Cervical Cancer

What is it?

Overview

What Is It?
Cervical cancer is a disease in which cancer cells develop in the tissues of the cervix. The cervix, the lower part of the uterus which protrudes into the vagina, connects the body of the uterus to the vagina.

Cancer of the cervix is second only to breast cancer as the most common type of cancer found in women worldwide. It affects an estimated 500,000 women each year. In the United States and other developed countries, the rates of cervical cancer are much lower; in fact, according to the National Cervical Cancer Coalition, more than 80 percent of all cases of cervical cancer occur in developing countries.

The American Cancer Society estimates that about 12,170 cases of invasive cervical cancer will be diagnosed in the United States in 2012, and about 4,220 women will die from the disease.

Cervical cancer is a disease in which cancer cells develop in the tissues of the cervix. The cervix, the lower part of the uterus which protrudes into the vagina, connects the body of the uterus to the vagina. Nearly all cases of cervical cancer can be linked to the human papillomavirus, or HPV, a sexually transmitted virus.

There are more than 100 strains of HPV, and at least 15 high-risk types have been linked to cancer of the cervix. While most women who develop cervical cancer have HPV, only a small proportion of women infected with HPV develop cervical cancer. Only persistent HPV infection leads to cervical cancer. Additionally, some low-risk types of HPV cause vaginal and vulvar warts; other HPV strains cause the warts that sometimes develop on the hands or feet.

The normal cervix is a firm muscle that feels much like the tip of your nose. It is reddish pink, and the outside is covered with scale-like cells called squamous cells. The cervical canal is lined with another kind of cell called columnar cells. Tthe area where the two cell type meet—called the squamocolumnar junction or transformation zone (T-zone)—is the most likely area for abnormal cells to develop. The T-zone is more exposed on the cervix of young women (teens through 20s), making them more susceptible to cervical infections.

Health care professionals use the Pap test to find abnormal cell changes in cervical tissue that are cancerous or may become cancerous. The earlier cervical cancer is diagnosed, the better the chance for a cure. The American Cancer Society reports that both incidence and deaths from cervical cancer have declined markedly over the last several decades, due to more frequent detection and treatment of preinvasive and cancerous lesions of the cervix from increased Pap test screening.

Because persistent infection with high-risk strains of HPV can be a predictor of the presence or future development of preinvasive and cervical cancer, many medical professionals now also test for this virus as an adjunct to the Pap test. The U.S. Food and Drug Administration (FDA) has approved use of an HPV test for screening women ages 30 and older. When combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.

Additionally, the FDA has approved two HPV vaccines, called Gardasil and Cervarix. Gardasil protects women against four HPV types—the two most common high-risk (cancer-causing) types of HPV, strains 16 and 18, and also the two most common low-risk types of HPV, 6 and 11, which cause 90 percent of genital warts. Cervarix protects against HPV 16 and 18. Both vaccines should be given before an infection occurs, ideally, before a girl becomes sexually active. Gardasil is approved for girls as young as nine and is routinely recommended for girls 11 and 12 years of age. It may also be given to women ages 13 to 26 who did not receive it when they were younger as well as males ages nine to 26. Cervarix is approved for use in girls and women ages nine through 25. If a woman is already infected with one of the four HPV types in one of the vaccines, the vaccine will not work against that particular HPV type. (It will still work against the remaining types she has not been exposed to.)

Clinical trials have shown that both Gardasil and Cervarix are safe and 100 percent effective in preventing HPV strains 16 and 18, which cause 70 percent of cervical cancers. Gardasil is also 99 percent effective in preventing HPV strains 6 and 11, which cause about 90 percent of genital wart cases. Both vaccines are given in three injections over six months. Although both Gardasil and Cervarix prevent two of the most serious high-risk HPV strains in women not previously exposed to them, they do not protect against all cancer-causing strains, so the FDA recommends continued screening with regular Pap tests.

The reason screening is so important in preventing cervical cancer is because the disease usually causes no symptoms in its earliest stages. Irregular bleeding, bleeding or pain during sex or vaginal discharge may be symptoms of more advanced disease. These symptoms should always be discussed with a health care professional.

All women are at risk for developing the disease, but several factors can increase a woman's risk of developing cervical cancer, according to the American Cancer Society:

  • Persistent infection with high-risk strains of the human papillomavirus (HPV), a common sexually transmitted disease. (Most women and men who have been sexually active have been exposed to the HPV virus, which is spread through skin-to-skin contact with an HPV-infected area. However, certain types of sexual behavior increase a woman's risk of getting an HPV infection, such as having sex at an early age, having many sexual partners and having unprotected sex at any age.)

    Recent studies find that using condoms cannot completely protect against HPV because the virus is passed through skin-to-skin contact, including the skin in the genital area that may not be covered by a condom. Correct and consistent condom use is still important, however, to protect against AIDS and other sexually transmitted diseases.
  • A compromised immune system related to certain illnesses such as human immunodeficiency virus (HIV) infection. Being HIV positive makes a woman's immune system less able to fight cancers such as cervical cancer.
  • Smoking cigarettes, which exposes the body to cancer-causing chemicals absorbed initially by the lungs but then carried in the bloodstream throughout the body. Women who smoke are about twice as likely to develop cervical cancer. The chemicals produced by tobacco smoke may damage the DNA in cells of the cervix and make cancer more likely to occur there.
  • Infection with chlamydia bacteria, which is spread by sexual contact and may or may not cause symptoms. Researchers don't know exactly why chlamydia infection increases cervical cancer risk, but they think it might be because active immune system cells at the site of a chlamydia infection might damage normal cells and cause them to turn cancerous.
  • A diet low in fruits and vegetables. Women who don't eat many fruits and vegetables miss out on the protective antioxidants and phytochemicals such as vitamins A, C, E and beta-carotene, which have all been shown to help prevent cervical cancer and other forms of cancer. Overweight women are also more likely to develop cervical cancer.
  • A family history of cervical cancer—if your mother or sister had cervical cancer—may mean you have a genetic tendency for the disease. This could be because such women are genetically less able to fight off HPV infection than other women.
  • Exposure in utero to diethylstilbestrol (DES), a synthetic hormone that was prescribed to pregnant women between 1940 and 1971 to prevent miscarriages. For every 1,000 women whose mother took DES when she was pregnant, about one develops clear-cell adenocarcinoma (cancer) of the vagina or cervix. For more information on DES exposure, contact the U.S. Centers for Disease Control and Prevention (CDC), toll-free: 1-800-CDC-INFO (232-4636), or online at www.cdc.gov.
  • Long-term oral contraceptive use (five or more years) may very slightly increase a woman's risk of cancer of the cervix, according to some statistical evidence. However, this risk appears to go back to normal after a woman has been off birth control pills for 10 years. The American Cancer Society advises women to discuss the benefits of oral contraceptive use versus this very slight potential risk with their health care professionals.

