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Cancer of the cervix is a disease in which malignant cells are found in the tissues of the cervix (see diagram below). The uterus is a hollow, pear shaped organ where a baby develops. The cervix connects the uterus to the vagina (birth canal).
Most precancerous conditions of the cervix can be detected and treated before cancer develops through pelvic exams and Pap smear testing. In a pelvic exam, the doctor checks the uterus, vagina, ovaries, fallopian tubes, bladder and rectum. The Pap test is a simple test to detect abnormal cells in and around the cervix. Women should have regular checkups, including a pelvic exam and a Pap test, if they are or have been sexually active or if they are age 18 or older. Those who are at increased risk of developing cancer of the cervix should be especially careful to follow their doctor's advice about checkups. Symptoms of Cervical Cancer Precancerous changes of the cervix usually do not cause pain. They generally do not cause any symptoms and are not detected unless a woman has a pelvic exam and Pap smear test. Symptoms usually do not appear until abnormal cervical cells become cancerous. Even early stage cervical cancer may be asymptomatic and discovered only by Pap smear and/or physical examination. CIN and very early stage invasive cervical cancer is usually asymptomatic and discovered because of an abnormal Pap smear. Patients with early stage cervical cancer may also have irregular vaginal bleeding, which is most often postcoital, but intermenstrual bleeding or menometorrhagia may occur. Patients with large cervical cancers or advanced stage disease may present with a foul smelling vaginal discharge, abnormal vaginal bleeding, pelvic pain or back pain. When this happens, the most common symptoms are:
Diagnosis of Cervical Cancer Regular screening has been effective in reducing the incidence and death rate from cervical cancer. The Pap smear is obtained by scraping a small wooden stick on the outside of the cervix and scraping the inside of the cervix (endocervix) with a small brush. The Pap smear is a screening test and does not give an absolute diagnosis. An accurate diagnosis is made by a biopsy of the cervix. If cells that are not normal are found on a Pap smear the doctor will usually need to investigate this further. The next step is usually a colposcopic exam, which can be done in the office and allows the physician to see a magnified view of the cervix. Areas on the cervix suspicious for abnormal changes can then be biopsied at that time. Only a very small amount of tissue is needed in this situtation. Over 50 million Pap smears are performed annually in the United States. At least 5% are abnormal requiring further investigation. The source of abnormal cells is usually the squamous ectocervix or the glandular endocervix. However, abnormalities of the endometrium, ovaries, fallopian tubes, vagina and vulva may occasionally contribute to an abnormal Pap smear. The combination of a thorough pelvic history and pelvic examiniation as well as colposcopy and directed biopsies, if necessary, are usually required to detect both preinvasive and invasive disease. Gynecologic oncologists are trained to evaluate patients for premalignant and malignant conditions of the lower genital tract (reproductive tract). Thorough colposcopic and histologic (biopsy of tissue) evaluation should minimize complications that may lead to under-treatment and over-treatment. Also, preservation of fertility may be a primary concern for many patients. The appropriate application of colposcopy, biopsies and therapeutic modalitites can reduce complications leading to infertility. Colposcopy results can be clinically correlated with the results of the Pap smear. Colposcopy-directed biopsy usually provides enough clinical evidence for an accurate diagnosis. If colpscopy evaluation is unsatisfactory or inconclusive, a cervical conization biopsy is required, performed via a loop electrical excision procedure (LEEP), laser or cold knife. Staging of Cervical Cancer The staging of cervical cancer is based on the size of the lesion and the extent (location) of disease. The gynecologic oncologist may perform an examination under anesthesia to more accurately feel the extent of the tumor. Other procedures such as cystoscopy (looking into the bladder) and sigmoidoscopy (looking into the rectum) or other X-ray tests such as intravenous pyelography, chest X-ray, CT scan or MRI may be obtained, if the gynecologic oncologist feels they are indicated. .
