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Cervical Cancer

 

There were approximately 12,000 cases of cervical cancer diagnosed in the United States in 2008, and about 4,000 women died of it.


What it is

Cervical cancer is cancer of the cervix (the lower part of the uterus). The uterus is a muscular organ located in the pelvic cavity of females in which the fertilized egg implants and develops. It is also called the womb.that connects to the vagina. The vagina is a 3- to 4-inch tube. Its upper part ends at the cervix and the lower part opens to the outside onto the vulva, the external female genitals.). It is usually a slow-growing cancer that may not have symptoms but can be found with regular Pap tests (a procedure in which cells are scraped from the cervix and looked at under a microscope).

Growths on the cervix can be
benign (polyps, cysts, genital warts)—rarely a threat to life, don't invade the tissues around them—or malignant (cervical cancer). Although cervical cancer begins in cells on the surface of the cervix, over time, it can invade more deeply into the cervix and nearby tissues. The cancer cells can spread by breaking away from the original (primary) tumor. They enter blood vessels or lymph vessels, which branch into all the tissues of the body. The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.

Who's at risk?

Unlike other cancers, cervical cancer is not passed down through family genes. Infection with certain types of human papillomavirus or HPV is the cause of nearly all cases of cervical cancer. HPV infection and other risk factors may act together to increase the risk even more:

  • HPV infection  HPV infections are very common. These viruses are passed from person to person through sexual contact. Most adults have been infected with HPV at some time in their lives, but most infections clear up on their own.



    Some types of HPV can cause changes to cells in the cervix. If these changes are found early, cervical cancer can be prevented by removing or killing the changed cells before they can become cancer cells.



    Now, a vaccine called Gardasil for females ages 9 to 26 can help protect against two types of HPV infection that cause 70 percent of cervical cancer.
  • Lack of regular Pap tests Cervical cancer is more common among women who don't have regular Pap tests. The Pap test helps doctors find abnormal cells. Removing or killing the abnormal cells usually prevents cervical cancer.
  • Smoking Among women who are infected with HPV, smoking cigarettes slightly increases the risk of cervical cancer.
  • Weakened immune system (the body's natural defense system) Infection with HIV (the virus that causes AIDS) or taking drugs that suppress the immune system increases the risk of cervical cancer.
  • Sexual history Women who have had many sexual partners have a higher risk of developing cervical cancer. Also, a woman who has had sex with a man who has had many sexual partners may be at higher risk of developing cervical cancer. In both cases, the risk of developing cervical cancer is higher because these women have a higher risk of HPV infection.
  • Using birth control pills for a long time Using birth control pills for five years or more may slightly increase the risk of cervical cancer among women with HPV infection. However, the risk decreases quickly when women stop taking the Pill.
  • Having many children Studies suggest that giving birth to five or more children may slightly increase the risk of cervical cancer among women with HPV infection.
  • DES (diethylstilbestrol) DES may increase the risk of a rare form of cervical cancer in daughters exposed to this drug before birth. DES was given to some pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.)

Having an HPV infection or other risk factors does not mean that a woman will develop cervical cancer. Most women who have risk factors for cervical cancer never develop it.

Symptoms

Precancerous lesions generally are not accompanied by any symptoms.  But once cancer has developed, women may notice one or more of these symptoms:

  • Abnormal vaginal bleeding
    • Bleeding that occurs between regular menstrual periods
    • Bleeding after sexual intercourse, douching, or a pelvic exam
    • Menstrual periods that last longer and are heavier than before
    • Bleeding after menopause
  • Increased vaginal discharge
  • Pelvic pain
  • Pain during sex

Infections or other health problems may also cause these symptoms. Only a doctor can tell for sure.

Detection and Diagnosis

Doctors recommend that women help reduce their risk of cervical cancer by having regular Pap tests. A Pap test (sometimes called Pap smear or cervical smear) is a simple test used to look at cervical cells. Pap tests can detect cervical cancer or abnormal cell changes that can lead to cervical cancer.