The death rate from cervical cancer in African-American women is nearly double that of the death rate in Caucasian women. Additionally, Hispanic women develop this cancer nearly twice as often as non-Hispanic Caucasian women. Lack of access to health services (and therefore, less screening), cultural influences and diagnosis of cancer at more advanced stages are all possible reasons for these differences.

Women of all ages are at risk of cervical cancer, but it occurs most often in women 30 and over because they are more likely to have persistent HPV infections. Regardless, it is important that even postmenopausal women continue having regular Pap tests if they still have a cervix. If a woman's cervix was removed during a hysterectomy because of cervical cancer or pre-cancer, she should continue screening with Pap tests and HPV tests. If her cervix was removed during a hysterectomy and there were no signs of cancer and no suspicious Pap tests before the surgery, then she may not need to continue screening. Women over age 65 should stop getting Pap tests if they have had adequate prior screenings and are not at high risk for cervical cancer. Always discuss screening needs with your primary care physician.

The benefits of the Pap test are clear: Once one of the most common causes of cancer death for American women, cervical cancer has caused 70 percent fewer deaths per year since the introduction of the Pap test in the 1950s.

Although both the incidence and death rates of cervical cancer are going down, it is still a fairly common cancer in U.S. women, which may be related to the prevalence of infection with HPV. According to the CDC, approximately 20 million people are currently infected with HPV. At least 50 percent of the reproductive-age population has been infected with one or more types of HPV, and up to 6 million new infections occur each year.

Diagnosis

Diagnosis

In its earliest stages, cervical cancer usually causes no symptoms. Irregular bleeding, bleeding or pain during sex or vaginal discharge may be symptoms of more advanced disease. These symptoms don't necessarily mean you have cancer, but they should always be discussed with a health care professional.

Despite the Pap test's 60-year record as a safe and highly accurate screening tool for cervical cancer and precancerous abnormalities of the cervix, many women do not have regular Pap tests. Most invasive cervical cancers occur in women who have not had regular Pap tests. Many other cases of cervical cancer are attributed to failure to follow up on screening results.

A Pap test is a simple procedure: After a speculum (the standard device used to examine the cervix) is placed in the vagina, cells are taken from the surface of the cervix with a cotton swab then smeared onto a glass slide or in a liquid solution. Another sample is taken from the T-zone (or the transition-zone, the area of transition between cervical cells and uterus cells) with a tiny wooden or plastic spatula, or a tiny brush. The "liquid-based" Pap tests may provide a higher degree of accuracy and reliability.

For women who have had total hysterectomies, in which the cervix is removed, cells are taken from the walls of the vagina.

The slide or vial is delivered to a laboratory where a cytotechnologist (a lab professional who reviews your tissue sample) and, when necessary, a pathologist (a health care professional who examines bodily tissue samples) examines the sample for any abnormalities. Each smear contains roughly 50,000 to 300,000 cells.

Though not infallible, when performed regularly, the Pap smear detects a significant majority of cervical cancers.

New Technology for Cervical Cancer Screening and Diagnosis

Because the Pap test can be associated with sampling and interpretation errors, research and development strategies are focused, to a large degree, on fine-tuning Pap test interpretation, visualization and tissue retrieval. The U.S. Food and Drug Administration has approved a number of devices to enhance the Pap test, including the following:

  • Liquid-based Pap tests: These tests use a solution that helps preserve the cells scraped from the cervix (the Pap smear), as well as remove mucus, bacteria and other cells from the specimen that may interfere with examining the cervical cells. Test vials preserve specimens for up to three weeks from the date of collection, giving the physician an opportunity to request HPV testing on a patient for screening women ages 30 and over if a borderline Pap test results.

  • Computerized instruments that help to more accurately identify abnormal cells on slides: Unfortunately, studies so far have not found a real advantage for this kind of automated testing.

Additional new technologies that enable health care professionals to more accurately interpret Pap smear slides and get a better view of abnormal tissue include larger photographs of the cervix used along with Pap test results and improved lighting devices.

In addition, the FDA has approved the HPV DNA test to be used together with the Pap test to screen for cervical cancer in women age 30 and over. The HPV DNA test may also be used for women of any age who have slightly abnormal Pap test results to see if additional testing or treatment is necessary. The HPV DNA test is designed to be used in conjunction with—not in place of—the Pap test. Health care professionals can use the HPV DNA test to look for the presence of high-risk types of HPV that are most likely to cause cervical cancer by looking for pieces of their DNA in cervical cells. The sample is collected similarly to the Pap test.

