Cervical Cancer

Illustration of the anatomy of the female pelvic area

What You Need to Know

  • Cervical cancer is preventable with the HPV vaccine.
  • The cervix is the lower, narrow part of the uterus (womb) that opens into the vagina.
  • Nearly all cases of cervical cancer are caused by HPV, a sexually transmitted disease.
  • An HPV infection can cause the cells of the cervix to change and grow, a condition known as cervical dysplasia, which is precancerous.
  • Out of all gynecologic cancers, cervical cancer is the only one with a screening test, the Pap test (Pap smear).
  • When found early, cervical cancer is highly treatable.

Cervical Cancer Prevention

The cervix is the lower, narrow part of the uterus (womb), located between the bladder and the rectum. It forms a canal that opens into the vagina, which leads to the outside of the body.

Early detection of cervical problems is the best way to prevent cervical cancer. Routine pelvic exams and Pap tests can detect cell abnormalities that can be treated before they turn cancerous. Women who are 21 or older should have regular checkups, including a pelvic exam and Pap test.

If an infection is found during a Pap test, doctors can treat the infection and perform another Pap test at a later time. If a pelvic exam or Pap test suggests something other than an infection, your doctor may do a repeat Pap test and other tests to determine the exact problem.

Guidelines for Pap Tests

  • Women under 30 who have never had an abnormal Pap test result should have the test every three years.

  • Women 30 and older who have never had an abnormal Pap test result can choose to have the test every three years, OR get both a Pap test and an HPV test every five years. An HPV test looks for the virus that causes cervical cell abnormalities.

  • Women older than 65 and women of any age who have had a hysterectomy (surgery to remove the uterus, including the cervix) should ask their doctor about having pelvic exams and Pap tests.

HPV Vaccines

HPV is a sexually transmitted disease. There are currently three vaccines that prevent the strains of HPV responsible for most cases of cervical cancer:

  • The HPV nine-valent is now the standard of care. It covers nine types of HPV.

  • The HPV quadrivalent (Types 6, 11, 16, 18) vaccine protects against four types of the HPV virus: the two types of viruses that cause most cervical cancers and the two that cause 90 percent of genital warts. It also protects against other cancers caused by HPV, such as cancers and precancerous conditions of the vagina, vulva and anus.

  • The HPV bivalent vaccine protects against the two types of the HPV virus that cause most cervical cancers. It also protects against anal cancers.

These vaccines can only be used to prevent certain types of HPV infection before a person is infected. They cannot be used to treat an existing HPV infection. Both vaccines are administered as a series of three injections over a six-month period. To be most effective, one of the vaccines should be given before a person becomes sexually active.

Cervical Cancer Symptoms

Symptoms of cervical cancer usually do not appear until abnormal cervical cells become cancerous and invade nearby tissue.

  • The most common symptom is abnormal bleeding, which may:

    • Start and stop between regular menstrual periods

    • Occur after sexual intercourse, douching or a pelvic exam

  • Other symptoms may include:

    • Heavier menstrual bleeding, which may last longer than usual

    • Bleeding after menopause

    • Increased vaginal discharge

    • Pain during intercourse

The symptoms of cervical cancer may resemble other conditions or medical problems. Consult a doctor for an accurate diagnosis.

Creating Vaccines to Kick Cancer’s Butt

The link between HPV and cervical cancer is bigger than the link between smoking and lung cancer. At a recent Tedx Talk in Boston, Cornelia Liu Trimble, M.D., professor in the Johns Hopkins Departments of Gynecology and Obstetrics, Pathology and Oncology, spoke about her work in creating vaccines to treat HPV and effectively prevent cervical cancers.

Cervical Cancer Causes

Precancerous conditions of the cervix occur when there are cervical cells that look abnormal but are not yet cancerous. However, the appearance of these abnormal cells may be the first evidence of cancer that develops years later.

Precancerous changes of the cervix usually do not cause pain and, in general, do not cause any symptoms. They are detected with a pelvic exam or a Pap test.

Squamous intraepithelial lesions (SILs) is a term that refers to abnormal changes in the cells on the surface of the cervix:

  • Squamous: These cells are the flat cells found on the surface of the cervix.

  • Intraepithelial: This means that the abnormal cells are present only in the surface layer of cells.

  • Lesion: This refers to an area of abnormal tissue.

According to the National Cancer Institute, changes in these cells can be divided into two categories:

  • Low-grade SILs: This refers to early changes in the size, shape and number of cells that form the surface of the cervix. They may go away on their own or, with time, may grow larger or become more abnormal, forming high-grade lesions. These changes may also be called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1).

  • High-grade SILs: This means there are a large number of precancerous cells, and, like low-grade SILs, these changes involve only cells on the surface of the cervix. The cells often do not become cancerous for many months, perhaps years, but without treatment, they will become cancer. High-grade lesions may also be called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ.

If abnormal cells on the surface of the cervix spread deeper into the cervix, or to other tissues or organs, the disease is then called cervical cancer, or invasive cervical cancer. Cervical cancer occurs most often in women younger than 50. It is different from cancer that begins in other parts of the uterus and requires different treatment. Most cervical cancers are squamous cell carcinomas and adenocarcinomas.

The mortality rates for cervical cancer have declined sharply as Pap screenings have become more prevalent. Some researchers estimate that noninvasive cervical cancer, also referred to as carcinoma in situ, is nearly four times more common than invasive cervical cancer.

Cervical Cancer Risk Factors

  • HPV infection: HPV is the cause of nearly all cervical cancers. Am HPV infection is most often the result of unprotected sex.

