Cervical Cancer

What is Cancer of the Cervix?

The cervix is the lower part of the uterus (womb). The uterus has 2 parts. The upper part, called the body of the uterus, is where a baby grows. The cervix, in the lower part, connects the body of the uterus to the vagina, or birth canal.

Cancer of the cervix (also called "cervical cancer") begins in the lining of the cervix. This cancer forms slowly. First, some cells begin to change from normal to pre-cancer and then to cancer. This can take many years, but sometimes it happens faster. These changes are referred to by several terms, including dysplasia. For some women, the pre-cancer changes may go away without any treatment. More often, they need to be treated to keep them from changing into true cancers.

There are two main types of cancer of the cervix. About 80% to 90% are squamous cell carcinomas. The other 10%-20% are adenocarcinomas. If the cancer has features of both types it is called mixed carcinoma. If you have cervical cancer, ask your doctor to explain exactly what type of cancer you have.

What Causes Cancer of the Cervix?

Risk factors for cervical cancer

A risk factor is anything that affects a person's chance of getting a disease. Some risk factors, such as smoking, can be controlled. Others, like a person's age or race, can't be changed. Several risk factors increase a woman's chance of getting cervical cancer. Women without any of these risk factors rarely get cervical cancer. On the other hand, while these risk factors increase the odds of getting cervical cancer, many women with these risks do not get this disease.

In looking at risk factors, it helps to focus on those that can be changed. Still, those that can't be changed also serve to remind women about the importance of getting a Pap test. Risk factors for cervix cancer include:

Human papilloma virus (HPV) infection

For cervical cancer, the most important risk factor is infection with a virus known as HPV. HPV is really a group of more than 100 types of viruses that cause warts. Some types of HPV cause genital warts. Other types cause cancer of the cervix. The kinds that cause cancer are called "high-risk" HPVs. HPV is passed from one person to another by skin-to-skin contact during vaginal, anal, or oral sex. Having unprotected sex, especially at a young age, makes HPV infection more likely. Also, women who have many sex partners (or who have sex with men who have had many partners) have a greater chance of getting HPV.

Many women may have HPV, but very few of these women will ever get cervical cancer. In most cases the body fights off the virus, and the infection goes away without any treatment. But in some women, the infection persists and can cause cervical cancer. HPV occurs mainly in young women and is less common in women over 30. We don't know why this is so. Condoms (rubbers) may protect against HPV when they are used correctly, and it is important to use them because they do protect against AIDS and other sexual diseases.

The Pap test, and some newer tests, can find changes that point to HPV infection..While there is no cure for HPV, the abnormal cell growth they cause can be treated. Vaccines have been made that will prevent infection with some types of HPV. Right now, one vaccine, called Gardasil^®, has been approved for use by the FDA and more vaccines are being made and tested.

Even though HPV is an important risk factor for cervical cancer, most women with this infection do not get cervical cancer. Doctors believe other factors must come into play for this cancer to develop. Some of these factors are listed below.

Smoking

Women who smoke are about twice as likely to get cervical cancer as those who don't. Tobacco smoke can produce chemicals that may damage the DNA in cells of the cervix and make cancer more likely to occur.

HIV infection

HIV (human immunodeficiency virus is the virus that causes AIDS--it is not the same as HPV). It can also be a risk factor for cancer of the cervix. Being HIV positive seems to make a woman's immune system less able to fight both HPV and early cancers.

Chlamydia infection

This is a common kind of bacteria that can infect women's sex organs. It is spread during sex. A woman may not know that she is infected at all unless she is tested for chlamydia when she gets her pelvic exam. Some studies suggest that women who have a past or current infection are at greater risk for cancer of the cervix. Long-term infection can cause other serious problems, too.

Diet

What you eat can play a part as well. Diets low in fruits and vegetables are linked to an increased risk of cervical and other cancers. Also, women who are overweight are at a higher risk.

