Everything You Need to Know About Cervical Cancer
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Table of Contents
Signs and Symptoms
Screening and Prevention
When to See a Doctor
Living with Cervical Cancer
Frequently Asked Questions
Cervical cancer is one of the most common cancers of women worldwide. This type of cancer affects the cervix, which is the lower part of the uterus. The cervix connects the uterus with the vagina. It has two distinct parts:
- Endocervix: The part closest to the uterus.
- Exocervix: The part closest to the vagina.
For 2019, the American Cancer Society (ACS) estimates there will be approximately 13,170 cases of newly diagnosed invasive cervical cancer in the United States. Of these newly diagnosed cases of cervical cancer, approximately 4,250 women will die from the disease.
Signs and Symptoms
Cervical cancer is a slow-growing cancer. In fact, its progression from a pre-cancerous lesion to full-blown cancer can take decades. As such, it is common for women with early-stage cervical cancers to have no signs or symptoms.
As cervical cancer progresses, it may lead to signs and symptoms, such as:
- Vaginal bleeding, especially if between periods, after sexual intercourse, or after menopause;
- Vaginal discharge, which may be watery and/or bloody with or without a foul odor;
- Pain/discomfort with sexual intercourse;
- Pelvic pain, and;
- Periods that are longer or heavier than normal.
Additionally, if cervical cancer has spread to nearby or distant organs, symptoms may include:
- Painful urination;
- Bloody urine;
- Low back pain and/or constipation;
- Weight loss;
- Rectal pain or bleeding with defecation, or;
- Abdominal swelling from excess fluid, which leads to an increased diameter.
No one knows exactly what causes cervical cancer. However, one of the main risk factors for this disease is human papillomavirus (HPV).
According to the Centers for Disease Control and Prevention (CDC), HPV is the most commonly sexually transmitted infection (STI) in the United States. Additionally, a diagnosis of another STI, such as chlamydia, gonorrhea, syphilis, or HIV, increases your risk for HPV. There are more than 100 types of HPV, of which approximately 13 types have the potential to cause cervical cancer.
Although HPV may cause genital warts, it should be noted that they are very common. Most people with this diagnosis do not go on to develop cervical cancer, especially with the availability of HPV vaccines today.
Other risk factors for cervical cancer include:
- Early sexual contact;
- Multiple sexual partners;
- A weakened immune system, and;
- Long-term use of oral contraceptives or birth control pills.
Furthermore, ethnicity is a risk factor. As such, Hispanic women at greatest risk for cervical cancer, followed by African American, Asian/Pacific Islander, and Caucasian women. In fact, American Indian and Alaskan native women are at the lowest risk for cervical cancer in the United States.
Lastly, if your mother was administered a miscarriage prevention drug called diethylstilbestrol in the 1950s, you are at increased risk for cervical cancer.
Screening and Prevention
Since cervical cancer is a slow-growing cancer, it provides opportunities for screening, early detection, and prevention.
At one time, cervical cancer was one of the most common causes of cancer death among American women. Fortunately, this death rate has dropped precipitously with the almost universal use of the Papanicolaou (Pap) smear, or Pap test, for cervical cancer screening. The Pap test or smear collects cells from the cervix to be looked at under a microscope to find pre-cancers and cancer.
Another screening tool that has emerged is the HPV DNA test. This test can be performed on the same sample of cells collected for the Pap test.
Because early cervical cancer diagnosis improves the success of treatment, the United States Preventive Services Task Force (USPSTF) recommends the following as routine cervical cancer screening:
- 21 to 29 Years: Pap smear alone every three years.
- 30 to 65 Years: Pap smear alone every three years, HPV DNA test alone every five years, or Pap smear plus HPV DNA test every five years.
Not every woman has to undergo screening for cervical cancer. At the moment, the USPSTF recommends against screening for cervical cancer in women:
- Younger than 21 years old;
- Older than 65 years old who had adequate prior screening and are not otherwise considered high-risk for cervical cancer, and;
- Who have had a hysterectomy with removal of the cervix and a personal history of a high-grade pre-cancerous lesion or cervical cancer.
As far as cervical cancer prevention, the recent development of an HPV vaccine has been tabbed as one of the most important preventative actions.
As of 2017, Gardasil 9 is the only HPV vaccine available in the United States. It prevents infections with HPV types 16 and 18, which account for 70 percent of all cervical cancers, along with the other high-risk HPV types 6, 11, 31, 33, 45, 52, and 58. All nine of these HPV types account for 90 percent of all cervical cancers.
The CDC recommends the HPV vaccine be routinely administered to adolescents starting at age 11 or 12, with catch-up vaccination through age 26. Although the public health benefit may be minimal, the HPV vaccine is recommended for all women and men age 27 to 45 who did not receive the vaccine as an adolescent.