To help improve the reliability of your Pap test, schedule your appointment two weeks after your last menstrual period and refrain from doing the following for at least 48 hours before the test:

  • having sex

  • douching

  • using tampons

  • using vaginal creams, suppositories, medicines, sprays or powders

Pap Test Results

An abnormal Pap test result does not mean you have cervical cancer. It indicates some degree of change or abnormality in the cells that cover the surface (lining or epithelium) of the cervix.

While the Pap test cannot confirm an HPV infection, it can show cell changes that suggest infection with HPV.

Pap test classifications include:

  • Negative for intraepithelial lesion or malignancy. This classification means that no signs of pre-cancerous changes, cancer or other significant abnormalities were detected. Some specimens under this classification are completely normal, and others may have changes unrelated to cervical cancer, such as signs of yeast infection, herpes or Trichomonas. Other specimens may show what are known as "reactive cellular changes," which is how cervical cells react to infection and other irritations.

  • Atypical squamous cells of undetermined significance, or ASCUS. These cellular changes appear abnormal for unknown reasons. It isn't possible to determine if the abnormality is caused by inflammation, infection, low estrogen after menopause or by precancerous changes. These types of cellular changes usually return to normal without intervention or after treatment of an infection. Follow-up for this Pap test result is usually a repeat Pap test in three to six months. Some doctors will use the HPV DNA test to help them decide the best course of action. And if a woman with ASCUS has a high-risk type of HPV, doctors will usually do a colposcopy.

  • Squamous intraepithelial lesion (SIL). This change is considered precancerous. SIL changes are divided into two categories: low-grade SIL and high-grade SIL.

    • Low-grade SIL refers to early changes in the size, shape and number of cells on the surface of the cervix. These changes may also be referred to as mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). Most of these lesions are caused by an active HPV infection and return to normal on their own without treatment. Others, however, may continue to grow or become increasingly abnormal in other ways and develop into a high-grade lesion.

      According to the National Cancer Institute, these cell changes occur most often in women ages 25 to 35, but can appear in other age groups.

      Because a Pap test cannot tell for sure whether a woman has high- or low-grade SIL, any patient with an SIL should have a colposcopy.

    • High-grade SIL. Cells in this category look very different from normal cells and are less likely to return to normal without treatment and are more likely to develop into cancer. These abnormal cellular changes are considered precancerous changes. High-grade SIL is most common in women age 30 to 40, but can occur in other age groups.

      Other terms for high-grade SIL are moderate or severe dysplasia (CIN 2 or CIN 3) carcinoma in situ.

      Follow-up for high-grade SIL (CIN 2 or CIN 3 are the usual pathologic results after biopsy) depends on the results of the colposcopy. In most cases, it involves additional procedures, including biopsy, endocervical curettage or both to determine the degree of abnormality and rule out invasive cancer.

Usually, cervical cancer grows slowly. Precancerous changes may not become cancerous for months or years. Once they spread deeper into cervical tissue or to other tissues and organs, the cellular abnormalities are classified as cervical cancer, or invasive cervical cancer. Cervical cancer tends to occur in midlife; about half of women diagnosed with cervical cancer are between the ages of 35 and 55, and it rarely occurs in women younger than 20.

A Pap test is a screening tool; other procedures are necessary to confirm Pap test abnormalities and diagnose conditions. All abnormal Pap tests should have some form of action plan. This may include a "watch and wait" approach with retesting in several months. Or, depending on the degree of abnormality, your health care provider may order other tests, including:

  • Colposcopy: The doctor uses a colposcope to magnify and focus light on the vagina and cervix to view these areas in greater detail. Depending on these findings, your health care professional may then use one or more of the following tests:

    • Biopsy: During this procedure, sample tissue is taken from the cervical surface. Often several areas are biopsied.

    • Endocervical curettage: Cells are scraped from inside the cervical canal using a spoon-shaped instrument called a curette to help make a more precise diagnosis. This procedure evaluates a portion of the cervix that cannot be seen.

    • Cone biopsy: When biopsy or endocervical curettage reveals a problem that requires further investigation, a cone biopsy may be performed. A "cone" of tissue is removed from around the opening of the cervical canal. In addition to diagnosing an abnormality, cone biopsy can be used as a treatment to remove the abnormal tissue. A pathologist examines tissue removed during cone biopsy to be sure all the abnormal cells are removed.

    • Loop Electrocautery Excision Procedure (LEEP): The suspicious area is removed with a loop device and the remaining tissue is electrocoagulated (vaporized with electrical current). LEEP is both a diagnostic test and a treatment. A pathologist examines tissue removed during LEEP to be sure all the abnormal cells are removed.

If cancer of the cervix is diagnosed, more tests will be conducted to learn if cancer cells have spread to other parts of the body. These tests may include:

  • Cystoscopy: This test is performed to see if the cancer has spread to the bladder. The doctor examines the inside of the bladder using a lighted tube.

  • Proctoscopy: Similar to a cystoscopy, this test is performed to see if the cancer has spread to the rectum.

  • Examination of the pelvis under anesthesia to check for further spread.

  • Chest x-ray to see if the cancer has spread to the lungs.

  • Other imaging tests such as CT (computed tomography) scans or magnetic resonance imaging (MRI) to see if the cancer has spread to lymph nodes or other organs.

In some cases, a Pap test may report that abnormal cells are present in a sample when, in fact, the cells in question are normal. This type of abnormal report is known as a false positive.

When a Pap test fails to detect an abnormality that is present, the result is called a "false negative." Even under the best of conditions, there is always a small false negative rate. Several factors may contribute to a false negative Pap test:

  • When irregular cells are located high in the cervical canal they are difficult to get to or scrape under normal Pap test procedures.

  • Menstrual blood and inflammatory cells can mask abnormal cells; these cells would not be visible to the cytotechnologist.

  • An inadequate sample—not enough cells were collected during the Pap test.

  • Human error, in which the person reviewing the slide misinterpreted abnormal cells as normal.

