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updated March 17, 2012

Cervical cancer

Filed under: Cancer & Chemo
Cervical cancer is a type of cancer that occurs in the cells of the cervix — the lower part of the uterus that connects to the vagina. Various strains of the human papillomavirus (HPV), a sexually transmitted infection, play a role in causing most cases of cervical cancer.

When exposed to HPV, a woman's immune system typically prevents the virus from doing harm. In a small group of women, however, the virus survives for years, contributing to the process that causes some cells on the surface of the cervix to become cancer cells.

The death rate from cervical cancer is declining, thanks in part to screening. Doctors hope a vaccine may prevent most cases of cervical cancer in the future.

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You may not experience any cervical cancer symptoms — early cervical cancer generally produces no signs or symptoms. As the cancer progresses, the following signs and symptoms of more advanced cervical cancer may appear:

  • Vaginal bleeding after intercourse, between periods or after menopause
  • Watery, bloody vaginal discharge that may be heavy and have a foul odor
  • Pelvic pain or pain during intercourse

When to see a doctor
Make an appointment with your doctor if you have any signs or symptoms that worry you.

Talk to your doctor about when to begin screening for cervical cancer and how often to repeat screening. The American Congress of Obstetricians and Gynecologists recommends that girls have their first visit with an obstetrician-gynecologist or family doctor between ages 13 and 15, or before beginning sexual activity, to discuss sexual activity and ways to prevent sexually transmitted infections, including HPV.

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Cervical cancer begins when healthy cells acquire a genetic mutation that turns normal cells into abnormal cells. Healthy cells grow and multiply at a set rate, eventually dying at a set time. Cancer cells grow and multiply out of control, and they don't die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from an initial tumor to spread elsewhere in the body (metastasize).

What causes cervical cancer isn't clear. However, it's certain that the sexually transmitted infection called human papillomavirus (HPV) plays a role. Evidence of HPV is found in nearly all cervical cancers. However, HPV is a very common virus and most women with HPV never develop cervical cancer. This means other risk factors, such as your genetic makeup, your environment or your lifestyle choices, also determine whether you'll develop cervical cancer.

Types of cervical cancer
The type of cell where the initial genetic mutation occurred determines the type of cervical cancer you have. The type of cervical cancer you have helps determine your prognosis and treatment. The main types of cervical cancer are:

  • Squamous cell carcinomas. These begin in the thin, flat cells that line the bottom of the cervix (squamous cells). This type accounts for the great majority of cervical cancers.
  • Adenocarcinomas. These occur in the glandular cells that line the cervical canal. These cancers make up a smaller portion of cervical cancers.

Sometimes both types of cells are involved in cervical cancer. Very rare cancers can occur in other cells in the cervix.

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These factors may increase your risk of cervical cancer:

  • Many sexual partners. The greater your number of sexual partners — and the greater your partner's number of sexual partners — the greater your chance of acquiring HPV.
  • Early sexual activity. Having sex before age 18 increases your risk of HPV.
  • Other sexually transmitted infections (STIs). If you have other STIs — such as chlamydia, gonorrhea, syphilis or HIV/AIDS — the greater your chance is of also having HPV.
  • A weak immune system. Most women who are infected with HPV never develop cervical cancer. However, if you have an HPV infection and your immune system is weakened by another health condition, you may be more likely to develop cervical cancer.
  • Cigarette smoking. Smoking and HPV infection may work together to cause cervical cancer.

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Treatments for invasive cervical cancer often make it impossible to become pregnant in the future. For many women — especially younger women and those who have yet to begin a family — infertility is a distressing side effect of treatment. If you're concerned about your ability to get pregnant in the future, discuss this with your doctor before your treatment begins. In most cases, preserving fertility is more successful than trying to restore fertility after treatment.

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Make an appointment with your doctor if you have any signs or symptoms that worry you. If you're thought to have cervical cancer, you may be referred to a doctor who specializes in treating gynecologic cancers (gynecologic oncologist).

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Write down your medical history, including other conditions with which you've been diagnosed.
  • Note any personal history that increased your risk of sexually transmitted infection, such as early sexual activity, multiple partners or unprotected sex.
  • Make a list of your medications. Include any prescription or over-the-counter medications you're taking, as well as all vitamins, supplements and herbal remedies.
  • Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Questions to ask your doctor can include:

  • Do I have cervical cancer?
  • Has my cancer spread?
  • What treatment approach do you recommend?
  • What are the possible side effects or complications of this treatment?
  • Am I at risk of this condition recurring?
  • How often will I need follow-up visits after I finish treatment?
  • Are there any brochures or other printed material that I can take with me? What websites do you recommend?

