Cervical cancer
Cervical cancer is a disease in which malignant (cancer) cells form in the tissues of
the cervix.
The cervix is the lower, narrow end of the uterus (the hollow, pear-shaped organ where a fetus grows).
The cervix leads from the uterus to the vagina (birth canal).
Cervical cancer usually develops slowly over time. Before cancer appears in the cervix, the cells of the
cervix go through changes known as dysplasia, in which cells that are not normal begin to appear in the
cervical tissue. Later, cancer cells start to grow and spread more deeply into the cervix and to
surrounding areas.
Cervical cancer in children is rare.
Infection of the cervix with human papillomavirus (HPV) is the most common cause of cervical cancer.
Not all women with HPV infection, however, will develop cervical cancer. Women who do not regularly
have a Pap smear to detect HPV or abnormal cells in the cervix are at increased risk of cervical cancer.
Other possible risk factors include the following:
- Giving birth to many children.
- Having many sexual partners.
- Having first sexual intercourse at a young age.
- Smoking cigarettes.
- Oral contraceptive use ("the Pill").
- Weakened immune system.
There are usually no noticeable signs of early cervical cancer but it can be detected
early with yearly check-ups.
Early cervical cancer may not cause noticeable signs or symptoms. Women should have yearly checkups,
including a Pap smear to check for abnormal cells in the cervix. The prognosis (chance of recovery)
is better when the cancer is found early.
Possible signs of cervical cancer include vaginal bleeding and pelvic pain.
These and other symptoms may be caused by cervical cancer. Other conditions may cause the same
symptoms. A doctor should be consulted if any of the following problems occur:
- Vaginal bleeding.
- Unusual vaginal discharge.
- Pelvic pain.
- Pain during sexual intercourse.
Tests that examine the cervix are used to detect (find) and diagnose cervical cancer.
The following procedures may be used:
- Pap smear: A procedure to collect cells from the surface of the cervix and vagina. A piece of
cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina.
The cells are viewed under a microscope to find out if they are abnormal. This procedure is also
called a Pap test.
- Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to
check the vagina and cervix for abnormal areas. Tissue samples may be taken using a curette
(spoon-shaped instrument) and checked under a microscope for signs of disease.
- Biopsy: If abnormal cells are found in a Pap smear, the doctor may do a biopsy. A sample of
tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of
cancer. A biopsy that removes only a small amount of tissue is usually done in the doctor’s office. A
woman may need to go to a hospital for a cervical cone biopsy (removal of a larger, cone-shaped
sample of cervical tissue).
- Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. The
doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and places
the other hand over the lower abdomen to feel the size, shape, and position of the uterus and
ovaries. A speculum is also inserted into the vagina and the doctor or nurse looks at the vagina and
cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts
a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
- Endocervical curettage: A procedure to collect cells or tissue from the cervical canal using a
curette (spoon-shaped instrument). Tissue samples may be taken and checked under a microscope
for signs of cancer. This procedure is sometimes done at the same time as a colposcopy.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) depends on the following:
- The stage of the cancer (whether it affects part of the cervix, involves the whole cervix, or has
spread to the lymph nodes or other places in the body).
- The type of cervical cancer.
- The size of the tumor.
Treatment options depend on the following:
- The stage of the cancer.
- The size of the tumor.
- The patient's desire to have children.
- The patient’s age.
Treatment of cervical cancer during pregnancy depends on the stage of the cancer and the stage of the
pregnancy. For cervical cancer found early or for cancer found during the last trimester of pregnancy,
treatment may be delayed until after the baby is born.
After cervical cancer has been diagnosed, tests are done to find out if cancer cells
have spread within the cervix or to other parts of the body.
The process used to find out if cancer has spread within the cervix or to other parts of the body is called
staging. The information gathered from the staging process determines the stage of the disease. It is
important to know the stage in order to plan treatment. The following tests and procedures may be used
in the staging process:
- Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam
that can go through the body and onto film, making a picture of areas inside the body.
- CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the
body, taken from different angles. The pictures are made by a computer linked to an x-ray machine.
A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly.
This procedure is also called computed tomography, computerized tomography, or computerized
axial tomography.
- Lymphangiogram: A procedure used to x-ray the lymph system. A dye is injected into the lymph
vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels, and x-rays
are taken to see if there are any blockages. This test helps find out whether cancer has spread to
the lymph nodes.
