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Cervical Cancer

The National Cancer Institute estimates that approximately 15,000 women are diagnosed with cervical cancer each year. The Cervix is the lower, narrow part of the uterus that opens into the vaginal canal. Cervical cancer is generally a disease of the squamous cells, which are thin, flat cells that form the outer layer of the cervix. If these cells begin to divide uncontrollably, they create a tumor. If the cells invade and damage surrounding tissue, the tumor is said to be malignant, and is classified as cancer. Benign tumors are not considered cancerous, since they do not spread and are not life threatening. The process by which cancer cells from a malignant tumor spread to other areas of the body is called "metastasis." Cervical cancer often spreads to the lymph nodes, rectum, bladder, spinal bones, and lungs. Precancerous changes usually have no symptoms, and thus are not detectable without a pelvic exam and Pap test. Symptoms do not usually occur until the cells have become cancerous and begin to invade surrounding tissue. Symptoms of cervical cancer include abnormal bleeding and increased vaginal discharge. However, these symptoms can result from other unrelated causes, so a doctor should be consulted if any symptoms are present.

Cause and Prevention

Researchers believe that two or more risk factors may act together to cause cervical cancer. Most important is exposure to a sexually transmitted virus known as human papilloma virus (HPV). HPV can first cause genital warts, and it has also been linked with the development of abnormal cells in the cervix. These abnormal cells can then lead to cervical cancer. Therefore, women who have HPV, or who have partners who have HPV, are at a higher risk for developing cervical cancer. However, most people with HPV do not develop cervical cancer, and HPV is not present in all cases of cervical cancer. More research is needed to determine HPV's role in cervical cancer, and to study other factors that may act to amplify the effects of HPV.

There are various risk factors, other than HPV, that may also play a role in the development of cervical cancer. The following have been identified as such.

GET YOUR PAP TESTS. At present, the early detection and treatment of precancerous tissues are the most effective means of preventing cervical cancer. Women should have regular pelvic exams and Pap tests, especially if they have increased risk for developing cervical cancer.

There have been reports that vitamin A may play a role in stopping or preventing cancerous changes in cells like those found on the surface of the cervix. However, more research needs to be done to clarify this connection.

A Cancerous Cell

Precancerous Conditions

Abnormal changes in the appearance of cervical cells are believed to be the beginning of a series of slow changes that can lead to cancer. An area of abnormal surface cells is called a squamous intraepithelial lesion (SIL). The word "lesion" refers to an area of abnormal tissue, and "intraepithelial" means that the abnormal cells are in the surface layer of the tissue. Doctors categorize these abnormalities into two classifications: low-grade and high-grade SIL. Both conditions are also known as dysplasia (which can be mild or severe). Low-grade SIL is used to describe early changes in the size, shape, and number of the cervix�s surface cells. It is possible that low-grade SIL will go away on its own, without medical help; but it can also progress if left untreated, becoming high-grade SIL. High grade SIL means that there are a large number of highly abnormal and precancerous cells. Low-grade SIL is most often found in women between the ages of 25 and 35, whereas high-grade SIL is more common in women between the ages of 30 and 40. The age ranges are generalities: Low and high grade SIL can be found in women at any age.

Diagnosis

When abnormal cells are found during a pelvic exam or Pap test, the doctor may repeat the Pap and order other tests. After two abnormal Pap results, the doctor will usually order a colposcopy to check the cervix for abnormal areas. In a colposcopy, a vinegar-like solution is applied to the cervix and an instrument (called a colposcope, which resembles a microscope), is used to closely inspect the cervix. A Schiller test may also be preformed, in which the cervix is coated with an iodine solution to reveal any abnormal cells (healthy cells turn brown, and abnormal cells turn white or yellow).

If the colposcopy identifies abnormal areas of the cervix, the doctor may perform a biopsy. A biopsy is the removal of small areas of cervical tissue for examination by a pathologist. There are several methods that can be used to remove tissue for examination. In one method, known as a cervical punch biopsy, forceps are used to pinch off small pieces of the affected tissue. Another method, known as a loop electrosurgical excision procedure (LEEP), uses an electrical wire loop to slice off a thin, round piece of surface tissue.