Finding and treating abnormal cells can prevent most cervical cancer. Also, the Pap test can help find cancer early, when treatment is more likely to be effective. The test should be done every year with a standard Pap smear, or every two years using a liquid-based test (such as ThinPrep), according to new guidelines from the American Cancer Society (ACS).

If you're 30 or older and have had three normal test results in a row, you may get screened every two to three years with your doctor's approval; recently, the U.S. Food & Drug Administration approved combining a Pap smear and an HPV test for women in this age group. That's because if you're diagnosed with HPV when you're older, you're more likely to have a strain of the virus that won't go away on its own and may lead to cancer, so you'll need to be monitored more regularly. If you're under 30, however, HPV tests are not useful, because HPV is so common in young women.

For most women, the Pap test is not painful. It's done in a doctor's office or clinic during a pelvic exam. The doctor or nurse scrapes a sample of cells from the cervix. A lab checks the cells under a microscope for cell changes. Most often, abnormal cells found by a Pap test are not cancerous. The same sample of cells may be tested for HPV infection.

If you have abnormal Pap or HPV test results, your doctor will suggest other tests to make a diagnosis:

  • ColposcopyThe doctor uses a colposcope, which combines a bright light with a magnifying lens, to look at the cervix. It is not inserted into the vagina. A colposcopy is usually done in the doctor's office or clinic.
  • Biopsy Most women have tissue removed in the doctor's office with local anesthesia. A pathologist checks the tissue under a microscope for abnormal cells. Types of biopsy:
    • Punch biopsy involves the use of a sharp tool to pinch off small samples of cervical tissue.
    • LEEP involves the use of an electric wire loop to slice off a thin, round piece of cervical tissue.
    • Endocervical curettage scrapes a  small sample of tissue from the cervix with a curette (a small, spoon-shaped instrument). Some doctors use a thin, soft brush instead of a curette.
    • Conizationinvolves the removal of a cone-shaped sample of tissue. A conization, or cone biopsy, lets the pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. The doctor may do this test in the hospital under general anesthesia.

Removing tissue from the cervix may cause some bleeding or other discharge. The area usually heals quickly. Some women also feel some pain similar to menstrual cramps.

Staging

If the biopsy shows that you have cancer, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. Staging is a careful attempt to find out whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body. Cervical cancer spreads most often to nearby tissues in the pelvis, lymph nodes, or lungs. It may also spread to the liver or bones.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of cancer cells and the same name as the original tumor. For example, if cervical cancer spreads to the lungs, the cancer cells in the lungs are actually cervical cancer cells. The disease is metastatic cervical cancer, not lung cancer. For that reason, it's treated as cervical cancer, not lung cancer. Doctors call the new tumor "distant" or metastatic disease.

Your doctor will do a pelvic exam, feel for swollen lymph nodes, and may remove additional tissue. To learn the extent of disease, the doctor may order some of the following tests:

  • Chest x-rays often can show whether cancer has spread to the lungs.
  • CT scan involves using an x-ray machine linked to a computer to takesa series of detailed pictures of your organs. A tumor in the liver, lungs, or elsewhere in the body can show up on the CT scan. You may receive contrast material by injection in your arm or hand, by mouth, or by enema. The contrast material makes abnormal areas easier to see.
  • MRI links a powerful magnet to a computer to make detailed pictures of your pelvis and abdomen. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether cancer has spread. Sometimes contrast material makes abnormal areas show up more clearly on the picture.
  • PET scan requires the injection of a small amount of radioactive sugar. A machine creates computerized pictures of the sugar being used by cells in your body. Cancer cells use sugar faster than normal cells, and areas with cancer look brighter on the pictures.

