Cervical 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 precancerous or cancerous cells, a biopsy is done. Usually, doctors do a procedure called colposcopy using an instrument with a binocular magnifying lens (colposcope Colposcopy Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more ), inserted through the vagina, to examine the cervix and to choose the best biopsy site.

Two different types of test are done:

These tests are similar to having a Pap test. They cause little pain and a small amount of bleeding.

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. Another alternative is to use a scalpel (cold knife). 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 and a chest x-ray. Usually, computed tomography (CT), magnetic resonance imaging (MRI), or a combination of CT and positron emission tomography Positron Emission Tomography (PET) Positron emission tomography (PET) is a type of radionuclide scanning. A radionuclide is a radioactive form of an element, which means it is an unstable atom that becomes more stable by releasing... read more (PET) is done to determine whether the cancer has spread to nearby tissues or to distant parts of the body. If these procedures are not available, doctors may do other procedures to check specific organs, such as cystoscopy (bladder), sigmoidoscopy (colon), or IV urography (urinary tract).

Doctors usually also check for spread to the lymph nodes by doing imaging tests or a biopsy. Knowing whether cancer has spread to the lymph nodes and how many lymph nodes are involved helps doctors predict the person's outcome and plan treatment.

Stages of cervical cancer range from I (the earliest) to IV (advanced). Staging is based on how far the cancer has spread:

Cervical cancer screening effectively prevents cervical cancer and deaths from the disease.

Two types of tests are used to screen for cervical cancer:

The number of deaths due to cervical cancer has been reduced by more than 50% since Pap tests were introduced in countries where Pap tests are available.

Cervical cancer screening is recommended for everyone with a cervix starting at age 21 to 25. Screening tests are usually done every 3 to 5 years, depending on the person's age and the type of test.

Screening may stop after age 65, but only if an adequate number of test results have been normal in the preceding 10 years.

If women have had a total hysterectomy (surgical removal of the uterus, including the cervix) and have not had cervical cancer or precancer, they do not need to have HPV or Pap tests.

If all women had cervical cancer tests as recommended, deaths due to this cancer could be virtually eliminated. However, in the United States, many women are not tested regularly, and in middle- and low-income countries, cervical cancer screening is often not available.

The HPV vaccine Human Papillomavirus (HPV) Vaccine The human papillomavirus (HPV) vaccine helps protect against infection by the strains of HPV that are most likely to cause the following: Cervical cancer, vaginal cancer, and vulvar cancer in... read more provides immunity to the types of HPV that cause most cervical cancers (and genital warts and other cancers, including those of the anus, vagina, penis, throat, and esophagus). The vaccine can help prevent cervical and other cancers.

Being vaccinated before becoming sexually active is best, but people who are already sexually active should also be vaccinated.

Doctors recommend that vaccination in children at age 11 or 12, but children can be vaccinated as early as age 9.

For people under age 15, two doses of the vaccine are given 6 to 12 months apart.

For people aged 15 to 26, three doses of the vaccine are given. The first dose is followed by a dose 2 months later. The last dose is given 6 months after the first.

Using condoms Condoms Barrier contraceptives physically block the sperm’s access to a woman’s uterus. They include condoms, diaphragms, cervical caps, contraceptive gels, contraceptive sponges, and spermicides (foams... read more correctly during sexual intercourse can help prevent the spread of HPV. However, because condoms do not cover all the areas that can be infected and because HPV can be transmitted with external oral, genital, or anal contact, condoms do not fully protect against getting HPV.

Precancerous cervical cells (cervical intraepithelial neoplasia) and cervical cancer that involves only the surface of the cervix (early stage I) are treated the same way. Doctors can often completely remove the cancer by removing part of the cervix during a cone biopsy. They may use the loop electrosurgical excision procedure (LEEP Loop Electrical Excision Procedure Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more ), a laser, or a scalpel. These treatments preserve a woman’s ability to have children.

Removal of the uterus (hysterectomy Treatment The most common type of cancer of the uterus develops in the lining of the uterus (endometrium) and is called endometrial cancer. Endometrial cancer usually affects women after menopause. It... read more ) may be done if women are not interested in preserving their ability to have children. If some cancer remains after the cone biopsy, hysterectomy or another cone biopsy may be done.

If early-stage cancer has spread deeply into the cervix or into blood vessels or lymphatic vessels, a modified radical hysterectomy is done, and nearby lymph nodes are removed. A modified radical hysterectomy involves removing the cervix and the tissue next to it (called the parametrium). But unlike a standard radical hysterectomy, the modified radical hysterectomy involves removing only half of the parametrium.

Lymph nodes may be checked for spread of cancer cells with a procedure called sentinel lymph node mapping Sentinel lymph node mapping and dissection Cervical cancer develops in the cervix (the lower part of the uterus). Most cervical cancers are caused by human papillomavirus (HPV) infection. Cervical cancer usually results from infection... read more .

Another treatment option is external radiation therapy plus radioactive implants placed in the cervix to destroy the cancer (a type of internal radiation called brachytherapy).

Radiation therapy Radiation and cancer Radiation injury is damage to tissues caused by exposure to ionizing radiation. Large doses of ionizing radiation can cause acute illness by reducing the production of blood cells and damaging... read more 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, and the vagina may narrow.

