Cervical cancer develops in the cervix (the lower part of the uterus).
The cervix is the lower part of the uterus. It extends into the vagina. In the United States, cervical cancer (cervical carcinoma) is the third most common gynecologic cancer among all women and the most common among younger women. It usually affects women aged 35 to 55, but it can affect women as young as 20.
This cancer is usually caused by the human papillomavirus (HPV), which is transmitted during sexual intercourse. This virus also causes genital warts (see Sexually Transmitted Diseases: Genital Warts). The younger a woman was the first time she had sexual intercourse and the more sex partners she has had, the higher her risk of cervical cancer. Risk is also increased by having intercourse with men whose previous partners had cervical cancer, by smoking cigarettes, and by having a weakened immune system (due to a disorder such as cancer or AIDS or to drugs such as chemotherapy drugs or corticosteroids).
About 80 to 85% of cervical cancers are squamous cell carcinomas, which develop in the flat, skinlike cells covering the cervix. Most other cervical cancers are adenocarcinomas, which develop from gland cells
Cervical cancer begins with slow, progressive changes in normal cells on the surface of the cervix. These changes, called dysplasia or cervical intraepithelial neoplasia (CIN), are considered precancerous. That means that if untreated, they may progress to cancer, sometimes after years.
Cervical cancer begins on the surface of the cervix and can penetrate deep beneath the surface. The cancer can spread directly to nearby tissues, including the vagina. Or it can enter the rich network of small blood and lymphatic vessels inside the cervix, then spread to other parts of the body.
Precancerous changes usually cause no symptoms. In the early stages, cervical cancer may cause no symptoms or cause abnormal bleeding from the vagina, most often after intercourse. Spotting or heavier bleeding may occur between periods, or periods may be unusually heavy. Large cancers are more likely to cause bleeding and may cause a foul-smelling discharge from the vagina and pain in the pelvic area.
If the cancer is widespread, it can cause lower back pain and swelling of the legs. The urinary tract may be blocked, and without treatment, kidney failure and death can result.
Routine Pap tests or other similar tests can detect the beginnings of cervical cancer (see Diagnosis of Gynecologic Disorders: Screening for Cervical Cancer). Pap tests accurately detect up to 90% of cervical cancers, even before symptoms develop. They can also detect dysplasia. Women with dysplasia should be checked again in 3 to 4 months. Dysplasia can be treated, thus helping prevent cancer.
If a growth, a sore, or another abnormal area is seen on the cervix during a pelvic examination or if a Pap test detects dysplasia or cancer, a biopsy is done. Usually, doctors use an instrument with a binocular magnifying lens (colposcope), inserted through the vagina, to examine the cervix and to choose the best biopsy site. Two different types of biopsy are done:
These biopsies cause little pain and a small amount of bleeding. The two together usually provide enough tissue for pathologists to make a diagnosis.
If the diagnosis is not clear, a cone biopsy is done to remove a larger cone-shaped piece of tissue. Usually, a thin wire loop with an electrical current running through it is used. This procedure is called the loop electrosurgical excision procedure (LEEP). Alternatively, a laser (using a highly focused beam of light) can be used. Either procedure requires only a local anesthetic and can be done in the doctor's office. A cold (nonelectric) knife is sometimes used, but this procedure requires an operating room and an anesthetic.
If cervical cancer is diagnosed, its exact size and locations (its stage) are determined. Staging begins with a physical examination of the pelvis. Various procedures (such as cystoscopy, a chest x-ray, and sigmoidoscopy) can be used to determine whether the cancer has spread to nearby tissues or to distant parts of the body. Other procedures, such as computed tomography (CT), magnetic resonance imaging (MRI), a barium enema, bone and liver scans, and positron emission tomography (PET) may be done.
Prognosis depends on the stage of the cancer (see Cancers of the Female Reproductive System: Staging Cancers of the Female Reproductive System*). The percentages of women who are alive 5 years after diagnosis and treatment are
If the cancer is going to recur, it usually does so within 2 years.
The number of deaths due to cervical cancer has been reduced by more than 50% since Pap tests were introduced. Doctors often recommend that women have their first Pap test when they become sexually active or reach the age of 18 and that a Pap test be done once a year. If test results are normal for 3 consecutive years, women may schedule Pap tests every 2 or 3 years as long as they do not change their sexual lifestyle. Any woman who has had cervical cancer or dysplasia should continue to have Pap tests at least once a year. If all women had Pap tests on a regular basis, deaths due to this cancer could be virtually eliminated. However, in the United States, about 50% of women are not tested regularly.
A newly developed vaccine targets the types of HPV that cause most cervical cancer (and genital warts). The vaccine can help prevent cervical cancer but does not treat it. Three doses of the vaccine are given (see Immunization: Human Papillomavirus). The first is followed by one 2 months and one 6 months after the first. Being vaccinated before becoming sexually active is best, but even if women are already sexually active, they should be vaccinated. (Using condoms during intercourse can help prevent spread of HPV.)
Treatment depends on the stage of the cancer.
If only the surface of the cervix is involved, doctors can often completely remove the cancer by removing part of the cervix using the loop electrosurgical excision procedure, a laser, or a cold knife, done during a cone biopsy. These treatments preserve a woman's ability to have children. Because cancer can recur, doctors advise women to return for examinations and Pap tests every 3 months for the first year and every 6 months after that. Rarely, removal of the uterus (hysterectomy) is necessary.
If early-stage cancer involves more than the surface of the cervix, doctors usually do a hysterectomy and give radiation therapy and chemotherapy. If women with early-stage cervical cancer wish to preserve their ability to have children, a procedure called radical trachelectomy may be done. In this procedure, the cervix, the tissue next to the cervix, the upper part of the vagina, and the lymph nodes in the pelvis are removed. The uterus and vagina that remain are attached to each other. Thus, women still can become pregnant. However, babies must be delivered by cesarean section. This treatment appears to be as effective as other more invasive treatments for women with early-stage cervical cancer.
Initial Spread Within the Pelvis:
Hysterectomy plus removal of surrounding tissues, ligaments, and lymph nodes (radical hysterectomy) is necessary. The ovaries may be removed. Normal, functioning ovaries in younger women are not removed. Radiation therapy may be used sometimes instead of hysterectomy. Radiation therapy may irritate the bladder or rectum. Later, as a result, the intestine may become blocked, and the bladder and rectum may be damaged. Also, the ovaries usually stop functioning. With either radical hysterectomy or radiation therapy, chemotherapy is usually also used, and about 85 to 90% of women are cured.
Further Spread Within the Pelvis or to Other Organs:
Radiation therapy plus chemotherapy (with cisplatin) is preferred. A laparoscope may be used or surgery done to determine whether lymph nodes are involved and thus determine where radiation should be directed.
If the cancer remains in the pelvis after radiation therapy, doctors may recommend surgery to remove all pelvic organs (pelvic exenteration). This procedure cures up to 50% of women.
Extensive Spread or Recurrence:
Chemotherapy, usually with cisplatin and topotecan, is sometimes recommended. However, chemotherapy reduces the cancer's size and controls its spread in only 15 to 25% of women treated, and this effect is usually only temporary.
Last full review/revision November 2008 by David M. Gershenson, MD; Pedro T. Ramirez, MD