Cervical Cancer

Overview

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The cervix is the portion of the uterus that extends into the vagina. Recent research into the cause of cervical cancer has discovered that persistent infections with the Human Papillomavirus (HPV) are the cause of virtually all cases of cervical cancer. Cervical cancer develops slowly in cells infected with the virus. These persistent, high-risk infections can result in cervical cancer. Screening and treatment of pre-invasive lesions can prevent most cases of this disease. . Most pre-cancerous treatments can be performed in the office.

There are two main types of cervical cancer:

1) Squamous cell carcinomas (80 to 85% of cervical cancers), which start in the superficial (squamous) layer of cells on the lower outer part of the cervix, but near the cervical canal. 2) Adenocarcinomas (15-20% of cervical cancers), which develop in the glandular cells in the cervix.

Cancer of the cervix is a devastating disease. It is the second leading cause of cancer deaths in women in developing countries. Cervical cell screens with Pap tests and follow up treatment has dramatically reduced the incidence of cervical cancer in the U.S.

Cancer of the cervix is a devastating disease. It is the second leading cause of cancer deaths in women in developing countries. Cervical cell screens with Pap tests and follow up treatment has dramatically reduced the incidence of cervical cancer in the U.S.

Risk Factors

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Women who do not get regular gynecologic examinations and Pap tests are at the greatest risk of developing cervical cancer.

Other risk factors include:

  • Multiple sexual partners
  • Partner with multiple partners
  • Sexual activity at an early age
  • Tobacco use
  • Conditions leading to impaired immune function, such as:
    • HIV
    • Chemotherapy
    • Organ transplant

Symptoms

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Early physical signs of cervical cancer include:

  • Abnormal vaginal bleeding
  • Postcoital bleeding
  • Discharge
  • Pelvic pain

These symptoms should never be ignored, even if a woman has not been sexually active for years. Cervical cancer, which begins as a cellular abnormality may take more than 10 years to cause symptoms. Fortunately, most routine cervical screening tests show abnormal cell changes long before an actual cancer develops.

Treatments

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Abnormal cellular changes detected in a Pap test are usually removed before they can grow into a cancer. Precancerous treatments for include minor procedures on the cervix, such as:

  • Biopsy
  • Laser removal (excision)
  • Freezing or Cryotherapy
  • LEEP (loop electrical excision procedure)
  • Conization

LEEP is a procedure to remove a portion of the cervix to excise the abnormal cells to prevent development into cancer. A wire loop conducts a radiofrequency wave that cuts through the tissue and seals the blood vessels at the same time.

Cone excision, or conization, is a procedure similar to a LEEP, in which a cone-shaped sample of tissue is removed from the cervix for treatment or diagnostic purposes. Most of these procedures can be performed in an outpatient setting.

Treatment of invasive cervical cancer depends upon the type and extent of the disease when it is diagnosed. In other words, the stage of the disease strongly dictates treatment. Most treatments consist of one or a combination of the following procedures:

  • Conization
  • Radical trachelectomy
  • Hysterectomy
  • Radical hysterectomy
  • Radiation
  • Chemotherapy

The very earliest stages of cervical cancer can be treated and cured with a simple hysterectomy (removal of the uterus), or in some cases, a conization. These tumors are small, and sometimes may only be seen under the microscope by examining biopsies or a LEEP or cone specimen.

For those in whom the cancer is confined to the cervix yet the tumor is larger, a more extensive hysterectomy, known as a radical hysterectomy, can be performed. This procedure removes some tissue around the cervix to assure all cancer is removed. In addition, lymph nodes in the pelvis are generally removed (lymphadenectomy) to remove any tumor that may have spread to these areas, and to determine the best means of treating these patients post-operatively.

In most cases, despite a radical hysterectomy, the ovaries can be preserved at the patient’s request. Some patients who want to protect future fertility may be candidates for radical trachelectomy, a procedure that removes the cancer and cervix but preserves the uterus.

Radiation in combination with chemotherapy is the preferred treatment for cancers at more advanced stages, and can also treat early stage cancers. The prognosis for patients diagnosed with cervical cancer depends upon the type, the degree of cellular abnormality, and the amount of spread or stage when first diagnosed and treated.

Prevention

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According to recommended guidelines, regular Pap tests can prevent most cases of cervical cancer. Current guidelines have lengthened the screening interval for women over 21, with normal immune systems who have no history of cervical dysplasia (precancerous changes in the inner lining of the cervix). Guidelines do not recommended screening for women younger than 21, as the incidence of significant lesions is so low, despite a high rate of HPV infection in this age group. Most of these infections in this age group will resolve spontaneously.

Strategies to prevent HPV infections include prophylactic vaccines which became available in 2006, HPV vaccines are expected to significantly decrease the incidence of dysplasia/pre-cancerous lesions and the number of invasive cervical cancers, and deaths from cervical cancer.

Staging of Cervical Cancer

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Staging is a process which determines the extent of the disease or the amount of spread. Most of the staging can be determined by a thorough pelvic exam where a tumor can be visualized and palpated.

Stage 0

This stage is also called carcinoma in situ (CIS). A tumor at this stage is small and cannot be seen without a microscope. It has not yet invaded the cervix, but exists only on the surface.

Stage I

The cancer is confined to the cervix. Stage I is divided into 4 groups:

  • Stage IA1. This lesion is a microscopic tumor measuring less than 3 mm in depth and less than 7 mm wide.
  • Stage IA2. Still a microscopic tumor, this lesion measures between 3 and 5 mm deep, but still less than 7 mm wide.
  • IB1. Visible to the naked eye upon speculum exam, this tumor is 4 cm or less in size.
  • Stage IB2. Visible to the naked eye upon speculum exam, this tumor is greater than 4 cm in size.

Stage II
The cancer has spread beyond the cervix, but not outside the pelvis. Stage II is further divided into two categories:

  • Stage IIA. This cancer extends to the upper vagina, but has not spread into the tissues deeper than the vagina.
  • Stage IIB. This cancer has spread to the tissues surrounding the vagina and cervix, but not yet to the sidewall of the pelvis.

Stage III
This cancer has spread to the lower vagina or to the sidewall of the pelvis. Stage III is further divided:

  • Stage IIIA. The cancer has spread to the lower third of the vagina, but has not spread to the sidewall of the pelvis.
  • Stage IIIB. The cancer has spread to the soft tissues surrounding the vagina and cervix, all the way to the wall of the pelvis. The tube draining from the kidney to the bladder (the ureter) may be blocked by tumor growth.

Stage IV
In this stage, the cancer has spread to other parts of the body, such as the bladder, rectum, or other tissues outside the pelvis. Stage IV is further divided as follows:

  • Stage IVA. The cancer has spread into nearby organs, such as the bladder or rectum.
  • Stage IVB. The cancer has spread to distant organs, such as the lungs.

Future Progress

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Clinical trials offer patients the opportunity to receive the latest and most advanced treatment. These trials are the only way to systematically evaluate new drugs and treatments for cervical cancer to prove or disprove improved efficacy. Patients should discuss with their doctor what clinical trials are available, and if they might benefit by participating. In the last few decades, medical science has made significant progress in understanding, preventing, diagnosing, and treating cervical cancer.

For more detailed information about the staging and treatment of cervical cancer, please visit the National Cancer Institute's website at www.nci.nih.gov/cancertopics. . The Women’s Cancer Network at http://www.wcn.org is another authoritative link for understanding cervical cancer.