The choice of treatment for cervical cancer depends on the location and size of the tumor, the stage (extent) of the disease, the woman's age and general health, and other factors. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Blood and urine tests usually are done. The doctor also may do a thorough pelvic exam in the operating room with the patient under anesthesia. During this exam, the doctor may do procedures called cystoscopy and proctosigmoidoscopy. In cystoscopy, the doctor looks inside the bladder with a thin, lighted instrument. Proctosigmoidoscopy is a procedure in which a lighted instrument is used to check the rectum and the lower part of the large intestine. Because cervical cancer may spread to the bladder, rectum, lymph nodes, or lungs, the doctor also may order x-rays or tests to check these areas. For example, the woman may have a series of x-rays of the kidneys and bladder, called an intravenous pyelogram. The doctor also may check the intestines and rectum using a barium enema. To look for lymph nodes that may be enlarged because they contain cancer cells, the doctor may order a CT or CAT scan, a series of x-rays put together by a computer to make detailed pictures of areas inside the body. Other procedures that may be used to check organs inside the body are ultrasonography and MRI. Here are some questions a woman with cervical cancer may want to ask the doctor before her treatment begins:
Methods of Treatment Surgery is local therapy to remove abnormal tissue in or near the cervix. If the cancer is only on the surface of the cervix, the doctor may destroy the cancerous cells in ways similar to the methods used to treat precancerous lesions. If the disease has invaded deeper layers of the cervix but has not spread beyond the cervix, the doctor may perform an operation to remove the tumor but leave the uterus and the ovaries. In most cases, however, a woman needs a specialized hysterectomy (radical hysterectomy). The gynecologic oncologist is specially trained to perform this complicated surgical procedure. In this procedure, the gynecologic oncologist removes the entire uterus and cervix as well as tissues in the immediate area. Sometimes the ovaries and fallopian tubes are removed as well. In addition, the gynecologic oncologist usually removes lymph nodes in the pelvis (pelvic lymphadenectomy) as a therapeutic measure and to determine whether the cancer has spread to this area. Radiation therapy (also called radiotherapy) uses high-energy x-rays to damage cancer cells and stop them from growing. Like surgery, radiation therapy is local therapy; the radiation can affect cancer cells only in the treated area. The radiation may come from a large machine (external radiation) or from radioactive materials placed directly into the cervix (implant radiation). Most patients receive both types of radiation therapy. Chemotherapy is the use of drugs to kill cancer cells. It is most often used when cervical cancer has spread to other parts of the body. The doctor may use just one drug or a combination of drugs. However, recent large randomized trials (studies) have shown that the addition of chemotherapy to irradiation improves the treatment results and survival in patients with bulky, large early stage or advanced cervical cancer. Anticancer drugs used to treat cervical cancer may be given by injection into a vein or by mouth. Either way, chemotherapy is systemic treatment, meaning that the drugs flow through the body in the bloodstream. Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most patients have chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). Depending on which drugs are given and the woman's general health, however, she may need to stay in the hospital during her treatment.
Cancer of the cervix may be called cervical cancer. Like most cancers, it is named for the part of the body in which it begins. Cancers of the cervix are also named for the type of cell in which they begin. Most cervical cancers are squamous cell carcinomas. Squamous cells are thin, flat cells that form the surface of the cervix. When cancer spreads to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the original (primary) cancer. For example, if cervical cancer spreads to the bones, the cancer cells in the bones are cervical cancer cells. The disease is called metastatic cervical cancer (it is not bone cancer). ANSWER: Cells on the surface of the cervix sometimes appear abnormal but not cancerous. Scientists believe that some abnormal changes in cells on the cervix are the first step in a series of slow changes that can lead to cancer years later. That is, some abnormal changes are precancerous; they may become cancerous with time. Over the years, doctors have used different terms to refer to abnormal changes in the cells on the surface of the cervix. One term now used is squamous intraepithelial lesion (SIL). (The word lesion refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells.) Changes in these cells can be divided into two categories:
If abnormal cell spread deeper into the cervix or to other tissues or organs, the disease is then called cervical cancer, or invasive cervical cancer. The average age of cervical cancer is 50.
ANSWER: Most precancerous conditions of the cervix could be detected and treated before cancer develops if all women had pelvic exams and Pap tests regularly. This way, most invasive cancers could be prevented. Any invasive cancer that does occur would likely be found at an early, curable stage.
ANSWER: In a pelvic exam, the doctor checks the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum. The doctor feels these organs for any abnormality in their shape or size. A speculum is used to widen the vagina so that the doctor can see the upper part of the vagina and the cervix. The Pap test is a simple, painless test to detect abnormal cells in and around the cervix. A woman should have this test when she is not menstruating; the best time is between 10 and 20 days after the first day of her menstrual period. For about 2 days before a Pap test, she should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician), which may wash away or hide any abnormal cells. Women should have regular checkups, including a pelvic exam and Pap test, if they are or have been sexually active or if they are age 18 or older. Those who are at increased risk of developing cancer of the cervix should be especially careful to follow their doctor's advice about checkups. Women who have had a hysterectomy (surgery to remove the uterus, including the cervix) should ask their doctor's advice about having pelvic exams and Pap tests.