The stage is based on where cancer is found. These are the stages of invasive cervical cancer:

  • Stage I: The tumor has invaded the cervix beneath the top layer of cells. Cancer cells are found only in the cervix.
  • Stage II: The tumor extends to the upper part of the vagina. It may extend beyond the cervix into nearby tissues toward the pelvic wall(the lining of the part of the body between the hips). The tumor does not invade the lower third of the vagina or the pelvic wall.
  • Stage III: The tumor extends to the lower part of the vagina. It may also have invaded the pelvic wall. If the tumor blocks the flow of urine, one or both kidneys may not be working well.
  • Stage IV: The tumor invades the bladder or rectum. Or the cancer has spread to other parts of the body.
  • Recurrent cancer: The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body.

Treatment

The good news is that most significant abnormalities are detected by screening and treated before cancer develops. When cervical lesions are still precancerous, they are virtually 100 percent treatable.  A combination of therapies may be used for invasive cervical cancer, such as surgery (hysterectomy), chemotherapy and/or radiation. The five-year relative survival rate for the earliest stage of invasive cervical cancer is 92 percent. For advanced invasive cervical cancer, the rate drops to about 16 percent. The overall (all stages combined) five-year survival rate for the disease is about 71 percent, according to the ACS.

Surgery

Surgery is an option for women with Stage I or II cervical cancer. The surgeon removes tissue that may contain cancer cells in the following ways:

  • Radical trachelectomy is removal of the cervix, part of the vagina, and the lymph nodes in the pelvis. This option is appropriate for a small number of women with small tumors who want to try to get pregnant later on.
  • Total hysterectomy is removal of the cervix and uterus.
  • Radical hysterectomyis removal of the cervix, some tissue around the cervix, the uterus, and part of the vagina.

With either total or radical hysterectomy, the surgeon may perform a salpingo-oophorectomy to remove the fallopian tubes and ovaries. He or she may also remove the lymph nodes near the tumor to see if they contain cancer. If cancer cells have reached the lymph nodes, it means the disease may have spread to other parts of the body.

Post-op

The time it takes to heal after surgery is different for each woman. You may have pain or discomfort for the first few days. Medication can help. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan.

After a radical trachelectomy, some women have bladder problems for a few days. The hospital stay usually is about 2 to 5 days.

After a hysterectomy, the length of the hospital stay may vary from several days to a week. It is common to feel tired or weak for a while. You may have problems with nausea and vomiting, and you may have bladder and bowel problems. The doctor may restrict your diet to liquids at first, with a gradual return to solid food. Most women return to their normal activities within 4 to 8 weeks after surgery.

When the ovaries are removed, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. You may wish to discuss this with your doctor before surgery. Some drugs have been shown to help with these symptoms, and they may be more effective if started before surgery.

For some women, a hysterectomy can affect sexual intimacy. You may have feelings of loss that make intimacy difficult. Sharing these feelings with your partner or a couples counselor may be helpful.

Radiation therapy

Radiation therapy (also called radiotherapy) is an option for women with any stage of cervical cancer. Women with early stage cervical cancer may choose radiation therapy instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. Women with cancer that extends beyond the cervix may have radiation therapy and chemotherapy

Radiation therapy uses high-energy rays to kill cancer cells and affects cells only in the treated area.

Doctors use two types of radiation therapy to treat cervical cancer. Some women receive both:

  • External radiation therapy A large machine directs radiation at your pelvis or other tissues where the cancer has spread. The treatment usually is given in a hospital or clinic. You may receive external radiation 5 days a week for several weeks. Each treatment takes only a few minutes.
  • Internal radiation therapyA thin tube is placed inside the vagina and a radioactive substance is loaded into the tube. You may need to stay in the hospital while the radioactive source is in place (up to 3 days). Or the treatment session may last a few minutes, and you can go home afterward. Once the radioactive substance is removed, no radioactivity is left in your body. Internal radiation may be repeated two or more times over several weeks.