Screening Guidelines for Cervical Cancer

The American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF) recommend:

  • All women should begin screening at age 21.

  • Women ages 21 to 29 should have a Pap test every three years. They should not have an HPV test unless it is needed because of an abnormal Pap test result.

  • Women ages 30 to 65 should have both a Pap test and an HPV test every five years or a Pap test alone every three years. (The ACS and ACOG prefer the two tests together every five years but say either method is acceptable; the USPSTF recommends either schedule.)

  • Women over age 65 who have been screened previously with normal results and are not at high risk for cervical cancer should stop getting screened. Women with cervical precancer should continue to be screened.

  • Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened.

  • Women who have received the HPV vaccine should still follow the screening guidelines for their age group.
  • Women who are at high risk for cervical cancer may need more frequent screening. Talk to your health care professional about what's right for you.

Talk to your health care provider about what is best for you, based on your medical history.

Treatment

Treatment

To plan your treatment, your health care professional needs to know the stage of the disease. The following stages are used for cervical cancer:

  • Stage 0 or carcinoma in situ. This is very early cancer. The abnormal cells are found only in the first layer of cells of the lining of the cervix and do not invade the deeper tissues of the cervix.

  • Stage I cancer involves the cervix but has not spread.

  • Stage IA indicates a very small amount of cancer that is only visible under a microscope and is found in the deeper tissues of the cervix.

  • Stage IB indicates a larger amount of cancer is found in the tissues of the cervix that can usually be seen without a microscope.

  • Stage II cancer has spread to nearby areas but is still inside the pelvic area.

  • Stage IIA cancer has not spread into the tissues next to the cervix, called the parametria. The cancer may have spread to the upper part of the vagina.

  • Stage IIB cancer has spread to the tissue around the cervix.

  • Stage III cancer has spread throughout the pelvic area. Cancer cells may have spread to the lower part of the vagina. The cells also may have spread to block the tubes that connect the kidneys to the bladder (the ureters).

  • Stage IV cancer has spread to other parts of the body.

  • Stage IVA cancer has spread to the bladder or rectum (organs close to the cervix).

  • Stage IVB cancer has spread to other organs such as the lungs.

The best treatment plans for cervical cancer take into account several factors: the location of abnormal cells, the results of colposcopy, your age and whether you want to have children in the future. Basically, treatment involves destroying or removing the abnormal cells. Three basic approaches are used alone or in various combinations:

Surgery is used to remove the cancer. Various surgical techniques may be used, including:

  • excision (cutting out the abnormal cells)

  • electrocautery (electric current is passed through a metal rod that touches, vaporizes and destroys abnormal cells)

  • cryosurgery (abnormal cells are frozen with nitrous oxide)

  • laser vaporization (precise destruction of the small areas of abnormal cells)

  • conization (a biopsy used as a treatment)

  • simple hysterectomy (removal of the cervix and uterus)

  • radical hysterectomy (removal of cervix, upper vagina, uterus and ligaments that support them)

Radiation therapy (using high-dose X-rays or other high-energy rays to kill cancer cells) is used to treat both early and advanced-stage diseases. Sometimes your health care professional will use it alone or in combination with surgery. A common way to receive radiation is externally, just like an X-ray. Another procedure, called brachytherapy, involves having the radioactive source placed inside your body; it continues to emit energy for a specific period of time. In most stages of cervical cancer, radiation should be used with chemotherapy.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill or infused into the body with a needle inserted into a vein. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body and can kill cancer cells outside the cervix. Combination chemotherapy is constantly evolving, with the goal of improving response to treatment. Chemotherapy with platinum can also make radiation more effective, depending on the stage of the cancer.

Based on the stage of your cancer, treatment regimens usually include the following:

  • Stage 0 cervical cancer is sometimes called carcinoma in situ. Treatment may be one of the following: conization; laser surgery; loop electrocautery excision procedure (LEEP); cryosurgery; and surgery to remove the cancerous area, cervix, and uterus (total abdominal or vaginal hysterectomy) for women who cannot or do not want to have children. The precancerous changes or the stage 0 cancer can recur in the cervix, vagina or, rarely, the anus, so close follow-up is very important.

  • Stage I cervical cancer treatments depend on how deep the tumor cells have invaded the normal tissue.

    • Stage IA cancer is divided into stage 1A1 and stage 1A2.

    • For stage 1A1, there are a few options. If you still want to be able to have children, your doctor will remove the cancer with a cone biopsy and then closely follow you to see if the cancer returns. If you are through having children or the cone biopsy doesn't remove all the cancer, your doctor may remove your uterus (simple hysterectomy). If the cancer has invaded your lymph nodes or blood vessels, treatment will involve a radical hysterectomy and removal of the pelvic lymph nodes. If you still want to have children, you may be able to have a radical trachelectomy (surgery to remove the cervix and pelvic lymph nodes) instead of a radical hysterectomy.

    • Stage 1A2 involves three treatment options: radical hysterectomy and removal of lymph nodes in the pelvis; brachytherapy with or without external beam radiation; or, if you still want to have children, radical trachelectomy combined with removal of pelvic lymph nodes.

      If the cancer has spread to the parametria or to any lymph nodes, your doctor will recommend radiation therapy and possibly chemotherapy. If the pathology report reveals that some of the cancer may have been left behind, you may be treated with pelvic radiation combined with chemotherapy and possibly, brachytherapy.

    • Stage IB cancer is divided into stage 1B1 and 1B2.

    • For pelvic stage 1B1, treatment may involve radical hysterectomy and removal of lymph nodes or para-aortic lymph nodes (lymph nodes higher up in the abdomen), possibly combined with radiation therapy and/or chemotherapy; high dose internal and external radiation; or, if you still want to be able to have children, radical trachelectomy combined with the removal of pelvic and some para-aortic lymph nodes.

