Cervical cancer usually results from infection with the human papillomavirus (HPV), transmitted during sexual intercourse.
The first symptom is usually irregular vaginal bleeding, usually after sexual intercourse, but symptoms may not occur until the cancer has enlarged or spread.
Papanicolaou (Pap) tests can usually detect abnormalities, which are then biopsied.
Getting regular Pap tests and being vaccinated against HPV can help prevent cervical cancer.
Treatment usually involves surgery to remove the cancer and often the surrounding tissue and often, if tumors are large, radiation therapy and chemotherapy.
(See also Overview of Female Reproductive System Cancers.)
In the United States, cervical cancer (cervical carcinoma) is the third most common gynecologic cancer among all women and is common among younger women. The average age at diagnosis is about 50, but it can affect women as young as 20.
The cervix is the lower part of the uterus. It extends into the vagina.
About 80 to 85% of cervical cancers are squamous cell carcinomas, which develop in the flat, skinlike cells that line 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. CIN is classified as mild (CIN 1), moderate (CIN 2), or severe (CIN 3).
Cervical cancer begins on the surface of the cervix and can penetrate deep beneath the surface. Cervical cancer can spread in the following ways:
Cervical cancer is most commonly caused by the human papillomavirus (HPV), which is transmitted during sexual intercourse. This virus also causes genital warts.
Risk factors for developing cervical cancer include the following:
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.
Precancerous changes usually cause no symptoms. In the early stages, cervical cancer may cause no symptoms.
The first symptom of cervical cancer is usually abnormal bleeding from the vagina, most often after sexual intercourse. Spotting or heavier bleeding may occur between periods, or periods may be unusually heavy. Large cancers are more likely to bleed 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. Pap tests accurately detect up to about 80% of cervical cancers, even before symptoms develop. Pap tests can also detect dysplasia. Women with dysplasia are 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 test are done:
These tests 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 and a chest x-ray. Usually, computed tomography (CT), magnetic resonance imaging (MRI), or a combination of CT and positron emission tomography (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:
Stage I: The cancer is confined to the cervix.
Stage II: The cancer has spread outside the uterus, to the upper two thirds of the vagina or to tissues outside the uterus, but is still within the pelvis (which contains the internal reproductive organs, bladder, and rectum).
Stage III: The cancer has spread throughout the pelvis and/or the lower third of the vagina and/or blocks the ureters and/or causes a kidney to malfunction and/or spreads to the lymph nodes near the aorta (the largest artery in the body).
Stage IV: The cancer has spread outside the pelvis and/or to the bladder or rectum or to distant organs.
Prognosis depends on the stage of the cervical cancer. 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.
Two types of tests are used to screen for cervical cancer:
Pap test: Cells from the cervix are examined under a microscope to determine whether any are cancerous or abnormal. Abnormal cells may, without treatment, progress to cancer (these cells are called precancerous cells).
HPV test: A sample from the cervix is tested to determine whether HPV is present.
The number of deaths due to cervical cancer has been reduced by more than 50% since Pap tests were introduced.
How often these screening tests are done depends mainly on the woman’s age and results of previous tests. If women have no risk factors for cervical cancer and have had no abnormal test results in the past, screening may be done as follows:
Screening begins at age 25.
When available, primary HPV testing should start at age 25 years and done every 5 years. Primary means that the HPV tests are approved by the Food and Drug Administration (FDA) for primary screening. Pap tests are not needed.
If primary HPV testing is not available, a Pap test can be done every 3 years or a Pap plus a HPV test (cotesting) can be done every 5 years. Pap tests and cotesting with Pap and HPV tests are stopped when primary HPV testing becomes available.
For women over age 65, testing is stopped if test results have been normal in the preceding 10 years. Testing should be continued if test results have not been normal for 10 years.
If women have not had abnormal Pap test results and have had their uterus removed for reasons other than cancer, they do not need to have Pap or HPV tests.
If all women had Pap tests as recommended, deaths due to this cancer could be virtually eliminated. However, in the United States, many women are not tested regularly. Also, many women who have cervical cancer have not had a Pap test in 10 years or more.
The HPV vaccine targets 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 but does not treat them.
Doctors recommend that girls and boys be vaccinated at age 11 or 12, but children can be vaccinated as early as age 9.
Being vaccinated before becoming sexually active is best, but even if girls or boys are already sexually active, they should be vaccinated.
For people under age 15, two doses of the vaccine are given 6 to 12 months apart.
For people ages 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 correctly during sexual intercourse can help prevent the spread of HPV. However, because condoms do not cover all the areas that can be infected, condoms do not fully protect against getting HPV.
Treatment of cervical cancer depends on the stage of the cancer. It may include surgery, radiation therapy, and chemotherapy.
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), a laser, or a cold knife. 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.
Removal of the uterus (hysterectomy) 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. Sentinel lymph node mapping may be done. Another treatment option is radiation therapy plus radioactive implants placed in the cervix to destroy the cancer (a type of internal radiation called brachytherapy).
If early-stage 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. Evidence 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
Either treatment results in about 85 to 90% of women being cured. 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 a laparoscope or do surgery 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.
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)—are made in the abdomen so that these waste products can leave the body and be collected in bags. After the procedure, women usually have some bleeding, a discharge, and considerable tenderness and pain for a few days. Typically, the hospital stay is 3 to 5 days. Complications, such as infection or opening of the surgical incision, blockages in the intestine, and formation of abnormal connections between organs (fistulas), can occur. This procedure cures up to 40% of women.
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—a monoclonal antibody used to treat several types of cancer) may extend survival by a few months.
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, advances in assisted reproductive techniques may enable women to have a child after these procedures. If being able to have children is important to them, women should talk to their doctor and get as much information as possible about risks of and requirements for these procedures, as well as the likelihood of becoming pregnant and having a child after such a procedure.
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 done. 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. About 50 to 70% of women who have this procedure become pregnant.
Trachelectomy appears to be as effective as radical hysterectomy for many women with early-stage cervical cancer. The cancer recurs in about 5 to 10% of women.
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, and the vagina may narrow.
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
National Cancer Institute: Cervical Cancer: This web site provides links to general information about cervical cancer, as well as links to information about causes, prevention, screening, treatment, and research and about coping with cancer.
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