What is Cervical Cancer ?

The cervix is the lower part of the uterus (womb). The uterus is divided into two parts. The upper part or body of the uterus is where a fetus grows. The cervix connects the body of the uterus to the vagina (birth canal). The part of the cervix closest to the body of the uterus is called the endocervix. The part next to the vagina is the ectocervix.

                                  

Cancer of the cervix (also known as cervical cancer) is a cancer beginning in the lining of the cervix. Cervical cancers do not form suddenly. There is a gradual change from a normal cervix to precancer to cancer. Some women with precancerous changes of the cervix will develop cancer. This usually takes several years but sometimes can happen in less than a year. For some women, precancerous changes may go away without any treatment. More often, if these precancers are treated, true cancers can be prevented.

Precancerous changes can be separated into several categories based on how the cells of the cervix look under a microscope. There are several systems for naming and describing these categories of potentially cancerous or precancerous changes.

There are two main types of cervical cancers: squamous cell carcinoma and adenocarcinoma. These, as well as rarer types of cervical cancer and cervical precancers, are classified according to how they look under a microscope. About 85%-90% of cervical cancers are squamous cells carcinomas. They begin in the ectocervix, most often at its border with the endocervix. The remaining 10%-15% of cervical cancers are adenocarcinomas. Cervical adenocarcinoma develops from the mucus-producing gland cells of the endocervix. Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.

Precancerous and cancerous changes of the cervix can usually be found by the Pap test (also called a Pap smear). This test involves scraping some cells from the surface of the cervix and looking at them under a microscope. Since precancers and very early cervical cancers are nearly 100% curable, this test can prevent nearly all deaths from cervical cancer.

Prevention
The vast majority of cervical cancers can be prevented. Since the most common form of cervical cancer starts with preventable and easily detectable precancerous changes, there are two ways to prevent this disease.

The first way is to prevent precancers. Most precancers of the cervix can be prevented by avoiding risk factors. Delaying onset of sexual intercourse if you are young can help avoid HPV infection. Limiting your number of sexual partners and avoiding sex with people who have had many other sexual partners decreases your risk of exposure to HPV. HPV infection does not always produce warts or other symptoms, so a person may be infected with, and pass on, HPV without knowing it. Recent research shows that condoms ("rubbers") cannot protect against infection with HPV. This is because HPV can be passed from person to person with any skin-to-skin contact with any HPV-infected area of the body, such as skin of the genital or anal area not covered by the condom. The absence of visible warts cannot be used to decide whether caution is warranted, since HPV can be passed on to another person even when there are no visible warts or other symptoms. HPV can be present for years with no symptoms. It is still important, though, to use condoms to protect against AIDS and other sexually transmitted diseases that are passed on through some body fluids. Not smoking is another way to reduce the risk of cervical cancer and precancer.

The second way to prevent invasive cancer is to have a Pap test to detect HPV infection and precancers. Treatment of these disorders can stop cervical cancer before it is fully developed. Most invasive cervical cancers are found in women who have not had regular Pap tests.

The American Cancer Society recommends that all women begin yearly Pap tests at age 18 or when they become sexually active, whichever occurs earlier. If a woman has had three negative annual Pap tests in a row, this test may be done less often at the judgment of a woman's health care provider.
If a hysterectomy was done for cancer, more frequent Pap tests may be recommended. Some women believe they do not have to be examined by a health care provider once they have stopped having children. This is not correct. They should continue to follow ACS guidelines.

It is important to remember that while the Pap test has been more successful than any other screening test in preventing a cancer, it is not perfect. Because some abnormalities may be missed (even when samples are examined in the best laboratories), it is not a good idea to have this test less often than ACS guidelines recommend.

How a Pap Test is Done
The health care provider first inserts a speculum, a metal or plastic instrument that keeps the vagina open so that the cervix can be seen clearly. Next, a sample of cells and mucus is lightly scraped from the ectocervix using a small spatula. A small brush or a cotton-tipped swab is used to take a sample from the endocervix. These samples are then smeared on glass slides. The slides are sent to the lab where specially trained technologists and doctors examine the samples under a microscope.

How Pap Test Results are Reported
The most widely used system for describing Pap test results is The Bethesda System (TBS). This system was developed during a conference of experts in cervical cancer that was held at the National Cancer Institute in Bethesda, Maryland.

The first category of TBS is within normal limits, which means that no signs of cancer or precancerous changes or other significant abnormalities were found.  The category of reactive cellular changes indicates that some squamous cells from the ectocervix or glandular cells from the endocervix are not completely normal but still show no evidence of being precancerous or cancerous. Reactive cellular changes are often due to infections (such as yeast, herpes, chlamydia, or trichomonas).