The following may prevent pre-cancerous lesions and certain conditions that can lead to pre-cancers:
- Regular cervical cancer screening with the Pap smear and/or HPV DNA test;
- Avoiding/quitting smoking;
- Limiting/reducing your sex partners;
- Safe sex with regular use of condoms, and;
- Delaying your first sexual encounter.
When to See a Doctor
If you have any symptoms that could be referable to cervical cancer — such as abnormal vaginal bleeding — you should bring them to the attention of your doctor at a scheduled visit. You most likely will need a complete gynecological exam, including a Pap smear and possibly an HPV DNA test, to investigate your symptoms.
Although abnormal vaginal bleeding can be caused by other factors, like vaginal dryness or non-cancerous uterine polyps, it is the most common symptom of both cervical and uterine cancer.
While most women are diagnosed with pre-cancerous cervical lesions in their 20s and 30s, most women are diagnosed with cervical cancer in their mid-50s. This difference highlights the slow-growing nature of this disease and the potential effectiveness of screening and prevention programs.
Pap and HPV DNA Test
The first step in the diagnosis of cervical cancer is the Pap test with or without an HPV DNA test. The tests often have an abnormal result whether it be screening (presenting with no symptoms) or diagnostic (presenting with symptoms) in nature.
Prior to the Pap test, your doctor will ask a series of questions about your current and past medical history, focusing on areas such as your current symptoms, family history, and risk factors. For example, you may be asked:
- What are your symptoms and how long have you been experiencing them?
- What is the severity of your symptoms and what makes them better or worse?
- When was your last Pap smear and have you ever had an abnormal Pap smear result?
- Have you ever been diagnosed with an STI?
- Have you ever been on oral contraceptives and if so, how long?
Next, your doctor will perform a thorough physical examination, including a pelvic exam, to evaluate your state of health. At this point, your doctor may pursue further testing to rule in or rule out cervical cancer. Your doctor may perform a colposcopy, which utilizes the colposcope to directly visualize any abnormal cervical tissue. If the colposcopy reveals any abnormal tissue, samples of these areas (biopsies) can be taken for evaluation of the cells under the microscope.
It should be kept in mind that the only way to definitively diagnose cervical cancer is through a biopsy. Your doctor has the choice of several methods, including:
- Punch Biopsy: Uses a sharp instrument to pinch off small samples.
- Endocervical Curettage: Uses a small, spoon-shaped instrument (curette) to scrape a small sample from inside the opening of the cervix.
- Loop Electrosurgical Excision Procedure (LEEP): Uses an electrified (low voltage) loop of wire to obtain samples.
- Cone Biopsy: Also known as conization. Removes a cone-shaped piece of the cervix and sent to the laboratory.
The latter two methods (LEEP and cone biopsy) can be used to obtain biopsies and remove pre-cancerous lesions and early-stage cervical cancers. Additionally, the LEEP can be performed under local anesthesia in your doctor’s office, while a cone biopsy is usually performed in the hospital under general anesthesia.
If the biopsy reveals cervical cancer, your doctor may order imaging studies, such as computed tomography, magnetic resonance imaging, and positron emission tomography, to determine the staging of cervical cancer.
The stage of your cervical cancer is one of the most important determinants of your treatment plan. Knowing the stage provides insight into how successful treatment might be.
Cervical cancer can be categorized by the following stages:
- Stage 0:Pre-cancerous cells are present only on the surface of the cervix.
- Stage I: Cancer cells are confined to the uterus, specifically the cervix.
- Stage II: Cancer cells have grown beyond the cervix and uterus.
- Stage III: Cancer cells have spread to the lower part of the vagina or the walls of the pelvis.
- Stage IV: Cancer cells have spread to distant organs, such as the bladder, rectum, liver, bones, lungs, or distant lymph nodes.
It should be kept in mind that Stages I to III may or may not be characterized by the spread of cervical cancer cells to local lymph nodes. Also, Stage IV is the most advanced stage of the disease.
Cervical cancers are classified by their appearance under a microscope. As such, there are two main types of cervical cancer:
- Squamous cell carcinoma, and;
The great majority — 90 percent in fact — of cervical cancers are squamous cell carcinomas. They typically develop in exocervical cells and have thin, flat sheets of cells under the microscope.
The rest of the cervical cancers are adenocarcinomas. They typically develop in endocervical cells, which are mucus-producing glands.
Occasionally, both types of cells are involved in cervical cancer. This type is adenosquamous carcinoma or mixed carcinoma. Very rarely does cervical cancer occur in other types of cells within the cervix.
The ACS references information from the Surveillance, Epidemiology, and End Results (SEER) database to provide five-year relative survival rates for cervical cancer. Think of a relative five-year relative survival rate as comparing women who have cervical cancer with women who don’t have cervical cancer and their propensity to live at least five years after their cancer diagnosis.
The SEER database groups cervical cancers into three categories. They are:
- Localized Disease: Confined to the cervix/uterus.
- Regional Disease: Cancer has grown outside of cervix/uterus to neighboring structures.
