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Cervical Cancer

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General Information About 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.

Human papillomavirus (HPV) infection is the major risk factor for development of cervical cancer.

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.
  • A diet lacking in vitamins A and C.
  • 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 check-ups, 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 or by other conditions. 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 to look inside the vagina and cervix for abnormal areas. A colposcope (a thin, lighted tube) is inserted through the vagina into the cervix. Tissue samples may be taken for biopsy.

  • 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. A biopsy that removes only a small amount of tissue is usually done in the doctorís 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 the other hand is placed 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 or Pap smear 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 for biopsy. 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 patientís 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.

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Stages of Cervical Cancer

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: 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.

The following stages are used for cervical cancer:

Stage 0 (Carcinoma in Situ)

In stage 0, cancer is found in the first layer of cells lining the cervix only and has not invaded the deeper tissues of the cervix. Stage 0 is also called carcinoma in situ.

Stage I

In stage I, cancer 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. The cancer is not deeper than 5 millimeters and not wider than 7 millimeters.

  • Stage IB: In stage IB, cancer is still within the cervix and either:
    • can only be seen with a microscope and is deeper than 5 millimeters or wider than 7 millimeters; or
    • can be seen without a microscope and may be 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). 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 and may have spread to the pelvic wall and nearby lymph nodes. 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.

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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.

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Treatment Option Overview

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. Before starting treatment, patients may want to think about taking part in a clinical trial. 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.

Clinical trials are taking place in many parts of the country. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

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.

  • Hysterectomy: A surgical procedure to remove the uterus and 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: A surgical procedure to remove both ovaries and both fallopian tubes.

  • Radical hysterectomy: A surgical procedure to remove the uterus, cervix, and part of the vagina. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed.

  • Pelvic exenteration: A surgical procedure 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. 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 the cells 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.

Other types of treatment are being tested in clinical trials.

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Treatment Options by Stage

Stage 0 Cervical Cancer (Carcinoma in Situ)

Treatment of stage 0 cervical cancer may include the following:

  • Loop electrosurgical excision procedure (LEEP).
  • Laser surgery.
  • Conization.
  • Cryosurgery.
  • 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:

  • 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.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site.

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.

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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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Cervical Cancer