    • For stage 1B2, the standard treatment is chemotherapy and radiation therapy to the pelvis combined with brachytherapy. In some cases, treatment may involve a radical hysterectomy combined with removal of pelvic and some para-aortic lymph nodes. If your doctor finds cancer in the removed lymph nodes, he or she may recommend radiation therapy after surgery, possibly with chemotherapy as well. And some doctors recommend starting with a combination of radiation and chemotherapy as a first option, followed by a hysterectomy.

  • Stage IIA cervical cancer treatment depends on the size of the tumor. If the tumor is larger than four centimeters, treatment may include brachytherapy and external radiation. Treatment may also include chemotherapy with cisplatin. Some doctors recommend removing the uterus after radiation. If the cancer is smaller than four centimeters, treatment may involve a radical hysterectomy and removal of pelvic and some para-aortic lymph nodes. If the removed tissue reveals cancer, treatment will also include a combination of radiation and chemotherapy, possibly with brachytherapy as well.

  • For stage IIB cancer, treatment may include internal and external radiation therapy combined with cisplatin chemotherapy and possibly other chemotherapy drugs.

  • Stage III and IVA: Most health care professionals combine these two groups in terms of prognosis and treatment. The treatment for these two groups includes combined internal and external radiation therapy with cisplatin chemotherapy. If the cancer has spread to the lymph nodes, especially if it has spread to lymph nodes in the upper part of the abdomen (para-aortic lymph nodes), the cancer may have spread to other areas of the body. Some doctors will check the lymph nodes with surgery, a CT scan or an MRI. If lymph nodes appear enlarged, they will be biopsied. If the para-aortic lymph nodes are indeed cancerous, the doctor may want to do further tests to see if the cancer has spread to other areas of the body.

  • Stage IVB cancer treatments often include chemotherapy and/or radiation therapy. Cancer at this stage is not usually considered curable, so treatments are more to relieve symptoms caused by the cancer than to treat the cancer itself.

  • Recurrent cervical cancer may require radiation therapy combined with chemotherapy. If the cancer has come back outside of the pelvis, a patient may choose to go into a clinical trial of a new treatment and/or use chemotherapy or radiation therapy to ease symptoms. If the recurrence is limited to the pelvis, radical pelvic surgery may be recommended.

Prevention

Prevention

Detecting precancerous changes in their earliest stages through regular Pap tests is the best way to prevent cervical cancer. Most women who develop invasive cervical cancer have not had regular Pap tests. Reducing or eliminating risk factors associated with the development of cervical cancer can also help prevent it:

  • Don't smoke cigarettes.

  • Use condoms correctly and consistently to protect yourself from sexually transmitted diseases. Note, however, that while condom use will decrease the risk of HPV infection, it can't prevent it entirely because HPV can infect cells anywhere on the skin in the genital area.

Additionally, the FDA has approved two HPV vaccines, called Gardasil and Cervarix. Gardasil protects women against four HPV types—the two most common high-risk (cancer-causing) types of HPV, strains 16 and 18, and also the two most common low-risk types of HPV, 6 and 11, which cause 90 percent of genital warts. Cervarix protects against HPV 16 and 18. Both vaccines should be given before an infection occurs, ideally, before a girl becomes sexually active. Gardasil is approved for girls as young as nine and is routinely recommended for girls 11 and 12 years of age. It may also be given to women ages 13 to 26 who did not receive it when they were younger, as well as males ages nine to 26. Cervarix is approved for use in girls and women ages nine through 25. If a woman is already infected with one of the four HPV types in one of the vaccines, the vaccine will not work against that particular HPV type. (It will still work against the remaining types she has not yet been exposed to.)

Clinical trials have shown that both Gardasil and Cervarix are safe and 100 percent effective in preventing HPV strains 16 and 18, which cause 70 percent of cervical cancers. Gardasil is also 99 percent effective in preventing HPV strains 6 and 11, which cause about 90 percent of genital wart cases. Both vaccines are given in three injections over six months.

Although Gardasil and Cervarix prevent two of the most serious high-risk HPV strains, these vaccines don't protect against all of them so the FDA recommends choosing one of them as a complement to safe sex practices and regular Pap tests.

HPV screening of women ages 30 and over is also an important part of preventing potential complications of cervical cancer. The easiest way to screen for HPV is with the HPV test which checks for the virus itself. The Pap test can identify cervical cancer in its earliest stage but can also find abnormal precancerous cells and signs of an active HPV infection.

In conjunction with the Pap test, the HPV test can be used in women over age 30 to help detect HPV infection. Because it specifically tests for the types of HPV that are most likely to cause cervical cancer, when combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.

The American Cancer Society (ACS) and the U.S. Preventive Services Task Force (USPSTF) recommend the following guidelines for early detection and prevention of cervical cancer:

  • All women should begin screening at age 21.

  • Women ages 21 to 29 should have a Pap test every three years. They should not have an HPV test unless it is needed because of an abnormal Pap test result.

  • Women ages 30 to 65 should have both a Pap test and an HPV test every five years or a Pap test alone every three years. (The ACS prefers the two tests together every five years but says either method is acceptable; the USPSTF recommends either schedule.)

  • Women over age 65 who have been screened previously with normal results and are not at high risk for cervical cancer should stop getting screened. Women with cervical precancer should continue to be screened.

  • Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened.
  • Women who have received the HPV vaccine should still follow the screening guidelines for their age group.

  • Women who are at high risk for cervical cancer, such as women with a family history of the disease, a history of treatment for precancer, DES exposure before birth, chlamydia infection or a weakened immune system (from HIV infection, organ transplant, chronic steroid use or chemotherapy), may need more frequent screenings. Talk to your health care professional about what's right for you.

