Cervical Cancer

Overview

Have you had your Pap smear?

Cervical cancer accounts for roughly 18% of all female genital cancers. It is most common in women between ages 35 and 55. The American Cancer Society estimates that 80,000 woman are currently diagnosed with cervical cancer.

Early detection is key to successful treatment. The best means of early detection is a Pap smear, which can find up to 90% of all cervical cancers. Most doctors suggest that women have the test performed each year. Deaths from cervical cancer could be eliminated if all women had regular Pap smears. Unfortunately, almost 40% of American women aren't tested regularly.

Detailed Description

The cervix is the lower end, or neck, of the uterus. It extends into the top of the vagina. Cancer occurs when normal cells in the cervix divide and grow at an uncontrolled rate. The disease may be caused by the human papillomavirus, which can be transmitted during sexual intercourse.

While other precise causes are unknown, certain factors — multiple sex partners, recurrent vaginal infections, and smoking — increase a woman's risk. Early signs and symptoms to look out for include vaginal bleeding between periods or after intercourse, and abdominal pain. However, because a woman may not experience symptoms until the later stages of the cancer, routine Pap smears remain the best method of early detection. The test involves sampling cells from the cervix and evaluating them in the laboratory for abnormalities. Women should have their first Pap test when they become sexually active, or at age 20 if they’re sexually inactive, and then have one done annually thereafter.

Early treatment is critical. Left untreated, cervical cancer can spread beyond the uterus to other parts of the body, resulting in death. Types of treatment depend on the stage of the cervical cancer. In the early stages, abnormal tissue is destroyed with relatively simple procedures. In more advanced cancer stages, radiation therapy, chemotherapy, and/or surgery may be necessary. After treatment, methods to prevent recurrence include avoiding risk factors and having regular Pap smears and pelvic examinations.

How Common Is Cervical Cancer?

Approximately 17,000 cases of cervical cancer occur each year in the United States. This condition usually occurs in women between the ages of 35 and 55. Statistically, it is seen most at age 53, and very rarely under age 20. Cervical cancer affects only females.

What You Can Expect

Preinvasive carcinoma is the earliest stage of cervical cancer, and produces no symptoms. Left untreated, this cancer will progress to invasive cervical cancer, with symptoms of spotting or bleeding after sexual intercourse or between periods. In advanced cancer stages, signs include abdominal pain and anemia. With early treatment, the five-year survival rate for cervical cancer is 75% to 90%. By the time symptoms are evident, the survival rate drops sharply, and with delayed treatment, the survival rate drops further. Early detection is the key to successful treatment of cervical cancer. Left untreated, cervical cancer can spread beyond the uterus to other parts of the body, resulting in death.

The five stages of cervical cancer:

  • Stage 0: Also known as pre-invasive carcinoma in situ; 100% five-year survival rate.
  • Stage I: Cancer cells confined to the cervix; 85% five-year survival rate.
  • Stage II: Cancer cells extend to the upper vagina or the tissue around the uterus; 50% to 60% five-year survival rate.
  • Stage III: Cancer cells in the lower one-third of the vagina and/or the pelvic wall and possibly the kidneys; 30% five-year survival rate.
  • Stage IV: Cancer cells beyond the pelvic organs, involving the bladder or rectum, or sometimes distant organs such as the lung, liver, and bone; 10% five-year survival rate.

Conventional Treatment

Goals of Treatment

If cervical cancer is detected early, treatment can be quite effective and a cure possible. Overall, cure rates for two methods, surgery and radiation therapy, are almost equal. Among women whose cancer is confined to the cervix, 75% to 90% are still alive at five years. If the cancer has spread beyond the cervix, the survival rate at five years is 45% to 55%.

Sometimes, the best therapy is a combination of surgery, radiation, and chemotherapy. Chemo aims to kill any remaining cancer cells that have spread, or it can be used to enhance the effects of radiation. It can also cause side effects, such as nausea or vomiting, which can be prevented or relieved with other drugs.

Drug Therapy

Cytoxan

Off-Label Efficacy

Accutane
http://www.nmihi.com/i/isotretinoin.html

Off-Label Efficacy

Surgery

The type of surgery you have depends on the stage of the cancer:

If mild, cervical dysplasia (abnormal, precancerous cells on the cervix) sometimes goes away without treatment. If not, dysplasia can lead to cancer. To prevent this, doctors remove dysplasia through several techniques including cryosurgery, a freezing technique; cauterization, which uses heat; laser surgery; or the loop electrical excision procedure (LEEP).If the cancer is an early-stage cancer confined to the outermost layer of the cervix (carcinoma in situ), a doctor can remove the cancer entirely with a scalpel or the loop electrical excision procedure (LEEP). Because the reproductive organs are spared, this surgery allows a woman to still bear children. But cancer can come back, so she'll need to be diligent about regular exams and Pap smears (see "Monitoring the Condition"). If a woman with cervical carcinoma in situ doesn't plan to have children, her doctor may suggest removing the cervix and the entire uterus.

