes AIDS) infection or who take drugs that suppress the immune system have a higher-than-average risk of developing cervical cancer. For these women, doctors suggest regular screening for cervical cancer.
• Age: Cancer of the cervix occurs most often in women over the age of 40.
• Sexual history: Women who have had many sexual partners have a higher-than-average risk of developing cervical cancer. Also, a woman who has had sexual intercourse with a man who has had many sexual partners may be at higher risk of developing cervical cancer. In both cases, the risk of developing cervical cancer is higher because these women have a higher-than-average risk of HPV infection.
• Smoking cigarettes: Women with an HPV infection who smoke cigarettes have a higher risk of cervical cancer than women with HPV infection who do not smoke.
• Using birth control pills for a long time: Using birth control pills for a long time (5 or more years) may increase the risk of cervical cancer among women with HPV infection.
• Having many children: Studies suggest that giving birth to many children may increase the risk of cervical cancer among women with HPV infection.

Diethylstilbestrol (DES) may increase the risk of a rare form of cervical cancer and certain other cancers of the reproductive system in daughters exposed to this drug before birth. DES was given to some pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.)

Women who think they may be at risk for cancer of the cervix should discuss this concern with their doctor. They may want to ask about a schedule for checkups.

 

Screening

Screening to check for cervical changes before there are symptoms is very important. Screening can help the doctor find abnormal cells before cancer develops. Finding and treating abnormal cells can prevent most cervical cancer. Also, screening can help find cancer early, when treatment is more likely to be effective.

For the past several decades, the number of women diagnosed each year with cervical cancer has been falling. Doctors believe this is mainly because of the success of screening.

Doctors recommend that women help reduce their risk of cervical cancer by having regular Pap tests. A Pap test (sometimes called Pap smear or cervical smear) is a simple test used to look at cervical cells. For most women, the test is not painful. A Pap test is done in a doctor's office or clinic during a pelvic exam. The doctor or nurse scrapes a sample of cells from the cervix, and then smears the cells on a glass slide. In a new type of Pap test (liquid-based Pap test), the cells are rinsed into a small container of liquid. A special machine puts the cells onto slides. For both types of Pap test, a lab checks the cells on the slides under a microscope for abnormalities.

Pap tests can find cervical cancer or abnormal cells that can lead to cervical cancer. Doctors generally recommend that:

• Women should begin having Pap tests 3 years after they begin having sexual intercourse, or when they reach age 21 (whichever comes first).
• Most women should have a Pap test at least once every 3 years.
• Women aged 65 to 70 who have had at least three normal Pap tests and no abnormal Pap tests in the past 10 years may decide, after speaking with their doctor, to stop cervical cancer screening.
• Women who have had a hysterectomy (surgery) to remove the uterus and cervix, also called a total hysterectomy, do not need to have cervical cancer screening. However, if the surgery was treatment for precancerous cells or cancer, the woman should continue with screening.

Women should talk with their doctor about when they should begin having Pap tests, how often to have them, and when they can stop having them. This is especially important for women at higher-than-average risk of cervical cancer.

Some activities can hide abnormal cells and affect Pap test results. Doctors suggest the following tips:

• Do not douche for 48 hours before the test.
• Do not have sexual intercourse for 48 hours before the test.
• Do not use vaginal medicines (except as directed by a doctor) or birth control foams, creams, or jellies for 48 hours before the test.

Doctors also suggest that a woman schedule her Pap test for a time that is 10 to 20 days after the first day of her menstrual period.

Most often, abnormal cells found by a Pap test are not cancerous. However, some abnormal conditions may become cancer over time:

• LSIL (low-grade squamous intraepithelial lesion): LSILs are mild cell changes on the surface of the cervix. Such changes often are caused by HPV infections. LSILs are common, especially in young women. LSILs are not cancer. Even without treatment, most LSILs stay the same or go away. However, some turn into high-grade lesions, which may lead to cancer.
• HSIL (high-grade squamous intraepithelial lesion): HSILs are not cancer, but without treatment they may lead to cancer. The precancerous cells are only on the surface of the cervix. They look very different from normal cells.

 

Symptoms

Precancerous changes and early cancers of the cervix generally do not cause pain or other symptoms. It is important not to wait to feel pain before seeing a doctor.

When the disease gets worse, women may notice one or more of these symptoms:

• Abnormal vaginal bleeding
• Bleeding that occurs between regular menstrual periods
• Bleeding after sexual intercourse, douching, or a pelvic exam
• Menstrual periods that last longer and are heavier than before
• Bleeding after menopause
• Increased vaginal discharge
• Pelvic pain
• Pain during sexual intercourse

Infections or other health problems may also cause these symptoms. Only a doctor can tell for sure. A woman with any of these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible.