- Pretreatment surgical staging: Surgery (an operation) is done to find out if the cancer has spread
within the cervix or to other parts of the body. In some cases, the cervical cancer can be removed at
the same time. Pretreatment surgical staging is usually done only as part of a clinical trial.
- Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off
internal tissues or organs and make echoes. The echoes form a picture of body tissues called a
sonogram.
- MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a
computer to make a series of detailed pictures of areas inside the body. This procedure is also
called nuclear magnetic resonance imaging (NMRI).
The results of these tests are viewed together with the results of the original tumor biopsy to determine
the cervical cancer stage.
There are three ways that cancer spreads in the body.
The three ways that cancer spreads in the body are:
- Through tissue. Cancer invades the surrounding normal tissue.
- Through the lymph system. Cancer invades the lymph system and travels through the lymph
vessels to other places in the body.
- Through the blood. Cancer invades the veins and capillaries and travels through the blood to
other places in the body.
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to
other places in the body, another (secondary) tumor may form. This process is called metastasis. The
secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast
cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease
is metastatic breast cancer, not bone cancer.
The following Stages are used for cervical cancer:
Stage 0 (Carcinoma in Situ)
In Stage 0, abnormal cells are found in the innermost lining of the cervix. These abnormal cells may
become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Stage I
Millimeters (mm). A sharp pencil point is about 1 mm, a new crayon point is about 2 mm, and a new pencil
eraser is about 5 mm.
In Stage I, cancer has formed and is found in the cervix only. Stage I is divided into Stages IA and IB,
based on the amount of cancer that is found.
- Stage IA: A very small amount of cancer that can only be seen with a microscope is found in the
tissues of the cervix. Stage IA is divided into Stages IA1 and IA2, based on the size of the tumor.
- In Stage IA1, the cancer is not more than 3 millimeters deep and not more than 7
millimeters wide.
- In Stage IA2, the cancer is more than 3 but not more than 5 millimeters deep, and not
more than 7 millimeters wide.
Stage IB: In Stage IB, cancer can only be seen with a microscope and is more than 5 millimeters
deep or more than 7 millimeters wide, or can be seen without a microscope. Cancer that can be
seen without a microscope is divided into Stages IB1 and IB2, based on the size of the tumor.
- In Stage 1B1, the cancer can be seen without a microscope and is not larger than 4
centimeters.
- In Stage 1B2, the cancer can be seen without a microscope and is larger than 4
centimeters.
Stage II
In Stage II, cancer has spread beyond the cervix but not to the pelvic wall (the tissues that line the part of
the body between the hips) or to the lower third of the vagina. Stage II is divided into stages IIA and IIB,
based on how far the cancer has spread.
- Stage IIA: Cancer has spread beyond the cervix to the upper two thirds of the vagina but not to
tissues around the uterus.
- Stage IIB: Cancer has spread beyond the cervix to the upper two thirds of the vagina and to the
tissues around the uterus.
Stage III
In Stage III, cancer has spread to the lower third of the vagina, may have spread to the pelvic wall, and/or
has caused the kidney to stop working. Stage III is divided into Stages IIIA and IIIB, based on how far the
cancer has spread.
- Stage IIIA: Cancer has spread to the lower third of the vagina but not to the pelvic wall.
- Stage IIIB: Cancer has spread to the pelvic wall and/or the tumor has become large enough to
block the ureters (the tubes that connect the kidneys to the bladder). This blockage can cause the
kidneys to enlarge or stop working. Cancer cells may also have spread to lymph nodes in the pelvis.
Stage IV
In Stage IV, cancer has spread to the bladder, rectum, or other parts of the body. Stage IV is divided into
Stages IVA and IVB, based on where the cancer is found.
- Stage IVA: Cancer has spread to the bladder or rectal wall and may have spread to lymph nodes
in the pelvis.
- Stage IVB: Cancer has spread beyond the pelvis and pelvic lymph nodes to other places in the
body, such as the abdomen, liver, intestinal tract, or lungs.
Recurrent Cervical Cancer
Recurrent cervical cancer is cancer that has recurred (come back) after it has been treated. The cancer
may come back in the cervix or in other parts of the body.
There are different types of treatment for patients with cervical cancer.
Different types of treatment are available for patients with cervical cancer. Some treatments are standard
(the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a
research study meant to help improve current treatments or obtain information on new treatments for
patients with cancer. When clinical trials show that a new treatment is better than the standard treatment,
the new treatment may become the standard treatment. Patients may want to think about taking part in a
clinical trial. Some clinical trials are open only to patients who have not started treatment.
