Cervical CancerLast Updated: September 23, 2008 This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/08 Overview
Cervical cancer starts in a woman's cervix, which is the lower, narrow part of the uterus. The uterus holds the growing fetus during pregnancy. The cervix connects the lower part of the uterus to the vagina and, with the vagina, forms the birth canal. Cervical cancer develops when normal cells on the surface of the cervix begin to change, grow uncontrollably, and eventually form a mass of cells called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous). At first, the changes in a cell are abnormal, not cancerous. Researchers believe, however, that some of these abnormal changes are the first step in a series of slow changes that can lead to cancer. Some of the abnormal cells go away without treatment, but others can become cancerous. This phase of the disease is called dysplasia (an abnormal growth of cells). The precancerous tissue needs to be removed to keep cancer from developing. Often, the precancerous tissue can be removed or destroyed without harming healthy tissue, but in some cases, a hysterectomy (removal of the uterus and cervix) is needed to prevent cervical cancer. Treatment of a lesion (a precancerous area) depends on the following factors:
If the precancerous cells change into true cancer cells and spread deeper into the cervix or to other tissues and organs, the disease is then called cervical cancer. There are two main types of cervical cancer, named for the type of cell where the cancer started.
In addition, there are a few other rare types of cervical cancer. Statistics In 2009, an estimated 11,270 women in the United States will be diagnosed with cervical cancer. It is estimated that 4,070 deaths from the disease will occur this year. The number of new cases of cervical cancer is decreasing as screening with the Pap test (see Prevention) becomes more prevalent. The one-year relative survival rate (percentage of women who survive at least one year after the cancer is detected, excluding those who die from other diseases) of women with cervical cancer is 88%. The five-year relative survival rate (percentage of women who survive at least five years after the cancer is detected, excluding those who die from other diseases) for all stages of cervical cancer is 71%. When detected at an early stage, the five-year survival rate for women with invasive cervical cancer is 92%. Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a woman how long she will live with cervical cancer. Because survival statistics are often measured in multi-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2009. Find out more about basic cancer terms used in this section. Medical Illustrations
Risk Factors
A risk factor is anything that increases a person's chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices. The following factors may raise a woman's risk of developing cervical cancer: Human papillomavirus (HPV) infection. The most important risk factor for cervical cancer is infection with HPV. This virus is passed from one person to another during sexual intercourse. Factors that raise the risk of being infected with HPV include becoming sexually active at an early age, having many sexual partners (or having sex with a man who has had many partners), and/or having sex with a man who has penile warts. Immune system deficiency. Women with lowered immune systems have a higher risk of developing cervical cancer. A lowered immune system can be caused by immune suppression from corticosteroid medications, kidney transplantations, or treatments for other types of cancer or from human immunodeficiency virus (HIV), the virus that causes acquired immune deficiency syndrome (AIDS). When a woman is infected with HIV, her immune system is less able to fight off early cancer. Herpes. Women who have genital herpes have a higher risk of developing cervical cancer. Smoking. Women who smoke are about twice as likely to develop cervical cancer as women who do not smoke. Age. Girls younger than 15 rarely develop cervical cancer. The risk goes up between the late teens and mid-30s. Women over 40 remain at risk and need to continue having regular Pap test screenings. Race. Cervical cancer is more common among black women, Hispanic women, and American Indian women. Oral contraceptives. Some research studies suggest that oral contraceptives, or birth control pills, may be associated with an increase in the risk of cervical cancer, but more research is needed to understand how oral contraceptive use and the development of cervical cancer are connected. Exposure to diethylstilbestrol (DES). Women whose mothers were given this drug during pregnancy to prevent miscarriage are at increased risk for cervical cancer. DES was given for this purpose from about 1940 to 1970. Women exposed to DES should have an annual pelvic examination that includes a cervical Pap test as well as a four-quadrant Pap test, in which samples of cells are taken from all sides of the vagina to check for abnormal cells. Prevention
Cervical cancer can often be prevented by preventing precancers and having regular Pap tests. Preventing precancers means controlling these risk factors.
The Pap test is the most common test for cervical cancer. Researchers have found that combining it with a test to detect HPV provides the most accurate results. In 2003, a U.S. Food and Drug Administration (FDA) panel recommended that Pap tests and HPV tests be used together when screening for cervical cancer in women over the age of 29. The HPV test is already being used as a secondary test in people with Pap test results that indicate abnormal cells are present. In 2006, a vaccine to prevent cervical cancer was approved by the FDA for girls and women between ages 9 and 26. It prevents infection by the four most common strains (types) of HPV. The vaccine does not protect people who are already infected with HPV. Doctors still recommend regular Pap tests using the guidelines below for all women. For more information on the HPV vaccine, read the ASCO Expert Corner: HPV Vaccination for Cervical Cancer. In 2003, the American Cancer Society, American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, Society of Gynecologic Oncologists, and the U.S. Preventive Task Force developed screening guidelines with the Pap test for cervical cancer.