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:

  • What are your symptoms?
  • When did you first notice these symptoms?
  • Have your symptoms changed over time?
  • Have you had regular Pap tests since you became sexually active?
  • Have you ever had abnormal Pap test results in the past?
  • Have you ever been treated for a cervical condition in the past?
  • Have you been diagnosed with any sexually transmitted infections?
  • Have you been diagnosed with any other medical conditions?
  • Have you ever taken medications that suppress your immune system?
  • Do you or did you smoke? How much?
  • Do you want to have children in the future?

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When cervical cancer is detected in its earliest stages, treatment is more likely to be successful. Regular screening for cervical cancer and precancerous changes in the cervix is recommended for all women. Most guidelines suggest beginning screening at age 21. Screening for cervical cancer includes:

  • Pap test. During a Pap test, your doctor brushes cells from your cervix — the narrow neck of the uterus — and sends the sample to a lab to be examined for abnormalities. A Pap test can detect abnormal cells in the cervix, including cancer cells and cells that show changes (dysplasia) that increase the risk of cervical cancer.
  • HPV DNA test. Your doctor may also use a lab test called the HPV DNA test to determine whether you are infected with any of the types of HPV that are most likely to lead to cervical cancer. Like the Pap test, the HPV DNA test involves collecting cells from the cervix for lab testing.

    The HPV DNA test isn't a substitute for regular Pap screening, and it's not used to screen women younger than 30 with normal Pap results. However, an HPV test may be combined with a Pap test to extend the recommended screening period from three to five years for women between the ages of 30 and 65. Most HPV infections in women of this age group clear up on their own and aren't associated with cervical cancer.

If you experience signs and symptoms of cervical cancer or if a Pap test has revealed cancerous cells, you may undergo further tests to diagnose your cancer. To make a diagnosis, your doctor may:

  • Examine your cervix. During an exam called colposcopy, your doctor uses a special microscope (colposcope) to examine your cervix for abnormal cells. If your doctor identifies unusual areas, he or she may take a small sample of cells for analysis (biopsy).
  • Take a sample of cervical cells. During a biopsy procedure your doctor removes a sample of unusual cells from your cervix using special biopsy tools.
  • Remove a cone-shaped area of cervical cells. A cone biopsy (conization) — so called because it involves taking a cone-shaped sample of the cervix — allows your doctor to obtain deeper layers of cervical cells for laboratory testing. Your doctor may use a scalpel, laser or electrified wire loop to cut away the tissue.

If your doctor determines that you have cervical cancer, you'll undergo further tests to determine whether your cancer has spread and to what extent — a process called staging. Your cancer's stage is a key factor in deciding on your treatment. Staging exams include:

  • Imaging tests. Tests such as X-rays, computerized tomography (CT) scans and magnetic resonance imaging (MRI) help your doctor determine whether your cancer has spread beyond your cervix.
  • Visual examination of your bladder and rectum. Your doctor may use special scopes to see inside your bladder (cystoscopy) and rectum (proctoscopy).

Your doctor then assigns your cancer a stage — typically a Roman numeral. Stages of cervical cancer include:

  • Stage I. Cancer is confined to the cervix.
  • Stage II. Cancer at this stage includes the cervix and uterus, but hasn't spread to the pelvic wall or the lower portion of the vagina.
  • Stage III. Cancer at this stage has moved beyond the cervix and uterus to the pelvic wall or the lower portion of the vagina.
  • Stage IV. At this stage, cancer has spread to nearby organs, such as the bladder or rectum, or it has spread to other areas of the body, such as the lungs, liver or bones.

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Treatment for cervical cancer depends on several factors, such as the stage of the cancer, other health problems you may have and your preferences about treatment. Treatment options may include:

  • Surgery. Surgery to remove the uterus (hysterectomy) is typically used to treat the early stages of cervical cancer. A simple hysterectomy involves the removal of the cancer, the cervix and the uterus. Simple hysterectomy is typically an option only when the cancer is very early stage — invasion is less than 3 millimeters (mm) into the cervix. A radical hysterectomy — removal of the cervix, uterus, part of the vagina and lymph nodes in the area — is the standard surgical treatment when there's invasion greater than 3 mm into the cervix.

