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
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
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
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
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
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,
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.
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.
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.
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.
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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