  • Not getting regular Pap tests: Cervical cancer is more common in women who do not have regular Pap tests. Pap tests help doctors find abnormal cells. These cells can then be removed, which usually prevents cervical cancer.

  • Infection with HIV or other conditions that weaken the immune system: HIV is the precursor to AIDS and can increase your risk of cervical cancer. Taking certain medications that suppress the immune system also increases the risk of cervical cancer.

  • Smoking: Women who smoke are nearly twice as likely as nonsmokers to have cervical cancer.

  • Diet: Women with diets low in fruits and vegetables and those who are overweight are at increased risk for cervical cancer.

  • Chlamydia infection: Some studies have seen a higher risk of cervical cancer in women whose blood tests show evidence of past or current chlamydia infection when compared with women who have normal test results. Chlamydia is spread by sexual contact.

  • Using birth control pills for a long time: Using birth control pills for five or more years may slightly increase the risk of cervical cancer, but the risk decreases when women stop using birth control pills.

  • Having many children: Studies suggest that giving birth to three or more children may slightly increase the risk of cervical cancer in women with HPV.

  • Having sexual intercourse before age 18

  • Having many sexual partners and having partners who have had many partners themselves

  • First full-term pregnancy at a young age: Women who were younger than 17 when they had their first full-term pregnancy are almost twice as likely to get cervical cancer later in life than women who waited until they were 25 or older to get pregnant.

  • Poverty: Many low-income women do not have access to adequate health care services, including Pap tests, so they are not screened or treated for precancerous conditions.

  • Family history of cervical cancer: This cancer may run in some families. Women are two to three times more likely to get cervical cancer if their mother or sister had cervical cancer than if no one in their family had it.

  • Diethylstilbestrol (DES): DES is a drug that was used to prevent miscarriage between 1940 and 1971. Women whose mothers took DES while pregnant with them develop this cancer more than would normally be expected. The risk seems to be highest in women whose mothers took the drug during their first 16 weeks of pregnancy. The Food and Drug Administration stopped the use of DES during pregnancy in 1971.

Doctor speaking with her patient

7 Things You Should Always Discuss with Your Gynecologist

When it comes to sexual and reproductive health, it can be hard to know what’s “normal” and what may be a sign of a potential health problem. Even if you feel embarrassed about certain issues, your gynecologist has seen and heard it all and is there to help you, not to pass judgment.

Cervical Cancer Diagnosis

When cervical problems are found during a pelvic examination or abnormal cells are found through a Pap test, a cervical biopsy may be performed.

There are several types of cervical biopsies that may be used to diagnose cervical cancer, and some of these procedures that can completely remove areas of abnormal tissue may also be used for treatment of precancerous lesions. Some biopsy procedures only require local anesthesia, while others require a general anesthesia. Several types of cervical biopsies include:

  • Loop electrosurgical excision procedure (LEEP): A procedure that uses an electric wire loop to obtain a piece of tissue so it can be examined under a microscope.

  • Colposcopy: This procedure uses an instrument, called a colposcope, with magnifying lenses to examine the cervix for abnormalities. If abnormal tissue is found, a biopsy is usually performed (colposcopic biopsy).

  • Endocervical curettage: This procedure uses a narrow instrument called a curette to scrape the lining of the endocervical canal. This type of biopsy is usually completed along with the colposcopic biopsy.

  • Cone biopsy (also called conization): This biopsy uses the loop electrosurgical excision or the cold knife cone biopsy procedure to remove a larger, cone-shaped piece of tissue from the cervix. The cone biopsy procedure may be used as a treatment for precancerous lesions and early cancers.

  • HPV DNA test: This test detects the presence of cervical HPV infection. The cells are collected as they are for a regular Pap test, but it is not a replacement for a Pap test. The HPV DNA test may be used as a screening test for women over 30 or for women with slightly abnormal Pap test results to determine if further testing or treatment is required.

  • Cold knife cone biopsy: This procedure uses a laser or a surgical scalpel to remove a piece of cervical tissue for further examination. This procedure requires the use of general anesthesia.

Gynecologic Cancer Surgery at Sibley Memorial Hospital in Washington, D.C.

  • Innovative treatments to address even the most advanced cancers.
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Gynecologist talking with a patient.

Treatment for cervical cancer

Specific treatment for cervical cancer will be determined by your doctor based on:

  • Your overall health and medical history

  • Extent of the disease

  • Your tolerance for specific medications, procedures or therapies

  • Expectations for the course of the disease

Treatment may include:

  • Surgery:

  • Loop electrosurgical excision procedure (LEEP) or conization may be used to remove abnormal tissue.

    • Hysterectomy: Surgery to remove the uterus, including the cervix; in some cases, a hysterectomy may be required, particularly if abnormal cells are found inside the opening of the cervix

    • Pelvic lymph node dissection: Removal of some lymph nodes from the pelvis

    • Para-aortic lymphadenectomy: Removal of lymph nodes that surround the aorta, the main artery of the heart

    • Sentinel lymph node mapping: The use of fluorescent imaging to identify potentially cancerous lymph nodes that would otherwise go undetected

  • Radiation therapy: Radiation may be used to fight cervical cancer. A combination of internal and external radiation therapies is recommended. External beam radiation treatment targets the pelvis. Highly precise targeting of the tumor using novel techniques and imaging results in a significant improvement in outcomes. Internal radiation, also known as brachytherapy, involves placing radioactive isotopes inside the tumor using a tandem (hollow tube).   Highly precise image-directed internal radiation using MR-based therapy offers better patient outcomes and fewer side effects.

  • Chemotherapy: The use of anticancer drugs to treat cancerous cells

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