The cells that cover the ectocervix (outer part of the cervix) are called squamous cells, and cancers of the ectocervix are classified as squamous cell carcinomas. Precancerous changes involving the ectocervix are placed in the category of squamous intraepithelial lesions. This category is often given the abbreviation of SIL. The SIL category is subdivided into low-grade SIL and high-grade SIL. The high-grade SILs are less likely than low-grade SILs to go away without treatment and are more likely to eventually develop into cancer if they are not treated. However, treatment can cure all SILs and prevent true cancer from developing. A Pap smear cannot say for certain whether or a woman has a high-or low-grade SIL. It merely flags the smear as fitting into one of these abnormal categories. The need for treatment is based on further testing and examination (see below).

The most confusing TBS category for cells of the ectocervix is atypical squamous cells of undetermined significance, often abbreviated as ASCUS and pronounced "ask-us". This category is used when it is not possible to tell from the Pap test whether the abnormal cells are due to inflammation or to a precancer. In these situations, a repeat Pap test in 4 months or other tests, such as colposcopy (explained below) and biopsy, may be recommended, depending on the patient's history and the results of previous Pap tests.

The Bethesda System also describes abnormalities of the glandular cells of the endocervix. Cancers of the endocervix are reported as adenocarcinoma. When endocervical glandular cells have features that do not permit a clear decision as to whether or not they are cancerous, the term atypical glandular cells of undetermined significance, abbreviated as AGUS, is used. The patient will usually undergo further testing if a Pap test shows AGUS.

The Bethesda System is not the only classification method for reporting Pap test results. Sometimes, squamous cell abnormalities are classified as mild, moderate, or severe dysplasia or cervical intraepithelial neoplasia (CIN)1, CIN2, or CIN3. Squamous intraepithelial lesion, dysplasia, and cervical intraepithelial neoplasia are all names for potentially precancerous changes of the cervix.


Additional Tests for Women with Abnormal Pap Test Results

Because the Pap test is a screening test rather than a diagnostic test, patients with abnormal Pap test results have additional tests (colposcopy and biopsy) to find out whether a precancerous change or cancer is present. If the biopsy shows SIL or dysplasia, steps will be taken to prevent progression to an actual cancer.

Colposcopy
If certain symptoms suggest cancer or if the Pap test shows abnormal cells, your health care provider may perform an additional test called a colposcopy. In this procedure the cervix is viewed through a colposcope, an instrument with magnifying lenses very much like binoculars. The colposcope makes it possible to see the surface of the cervix closely and clearly. The exam is not painful, has no side effects, and it can be performed safely throughout pregnancy. If abnormal areas are seen on the cervix, a biopsy (removal of a small tissue sample) is done. This is examined under the microscope by a pathologist.. If an abnormal area is seen by colposcopy, a biopsy is the only way to tell for certain whether you have a precancer, a true cancer, or neither.

Cervical Biopsies
There are several types of biopsies used to diagnose cervical precancers and cancers. For precancers and early cancers, some types of biopsies can completely remove the abnormal tissue and may be the only treatment needed. In some situations, additional treatment of precancers or cancers is needed.

Colposcopic biopsy: For this type of biopsy, a doctor or other health care provider first examines the cervix with a colposcope. This instrument uses magnifying binoculars to help find abnormal areas. A biopsy forceps is used to remove a small (about 1/8 inch) section of the abnormal area on the surface of the cervix. The biopsy procedure may cause mild cramping or brief pain, and there may be light bleeding afterwards. A local anesthetic may be used to numb the cervix.

Endocervical curettage (endocervical scraping): This procedure is usually done during the same session as the colposcopic biopsy. A narrow instrument (the curette) is inserted into the endocervical canal (the passage between the outer part of the cervix and the inner part of the uterus). Some of the tissue lining the endocervical canal is removed by scraping with the curette and sent to the laboratory. Because the colposcope views only the outer part of the cervix and cannot see into the endocervix , health care providers use the endocervical scraping to find out if this area is affected by precancer or cancer. A local anesthetic may be used to numb the cervix. Patients may have a temporary cramping sensation, similar to a severe menstrual cramp. There may be light bleeding after the procedure.

Cone biopsy: This procedure removes a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the ectocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal. The transformation zone (the border between the ectocervix and endocervix) is contained within the cone. This is the area of the cervix where precancers and cancers are most likely to develop. The cone biopsy is also a treatment, and can completely remove many precancers and very early cancers. There are two methods commonly used for cone biopsies, the loop electrosurgical excision procedure (LEEP or LLETZ) and the cold knife cone biopsy.