In more advanced stages in which the cervical cancer has invaded the uterus, the surgeon may perform a hysterectomy (removal of the uterus). Several types of hysterectomy can be performed. Sometimes, hysterectomy is followed by radiation therapy and chemotherapy.

  • Total hysterectomy: The uterus and cervix are removed, leaving the ovaries and fallopian tubes intact.
  • Radical hysterectomy: The cervix, uterus, and fallopian tubes are removed, as well as the upper vagina and some surrounding tissue and lymph nodes. The surgeon may also remove the ovaries, but one or both may be left in place in a young woman to prevent immediate menopause.
  • Pelvic exteneration: All reproductive and pelvic structures, including the vagina, bladder, and rectum are removed.

Radiation

Radiation can be used in cases ranging from early-stage cervical cancers to advanced cases that have not spread beyond the pelvis. Radiation therapy is given from outside the body or from within to destroy cancer cells.

  • External radiation: A large machine beams X-rays at the tumor, destroying cancer cells and some healthy cells.
  • Internal radiation: A radioactive source is placed inside the body in one of two ways. With the interstitial approach, the therapist inserts a radioactive needle or seeds into the tumor or surrounding tissues. The devices may remain in place temporarily or permanently. With the intracavitary approach, the therapist places a special holder containing the radioactive substances into the vagina.

Chemotherapy

In many cases of cervical cancer, chemotherapy combined with radiation is given to increase survival time. In advanced stages, chemotherapy agents such as hydroxyurea, cisplatin, and fluorouracil have been used in combination with radiation therapy.

Appropriate Health Settings

Whether you are treated on an outpatient basis or admitted to the hospital depends on how advanced your disease is and the types of treatment you'll receive.

Healthcare Professionals Who May Be Involved in Treatment

  • Gynecologists
  • Gynecologic oncologists
  • Medical oncologists
  • Radiation oncologists
  • General surgeons
  • Radiologists
  • Pathologists
  • Internists
  • Family doctors

Activity and Diet Recommendations

If you have a hysterectomy, you'll probably stay in the hospital four days. When you return home, you'll need to avoid tub baths and douches, driving, and lifting heavy objects for a time. Don't resume sex or active sports for six to eight weeks.

If you undergo radiation therapy, it can irritate the lining of your intestines. You may need a lactose-restricted diet to prevent diarrhea.

Monitoring the Condition

After therapy, you'll need a physical exam and Pap smear every three months for one to two years; every six months for the next five years; and yearly after that.

Possible Complications and Side Effects

After undergoing cervical cancer treatment, possible complications and side effects include the following:

Hysterectomy:

  • Pelvic, kidney and bladder infections
  • Bleeding (hemorrhage)
  • Intestinal adhesions
  • Acute blood clotting

Radiation:

  • Diarrhea
  • Rectal bleeding
  • Irritation to rectum and vagina
  • Delayed damage to the bladder and rectum
  • Ovaries may stop functioning
  • Disrupted menstrual cycle
  • Hot flashes
  • Fatigue
  • Trouble retaining urine
  • Narrowing and shortening of vagina
  • Chronic bladder infections

Chemotherapy:

  • Nausea
  • Vomiting
  • Low blood cell counts
  • Hair loss

Quality of Life

If you plan to have children, the decision will affect your treatment options, so talk to your doctor about your choices. Obviously, a hysterectomy will prevent you from having children, but even pelvic radiation may halt menstruation (amenorrhea) and cause infertility. Also, if you have a cone biopsy, or conization, you may become more prone to miscarriage. If you become pregnant after having had a cone biopsy, tell your doctor about the surgery.

After treatment, you will be able to resume having sex. But radiation therapy can alter the vagina, so you may find that you need more lubrication. Try over-the-counter lubricants such as K-Y jelly. Check with your doctor before resuming sex after a hysterectomy or other pelvic surgery.

Considerations

Pregnancy

Cervical cancer can occur in pregnant women. An abnormal Pap smear during pregnancy should be followed by colposcopy and biopsy, but endocervical curettage should be avoided. If the biopsy shows an invasion of cancer cells, you will need a cone biopsy. There is a small risk of miscarriage, but there is no safer procedure available.

Pregnancy can also make treatment more complex. The choice of therapy will depend upon how far the cancer has progressed, as well as the stage of pregnancy. Discuss your individual situation with your doctor.

Cervical Cancer

Last updated 23 May 2012

Synonyms

  • Cancer of the uterine cervix
  • Cervical malignancy
  • Cervical carcinoma

Pronunciation

SER-vi-kal KAN-ser


Causes

Theoretical Causes

Doctors believe that cervical most cervical cancer is is caused by infection with papilloma viruses, such as the human papilloma virus (HPV), which causes genital warts. A vaccine against papilloma virus shows promise in preventing cervical cancer.