The guidelines from the American College of Obstetricians and Gynecologists (ACOG) differ slightly. ACOG recommends that women between the ages of 21 and 29 get Pap tests every two years, and women 30 years of age and older with three consecutive negative Pap tests be tested every three years.

Talk to your health care provider about what is best for you, based on your medical history.

Facts to Know

Facts to Know

  1. The American Cancer Society estimates that in 2012, about 12,170 cases of invasive cervical cancer will be diagnosed in the United States and about 4,220 women will die from the disease.

  2. The death rate from cervical cancer in African-American women is nearly double that of Caucasian women. Additionally, Hispanic women develop this cancer nearly twice as often as non-Hispanic Caucasian women. The highest rate of cervical cancer is in underdeveloped countries.

  3. Both incidence and deaths from cervical cancer have declined markedly over the last several decades, due to more frequent detection and subsequent treatment of pre-invasive and cancerous lesions of the cervix from increased Pap screening.

  4. The five-year survival rate for early invasive cancer of the cervix is 93 percent. The survival rate falls steadily as the cancer spreads to other areas.

  5. Changes in cervical cells are classified by their degree of abnormality. If your test is abnormal, ask your health care professional to discuss how your abnormalities were described. Many abnormalities return to normal with no treatment, so your health care professional may want to wait and perform another Pap test in several months. Overtreating mild dysplasia can harm the cervix. However, if the Pap results reveal atypical squamous cells of undetermined significance (ASCUS), then HPV testing is routinely done. If no high-risk strains are identified, then no further testing in needed. You should repeat the Pap test in one year. If the Pap reveals ASCUS and the HPV test is positive, a colposcopy will be needed. Colposcopy also is needed if any other more serious changes are shown by the Pap results. Further screening and treatments will depend on the results of the colposcopy. CIN 1 should not be treated, but the Pap will be repeated in 6 to 12 months. For CIN 2-3, further treatment is needed to remove the abnormal cells.

  6. The primary risk factor for cervical cancer is infection with certain types of the human papillomavirus (HPV). Together, HPV 16 and HPV 18 account for about 70 percent of cervical cancer cases. However, it is important to note that not every HPV infection with high-risk strains is destined to become cervical cancer. Only infections that persist are likely to develop precancerous cell changes if untreated.

  7. Rates of low-grade squamous intraepithelial lesion (low-grade SIL), usually caused by an active HPV infection, peak in both black and white women between the ages of 25 and 35. However, the number of cases of invasive cervical cancer increases with age, as does the chance of dying from cervical cancer.

  8. Women who had first sexual intercourse at an early age or who have had many sexual partners or who have partners who have many sexual partners have a higher-than-average risk of developing cervical cancer.

  9. The majority of cervical cancers develop through a series of gradual, well-defined precancerous lesions. During this usually lengthy process, the abnormal cells can usually be detected by the Pap test and treated.

  10. Pap tests, like other early detection tests, are not 100 percent accurate. When performed properly, the Pap smear detects a significant majority of cervical cancers—usually in the early stages when the likelihood of a cure is the greatest.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about cervical cancer so you're prepared to discuss this important health issue with your health care professional.

  1. What is my risk for developing cervical cancer? How can I limit my risks?

  2. What should I do before getting a Pap test to make sure the test is as accurate as possible?

  3. Are you sending my Pap test to a board-certified lab? Does a board-certified pathologist oversee this lab? Do I need the HPV test?

  4. How will I be informed of the results?

  5. If I have abnormal cells on Pap test or a positive HPV test, what next steps are necessary?

  6. I was diagnosed with human papillomavirus (HPV). How often do I need pelvic exams and Pap tests?

  7. I am so afraid to find out I may have cancer that I'm afraid to come in for a Pap test or pelvic exam. What should I do?

  8. What is a colposcopy and why do you recommend it? Will it hurt?

  9. Can cervical cancer be cured? How? Can it come back after it's been treated?

  10. If you are diagnosed with cervical cancer, ask what kind of experience do you have in treating cervical cancer? Have you had specialty training in gynecological oncology?

  11. Will I have to be "checked for cancer" for the rest of my life?

  12. What are the risks that my daughter will have cervical cancer too?

Key Q&A

Key Q&A

  1. My Pap test was abnormal—what should I do?

    Don't panic. There are many things that can produce an abnormal result. To improve the reliability of the test, schedule your appointment two weeks after your menstrual period and refrain from having intercourse or using vaginal contraceptives or douches for at least 48 hours before the test. Return for further testing if your doctor recommends it.

  2. I've already gone through menopause. Should I continue to have Pap tests?

    Current guidelines suggest that if you are age 65 or older and have had adequate prior screening and are not otherwise at high risk for cervical cancer, you can stop having Pap tests. Annual pelvic exams are still recommended.

  3. My health care professional has recommended a hysterectomy for invasive cervical cancer. How do I know if this is the right thing to do?

    There are a number of diagnostic steps your health care professional should take before surgery, including a colposcopy and biopsy. Treatment regimens are always your choice and should be discussed thoroughly with your health care professional. Additionally, you should seek a second opinion from a gynecological oncologist before undergoing any surgical procedure. A gynecological oncologist is an obstetrician-gynecologist who has had special training in the care of women with cancers of the cervix, ovary, uterus and vulva.

  4. Is it true that there are new tests to replace the Pap test?

    There are several new technologies, but most are designed to improve the reliability of the Pap test, which is still the most widely used screening test to detect changes in cervical cells. Pap tests, like other early detection tests, are not 100 percent accurate. Still, when performed properly, the Pap smear detects a significant majority of cervical cancers—usually in the early stages when the likelihood of a cure is the greatest.

