Cervical Cancer

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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, 83 percent of all cases of cervical cancer occur in developing countries.

The American Cancer Society estimates that about 11,070 cases of invasive cervical cancer were diagnosed in the United States in 2008, and about 3,870 women died 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 approximately 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 strains cause the warts that sometimes develop on the hands or feet.

The normal cervix is a firm muscle feeling 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. But the area where the two cells 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 cellular abnormalities 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 of preinvasive and cancerous lesions of the cervix from increased Pap screening.

Because persistent infection with high-risk strains of HPV can be a predictor of the presence or future development of cervical cancer, many medical professionals now also test for this disease as an adjunct to the Pap test. In March 2003, the U.S. Food and Drug Administration (FDA) expanded 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 an HPV vaccine, called Gardasil, which can protect 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. The vaccine, however, should be given before an infection occurs, ideally, before a girl becomes sexually active. The vaccine 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, but will not work against the particular HPV type if a woman is already infected with one of the four HPV types in the vaccine. (It will still work against the remaining types she has not yet been exposed to.)

Clinical trials have shown that the vaccine is safe and 100 percent effective in preventing HPV strains 16 and 18, which cause 70 percent of cervical cancers. Gardasil, given in three injections over six months, is also 99 percent effective in preventing HPV strains 6 and 11, which cause about 90 percent of genital wart cases. Although Gardasil prevents two of the most serious high-risk HPV strains in women not previously exposed to them, it doesn't protect against all 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 (OC) 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 OC use versus this very slight potential risk with their health care professionals.

About 50 percent more African-American women die from cervical cancer as Caucasian women. Additionally, Hispanic women develop this cancer 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. Always discuss screening needs with your primary care physician.

The benefits of the Pap test are clear: The overall death rate in the United States from the disease has declined by 74 percent 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. As many as 75 percent of the reproductive-age population has been infected with one or more types of HPV, and up to 6.2 million new infections occur each year.