Types of Cancer : Cervical Cancer

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Definition

Cervical cancer is one of the most common cancers that affect a woman's reproductive organs. Various strains of the human papillomavirus (HPV), a sexually transmitted infection, play a role in causing most cases of cervical cancer.

When exposed to HPV, a woman's immune system typically prevents the virus from doing harm. In a small group of women, however, the virus survives for years before it eventually converts some cells on the surface of the cervix into cancer cells. Cervical cancer occurs most often in women over age 30.

Thanks largely to Pap test screening, the death rate from cervical cancer has decreased greatly over the last 50 years. And today, most cases of cervical cancer can be prevented with a vaccine for young women.

Symptoms

You may not experience any cervical cancer symptoms — early cervical cancer generally produces no signs or symptoms. This is why regular screening is so important. As the cancer progresses, the following signs and symptoms of more advanced cervical cancer may appear:

• Vaginal bleeding after intercourse, between periods or after menopause
• Watery, bloody vaginal discharge that may be heavy and have a foul odor
• Pelvic pain or pain during intercourse

When to see a doctor
If you experience any unusual bleeding between periods or pain during intercourse, make an appointment with your doctor.

Talk to your doctor about when to begin screening for cervical cancer, how often the screening needs to be done and when do you no longer need to be screened. The American College of Obstetricians and Gynecologists recommends that girls have their first visit with an obstetrician-gynecologist between ages 13 and 15 to discuss sexual activity and ways to prevent sexually transmitted infections, including HPV.

Causes

In general, cancer begins when healthy cells acquire a genetic mutation that turns normal cells into abnormal cells. Healthy cells grow and multiply at a set rate, eventually dying at a set time. Cancer cells grow and multiply out of control, and they don't die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from an initial tumor to spread elsewhere in the body (metastasize).

There are two main types of cervical cancer:

• Squamous cell carcinomas begin in the thin, flat cells that line the bottom of the cervix (squamous cells). This type accounts for 80 to 90 percent of cervical cancers.
• Adenocarcinomas occur in the glandular cells that line the upper portion of the cervix. These cancers make up 10 to 20 percent of cervical cancers.

Sometimes both types of cells are involved in cervical cancer. Very rare cancers can occur in other cells in the cervix.

What causes squamous cells or glandular cells to become abnormal and develop into cancer isn't clear. However, it's certain that the sexually transmitted infection called human papillomavirus (HPV) plays a role. Evidence of HPV is found in nearly all cervical cancers. However, HPV is a very common virus and most women with HPV never develop cervical cancer. This means other risk factors, such as your genetic makeup, your environment or your lifestyle choices, also determine whether you'll develop cervical cancer.

Risk factors

These factors may increase your risk of cervical cancer:

• Many sexual partners. The greater your number of sexual partners — and the greater your partner's number of sexual partners — the greater your chance of acquiring HPV.
• Early sexual activity. Having sex before age 18 increases your risk of HPV. Immature cells seem to be more susceptible to the precancerous changes that HPV can cause.
• Other sexually transmitted diseases (STDs). If you have other STDs — such as chlamydia, gonorrhea, syphilis or HIV/AIDS — the greater your chance is of also having HPV.
• A weak immune system. Most women who are infected with HPV never develop cervical cancer. However, if you have an HPV infection and your immune system is weakened by another health condition, you may be more likely to develop cervical cancer.
• Cigarette smoking. The exact mechanism that links cigarette smoking to cervical cancer isn't known, but tobacco use increases the risk of precancerous changes as well as cancer of the cervix. Smoking and HPV infection may work together to cause cervical cancer.

Complications

Treatments for invasive cervical cancer often make it impossible to become pregnant in the future. For many women — especially younger women and those who have yet to begin a family — infertility is a distressing side effect of treatment. If you're concerned about your ability to get pregnant in the future, discuss this with your doctor.

For a specific subgroup of women with early cervical cancer, fertility-sparing surgery may be a treatment option. A surgical procedure to remove only your cervix and surrounding lymphatic tissue (radical trachelectomy) may preserve your uterus.

Studies of radical trachelectomy suggest that cervical cancer can be cured using this technique, though it isn't appropriate for every woman and there may be added risks to this surgery. Future pregnancies are possible, but must be managed carefully because removing the cervical tissue can lead to a higher incidence of miscarriage and premature birth.