  5. How often should I have a Pap test? What about the HPV test?

    The American Cancer Society (ACS) and the U.S. Preventive Services Task Force recommend that screenings begin at age 21. Women ages 21 to 29 should have a Pap test every three years. They should not have an HPV test unless it is needed because of an abnormal Pap test result. Women ages 30 to 65 should have both a Pap test and an HPV test every five years or a Pap test alone every three years.

    The American College of Obstetricians and Gynecologists recommends that women between the ages of 21 and 29 get Pap tests every two years, and women 30 years of age and older with three consecutive negative Pap tests get tested every three years.

    However, women who are at an increased risk for developing cervical cancer (those with new or multiple sexual partners, family history of the disease, or other risk factors) should be screened more frequently. Women who have abnormal Pap test results or a positive HPV test should discuss subsequent tests and follow-up with their health care professionals.

    Women who are 65 or older and have had adequate prior screening and are not at high risk for cervical cancer may stop screening for cervical cancer altogether.

    Women who have had a total hysterectomy (removal of the uterus and cervix) may also stop screening unless the hysterectomy was performed because of cervical cancer or pre-cancer-related reasons, or you have a history of abnormal Pap smears. If the hysterectomy was performed to treat cervical cancer, more frequent Pap screenings may be recommended.

    Talk to your health care provider about what is best for you, based on your medical history.

  6. I've avoided going to the health care professional for years and never even had a Pap test. What can I expect when I have the test?

    A Pap test is a simple procedure: After a speculum (the standard device used to examine the cervix) is placed in your vagina, cells are skimmed from the surface of the cervix then smeared onto a glass slide or placed in a liquid. A sample is taken from the T-zone with a tiny wooden or plastic spatula or a tiny brush. The cervix is the narrow neck of the uterus that opens into the vagina. For women who have had total hysterectomies, in which the cervix is removed, cells are taken from the walls of the vagina. The cell sample is delivered to a laboratory where a cytotechnologist (a lab professional who reviews your Pap test) and, when necessary, a pathologist (a physician who examines bodily tissue samples) examine the sample for any abnormalities.

  7. I have cervical cancer and my health care professional has not recommended chemotherapy. I thought it was used for all cancers?

    Depending on the stage of your cancer, sometimes radiation alone will be recommended as a treatment. However, clinical trials show that the combination of radiation therapy and chemotherapy with cisplatin is more effective than radiation alone for women with stage IB2 cervical cancer. This prompted the National Cancer Institute to recommend that chemotherapy be considered in all patients receiving radiation therapy for cervical cancer larger than four centimeters. If you're unsure of whether chemotherapy is an option for you, talk to your health care professional.

  8. My Pap test was reported as a false negative. What does that mean?

    When a Pap test fails to detect an existing abnormality, the result is referred to as a false negative. Several factors can contribute to a Pap test reporting a false negative:

    • When irregular cells are located high in the cervical canal and are difficult to access under normal Pap test procedures

    • When menstrual blood masks abnormal cells; these cells would not be visible to the cytotechnologist

    • An inadequate sample—when not enough cells were collected during the Pap test

    • Human error, where the person reviewing the slide misinterpreted abnormal cells as normal

  9. I haven't had a Pap test in several years because I don't have health insurance and can't afford it. Are there any options for me?

    The National Breast and Cervical Cancer Early Detection Program provides breast and cervical cancer screening services to underserved women throughout the country, including 12 American Indian/Alaska Native organizations. Services are either free or provided on a sliding scale based on your income. For information about access in your area, call 1 (800) CDC-INFO (232-4636) or log onto www.cdc.gov/cancer/nbccedp.

    The federal Affordable Care Act, approved in 2010, will also make more low-income women eligible for Medicaid coverage, particularly single women who are not currently covered.

    Additionally, Medicare provides 100 percent coverage for a Pap smear and pelvic examination once every 24 months. If you are at high risk for cervical or vaginal cancer, or if you are of childbearing age and have had an abnormal Pap smear in the preceding 36 months, Medicare covers these tests every 12 months.

    For women who do have health insurance but were still concerned about screening costs, the federal Affordable Care Act makes free screenings available to many women. If you have a new health insurance plan beginning on or after September 23, 2010, Pap tests and many other preventive screenings must be covered (when performed by a network provider) without you being required to pay a co-payment or coinsurance or deductible.

Lifestyle Tips

Lifestyle Tips

  1. Give yourself the best odds after treatment for cervical cancer or precancerous conditions

    If you smoke, look seriously for opportunities or resources to quit. Smoking exposes your body to cancer-causing chemicals that promote the growth of cervical cancer. The chemicals produced by tobacco smoke may damage the DNA in cells of the cervix and make cancer more likely to occur there. Also avoid drinking excessive alcohol and follow the dietary recommendations of your cancer care team. Assuming there's no reason for you to avoid these foods, eat plenty of dark green leafy vegetables, red, orange or yellow vegetables and whole grains. This will help you heal faster and give you a better chance of recovering completely. Exercise as soon as your condition permits. Know your recommended medical follow-ups and keep up with them.

  2. Face your fertility issues

    If you're concerned about your ability to have children, make this clear to your cancer care team. Ask how the medical and surgical procedures necessary for your care will affect your fertility. If you have early cervical cancer, it may be possible for you to be treated with a cone biopsy, a surgical procedure that allows most women to remain fertile. If your fertility can't be spared, you're entitled to your feelings and consideration from others. A good counselor or support group may help. You can also consider looking into newer options, such as ovarian tissue banking.

  3. Reclaim your sex life

    During this stressful time, it is normal for you to be less interested in sex than before. Counseling can help you and your partner adjust and stay physically intimate in other ways as you return to intercourse at your own pace. If you are experiencing vaginal dryness, hormone creams and lubricating gels can help. To keep your vagina elastic and flexible after radiotherapy, use a vaginal dilator and talk to your partner about having regular sex. This won't make the cancer worse or hurt your partner. Make sure that penetrative sex is very gentle at first.