- Distant Disease: Cancer has spread to other parts of the body.
The prognosis for cervical cancer (with treatment) is good with an overall five-year relative survival rate of 66 percent. Additionally, five-year relative survival rates were 92 percent for localized disease (Stage I), 56 percent for regional disease (Stage II and III), and 17 percent for distant disease (Stage IV). These results lend validity to the early diagnosis of cervical cancer through screening programs, which should increase your chances of survival.
It should be kept in mind that these five-year relative survival rates are averages and do not apply to everyone. There have been reports of successful treatment of Stage IV cervical cancer.
Complications of cervical cancer can be the result of advanced disease or side effects of treatment.
The most alarming complication of cervical cancer is metastasis. Metastasis is the spread of cancer to other parts of the body. Common sites for metastasis of cervical cancer include lymph nodes, pelvis, abdomen, ureters, liver, lungs, and bones. This spread of the cancer may limit — sometimes severely — your treatment options, leading to lower survival rates. Many times patients with Stage IV cervical cancer have to be referred for hospice and/or palliative care.
Other complications of advanced cervical cancer may include:
- Kidney failure;
- Blood clots;
- Bleeding, especially from the vagina or rectum, and;
- A fistula, an abnormal connection between the vagina and rectum.
Complications or side effects of cervical cancer treatment may include:
- Early menopause, resulting from surgical removal of the ovaries or damage from chemotherapy or radiation therapy;
- Narrowing of the vagina, resulting from radiation therapy;
- A build-up of fluid in the legs, and;
There are various options for the treatment of cervical cancer. Staging allows doctors to characterize the aggressiveness of cervical cancer, which ultimately determines the treatment option(s) available to you.
Choosing the best treatment option for your cervical cancer should entail an in-depth conversation with your doctor. In this conversation, make sure to take the following into consideration:
- The stage of disease;
- Your age and general level of health;
- Location of the tumor;
- Type of cervical cancer, and;
- The desire for fertility.
Possibilities for surgery include cryosurgery, laser surgery, conization, or removal of the uterus.
Kills cervical cancer cells using high-energy X-rays. There are two main types:
- External beam, and;
- Internal beam, which is also known as brachytherapy.
Drugs/chemicals that kill cervical cancer cells. They are commonly administered by injection into a vein or by mouth.
Kills cervical cancer cells by inhibiting the formation of new blood vessels (angiogenesis), which is crucial for cancer growth.
It allows an individual’s immune system to more effectively detect and destroy cervical cancer cells. It is best for Stage IV cervical cancer or if the cancer has returned after initial treatment.
Living with Cervical Cancer
If you have or have had cervical cancer, you may want to know if there are things you can do to potentially lower your risk of cancer progression or recurrence. Some general recommendations for women living with cervical cancer include:
- Regular exercise for at least 30 minutes, four or more times per week;
- A healthy diet that includes plenty of fruits and vegetables, whole grains, poultry, and fish;
- Limit your intake of both red and processed meats and high-fat dairy products;
- Maintaining a healthy weight, which is typically a BMI between 18.5 and 24.9 kg/m2, and;
- Get enough rest, specifically seven to nine hours of sleep per night.
No one really knows if the adoption of these behaviors will prevent or treat cervical cancer. However, many believe the positive effects on your health as a result of these behaviors can extend to lowering your risk of cervical cancer progression or recurrence.
Frequently Asked Questions
What If My Pap Test Is Normal, but My HPV DNA Test Is Positive?
You still may be at risk of developing cervical cancer. Therefore, your doctor may recommend:
- Repeat co-testing (getting both a Pap test and an HPV DNA test) in one year, or;
- Testing for HPV types 16 or 18, which can often be performed on the same sample as the Pap test.
What Does an “ASCUS” Pap Smear Result Mean?
ASCUS is the abbreviation for atypical squamous cells of undetermined significance. It means the Pap test is equivocal or inconclusive. As a result, your doctor may recommend getting an HPV DNA test.
Will the Pap Test Tell Me If I Have Cervical Cancer?
No, an abnormal Pap test suggests that there may be a serious problem. So, your doctor should do further investigation.
A biopsy is the only definitive method for the diagnosis of cervical cancer.
How Painful Is the Pelvic Examination and Pap Test?
Depending on the type of exam, you may experience some discomfort, stinging, and/or pressure. Relaxation techniques can go a long way at relieving or significantly decreasing any discomfort.
Is the Pap Smear a Test for HIV/Aids or Other STIs?
No. If you have concerns about STIs, additional testing may be needed.
In summary, the preferred method to detect cervical cancer, especially early-stage, is to have regular screening with a Pap test with or without an HPV DNA test. As a result of the Pap test being universal in the United States, pre-cancerous cervical lesions are far more commonly diagnosed than invasive cancer. This translates into more definitive curative treatments, which should improve measures such as the five-year relative survival rate.
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