Symptoms
Women with cervical cancer may experience the following symptoms. Sometimes, women with cervical cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. Most women do not have any signs or symptoms of a precancer or early stage cervical cancer. Symptoms usually do not appear until the cancer has spread to other tissues and organs. Any of the following could be signs or symptoms of cervical dysplasia or cancer:
Any of these six symptoms should be reported to the doctor. If these symptoms appear, it is important to talk with your doctor about them even if they appear to be symptoms of other, less serious conditions. The earlier precancerous cells or cancer is found and treated, the better the chance that the cancer can be prevented or cured. Diagnosis
Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
In addition to a physical examination, the following tests may be used to diagnose cervical cancer: Pap test. The doctor gently scrapes the outside of the cervix and vagina and takes samples of the cells for testing. For more information, read Pap Test – What to Expect. Pelvic examination. In this examination, the doctor feels a woman’s uterus, vagina, ovaries, fallopian tubes, cervix, bladder, and rectum to check for any unusual changes. A Pap test is often done at the same time. If the doctor finds abnormal changes to the cervix during a pelvic examination and a Pap test, the doctor may test for HPV. An HPV test is similar to a Pap test, where the test is done on a sample of cells from the patient’s cervix. Certain strains (kinds) of HPV, such as HPV 16, are seen more often in women with cervical cancer and may help confirm a diagnosis. Many women carry HPV, so HPV testing alone is not an accurate test for cervical cancer. But if the Pap tests show some cellular abnormality, and the HPV test is also positive, the doctor may suggest one or more of the following diagnostic tests: Colposcopy. The doctor may do a colposcopy to check the cervix for abnormal areas. A special instrument called a colposcope (an instrument that magnifies the cells of the cervix and vagina, similar to a microscope) is used. The colposcope gives the doctor a lighted, magnified view of the tissues of the vagina and the cervix. The colposcope is not inserted into the woman’s body and the examination is not painful, can be done in the doctor's office, and has no side effects. It can be done on pregnant women. Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and diagnosing disease). If the lesion is small, the doctor may remove all of it during the biopsy. There are several types of biopsies:
The first three procedures are usually done in the doctor's office using a local anesthetic to numb the area. There may be some bleeding and other discharge and, for some women, discomfort similar to menstrual cramps. Conization is done under a general or local anesthetic and may be done in the doctor's office or the hospital. If the biopsy indicates that cervical cancer is present, the doctor will refer the woman to a gynecologic oncologist, who specializes in treating this type of cancer. The specialist may suggest additional tests to see if the cancer has spread beyond the cervix. Pelvic examination. The specialist may re-examine the pelvic area while the patient is under anesthetic to see if the cancer has spread to organs near the cervix, including the uterus, vagina, bladder, and rectum. Cystoscopy. This procedure allows the doctor to view the inside of the bladder and urethra (canal that carries urine from the bladder) with a cystoscope (a thin, flexible tube with a camera). A cystoscopy is used to determine whether cancer has spread to the bladder. Proctoscopy (also called a sigmoidoscopy). This procedure allows the doctor to view the colon and rectum using a sigmoidoscope (a thin, flexible tube with a camera). A proctoscopy is used to see if the cancer has spread to the rectum. Laparoscopy. This procedure allows the doctor to see the abdominal area with a laparoscope (a thin, lighted, flexible tube with a camera). X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs. An intravenous urography is a type of x-ray that is used to view the kidneys and bladder. Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture. Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images. To learn more about what to expect during common diagnostic tests, read Cancer.Net: Tests and Procedures. To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: Newly Diagnosed. Staging
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail. (Roman numerals given are stages used in another widely used staging system from the Federation Internationale de Gynecologie et d' Obstetrique, or FIGO). Treatment
The treatment of cervical cancer depends on the size and location of the tumor, whether the cancer has spread, and the woman's overall health. In many cases, a team of doctors will work with the woman to determine the best treatment plan. This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section The most common treatments for cervical cancer are surgery, radiation therapy, and chemotherapy. The type of treatment used depends on the stage of the disease, the size of the tumor, the woman's age, her health, and her desire to have children. A woman who is pregnant should talk with her doctor about how treatments could affect both her and the unborn child, and whether treatment can be delayed until after the baby is born. Radiation therapy alone or surgery is generally used for a small tumor. Chemoradiation (a combination of chemotherapy and radiation therapy) is generally used for women with invasive cervical cancer. Surgery and radiation therapy are both called local therapies because they affect only the area around the cancer site. Chemotherapy is a systemic therapy because it affects the entire body. Surgery In surgery, the doctor operates on the patient to remove the cancerous tissue. For cervical cancer that has not spread beyond the cervix, these procedures are often used:
For cervical cancer that has spread beyond the cervix, one of these procedures may be used:
Complications or side effects from surgery vary depending on the extent of the procedure. Occasionally, patients experience significant bleeding, infection, or damage to the urinary and intestinal systems. If extensive surgical procedures have affected sexual function, other surgical procedures can construct an artificial vagina. Because these surgical procedures can affect a woman's sexual health, women should talk with their doctor about their symptoms in detail. The doctor may be able to help reduce the side effects of surgery. Chemotherapy Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The goal of chemotherapy can be to destroy cancer remaining after surgery, slow the tumor's growth, or reduce side effects. Although chemotherapy can be given orally (by mouth), most drugs used to treat cervical cancer are given intravenously (IV). IV chemotherapy is either injected directly into a vein or through a thin tube called a catheter, a tube temporarily put into a large vein to make injections easier. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Other potential longer-term side effects include the inability to become pregnant and premature menopause. Rarely, specific drugs may cause some hearing loss. Others may cause kidney damage. Patients may be given extra fluid intravenously for kidney protection. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases. Radiation therapy Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Radiation therapy may be given alone or before surgery to shrink the tumor. Some women may be treated with a combination of radiation therapy and chemotherapy. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Side effects of internal radiation therapy may include abdominal pain and bowel obstruction. Most side effects usually go away soon after treatment is finished. Sometimes, doctors advise their patients not to have sexual intercourse during radiation therapy. Women may resume normal sexual activity within a few weeks after treatment if they feel ready. For more information about radiation therapy, see the American Society for Therapeutic Radiology and Oncology’s pamphlet, Radiation Therapy for Gynecologic Cancers. Advanced cervical cancer Cancer that has spread beyond the cervix may be called advanced cervical cancer. Palliative treatment with radiation therapy may be given to relieve pain. Chemotherapy and surgery may be used to treat or remove newly affected areas both within the pelvic area and in other parts of the body. The doctor may also suggest entering a clinical trial, which is a research study to test a new treatment. To learn more about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment. Clinical Trials Resources
Doctors and scientists are always looking for better ways to treat women with cervical cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. Women who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. Women decide to participate in clinical trials for many reasons. For some women, a clinical trial is the best treatment option available. Because standard treatments are not perfect, women are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other women volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating cervical cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with cervical cancer. To join a clinical trial, women must complete a learning process known as informed consent. During informed consent, the doctor should list all of the woman's options, so she understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials. Side Effects
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur. Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatment you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health. Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net’s section on Managing Side Effects, based on ASCO’s curriculum. In addition to physical side effects, there may be psychosocial (emotional and social) effects are well. Learn more about the importance of addressing these needs in Cancer.Net’s section on Caring for the Whole Patient. For more information on late effects or long-term effects, please read the After Treatment section or talk with your doctor. After Treatment
After treatment for cervical cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests, such as pelvic examinations and Pap tests, to monitor your recovery in the coming months and years. Women recovering from cervical cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. For women who smoke, quitting smoking can help recovery and reduce the risk of cancer recurrence. Learn more about Tobacco. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about healthy living after cancer. Find out more about common terms used after cancer treatment is complete. Current Research
Research for cervical cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor. Improved detection and screening methods. Because cervical cancer is highly treatable when detected early, researchers are developing better ways to detect cervical cancer. For example, fluorescent spectroscopy is the use of fluorescent light to detect changes in precancerous cervix cells. Improved Pap test methods. These improvements have made it easier for doctors to find cancerous cells. Traditional Pap tests can be hard to read, because cells can be dried out, be covered with mucus or blood, or clump together on the slide.
Immunotherapy. Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function. For women who already have cervical cancer, a therapeutic vaccine is being developed. These vaccines help "train" the immune system to recognize cervical cancer cells and destroy them. Fertility-preserving surgery. There is continued interest in refining the surgical techniques and finding out which patients with cervical cancer can be treated successfully without loss of fertility. Targeted therapy. Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development. Drugs called anti-angiogenesis inhibitors that block the action of a protein called vascular endothelial growth factor (VEGF) are being tested for women with cervical cancer. VEGF promotes angiogenesis (the formation of new blood vessels), which is necessary for tumor growth and metastasis. Combination therapy. Some clinical trials are exploring various combinations of immunotherapy, radiation therapy, and chemotherapy. Questions to Ask the Doctor
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor: Prevention/before a diagnosis of cervical cancer
After a diagnosis of cervical cancer or precancer
Patient Information Resources
Gynecologic Cancer Foundation (GCF) National Cervical Cancer Coalition National Breast and Cervical Cancer Early Detection Program View all of Cancer.Net's Patient Information Resources. |