  4. If you're going to have a hysterectomy...

    Ask your surgeon whether your ovaries will also be removed and research this decision carefully. It is not always a good idea to remove your ovaries, especially if you are young, because it will cause you to go into sudden menopause. Studies also have shown increased risk of lung cancer, coronary artery disease and even premature death from other causes in young women who have their ovaries removed.

    Also ask whether you'll be having abdominal laparoscopic surgery with or without robotic assistance or surgery through the vagina, since the procedures have different recovery rates. Arrange for help at home; you'll be glad later, even if you don't need it for long. Freeze your favorite meals ahead of time, and prepare the room in which you'll be resting after surgery with reading materials and pictures or posters on the wall. Also have a supply of sanitary pads for post-operative drainage and large-size, comfortable panties.

  5. After your hysterectomy...

    Cooperate when you're asked to get up and walk after surgery. You'll recover faster and won't have as many problems with gas. Once you're home, don't lift heavy objects or walk up stairs too soon after surgery. If you've had an abdominal incision, edema (swelling) may make your abdomen look like it sags; with time, this will subside. Stick to a healthy, nutritious diet, not a weight-loss diet, while recovering from surgery. After your surgeon has cleared you for normal activity, exercise to tighten your muscles, build up strength and endurance and improve sleep.

Organizations and Support

Organizations and Support

For information and support on coping with Cervical Cancer, please see the recommended organizations, books and Spanish-language resources listed below.

American Cancer Society (ACS)
Website: http://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

American Institute for Cancer Research
Website: http://www.aicr.org
Address: 1759 R Street, NW
Washington, DC 20009
Hotline: 1-800-843-8114
Phone: 202-328-7744
Email: aicrweb@aicr.org

Association of Cancer Online Resources, Inc.
Website: http://www.acor.org
Address: 173 Duane Street, Suite 3A
New York, NY 10013
Phone: 212-226-5525

Cancer Care, Inc.
Website: http://www.cancercare.org
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Phone: 212-712-8400
Email: info@cancercare.org

Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Hotline: 1-800-525-3777
Email: contactus@amc.org

Cancer Support Community
Website: http://www.gildasclub.org/
Address: Gilda's Club Worldwide
48 Wall Street, 11th Floor
New York, NY 10005
Phone: 888-GILDA-4-U
Email: info@gildasclub.org

Corporate Angel Network
Website: http://www.corpangelnetwork.org
Address: Westchester County Airport
One Loop Road
White Plains, NY 10604
Hotline: 1-866-328-1313
Phone: 914-328-1313
Email: info@corpangelnetwork.org

Gathering Place
Website: http://www.touchedbycancer.org
Address: The Arnold & Sydell Miller Family Campus 23300 Commerce Park
Beachwood, OH 44122
Phone: 216-595-9546
Email: info@touchedbycancer.org

Gynecologic Cancer Foundation
Website: http://www.thegcf.org
Address: 230 W. Monroe, Suite 2528
Chicago, IL 60606
Hotline: 1-800-444-4441
Phone: 312-578-1439
Email: info@thegcf.org

Mautner Project - The National Lesbian Health Organization
Website: http://www.mautnerproject.org
Address: 1875 Connecticut Ave., NW Suite 710
Washington, DC 20009
Hotline: 1-866-MAUTNER (1-866-628-8637)
Phone: 202-332-5536
Email: info@mautnerproject.org

Memorial Sloan-Kettering Cancer Center, New York
Website: http://www.mskcc.org
Address: 1275 York Ave
New York, NY 10065
Phone: 212-639-2000
Email: publicaffairs@mskcc.org

National Cancer Institute (NCI)
Website: http://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Cervical Cancer Coalition (NCCC)
Website: http://www.nccc-online.org
Address: 6520 Platt Ave., #693
West Hills, CA 91307
Hotline: 1-800-685-5531
Phone: 818-909-3849
Email: info@nccc-online.org

National Coalition for Cancer Survivorship (NCCS)
Website: http://www.canceradvocacy.org
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Phone: 301-650-9127
Email: info@canceradvocacy.org

National Comprehensive Cancer Network
Website: http://www.nccn.org
Address: 275 Commerce Dr, Suite 300
Fort Washington, PA 19034
Phone: 215-690-0300

Native American Cancer Research
Website: http://www.natamcancer.org
Address: 3022 South Nova Rd.
Pine, CO 80470-7830
Phone: 303-838-9359
Email: info@natamcancer.net

Prevent Cancer Foundation
Website: http://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

Women's Cancer Resource Center
Website: http://www.wcrc.org
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Hotline: 1-888-421-7900
Phone: 510-420-7900
Email: info@wcrc.org

Johns Hopkins Patients' Guide to Cervical Cancer
by Colleen McCormick, Robert Giuntoli

A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker, Rachel L. Parker

Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd, Dana Rowett

The HPV Vaccine Controversy: Sex, Cancer, God, and Politics: A Guide for Parents, Women, Men, and Teenagers
by Shobha S. Krishnan

National Cancer Institute
Website: http://cancernet.nci.nih.gov/sp_menu.htm
Hotline: 1-800-422-6237
Email: nciespanol@mail.nih.gov

H. Lee Moffitt Cancer Center & Research Institute
Website: http://www.moffitt.usf.edu/pated/español.htm
Address: 12902 Magnolia Drive
Tampa, FL 33612
Hotline: 1-888-663-3488
Phone: 813-745-4673

Medline Plus: Cervical Cancer
Website: http://www.nlm.nih.gov/medlineplus/spanish/cervicalcancer.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Thu, 2012-03-15

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"Immunotherapy for Specific Cancers." American Cancer Society. April 11, 2005. http://www.cancer.org. Accessed February 2006.


Last date updated: 2012-03-15