In some cases a doctor may want to sample tissue that is not visible during a colposcopy. There are several biopsy methods that may be used in this circumstance. A method that allows the doctor to check inside the opening of the cervix is called endocervical curettage (ECC). In this procedure, a curette (a small, spoon-shaped instrument) is used to scrape tissue from the inside of the cervical opening. The doctor may want to check deeper in the tissue for abnormal cells, in which case a method called conization or cone biopsy can be used. In this procedure, a larger, cone-shaped area of tissue is removed, which will reveal whether abnormal cells have invaded tissue beneath the surface of the cervix. A procedure that allows the doctor to check if the affected area is in the endometrium (the lining of the uterus) is "dilation and curettage" (D and C). In this procedure, the doctor stretches the cervical opening and uses a curette to scrape tissue form the lining of the uterus and cervical canal.

These procedures can be performed in a doctor's office using local or general anesthesia. The doctor will determine which procedure that is necessary, depending on the type and extent of the abnormal lesions. These procedures may cause some bleeding or other discharge, and they may cause some pains that are similar to cramping. Healing usually occurs quickly, and discomfort may be alleviated with medication. If discovered early (through regular pelvic exams and Pap tests), many cervical lesions can be removed during this stage using LEEP or conization procedures. However, more advanced precancerous or cancerous lesions may require treatment for advanced conditions.

Preparing for Treatment

Cervical cancer is first judged in stages to determine the proper treatment. Staging refers to the determination of whether the cancer has spread and, if so, to what parts of the body. This can be done through blood and urine tests, or through pelvic examination with procedures called "cystoscopy" and "proctosigmoidoscopy." Cystoscopy is a method of inspecting the interior of the bladder with a thin, lighted instrument. Proctosigmoidoscopy similarly uses a lighted instrument to inspect the rectum and lower part of the large intestine. Another method for checking the rectum is a barium enema. Cervical cancer may also spread to the lymph nodes, lungs or kidneys. X-rays, CT or CAT Scans, ultrasonograpy and MRI are all methods that can be used to check these areas. The doctor can determine which is the appropriate method, depending on the extent of the lesion.

A woman may want to get a second or third opinion from different doctors before staring treatment. By having a second or third specialist review the diagnosis and treatment plan, a patient may increase her likelihood of receiving the most appropriate medical treatment for her situation. It may take one to two weeks to get a second or third opinion, but this delay will not decrease the likelihood for successful treatment. A patient may find another doctor by referral from her doctor or through local medical hospital, clinic, or school. The Cancer Information Service, at 1-800-4-CANCER, can also provide additional resource options.

Asking her doctor questions about planned treatment will help a woman to learn about her treatment choices and to take an active role in important decisions. The following are some of the possible questions she might want to ask.

Additionally, a patient may want to ask about possible clinical trials and whether they are appropriate for their situation. A clinical trial is a scientific study that tests safety and effectiveness of new medical treatments. The benefit of being in a clinical trial is that a patient has the chance to be the first to receive new, possibly more effective treatment methods while helping contribute to medical science. Some patients who participate in a clinical trial will receive the standard treatment approach, serving as comparison for the new approach. Currently, there are clinical trials being developed for new treatments of cervical cancer, such as new types and schedules of radiation therapy, and new drugs and drug combinations. A resource that will explain possible benefits and risks of clinical trials is the National Cancer Institute booklet called Taking Part in Clinical Trials: What Cancer Patients Need to Know. Additionally, a patient can learn about clinical trials through PDQ, a computerized resource developed by the National Cancer Institute that provides information about cancer treatment and clinical trials.

Treatment

Treatments for cervical lesions -- both precancerous and cancerous -- can be quite different depending on various factors, including the stage or extent of the disease, size of the tumor, age and health of the woman, and the preference of the woman and her doctor. Precancerous lesions that require treatment beyond biopsy may be removed through cryosurgery (freezing), cauterization (burning, also called diathermy), or laser surgery. These treatments will destroy the affected area without harming the surrounding healthy tissue. When abnormal cells are found inside the cervix, the most common treatments are surgery and radiation therapy, and depending on extent of the disease, chemotherapy and biological therapy. Treatments are often combined to increase effectiveness. When a woman does not plan on having children in the future, hysterectomy may be an option for treatment. A hysterectomy is an operation where the uterus, including the cervix and sometimes the ovaries and fallopian tubes, are removed.