 

Diagnosis

If a woman has a symptom or Pap test results that suggest precancerous cells or cancer of the cervix, her doctor will suggest other procedures to make a diagnosis.

These may include:

• Colposcopy: The doctor uses a colposcope to look at the cervix. The colposcope combines a bright light with a magnifying lens to make tissue easier to see. It is not inserted into the vagina. A colposcopy is usually done in the doctor's office or clinic.
• Biopsy : The doctor removes tissue to look for precancerous cells or cancer cells. Most women have their biopsy in the doctor's office with local anesthesia. A pathologist checks the tissue with a microscope.
• Punch biopsy: The doctor uses a sharp, hollow device to pinch off small samples of cervical tissue.
• LEEP: The doctor uses an electric wire loop to slice off a thin, round piece of tissue.
• Endocervical curettage: The doctor uses a curette (a small, spoon-shaped instrument) to scrape a small sample of tissue from the cervical canal. Some doctors may use a thin, soft brush instead of a curette.
• Conization: The doctor removes a cone-shaped sample of tissue. A conization, or cone biopsy, lets the pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. The doctor may do this test in the hospital under general anesthesia. Conization also may be used to remove a precancerous area.

Removing tissue from the cervix may cause some bleeding or other discharge. The area usually heals quickly. Women may also feel some pain similar to menstrual cramps. Medicine can relieve this discomfort.

 

 

Staging

If the biopsy shows that you have cancer, your doctor will do a thorough pelvic exam and may remove additional tissue to learn the extent (stage) of your disease. The stage tells whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body.

These are the stages of cervical cancer:

• Stage 0: The cancer is found only in the top layer of cells in the tissue that lines the cervix. Stage 0 is also called carcinoma in situ.
• Stage I: The cancer has invaded the cervix beneath the top layer of cells. It is found only in the cervix.
• Stage II: The cancer extends beyond the cervix into nearby tissues. It extends to the upper part of the vagina. The cancer does not invade the lower third of the vagina or the pelvic wall (the lining of the part of the body between the hips).
• Stage III: The cancer extends to the lower part of the vagina. It also may have spread to the pelvic wall and nearby lymph nodes.
• Stage IV: The cancer has spread to the bladder, rectum, or other parts of the body.
• Recurrent cancer: The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body.

To learn the extent of disease and suggest a course of treatment, the doctor may order some of the following tests:

• Chest x-rays: X-rays often can show whether cancer has spread to the lungs.
• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your organs. You may receive contrast material by injection in your arm or hand, by mouth, or by enema. (Some people are allergic to contrast materials that contain iodine. Tell your doctor or nurse if you have allergies.) The contrast material makes abnormal areas easier to see. A tumor in the liver, lungs, or elsewhere in the body can show up on the CT scan.
• MRI: A powerful magnet linked to a computer is used to make detailed pictures of your pelvis and abdomen. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether cancer has spread. Sometimes contrast material makes abnormal areas show up more clearly on the picture.
• Ultrasound: An ultrasound device is held against the abdomen or inserted into the vagina. The device sends out sound waves that people cannot hear. The waves bounce off the cervix and nearby tissues, and a computer uses the echoes to create a picture. Tumors may produce echoes that are different from the echoes made by healthy tissues. The picture can show whether cancer has spread.

 

Treatment

 

Many women with cervical cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and your treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask the doctor. It often helps to make a list of questions before an appointment.

To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor - to take part in the discussion, to take notes, or just to listen.

You do not need to ask all your questions at once. You will have other chances to ask your doctor to explain things that are not clear and to ask for more information.

Your doctor may refer you to a specialist, or you may ask for a referral. Gynecologists, gynecologic oncologists, medical oncologists, and radiation oncologists are specialists who treat cervical cancer.

Getting a Second Opinion

Before starting treatment, you might want a second opinion about the diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it. It may take some time and effort to gather medical records and arrange to see another doctor. Usually it is not a problem to take several weeks to get a second opinion. In most cases, the delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Some women with cervical cancer need treatment right away.

There are a number of ways to find a doctor for a second opinion:

• Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.
• A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists in your area.
• The American Board of Medical Specialties (ABMS) has a list of doctors who have had training and passed exams in their specialty. You can find this list in the Official ABMS Directory of Board Certified Medical Specialists. This Directory is in most public libraries. Or you can look up doctors at http://www.abms.org. (Click on "Who's Certified.")

 

Preparing for Treatment

The choice of treatment depends mainly on the size of the tumor and whether the cancer has spread. If a woman is of childbearing age, the treatment choice may also depend on whether she wants to become pregnant someday.

Your doctor can describe your treatment choices and the expected results of each. You and your doctor can work together to develop a treatment plan that meets your medical needs and personal values.