If cervical cancer involves more than the surface of the cervix but the cancer is still relatively small, treatment is typically

Hysterectomy is done by making a large incision in the abdomen (open surgery) or by using a thin viewing tube (laparoscope) and specialized surgical instruments inserted through small incisions just below the navel. Research suggests that when open surgery is done, the cancer is less likely to return and women are more likely to live longer than when laparoscopic surgery is done.

Another treatment option is external radiation therapy plus radioactive implants placed in the cervix to destroy the cancer (brachytherapy).

If the cancer has grown or has begun to spread within the pelvis, treatment is typically

The ovaries are usually left in place because cervical cancer is unlikely to spread (metastasize) to the ovaries.

If during surgery, doctors discover that cancer has spread outside the cervix, hysterectomy is not done, and radiation therapy plus chemotherapy is recommended.

When cervical cancer has spread further within the pelvis or has spread to other organs, the following treatment is preferred:

Doctors may use positive emission tomography Positron Emission Tomography (PET) Positron emission tomography (PET) is a type of radionuclide scanning. A radionuclide is a radioactive form of an element, which means it is an unstable atom that becomes more stable by releasing... read more with computed tomography (PET-CT) to determine whether lymph nodes are involved and thus determine where radiation should be directed. External radiation (directed at the pelvis from outside the body) is used to shrink the cancer and treat cancer that may have spread to nearby lymph nodes. Then radioactive implants are placed in the cervix to destroy the cancer (a type of internal radiation called brachytherapy).

Chemotherapy is usually given with radiation therapy, often to make the tumor more likely to be damaged by radiation therapy.

The main treatment for extensive spread or recurrence of cervical cancer is

However, chemotherapy reduces the cancer’s size and controls its spread in almost half of women treated, and the beneficial effect is usually only temporary. Adding another drug (bevacizumab or pembrolizumab—monoclonal antibodies used to treat several types of cancer) may extend survival by a few months.

If the cancer remains in the pelvis after radiation therapy, doctors may recommend surgery to remove some or all pelvic organs (called pelvic exenteration). These organs include the reproductive organs (vagina, uterus, fallopian tubes, and ovaries), bladder, urethra, rectum, and anus. Which organs are removed and whether all are removed depends on many factors, such as the cancer's location, the woman's anatomy, and her goals after surgery. Permanent openings—for urine (urostomy) and for stool (colostomy Understanding Colostomy )—are made in the abdomen so that these waste products can leave the body and be collected in bags.

A sentinel lymph node What Is a Sentinel Lymph Node? is the first lymph node that cancer cells are likely to spread to. There may be more than one sentinel lymph node. These nodes are called sentinel lymph nodes because they are the first to warn that cancer has spread.

A sentinel lymph node dissection involves

To identify sentinel lymph nodes, doctors inject a blue or green dye and/or a radioactive substance into the cervix near the tumor. These substances map the pathway from the cervix to the first lymph node (or nodes) in the pelvis. During surgery, doctors then check for lymph nodes that look blue or green or that give off a radioactive signal (detected by a handheld device). Doctors remove this node (or nodes) and send it to a laboratory to be checked for cancer. If the sentinel lymph node or nodes do not contain cancer cells, no other lymph nodes are removed (unless they look abnormal).

For women with early-stage cervical cancer, sentinel lymph node dissection is an alternative to removing lymph nodes in the pelvis. Cervical cancer spreads to the lymph nodes in only 15 to 20% of women with early-stage cancer. Sentinel lymph node dissection may help doctors limit the number of lymph nodes that need to be removed, sometimes to only one. Removing lymph nodes often causes problems such as accumulation of fluids in tissues, which can cause persistent swelling (lymphedema), and nerve damage.

Treatment with radical hysterectomy, chemotherapy, and/or radiation therapy usually makes it impossible for women to become pregnant or to carry a pregnancy to term. However, if being able to have children is important to them, women should talk to their doctor and get as much information as possible about how treatment affects fertility and whether they are eligible for treatments that do not make future pregnancy impossible.

A cone biopsy (conization) may be an option for women who have low-risk, early-stage cervical cancer and who wish to preserve their ability to have children. Before this procedure, doctors check to see whether the cancer has spread to lymph nodes in the pelvis. If the cancer has not spread, doctors may completely remove the cancer by removing part of the cervix during a cone biopsy.

If women with early-stage cervical cancer wish to preserve their ability to have children, a different cancer treatment called radical trachelectomy (a fertility-preserving treatment) may be possible. Doctors remove the cervix, the tissue next to the cervix, the upper part of the vagina, and the lymph nodes in the pelvis. To remove these tissues, doctors may do one of the following:

Then the uterus is re-attached to the lower part of vagina. Thus, women still can become pregnant. However, babies must be delivered by cesarean.

Trachelectomy appears to be as effective as radical hysterectomy for many women with early-stage cervical cancer.

If premenopausal women are having radiation therapy, doctors discuss options for protecting the ovaries to avoid causing premature menopause. Before radiation therapy of the pelvis, ovaries may be moved outside the radiation field (oophoropexy) to avoid exposing them to radiation.