Drugs That Can Cause or Aggravate Cervical Cancer

DES, or Diethylstilbestrol, widely prescribed between the years 1941 and 1971 to prevent miscarriages, has been shown to increase one's chances of developing cervical cancer. If you were exposed to this drug in utero, it is important to tell your physician so you can get what is known as a "DES exam," a careful examination of the cervix and vaginal walls. Pap smears from DES exams are labeled as such, and any abnormalities are more carefully inspected to see if they are cancerous. Ask your mother what kind of DES she took, or ask her physician, if he or she is still practicing, for the exact prescription for more effective DES examinations and treatments.

Risk Factors

If you have any of the following factors in your medical history, you are at greater risk for developing cervical cancer:

  • Infection with human papilloma virus (HPV)
  • Infection with HIV
  • Multiple sexual partners
  • Engaging in sexual intercourse at a young age
  • Multiple pregnancies
  • Smoking
  • Body's natural defenses not working at their optimum (immunosuppression)
  • Long-term use of oral contraceptives
  • Women born to mothers who took the drug diethylstilbestrol (DES) during pregnancy

Symptoms & Diagnosis

When cervical cancer is caught early, treatment can be highly effective. Be sure to see your doctor if you have any of these symptoms:

  • Bleeding from the vagina between periods
  • Bleeding after sexual intercourse
  • Bleeding after menopause
  • Painful sexual intercourse (dyspareunia)
  • Vaginal discharge that is heavy, smelly, watery or bloody
  • In later stages of the disease, dull backache, low pelvic pain, and overall poor health

Conditions That May Be Mistaken for Cervical Cancer Some signs of cervical cancer resemble those of other conditions, such as:

  • Cervicitis (inflamed cervix)
  • Cervical polyp (noncancerous growth from cervix)
  • Cancer of the ovary or uterus
  • Cancer that has spread from other sites

How Cervical Cancer Is Diagnosed

If a pelvic exam reveals a sore, growth or other unusual symptom on your cervix, or if a Pap test shows abnormal or cancerous cells, your doctor may do more tests:

Colposcopy: During this procedure, your doctor uses a colposcope, a viewing tube with a magnifying lens, to look closely at the cervix for the location of any cancer. You’ll be asked to disrobe and lie on an exam table with your feet in stirrups as the doctor inserts a speculum into your vagina. Then your doctor will perform the colposcopy and perhaps do a biopsy at the same time.

Biopsy: Your doctor cuts tissue from your cervix, which a pathologist will check under a microscope for cancer. There are several types of biopsies:

  • Punch biopsy: The doctor removes a tiny piece of cervical tissue as he or she views the cervix with the colposcope.
  • Endocervical curettage. The doctor uses a small instrument to scrape tissue from the canal of the cervix, an area which can’t be seen with colposcopy.
  • Cone biopsy (conization): A larger, cone-shaped piece of tissue is removed with a scalpel, laser, electrocautery (heat), or loop electrosurgical excisional procedure (LEEP). With LEEP, the doctor removes tissue with a thin wire loop and a tightly controlled current of electricity. In some cases, a cone biopsy removes the entire cancer.

Staging Tests

If cervical cancer is confirmed, you’ll need tests to find the exact size and location of the cancer, and to check whether the cancer has spread to nearby structures or to distant parts of the body. This process is called "staging" the cancer. For instance, your doctor may scrape the lining of your uterus — a procedure called dilatation and curettage — to check whether cancer has spread to that organ. Your doctor may also do a pelvic exam under anesthesia, as well as have you undergo a chest X-ray, a viewing of the bladder and urethra (cystocopy), and a viewing of the rectum and lower large intestine (sigmoidoscopy). Depending on how advanced the cancer appears, a woman may also need a CT scan of the abdomen and pelvis, barium enema, and bone scans. Staging not only helps your doctor to determine whether cancer has spread, but also to plan your treatment.

Self care & Prevention

Preventing Cervical Cancer

Several measures can help reduce your risk of developing cervical cancer:

  • Stop smoking.
  • Minimize your number of sexual partners. It also helps if your current partner has had a small number of previous partners.
  • Use latex condoms, particularly if you or your partner has had previous partners.
  • Maintain good personal hygiene.
  • Have your first Pap smear soon after becoming sexually active, and every year thereafter.
  • Have regular gynecological checkups, including a Pap smear.
  • Look out for such warning signs as vaginal discharge, bleeding between periods, bleeding with intercourse, and painful intercourse. Seek medical advice promptly.

Self-Care Measures

Highly stressful situations can affect your immune system's ability to fight off disease. It's always a good idea to reduce stress in your life, especially when diagnosed with a serious, potentially life-threatening illness. Support groups and the support of friends and family may help.

After treatment

  • Consult your doctor before resuming intercourse, douching, or using tampons.
  • Your doctor will recommend frequent exams and Pap smears to look for early signs of recurrence.
  • If your ovaries have stopped functioning as a result of treatment, your doctor may recommend estrogen replacement therapy.