Tell your doctor about your concerns about infertility before your treatment begins. In most cases, preserving fertility is more successful than trying to restore fertility after treatment.

Preparing for your appointment

Most cases of cervical cancer are detected during routine Pap tests. The most important thing you can to do prevent cervical cancer is to follow the recommended screening guidelines for your age group. For most young women, this means seeing your doctor for a Pap test every one to three years. Ask your doctor if you're not sure how often you should be screened for cervical cancer.

If you have pain during intercourse or any unusual bleeding — such as between periods, after sex or after menopause — call your doctor.

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down your medical history, including other conditions with which you've been diagnosed.
• Note any personal history that increased your risk of sexually transmitted disease, such as early sexual activity, multiple partners or unprotected sex.
• Make a list of your medications. Include any prescription or over-the-counter medications you're taking, as well as all vitamins, supplements and herbal remedies.
• Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Below are some basic questions to ask your doctor about cervical cancer. If any additional questions occur to you during your visit, don't hesitate to ask.

• Do I have cervical cancer?
• Has my cancer spread?
• What treatment approach do you recommend?
• What are the possible side effects or complications of this treatment?
• Am I at risk of this condition recurring?
• How often will I need follow-up visits after I finish treatment?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:

• What are your symptoms?
• When did you first notice these symptoms?
• Have your symptoms changed over time?
• Have you had regular Pap tests since you became sexually active?
• Have you ever had abnormal Pap test results in the past?
• Have you ever been treated for a cervical condition in the past?
• Have you been diagnosed with any sexually transmitted diseases?
• Have you been diagnosed with any other medical conditions?
• Have you ever taken medications that suppress your immune system?
• Do you or did you smoke? How much?
• Do you want to have children in the future?

Tests and diagnosis

Screening
Each year more than 10,000 women in the United States are diagnosed with invasive cervical cancer, and nearly 4,000 die of the disease. Most of these deaths could be prevented if all women received recommended screening.

Most guidelines suggest beginning screening within three years of becoming sexually active, or no later than age 21. Screening may include:

• Pap test. During a Pap test, your doctor brushes cells from your cervix — the narrow neck of the uterus — and sends the sample to a lab to be examined for abnormalities.

  A Pap test can detect abnormal cells in the cervix. This is the precancerous stage, when the abnormal cells (dysplasia) exist only in the outer layer of the cervix and haven't invaded deeper tissues. If untreated, the abnormal cells may convert to cancer cells, which may spread in various stages into the cervix, the upper vagina and the pelvic areas and to other parts of your body. Cancer or precancerous conditions that are caught at the pre-invasive stage are rarely life-threatening and typically require only outpatient treatment.

• HPV DNA test. Your doctor also may use a lab test called the HPV DNA test to determine whether you are infected with any of the 13 types of HPV that are most likely to lead to cervical cancer. Like the Pap test, the HPV DNA test involves collecting cells from the cervix for lab testing. It can detect high-risk strains of HPV in cell DNA before changes to the cells of the cervix can be seen.

  The HPV DNA test isn't a substitute for regular Pap screening, and it's not used to screen women younger than 30 with normal Pap results. Most HPV infections in women of this age group clear up on their own and aren't associated with cervical cancer.

Diagnosis
If you experience signs and symptoms of cervical cancer or if a Pap test has revealed cancerous cells, you may undergo further tests to diagnose your cancer. To make a diagnosis, your doctor may:

• Examine your cervix. During an exam called colposcopy, your doctor uses a special microscope (colposcope) to examine your cervix for abnormal cells. If unusual areas are identified, your doctor may take a small sample of cells for analysis (biopsy).
• Take a sample of cervical cells. During a biopsy procedure your doctor removes a sample of unusual cells from your cervix using special tools. During one type of biopsy — punch biopsy — your doctor uses a circular knife to remove a small circular section of the cervix. Other special types of biopsy may be used depending on the location and size of the unusual area of cells.
• Remove a cone-shaped area of cervical cells. A cone biopsy (conization) — so called because it involves taking a cone-shaped sample of the cervix — allows your doctor to obtain deeper layers of cervical cells for laboratory testing. Your doctor may use a scalpel, laser or electrified wire loop to remove the tissue.