Potential side effects

Side effects depend mainly on how much radiation is given and which part of your body is treated. Radiation to the abdomen and pelvis may cause nausea, vomiting, diarrhea, or urinary problems. You may lose hair in your genital area. Also, skin in the treated area may become red, dry, and tender.

You may also experience vaginal dryness, itching, or burning. Your doctor may advise you to wait to have sex until a few weeks after radiation treatment ends.

You are likely to become tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Although the side effects of radiation therapy can be upsetting, they can usually be treated or controlled. Talk with your doctor or nurse about ways to relieve discomfort.

It may also help to know that most side effects go away when treatment ends. However, you may wish to discuss with your doctor the possible long-term effects of radiation therapy. For example, radiation may narrow the vagina, making sex or follow-up exams difficult. There are ways to prevent this problem. If it does occur, however, your health care team can tell you about ways to expand the vagina.

Another long-term effect is that radiation aimed at the pelvic area can harm the ovaries. Menstrual periods usually stop, and women may have hot flashes and vaginal dryness. Menstrual periods are more likely to return for younger women. Women who may want to get pregnant after radiation therapy should ask their health care team about ways to preserve their eggs before treatment starts.

Chemotherapy

For the treatment of cervical cancer, chemotherapy is usually combined with radiation. For cancer that has spread to distant organs, chemotherapy alone may be used.

Chemotherapy uses drugs to kill cancer cells. The drugs for cervical cancer are usually given through a vein (intravenous). You may receive chemotherapy in a clinic, at the doctor's office, or at home. Some women need to stay in the hospital during treatment.

The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

  • Blood cells When chemotherapy lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of drug. There are also medicines that can help your body make new blood cells.
  • Cells in hair roots Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture.
  • Cells that line the digestive tract Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems.

Other side effects include skin rash, tingling or numbness in your hands and feet, hearing problems, loss of balance, joint pain, or swollen legs and feet. Your health care team can suggest ways to control many of these problems. Most go away when treatment ends.

Nutrition and physical activity

It's important for you to take care of yourself by eating well and staying as active as you can.

You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.

However, you may not feel like eating during or soon after treatment. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. Your doctor, a registered dietitian, or another health care provider can suggest ways to cope with these problems.

Research shows that people with cancer feel better when they stay active. Walking, yoga, swimming, and other activities can keep you strong and increase your energy. Exercise may reduce nausea and pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems, be sure to let your doctor or nurse know about it.

Follow-up care

You'll need regular checkups after treatment for cervical cancer. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, you should contact your doctor.

Your doctor will check for the return of cancer. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Checkups may include a physical exam, Pap tests, and chest x-rays.



Research

Doctors all over the country are conducting many types of clinical trials (research studies in which people volunteer to take part). They are studying new ways to treat cervical cancer. Some are also studying therapies that may improve the quality of life for women during or after cancer treatment.

Clinical trials are designed to answer important questions and to find out whether new approaches are safe and effective. Research already has led to advances in the prevention, diagnosis, and treatment of cervical cancer. Doctors continue to search for new and better ways to treat cervical cancer. They are testing new treatments, including new drugs, combinations, and schedules. Some trials are combining chemotherapy, surgery, and radiation therapy.

Doctors also are studying surgery to remove sentinel lymph nodes. A sentinel lymph node is the first lymph node to which the cancer is likely to spread. Today, surgeons often have to remove many lymph nodes and check each of them for cancer. But if the research shows that it's possible to identify the sentinel lymph node (the lymph node most likely to have cancer), doctors may be able to avoid more surgery to remove other lymph nodes.

Although clinical trials may pose some risks, researchers do all they can to protect their patients. If you are interested in taking part in a clinical trial, talk with your doctor or visit http://www.cancer.gov/clinicaltrials. NCI's Information Specialists at 1-800-4-CANCER or at LiveHelp at http://www.cancer.gov/help can answer questions and provide information about clinical trials as well.

Adapted from the National Cancer Institute (www.cancer.gov)

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