Three types of standard treatment are used:
Surgery
Surgery (removing the cancer in an operation) is sometimes used to treat cervical cancer. The following
surgical procedures may be used:
- Conization: A procedure to remove a cone-shaped piece of tissue from the cervix and cervical
canal. A pathologist views the tissue under a microscope to look for cancer cells. Conization may be
used to diagnose or treat a cervical condition. This procedure is also called a cone biopsy.
- Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix
are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and
cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total
abdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the
abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
- Bilateral salpingo-oophorectomy: Surgery to remove both ovaries and both fallopian tubes.
- Radical hysterectomy: Surgery to remove the uterus, cervix, and part of the vagina. The ovaries,
fallopian tubes, or nearby lymph nodes may also be removed.
- Pelvic exenteration: Surgery to remove the lower colon, rectum, and bladder. In women, the
cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are
made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to
make an artificial vagina after this operation.
- Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as
carcinoma in situ. This type of treatment is also called cryotherapy.
- Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a
knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
- Loop electrosurgical excision procedure (LEEP): A treatment that uses electrical current passed
through a thin wire loop as a knife to remove abnormal tissue or cancer.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill
cancer cells or keep them from growing. There are two types of radiation therapy. External radiation
therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy
uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or
near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer
being treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing
the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein
or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic
chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity
such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The
way the chemotherapy is given depends on the type and stage of the cancer being treated.
New types of treatment are being tested in clinical trials.
This summary section describes treatments that are being studied in clinical trials. It may not mention every new
treatment being studied.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of
the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and
effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part
in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even
when clinical trials do not lead to effective new treatments, they often answer important questions and
help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer
treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments
for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop
cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be
repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about
whether to continue, change, or stop treatment may be based on the results of these tests. This is
sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of
these tests can show if your condition has changed or if the cancer has recurred (come back). These
tests are sometimes called follow-up tests or check-ups.
Treatment Options by Stage
Stage 0 (Carcinoma in Situ)
Treatment of Stage 0 may include the following:
- Loop electrosurgical excision procedure (LEEP).
- Laser surgery.
- Conization.
- Cryosurgery.
- Total hysterectomy for women who cannot or no longer want to have children.
- Internal radiation therapy for women who cannot have surgery.
Stage IA Cervical Cancer
Treatment of Stage IA cervical cancer may include the following:
- Total hysterectomy with or without bilateral salpingo-oophorectomy.
- Conization.
- Radical hysterectomy and removal of lymph nodes.
- Internal radiation therapy.
Stage IB Cervical Cancer
Treatment of Stage IB cervical cancer may include the following:
- A combination of internal radiation therapy and external radiation therapy.
- Radical hysterectomy and removal of lymph nodes.
- Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus
chemotherapy.
- Radiation therapy plus chemotherapy.
- A clinical trial of high- dose internal radiation therapy combined with external radiation therapy.
Stage IIA Cervical Cancer
Treatment of Stage IIA cervical cancer may include the following:
- A combination of internal radiation therapy and external radiation therapy.
- Radical hysterectomy and removal of lymph nodes.
- Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus
chemotherapy.
- Radiation therapy plus chemotherapy.
- A clinical trial of high- dose internal radiation therapy combined with external radiation therapy.
Stage IIB Cervical Cancer
Treatment of Stage IIB cervical cancer may include internal and external radiation therapy combined with
chemotherapy.
Stage III Cervical Cancer
Treatment of Stage III cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Stage IVA Cervical Cancer
Treatment of Stage IVA cervical cancer may include internal and external radiation therapy combined with
chemotherapy.
Stage IVB Cervical Cancer
Treatment of Stage IVB cervical cancer may include the following:
- Radiation therapy as palliative therapy to relieve symptoms caused by the cancer and improve
quality of life.
- Chemotherapy.
- Clinical trials of new anticancer drugs or drug combinations.
Treatment Options for Recurrent Cervical Cancer
Treatment of recurrent cervical cancer may include the following:
- Pelvic exenteration followed by radiation therapy combined with chemotherapy.
- Chemotherapy as palliative therapy to relieve symptoms caused by the cancer and improve
quality of life.
- Clinical trials of new anticancer drugs or drug combinations
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