Staging
If your doctor determines that you have cervical cancer, you'll undergo further tests to determine whether your cancer has spread and to what extent — a process called staging. Your cancer's stage is a key factor in deciding on your treatment. Staging exams include:

• Imaging tests. Tests such as X-rays, computerized tomography (CT) scans and magnetic resonance imaging (MRI) help your doctor determine whether your cancer has spread beyond your cervix.
• Visual examination of your bladder and rectum. Your doctor may use special scopes to see inside your bladder (cystoscopy) and rectum (proctoscopy).

Your doctor then assigns your cancer a stage — typically a Roman numeral. Stages of cervical cancer include:

• Stage 0. Also called carcinoma in situ or noninvasive cancer, this early cancer is small and confined to the surface of the cervix.
• Stage I. Cancer is confined to the cervix.
• Stage II. Cancer at this stage includes the cervix and uterus, but hasn't spread to the pelvic wall or the lower portion of the vagina.
• Stage III. Cancer at this stage has moved beyond the cervix and uterus to the pelvic wall or the lower portion of the vagina.
• Stage IV. At this stage, cancer has spread to nearby organs, such as the bladder or rectum, or it has spread to other areas of the body, such as the lungs, liver or bones.

Treatments and drugs

Limited, noninvasive cancer
Treatment of cervical cancer that's confined to the outside layer of the cervix typically requires treatment to remove the abnormal area of cells. For most women in this situation, no additional treatments are needed. Procedures to remove noninvasive cancer include:

• Cone biopsy (conization). During this surgery, the doctor uses a scalpel to remove a cone-shaped piece of cervical tissue where the abnormality is found.
• Laser surgery. This operation uses a narrow beam of intense light to kill cancerous and precancerous cells.
• Loop electrosurgical excision procedure (LEEP). This technique uses a wire loop to pass electrical current, which cuts like a surgeon's knife, and remove cells from the mouth of the cervix.
• Cryosurgery. This technique involves freezing and killing cancerous and precancerous cells.
• Hysterectomy. This major surgery involves removal of the cancerous and precancerous areas, the cervix and the uterus. Hysterectomy is usually done only in certain selected cases of noninvasive cervical cancer.

Invasive cancers
Cervical cancer that invades deeper than the outside layer of cells on the cervix is referred to as invasive cancer and requires more extensive treatment. Treatment for cervical cancer depends on several factors, such as the stage of the cancer, other health problems you may have and your own preferences about treatment. Treatment options may include:

• Surgery. Surgery to remove the uterus (hysterectomy) is typically used to treat the early stages of cervical cancer. A simple hysterectomy involves the removal of the cancer, the cervix and the uterus. Simple hysterectomy is typically an option only when the cancer is very early stage — invasion is less than 3 millimeters (mm) into the cervix. A radical hysterectomy — removal of the cervix, uterus, part of the vagina and lymph nodes in the area — is the standard surgical treatment when there's an invasion of greater than 3 mm into the cervix and no evidence of tumor on the walls of the pelvis.

  Hysterectomy can cure early-stage cervical cancers and prevent cancer from coming back, but removing the uterus makes it impossible to become pregnant. Expect about six weeks of recovery time. Temporary side effects of radical hysterectomy include pelvic pain and difficulty with bowel movements and urination.

• Radiation. Radiation therapy uses high-powered energy to kill cancer cells. Radiation therapy can be given externally using external beam radiation or internally (brachytherapy) by placing devices filled with radioactive material near your cervix. Radiation therapy is as effective as surgery for early-stage cervical cancer. For women with more advanced cervical cancer, radiation combined with cisplatin-based chemotherapy is considered the most effective treatment.

  Side effects of radiation to the pelvic area include upset stomach, nausea, diarrhea, bladder irritation and narrowing of your vagina, which can make intercourse difficult. Premenopausal women may stop menstruating as a result of radiation therapy and begin menopause.

• Chemotherapy. Chemotherapy uses strong anti-cancer medications to kill cancer cells. Chemotherapy drugs, which can be used alone or in combination with each other, are usually injected into a vein and they travel throughout your body killing quickly growing cells, including cancer cells. The chemotherapy drug called cisplatin is often combined with radiation therapy to enhance overall treatment effectiveness. Side effects of chemotherapy depend on the drugs, but generally include diarrhea, fatigue, nausea and hair loss. Certain chemotherapy drugs may cause infertility and early menopause in premenopausal women.