Birth control pills

Long-term use of birth control pills increases the risk of this cancer. Research suggests that the risk of cervical cancer goes up the longer a woman takes "the pill," but the risk goes back down again after she stops. You should talk to your doctor about the pros and cons of birth control in your case.

Having many pregnancies

Woman who have had many full-term pregnancies have an increased risk of this cancer. No one really knows why this is true.

Low income

Poor women are at greater risk for cancer of the cervix. This may be because they cannot afford good health care, such as regular Pap tests.

DES (diethylstilbestrol)

This drug is a hormone that was used between 1940 and 1971 for some women who were in danger of miscarriages. The daughters of women who took this drug have a slightly higher risk of cancer of the vagina and cervix.

Family history

Cervical cancer may run in some families. If your mother or sister had cervical cancer, your chances of getting the disease are higher. This could be because these women are less able to fight off HPV than other women.

How is Cancer of the Cervix Found?

Early cervical pre-cancers or cancers often have no signs or symptoms. That's why it's important for women to have regular Pap tests. Symptoms usually appear when the cancer is further along and has spread to nearby areas. You should report any of the following to your doctor right away:

• any unusual discharge from the vagina (not your normal period)

• blood spots or light bleeding other than your normal period, such as bleeding after sex, bleeding after menopause, bleeding and spotting between periods, and having periods that are longer or heavier than usual

• bleeding or pain after sex, douching, or after a pelvic exam

Of course, these symptoms do not mean that you have cancer. They can also be caused by something else. But you must check with your doctor to find out.

Tests for cervical cancer

Medical history and physical exam

The doctor will ask you abut your own health, risk factors, and about the health of your family members. A complete physical exam will be done with special attention to your lymph nodes for any signs that cancer has spread.

Cystoscopy, proctoscopy, and exam under anesthesia

These are most often done in women who have large tumors. They are not needed if the cancer is caught early.

In cystoscopy a slender tube with a lens and a light is placed into the bladder through the urethra. This lets the doctor check to see if cancer is growing into these areas. Biopsy samples can also be removed. Cystoscopy can be done under a local anesthetic (the area is numbed with medicine), but some patients may need general anesthesia (drugs will put you in a deep sleep). Your doctor will let you know what to expect before and after the tests.

For proctoscopy a thin, lighted tube is used to check for spread of cervical cancer into your rectum.

Your doctor may also do a pelvic exam while you are under anesthesia to find out whether the cancer has spread beyond the cervix.

Methods used to make pictures of the inside of the body (imaging studies)

If your doctor finds that you have cervical cancer imaging studies may be used to show the inside of your body. They can show whether the cancer has spread beyond the cervix.

Chest x-ray: A plain x-ray of your chest will be done to see if your cancer has spread to your lungs. This is very unlikely unless your cancer is very advanced.

CT scan (computed tomography): The CT scan is a special kind of x-ray. Instead of taking just one picture, a CT scanner takes many pictures as it moves around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread).

CT scans can help tell if your cancer has spread to other places in the body. CT scans are also sometimes used to guide a biopsy needle into a place where the cancer might have spread. A biopsy (tiny sample or thin core of tissue) is removed and looked at under a microscope.

Before the first set of CT pictures is taken you may be asked to drink some liquid that helps outline structures in your body. You might also have an IV line through which a different kind of contrast is injected.

The IV contrast can cause your body to feel flushed (a feeling of warmth with some redness of the skin). A few people are allergic to the dye and can get hives. Rarely, more serious reactions, like trouble breathing and low blood pressure, can happen. Be sure to tell your doctor if you have ever had a reaction to contrast material used for x-rays. It is also important to let your doctor know about any other allergies.

CT scans take longer than regular x-rays and you will need to lie still on a table while they are being done. But they are getting faster and your stay might be short. Also, you might feel a bit confined by the ring-like equipment you're in when the pictures are being taken.