    Hysterectomy can cure early-stage cervical cancers and prevent cancer from coming back, but removing the uterus makes it impossible to become pregnant.

  • Radiation. Radiation therapy uses high-powered energy to kill cancer cells. Radiation therapy can be given externally using external beam radiation or internally (brachytherapy) by placing devices filled with radioactive material near your cervix. Radiation therapy is as effective as surgery for early-stage cervical cancer. For women with more advanced cervical cancer, radiation combined with chemotherapy is considered the most effective treatment.

    Both methods of radiation therapy can be combined. Radiation therapy can be used alone, with chemotherapy, before surgery to shrink a tumor or after surgery to kill any remaining cancer cells. Premenopausal women may stop menstruating as a result of radiation therapy and begin menopause.

  • Chemotherapy. Chemotherapy uses drugs to kill cancer cells. Chemotherapy drugs, which can be used alone or in combination with each other, are usually injected into a vein and they travel throughout your body killing rapidly growing cells, including cancer cells. Low doses of chemotherapy are often combined with radiation therapy, since chemotherapy may enhance the effects of the radiation. Higher doses of chemotherapy are used to control advanced cervical cancer that may not be curable. Certain chemotherapy drugs may cause infertility and early menopause in premenopausal women.

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No one can be prepared for a cancer diagnosis. You can, however, try to manage the shock and fear you're feeling by taking steps to control what you can about your situation. Every woman deals with a cervical cancer diagnosis in her own way. With time you'll discover what helps you cope. Until then, you can start to take control by attempting to:

  • Learn enough about cervical cancer to make decisions about your care. Write down your questions and ask them at the next appointment with your doctor. Get a friend or family member to come to appointments with you to take notes. Ask your health care team for further sources of information. Learn enough about your cervical cancer so that you feel confident in making decisions about your treatment. Contact the National Cancer Institute at 800-4-CANCER (800-422-6237) or go online for information. The American Cancer Society also offers support and information on its website and by telephone at 800-ACS-2345 (800-227-2345).
  • Create a support network. Don't face your diagnosis alone. Friends and family are likely feeling helpless and afraid, too. They want to help, so take them up on their offers. Ask loved ones to take over daily tasks such as cooking, household chores or child care. Talk with close friends and family when you're feeling overwhelmed. Other people with cancer can offer unique emotional support during your diagnosis and treatment. Connect with cancer survivors through support groups - in your community and on the Web. Ask your health care team about support groups in your community or contact your local chapter of the American Cancer Society.
  • Take time for yourself. Take care of yourself during cancer treatment. It's OK to tell friends and family that you need some time for yourself. Writing in a journal, listening to music or going for walks can all be beneficial ways to reduce stress and cope with your emotions.

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You may reduce your risk of cervical cancer if you:

  • Use a condom every time you have sex, to reduce your risk of contracting HPV
  • Delay first intercourse
  • Have fewer sexual partners
  • Avoid smoking
  • Get vaccinated against HPV

Get vaccinated against HPV
Vaccines can protect against the most dangerous types of HPV — the virus that plays a role in causing most cervical cancers. Vaccination is available for girls ages 9 to 12, as well as girls and women ages 13 to 26 if they haven't received the vaccine already. The vaccine is most effective if given to girls before they become sexually active.

Although it's hoped that the vaccine will prevent most cervical cancer cases, it can't prevent infection with every virus that causes cervical cancer. Routine Pap tests to screen for cervical cancer remain important.

Have routine Pap tests
Routine Pap tests can detect precancerous conditions of the cervix so they can be followed or treated in order to prevent cervical cancer. Work with your doctor to determine the best schedule for Pap tests. Most medical organizations suggest women begin routine Pap tests at age 21. For women between the ages of 21 and 29, most organizations recommend having the test every two to three years. For women between the ages of 30 and 65, the recommendation is for a Pap test every three years, or every five years when the Pap test is combined with an HPV test. Talk with your doctor about what's best for you.

If you're at high risk of cervical cancer, you'll need more frequent Pap tests. If you've had a hysterectomy, talk with your doctor about whether to continue getting Pap tests. If the hysterectomy was done for a noncancerous condition, such as fibroids, you may be able to discontinue routine Pap tests, but not pelvic exams. If the hysterectomy was done for a precancerous or cancerous condition, your vaginal canal still needs to be checked for abnormal changes.

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