Surgery is performed to remove any abnormal tissue from the cervix. In cases where the lesion is only on the surface of the cervix, methods similar to those used on precancerous lesions may be appropriate. Surgery may cause pain and cramping in the lower abdomen, bleeding, or watery discharge. Other possible side effects include difficulties urinating and trouble having normal bowel movements for several days after surgery. The doctor can provide medication to alleviate discomfort.

If cancer has progressed to the uterus, a hysterectomy may be necessary. After a hysterectomy, women cease menstruation, however, their sexual desire and intercourse are not affected. Some women may experience emotional difficulties or feelings of loss after a hysterectomy and they may want to talk to a doctor or nurse to discuss these issues. Another resource the may be helpful is the National Cancer Institute booklet called Taking Time.

The following are some questions a patient may want to ask prior to surgery.

Radiation therapy is a method of treatment that uses radiation (high-energy rays) to kill cancer cells and stop them from growing or spreading. Radiation affects cancer cells only in the treated area, and does not affect the surrounding healthy tissue. There are two types of radiation, external and implant radiation. External radiation is administered by a large machine that emits powerful rays at clusters of cancer cells. Implant radiation involves placing a capsule containing radioactive materials directly next to cancer cells. The two types of radiation can be used separately or together. External radiation is an outpatient process, in which a patient goes to the hospital for treatment 5 days a week, for 5 to 6 weeks. Implant radiation requires that the patient stays in the hospital while the implant is in place. The implant is usually left in place for 1-3 days at a time, being replaced with a new capsule several times over the course of 1-2 weeks. Side effects of external radiation therapy include fatigue, hair loss in the treated area, dry, red, tender, or itchy skin at the treatment site, and possibly permanent darkening ("bronzing") of the skin. Internal radiation may cause diarrhea and frequent, uncomfortable urination. Women are advised against having intercourse during radiation therapy, but they can resume sexual activities within a few weeks of completing treatment. After radiation treatment, the vagina sometimes can become narrower and less flexible, causing painful intercourse. The use of water-based lubricants and a dilator can help minimize these problems. Women can consult the National Cancer Institute booklet Radiation Therapy and You for questions regarding radiation therapy.

The following are some questions that a patient may want to ask her doctor before starting radiotherapy treatment.

Chemotherapy is generally used when cervical cancer has spread to other parts of the body. This treatment that kills cancer cells throughout the body with the use of anti-cancer drugs. The drugs may be given orally or via injection. Chemotherapy is given in cycles of treatment followed by recovery and is generally an outpatient procedure. The drugs work by killing cancer cells when they are in the process of division. Cells that divide rapidly, such as cancer cells, are affected most. However, any other cells in the body also divide rapidly are also affected. These cells include blood cells, which fight infection, contain clotting factors, and carry oxygen to various parts of the body. Chemotherapy harms blood cells, causing patients to be more likely to get infections, bruise and bleed more easily, and have less energy. The cells in hair roots and stomach lining are also fast dividing, and thus, chemotherapy patients often loose their hair, and may suffer from nausea, poor appetite, vomiting, or mouth sores.

The following are some questions that a patient may want to ask her doctor before chemotherapy begins

Immunotherapy uses substances to improve the way the body's immune system fights disease. Interferon is the most common form of this therapy used to treat cervical cancer. Interferon interferes with division of cancer cells and can slow tumor growth. It can be used alone or in combination with chemotherapy to treat cancer that has spread from the cervix to other parts of the body. Patients receiving interferon may experience flu-like symptoms such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Other side effects include rash and bleeding or bruising more easily. Symptoms gradually disappear after treatment stops.

*Summarized from the National Cancer Institute's What You Need to Know About Cancer of the Cervix

Created April 28, 2003, last updated May 26, 2009