Methods of Treatment

Women with cervical cancer may be treated with surgery, radiation therapy, chemotherapy, radiation therapy and chemotherapy, or a combination of all three methods.

At any stage of disease, women with cervical cancer may have treatment to control pain and other symptoms, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called supportive care, symptom management, or palliative care.

You may want to talk to your doctor about taking part in a clinical trial, a research study of new treatment methods.

 

Surgery

Surgery treats the cancer in the cervix and the area close to the tumor.

Most women with early cervical cancer have surgery to remove the cervix and uterus (total hysterectomy). However, for very early (Stage 0) cervical cancer, a hysterectomy may not be needed. Other ways to remove the cancerous tissue include conization, cryosurgery, laser surgery, or LEEP.

Some women need a radical hysterectomy. A radical hysterectomy is surgery to remove the uterus, cervix, and part of the vagina.

With either total or radical hysterectomy, the surgeon may remove both fallopian tubes and ovaries. (This procedure is a salpingo-oophorectomy.)

The surgeon may also remove the lymph nodes near the tumor to see if they contain cancer. If cancer cells have reached the lymph nodes, it means the disease may have spread to other parts of the body.

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area.

Women have radiation therapy alone, with chemotherapy, or with chemotherapy and surgery. The doctor may suggest radiation therapy instead of surgery for the small number of women who cannot have surgery for medical reasons. Most women with cancer that extends beyond the cervix have radiation therapy and chemotherapy. For cancer that has spread to distant organs, radiation therapy alone may be used.

Doctors use two types of radiation therapy to treat cervical cancer. Some women receive both types:

• External radiation: The radiation comes from a large machine outside the body. The woman usually has treatment as an outpatient in a hospital or clinic. She receives external radiation 5 days a week for several weeks.
• Internal radiation (intracavitary radiation): Thin tubes (also called implants) containing a radioactive substance are left in the vagina for a few hours or up to 3 days. The woman may stay in the hospital during that time. To protect others from the radiation, the woman may not be able to have visitors or may have visitors for only a short period of time while the tubes are in place. Once the tubes are removed, no radioactivity is left in her body. Internal radiation may be repeated two or more times over several weeks.

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. It is called systemic therapy because the drugs enter the bloodstream and can affect cells all over the body. For treatment of cervical cancer, chemotherapy is generally combined with radiation therapy. For cancer that has spread to distant organs, chemotherapy alone may be used.

Anticancer drugs for cervical cancer are usually given through a vein. Women usually receive treatment in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, a woman needs to stay in the hospital during treatment.

 

Side Effects of Treatment

 

Because cancer treatment often damages healthy cells and tissues, unwanted side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, and they may change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

 

Surgery

It takes time to heal after surgery, and the recovery time is different for each woman. You may be uncomfortable for the first few days. However, medicine can usually control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

If you have surgery to remove a small tumor on the surface of the cervix, you may have cramping or other pain, bleeding, or a watery discharge.

If you have a hysterectomy, the length of the hospital stay may vary from several days to a week. It is common to feel tired or weak for a while. You may have problems with nausea and vomiting, and you may have bladder and bowel problems. The doctor may restrict your diet to liquids at first, with a gradual return to solid food. Most women return to their normal activities within 4 to 8 weeks after surgery.

After a hysterectomy, women no longer have menstrual periods. They cannot become pregnant.

When the ovaries are removed, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. You may wish to discuss this with your doctor before surgery. Some drugs have been shown to help with these symptoms, and they may be more effective if started before surgery.

After surgery, some women may be concerned about sexual intimacy. Many women find that it helps to share these concerns with their partner. A couple may want to ask a counselor to help them express their concerns.

Radiation Therapy

Side effects depend mainly on the dose of radiation and the part of your body that is treated. Radiation to the abdomen and pelvis may cause nausea, vomiting, diarrhea, or urinary problems. You may lose hair in your genital area. Also, your skin in the treated area may become red, dry, and tender.

You may have dryness, itching, or burning in your vagina. The radiation may also make your vagina narrower. The doctor or nurse may suggest ways to relieve discomfort. There also are ways to expand the vagina, which will help make follow-up exams easier. Your doctor may advise you not to have intercourse during treatment. But most women can resume sexual activity within a few weeks after treatment ends.

You are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Although the side effects of radiation therapy can be distressing, your doctor can usually find ways to relieve them.

Chemotherapy

The side effects of chemotherapy depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly:

• Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired.
• Cells in hair roots: Chemotherapy can cause you to lose your hair. The hair will grow back, but it may be somewhat different in color and texture.
• Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.

The drugs used for cervical cancer also may cause skin rash, hearing problems, loss of balance, joint pain, or swollen legs and feet.

Your doctor can suggest ways to control many of these side effects.