MRI scans (magnetic resonance imaging): MRI scans use radio waves and strong magnets instead of x-rays to take pictures. MRI images are very useful in looking at pelvic tumors. They are also helpful in finding cancer that has spread to the brain or spinal cord.

An MRI scans take longer than CT scans -- often up to an hour. Also, you have to be placed inside a narrow, tube-like machine, which can upset people with a fear of enclosed spaces. The machine makes a thumping noise that you may find annoying. Some places provide headphones with music to block this out.

PET scan (positron emission tomography): PET scans use glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the treated sugar and a special camera can spot the cells. This test can help see whether the cancer has spread to lymph nodes. PET scans are also useful when your doctor thinks the cancer has spread but doesn't know where.

How Is Cancer of the Cervix Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

The treatment options for cervical cancer depend mostly on the stage of the cancer. After your cancer is staged, the doctor will tell you what choices you have. If there is anything you don't understand, ask for it to be explained. Factors other than the stage of the cancer that might have an impact on your treatment decision include your age, your overall health, and your own preferences.

It is often a good idea to get a second opinion. A second opinion can give you more information and help you feel better about the treatment plan you choose. In fact, some insurance companies require you to get a second opinion.

The 3 main types of treatment for cervical cancer are surgery, radiation, and chemotherapy (often called simply "chemo"). Sometimes the best approach is to use 2 or more of these methods. If a cure isn't likely, the goal may be to remove or destroy as much of the cancer as possible. This is to keep it from growing or spreading for as long as possible. Sometimes treatment is aimed at relieving symptoms. This is called palliative treatment.

Surgery

There are several kinds of surgery for cervical cancer. Some involve removing the uterus (hysterectomy), others do not. The list below covers the most common types of surgery for cancer of the cervix.

Cryosurgery: A metal probe cooled with liquid nitrogen is placed in the vagina and on the cervix. This kills the abnormal cells by freezing them. Cryosurgery is used to treat pre-invasive cervical cancer (stage 0), but not for treating invasive cancer.

Laser surgery: A laser beam is used to burn off cells or to remove a small piece of tissue for study. Laser surgery is used as a treatment for pre-invasive cervical cancer only.

Conization: A cone-shaped piece of tissue is removed from the cervix. This approach can be used to find cancer or to treat early cancer. It is seldom used as the only treatment except for women with early cancer who might want to have children.

Simple hysterectomy: The uterus is removed, but not the tissue next to the uterus. Neither the vagina nor the pelvic lymph nodes are removed. The uterus can be removed through either an incision in the front of the belly (abdomen) or through the vagina. After this operation, a woman cannot become pregnant.

Radical hysterectomy and pelvic lymph node dissection: For this operation the surgeon removes more than just the uterus. The tissues next to the uterus, the upper part of the vagina next to the cervix, and some lymph nodes from the pelvis are also removed. This surgery is most often done through an incision in the front of the belly and less often through the vagina. After this surgery, a woman cannot become pregnant.

Sexual impact of hysterectomy: After hysterectomy a woman can still feel sexual pleasure. A woman does not need a uterus to reach orgasm. But some women feel less feminine after this operation. They may see themselves as "an empty shell." If the cancer has caused pain or bleeding, though, the operation could actually improve a woman's sex life by stopping these symptoms.

Trachelectomy: A newer procedure (known as a radical trachelectomy) may allow certain young women with early stage cancer to be treated and still be able to have children. This method involves removing the cervix and the upper part of the vagina and placing a "purse-string" stitch to act as an artificial opening of the cervix inside the uterus. The nearby lymph nodes are also removed. The operation is done either through the vagina or the abdomen.

After this surgery, some women are able to carry a pregnancy to term and deliver a healthy baby by C-section. In one study, the pregnancy rate after 5 years was over 50%, but the risk of miscarriage is higher than is seen normal healthy women. The risk of the cancer coming back after this approach is low.