ANSWER: Precancerous changes of the cervix usually do not cause pain. In fact, they generally do not cause any symptoms and are not detected unless a woman has a pelvic exam and a Pap test. Symptoms usually do not appear until abnormal cervical cells become cancerous and invade nearby tissue.
These symptoms may be caused by cancer or by other health problems. Only a doctor can tell for sure. It is important for a woman to contact her doctor if she is having any of these symptoms.
ANSWER: The pelvic exam and Pap test allow the doctor to detect abnormal changes in the cervix. If these exams show that an infection is present, the doctor treats the infection and then repeats the Pap test at a later time. If the Pap test or exam suggest something other than an infection, the doctor may repeat the Pap test and do other tests to find out what the problem is. The Pap smear is only a screening test and does not give a final diagnosis. A diagnosis and subsequent treatment is based on biopsy results, which are usually obtained after an abnormal Pap smear is discovered.
These procedures can be done in the doctor's office.
These types of biopsies may be done in the doctor's office using local anesthesia.
These procedures for removing tissue may cause some bleeding or other discharge. However, healing occurs quickly. Women often experience some pain similar to menstrual cramping, which can be relieved with medicine.
ANSWER: All treatments directed towards neoplastic conditions of the cervix should be based on a biopsy and not a Pap smear alone. Treatment for a precancerous lesion of the cervix depends on a number of factors. These factors include whether the lesion is low or high grade, whether the woman wants to have children in the future, the woman's age and general health, and the preference of the woman and her doctor. A woman with a low -grade lesion may not need further treatment, especially if the abnormal area was completely removed during biopsy, but she should have a Pap test and pelvic exam regularly by a physician with expertise in this area. When a precancerous lesion requires treatment, the doctor may use:
Treatment for precancerous lesions may cause cramping or other pain, bleeding, or a watery discharge. Occasionally, a hysterectomy is performed to treat percancerous conditions of the cervix. However, the hysterectomy is considered to be unnecessary in the great majority of cases of precancerous conditions of the cervix unless other gynecologic problems co-exist. Women are likely to benefit from pretreatment evaluation by a gynecologic oncologist if they have:
ANSWER: The choice of treatment for cervical cancer depends on the location and the size of the tumor, the stage (extent) of the disease, the woman's age and general health and other factors. Gynecologic oncologists have special expertise in the diagnostic evaluation and treatment of patients with cervical carcinoma. Gynecologic oncologists have surgical expertise in the procedures of radical hysterectomy, pelvic and paraaortic lymphadenectomy, pretreatment surgical staging procedures, and exenterations for those patients with recurrent cervical cancer. Gynecologic oncologists also work closely with radiation therapists when this is the primary treatment modality. During that time they function as the patient's primary care oncologist and continue to direct their care after the radiation therapy is finished. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Blood and urine tests are usually done. The doctor also may do a thorough pelvic exam in the operating room with the patient under anesthesia. During this exam, the doctor may do procedures called cystoscopy and proctosigmoidoscopy. In cystoscopy, the doctor looks inside the bladder with a thin, lighted instrument. Proctosigmoidoscopy is a procedure in which a lighted instrument is used to check the rectum and the lower part of the large intestine. Because cervical cancer may spread to the bladder, rectum, lymph nodes, or lungs, the doctor also may order x-rays or tests to check these areas. For example, the woman may have a series of x-rays of the kidneys and bladder, called an intravenous pyelogram (IVP). The doctor also may check the intestines and rectum using a barium enema. To look for lymph nodes that may be enlarged because they contain cancer cells, the may order a CT or CAT scan, a series of x-rays put together by a computer to make detailed pictures of areas inside the body. Other procedures that may be used to check organs inside the body are ultrasonography and MRI.
8. Is a second opinion important? ANSWER: Before starting treatment, you may want a second pathologist to review the diagnosis and another specialist to review the treatment plan. Some insurance companies require a second opinion; others may cover second opinion if the patient requests it. It may take a week or two to arrange for a second opinion. This short delay will not reduce the chance that treatment will be successful.
Here are some questions you may want to ask your doctor before treatment begins:
When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often it helps to make a list of questions. Taking notes will help you to remember what the doctor says. You may also want to have a family member/friend with you when you talk to the doctor to assist you in taking notes, asking questions, or just listen. You do not have to feel that you need to ask all your questions or remember all the answers at one time. There will be other opportunities to ask the doctor to explain things and to get more information.
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