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Cervical Cancer

By

Pedro T. Ramirez

, MD, The University of Texas MD Anderson Cancer Center;


Gloria Salvo

, MD, MD Anderson Cancer Center

Last full review/revision Aug 2022| Content last modified Sep 2022
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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 with the human papillomavirus (HPV), transmitted during sexual contact.

  • The first symptom is usually irregular vaginal bleeding, usually after sexual activity, 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.

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 is most often diagnosed in women aged 35 to 44 years.

Worldwide, incidence of cervical cancer and deaths due to cervical cancer are higher in low- and middle-income countries than in high-income countries. Rates are highest in sub-Saharan Africa. Cervical cancer is the most common cancer among females in 23 countries and the leading cause of cancer death in 36 countries.

Locating the Internal Female Reproductive Organs

Internal Female Genital Organs

About 80 to 85% of cervical cancers are squamous cell carcinomas Squamous Cell Carcinoma Squamous cell carcinoma is cancer that begins in the squamous cells of the skin. Thick, scaly growths appear on the skin and do not heal. To diagnose the cancer, doctors do a biopsy. Treatment... read more Squamous Cell Carcinoma , 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:

  • By spreading directly to nearby tissues, including the vagina

  • By entering the rich network of lymphatic vessels inside the cervix, then spreading to other parts of the body

  • Rarely, by spreading through the bloodstream

Causes of Cervical Cancer

Precancerous changes in cervical cells (cervical intraepithelial neoplasia) and cervical cancer are almost always caused by the human papillomavirus (HPV) transmitted through sexual contact. The HPV virus also causes genital warts Human Papillomavirus (HPV) Infection Human papillomavirus (HPV) causes warts. Some types of HPV cause skin warts, and other types cause genital warts (growths in or around the vagina, penis, or rectum). Infection with some HPV... read more Human Papillomavirus (HPV) Infection . Rates of cervical cancer have decreased steadily over the past several decades in countries that have access to HPV vaccines, cervical cancer screening, and treatment of cervical intraepithelial neoplasia.

Risk factors for developing cervical cancer include the following:

  • Having an increased chance of exposure to sexually transmitted infections (for example, having sexual intercourse for the first time at a young age, having more than one sex partner, or having sex partners who have risk factors for sexually transmitted infections)

  • Using oral contraceptives (birth control pills)

  • Smoking cigarettes

  • Having had precancerous changes or cancer in the vulva, vagina, or anus

  • Having a weakened immune system (due to a disorder such as cancer or AIDS or to drugs such as chemotherapy drugs or corticosteroids)

HPV can be transmitted through any kind of sexual activity, including oral, genital, or anal contact. HPV infection is very common, and about 80% of sexually active people are exposed to HPV infection at least once during their lifetime. Many HPV infections last only a short time, but some people can be infected with HPV more than one time, and some HPV infections last for years.

Symptoms 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 activity. 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 can result.

Diagnosis of Cervical Cancer

  • Papanicolaou (Pap) tests

  • Biopsy

Routine Pap tests Screening for Cervical Cancer 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 Screening for Cervical Cancer can detect abnormal, precancerous cells (dysplasia) on the surface of the cervix. Doctors check women with precancerous cells at regular intervals. Dysplasia can be treated, thus helping prevent cancer.

Biopsy

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 Colposcopy ), inserted through the vagina, to examine the cervix and to choose the best biopsy site.

Two different types of test are done:

  • Cervical biopsy: A tiny piece of the cervix, selected using the colposcope, is removed.

  • Endocervical curettage: Tissue is scraped from inside the cervix.

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.

Staging of cervical cancer

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 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 Positron Emission Tomography (PET) (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 for Cervical Cancer

Prognosis depends on the stage of the cervical 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 recurs, it usually does so within 2 years.

Did You Know...

  • The number of deaths due to cervical cancer have decreased by more than 50% since Pap tests were introduced in countries where these tests are available.

  • If all women had HPV and/or Pap tests regularly, deaths due to this cancer could be virtually eliminated.

  • Getting vaccinated against the human papillomavirus (HPV) helps prevent cervical cancer.

Prevention of Cervical Cancer

Screening tests

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

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

  • HPV test: A sample from the cervix is tested to determine whether the HPV strains that cause most cervical cancers are present.

  • 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).

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.

HPV vaccine

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.

Condoms

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 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 and because HPV can be transmitted with external oral, genital, or anal contact, condoms do not fully protect against getting HPV.

Treatment of Cervical Cancer

  • Surgery, radiation therapy, and/or chemotherapy

Treatment of cervical cancer depends on the stage of the cancer. It may include surgery, radiation therapy, and chemotherapy.

Precancerous changes and early stage I cervical cancer

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 Loop Electrical Excision Procedure ), 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 Treatment ) 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.

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.

Late stage I and early stage II cervical cancer

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

  • Radical hysterectomy (a hysterectomy plus removal of surrounding tissues including the upper part of the vagina and ligaments) and evaluation of lymph nodes

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

  • Radiation therapy and chemotherapy

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.

Late stage II through early stage IV cervical cancer

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

  • Radiation therapy plus chemotherapy

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 Positron Emission Tomography (PET) 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.

Extensive spread or recurrence of cervical cancer

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

  • Chemotherapy, usually with paclitaxel plus cisplatin or topotecan

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 Understanding Colostomy )—are made in the abdomen so that these waste products can leave the body and be collected in bags.

Sentinel lymph node mapping and dissection

A sentinel lymph node What Is 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

  • Identifying the sentinel lymph node (called mapping)

  • Removing it

  • Examining it to determine whether cancer cells are present

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.

Fertility and menopause after cervical cancer

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:

  • Do open surgery

  • Use a 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 (vaginal surgery)

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.

More Information

The following English-language resource 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.

NOTE: This is the Consumer Version. DOCTORS: CLICK HERE FOR THE PROFESSIONAL VERSION
CLICK HERE FOR THE PROFESSIONAL VERSION
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