Pelvic exenteration: Besides removing all the organs and tissues mentioned above, in this operation the bladder, vagina, rectum, and part of the colon may also be removed. This operation is used when the cancer has come back after earlier treatment.

If the bladder is removed, a new way to store and pass urine is needed. A short piece of the intestine might be used to make a new bladder. Urine can be drained by placing a small tube (catheter) into a small opening called a urostomy. Or the urine might drain into a small plastic bag worn on the front of the stomach.

If the rectum and part of the colon are removed, a new way to pass solid waste (stool) is needed. This is done with a colostomy, a small opening on the abdomen through which the stool can pass. Or the surgeon might be able to reconnect the colon so that no bags outside of the body are needed. If the vagina is removed, a new one can be made out of skin or other tissue.

It can take a long time, 6 months or even more, to recover from this surgery. But women who have had this surgery can lead happy and productive lives. With practice and patience, they can also have sexual desire, pleasure, and orgasm.

Ask your doctor to explain the details of the surgery he or she recommends. You'll want to know how long you will be in the hospital, how long it could take you to recover, how the surgery will change the way your body works, and what side effects you can expect to have.

Radiation therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor (internal or implant radiation).

Side effects of radiation: There are quite a few side effects that could happen as a result of radiation treatment, for example:

• tiredness
• upset stomach
• loose bowels
• nausea
• vomiting
• skin changes (looks and feels like sunburn)
• dryness or scar tissue in the vagina causing sex to be painful
• early change of life (menopause)
• problems with urination
• weak bones leading to fractures
• low red blood cell counts (anemia)
• low white blood cell counts

Be sure to talk with your doctor or nurse about any side effects you might have. Often there are medicines or other methods that will help. Because smoking increases the side effects from radiation, if you smoke, you should stop.

Chemotherapy

Chemotherapy (often called just "chemo") refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body. Sometimes several drugs are given at one time.

Chemo can cause side effects. These side effects will depend on the type of drugs given, the amount taken, and how long treatment lasts. Side effects could include the following:

• upset stomach and vomiting (drugs given at the same time can prevent or reduce nausea and vomiting)
• loss of appetite
• short-term hair loss
• mouth sores
• increased chance of infection (from low white blood cell counts)
• bleeding or bruising after minor cuts or injuries (from low blood platelets)
• shortness of breath (from low red blood cell counts)
• tiredness
• early change of life (menopause)
• loss of ability to become pregnant (infertility)

Most of the side effects (except for menopause and infertility) stop when treatment is over. If you have problems with side effects, talk with your doctor or nurse, as there are often ways to help. Giving chemo at the same time as radiation can improve the patient's outlook, but it may cause more side effects. Your health care team will watch for side effects and can give you medicines to help you feel better.

Survival rates for cancer of the cervix

The 5-year survival rate for early invasive cancer of the cervix is 92%. The overall 5-year survival rate (for all stages combined) is about 72%. The 5-year survival rate refers to the percent of patients who live at least 5 years after their cancer is found. Many of these patients live much longer than 5 years. Talk with your cancer care team if you have questions about your own chances of a cure, or how long you might survive your cancer. They know your situation best.

Cervical cancer and pregnancy

A small number of cervical cancers are found in pregnant women. Most doctors feel that if it is a very early cancer, then it is safe to continue the pregnancy to term. Several weeks after the baby is born, treatment, most likely a hysterectomy, is recommended. If the cancer is at a later stage, then the woman and her doctor must decide whether to continue the pregnancy. If they decide to continue the pregnancy, the baby should be delivered by C-section as soon as it is able to survive outside the womb. More advanced cancers should be treated right away.

Financial help

In 2000, the Breast and Cervical Cancer Treatment Act was signed into law. This act provides funds to treat breast and cervical cancer for some low-income women. States must adopt the program in order to get matching federal funds. For more information, you can contact the CDC at 1-888-842-6355 or on the Internet at www.cdc.gov/cancer.