The LEEP (LLETZ) removes tissue with a wire that is heated by electrical current. This procedure uses a local anesthetic, and can be done in your doctor's office. It takes only about 10 minutes. There may be mild cramping during and after the procedure, and mild to moderate bleeding may persist for several weeks.
The cold knife cone biopsy uses a surgical scalpel or a laser as a scalpel, rather than a heated wire to remove tissue. It requires general anesthesia (you are asleep during the operation). It is done in a hospital, but no overnight stay is needed. After the procedure, cramping and some bleeding may persist for a few weeks.

How Patients with Abnormal Pap Test Results Are Treated to Prevent Cancers from Developing

If an area of SIL can be seen during the colposcopy, your doctor will be able to remove the abnormal area by using such biopsy techniques as the LEEP (LLETZ) technique or a cold knife cone biopsy or by destroying the abnormal cells with cryosurgery or laser surgery. During cryosurgery a metal probe cooled with liquid nitrogen is used to kill the abnormal cells by freezing them. Laser surgery uses a focused beam of high energy light to vaporize the abnormal tissue. Both of these are outpatient treatments that can be done in a doctor's office or clinic. After treatment, women may have a watery brown discharge for a few weeks.
These treatments are almost always effective in destroying precancers and preventing them from developing into true cancers. Follow-up examinations will be needed to make sure that the abnormality does not come back. If it does, treatments can be repeated.

Diagnostic:
If your biopsy indicates that you have cervical cancer, you may need to consult with a surgeon who specializes in treating this type of cancer. Precancers can be treated by your routine health care provider. However, if there is a question of invasive cancer, your health care provider will refer you to a gynecologic oncologist, a doctor who specializes in women's reproductive system cancers. Some patients will be referred to a radiation oncologist, a doctor specializing in treating cancers with radiation. Many of the diagnostic tests described below are not necessary for every patient. Decisions about use of these tests are based on the results of the physical examination and initial biopsy.

Medical history and physical examination: A complete personal and family medical history will be the first step in your consultation. This will include information related to risk factors and symptoms of cervical cancer. A complete physical examination will help evaluate your general state of health. In addition, special attention will be paid to the lymph nodes for evidence of metastasis (spreading of the cancer).

Cystoscopy, proctoscopy, and examination under anesthesia: In cystoscopy a slender tube with a lens and a light is placed into the bladder through the urethra. This allows the doctor to check the bladder and urethra for possible cancers. Small tissue samples can also be removed during cystoscopy for pathologic (microscopic) testing. This procedure can be done using a local anesthetic but some patients may require general anesthesia. Your doctor will let you know what to expect before and after the procedure. Proctoscopy is a visual inspection of the rectum through a lighted tube to check for spread of cervical cancer. Examination of the pelvis under anesthesia can help to find out whether the cancer has spread beyond the cervix.

Imaging tests: A chest x-ray may be done to see if a cervical cancer has spread to the lungs.
A computed tomography (CT) scan is useful in helping to determine whether cervical cancer has spread to pelvic and para-aortic lymph nodes. This is an imaging method in which an x-ray beam rotates around the body, taking images at various angles. The images are then put together by a computer to show a detailed view of the inside of the body. Details are often highlighted by injection of a special dye, called contrast medium, before the x-rays are taken.

A magnetic resonance imaging (MRI) scan is another imaging test that can help in find out whether a cervical cancer has spread to lymph nodes and/or other organs near the cervix. MRI uses magnetic fields and a computer to produce detailed pictures of the inside of the body. It does not use x-rays. MRI is not often used for evaluating cervical cancer because CT scans are less expensive and provide similar information.

Intravenous urography (also known as intravenous pyelogram or IVP) is useful in finding abnormalities of the urinary tract, such as changes caused by spread of cervical cancer to the pelvic lymph nodes, which may compress or block a ureter. It is an x-ray of the urinary system, taken after injecting a special dye into a vein. This dye is removed from the bloodstream by the kidneys, and passes into the ureters and bladder. An IVP might not be done if a CT or MRI has been done.


Treatment
Options for treating each patient with cervical cancer depend on the stage of her disease. The stage of a cancer describes its size, depth of invasion and how far it has spread.
After the stage of your cervical cancer has been established, your cancer care team will recommend a treatment strategy. Consider the options without feeling rushed. If there is anything you do not understand, ask for explanations. While the choice of treatment depends largely on the stage of the disease at the time of diagnosis, other factors that may influence your options are your age, your general health, your individual circumstances, and your preferences. Be sure you understand all the risks and side effects of the various therapies before making a decision about treatment.

You may want to seek a second opinion for personal or practical reasons. On the personal level, a second opinion can help you learn more about treatment options and help you decide whether to work with your initial medical team or with those proposing a second view. On the practical side, some insurance companies require a second opinion before agreeing to pay for certain treatments.

The three main types of treatment used for patients with cervical cancer are surgery, radiation therapy and, chemotherapy.

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