Pedro T. Ramirez, MD, Professor, Department of Gynecologic Oncology and Reproductive Medicine, David M. Gershenson Distinguished Professor in Ovarian Cancer Research, and Director of Minimally Invasive Surgical Research and Education, The University of Texas MD Anderson Cancer Center;David M. Gershenson, MD, Professor and Chairman, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center
Cervical cancer develops in the cervix (the lower part of the uterus).
Cervical cancer usually results from infection with the human papillomavirus (HPV), transmitted during sexual intercourse.
Cervical cancer may cause irregular vaginal bleeding, but symptoms may not occur until the cancer has enlarged or spread.
Papanicolaou (Pap) tests can usually detect abnormalities, which are then biopsied.
Treatment usually involves surgery to remove the cancer and often the surrounding tissue and often, if tumors are large, radiation therapy and chemotherapy.
Getting regular Pap tests and being vaccinated against HPV can help prevent cervical cancer.
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 is common among younger women. The average age at diagnosis is about 50, but it can affect women as young as 20.
Risk of developing cervical cancer is increased by the following:
Having sexual intercourse for the first time at a young age
Having more than one sex partner
Having intercourse with men whose previous partners had cervical cancer
Having a weakened immune system (due to a disorder such as cancer or AIDS or to drugs such as chemotherapy drugs or corticosteroids)
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.
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.
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 lymphatic vessels inside the cervix, then spread to other parts of the body. Rarely, it is spread through the bloodstream.
Precancerous changes usually cause no symptoms. In the early stages, cervical cancer may cause no symptoms. The first symptom 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 (see Gynecologic Examination : Pelvic Examination). 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—see Diagnostic Procedures : Colposcopy), inserted through the vagina, to examine the cervix and to choose the best biopsy site. Two different types of biopsy are done:
Punch biopsy: A tiny piece of the cervix, selected using the colposcope, is removed.
Endocervical curettage: Tissue that cannot be viewed is scraped from inside the cervix.
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 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).
Stages 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 cervix, including the upper part of the vagina, but is still within the pelvis (which contains the internal reproductive organs, bladder, and rectum).
Stage III: The cancer has spread throughout the pelvis (including the lower part of the vagina), sometimes blocking the ureters and/or causing a kidney to malfunction.
Stage IV: The cancer has spread to the bladder or rectum or to distant organs.
Did You Know...
Pap tests have reduced the number of deaths due to cervical cancer by more than 50%.
If all women had Pap tests regularly, deaths due to this cancer could be virtually eliminated.
Getting vaccinated against the human papillomavirus (HPV) helps prevent cervical cancer.
Prognosis depends on the stage of the cancer. The percentages of women who are alive 5 years after diagnosis and treatment are
Stage I: 80 to 90% of women
Stage II: 60 to 75%
Stage III: 30 to 40%
Stage IV: 15% or fewer
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 Pap tests every 2 years between the ages of 21 and 30. At age 30, they should have a Pap test and an HPV test, done at the same time. If results of both tests are normal, women may then schedule Pap tests every 3 to 5 years as long as they do not change their sexual lifestyle. They should continue to be tested until age 65.
Any woman who has had cervical cancer or dysplasia should have Pap tests at least once a year.
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, about 50% of women are not tested regularly. Also, about half the 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. Three doses of the vaccine are given (see Human Papillomavirus Vaccine). The first dose is followed by a dose 2 months later. The last dose is given 6 months after the first. 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 women are already sexually active, they should be vaccinated.
Whether using condoms during sexual intercourse helps prevent the spread of HPV is unclear.
Treatment depends on the stage of the cancer. It may include surgery, radiation therapy, and chemotherapy.
If only the surface of the cervix is involved (early stage I), 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 (late stage I) or has begun to spread within the pelvis (early stage II), options include
A hysterectomy plus removal of surrounding tissues, ligaments, and lymph nodes (radical hysterectomy)
A radical hysterectomy plus radiation therapy and chemotherapy (which are often given before surgery to shrink the tumor)
Either treatment results in about 85 to 90% of women being cured. The ovaries may be removed, but normal, functioning ovaries in younger women are not removed. If doctors discover during surgery that cancer has spread outside the cervix, radiation therapy may be used after surgery.
If women with late stage I cervical cancer wish to preserve their ability to have children, a procedure called radical trachelectomy 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
Make an incision in the abdomen (open surgery)
Use a thin, flexible viewing tube (laparoscope) inserted through a small incision just below the navel, then thread instruments through the laparoscope, sometimes with robotic assistance (laparoscopic surgery).
Remove the tissues through the vagina (no incision needed)
The uterus and vagina that remain are attached to each other. Thus, women still can become pregnant. However, babies must be delivered by cesarean. This treatment appears to be as effective as radical hysterectomy for many women with early-stage cervical cancer.
Later stages (late stage III through early stage IV)
When the cancer has spread further within the pelvis or has spread to other organs, radiation therapy plus chemotherapy (with cisplatin) 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).
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—see Figure: Understanding 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.
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.
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.