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cervical-cancer

Cervical Cancer

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What is Cervical Cancer?

Cervical cancer starts in a woman's cervix, which is the lower, narrow part of the uterus. The uterus holds the growing fetus during pregnancy. The cervix connects the lower part of the uterus to the vagina and, with the vagina, forms the birth canal.

Cervical cancer begins when normal cells on the surface of the cervix change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

At first, the changes in a cell are abnormal, not cancerous. Researchers believe, however, that some of these abnormal changes are the first step in a series of slow changes that can lead to cancer. Some of the abnormal cells go away without treatment, but others can become cancerous. This phase of the disease is called dysplasia (an abnormal growth of cells). The precancerous tissue needs to be removed to keep cancer from developing. Often, the precancerous tissue can be removed or destroyed without harming healthy tissue, but in some cases, a hysterectomy (removal of the uterus and cervix) is needed to prevent cervical cancer. Treatment of a lesion (a precancerous area) depends on the following factors:

The size of the lesion and the type of changes that have occurred in the cells

If the woman wants to have children in the future

The woman's age

The woman's general health

The preference of the woman and her doctor

If the precancerous cells change into true cancer cells and spread deeper into the cervix or to other tissues and organs, then the disease is called cervical cancer.

There are two main types of cervical cancer, named for the type of cell where the cancer started. Other types of cervical cancer are rare.

Squamous cell carcinoma, which makes up about 80% to 90% of all cervical cancers

Adenocarcinoma, which makes up 10% to 20% of all cervical cancers

Symptoms & Signs

Most women do not have any signs or symptoms of a precancer or early stage cervical cancer. Symptoms usually do not appear until the cancer has spread to other tissues and organs. These symptoms may also be caused by a medical condition that is not cancer.

Any of the following could be signs or symptoms of cervical dysplasia or cancer:

Blood spots or light bleeding between or following periods

Menstrual bleeding that is longer and heavier than usual

Bleeding after intercourse, douching, or a pelvic examination

Pain during sexual intercourse

Bleeding after menopause

Increased vaginal discharge

Any of these six symptoms should be reported to the doctor. If these symptoms appear, it is important to talk with your doctor about them even if they appear to be symptoms of other, less serious conditions. Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often. The earlier precancerous cells or cancer is found and treated, the better the chance that the cancer can be prevented or cured.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Risk Factors

A risk factor is anything that increases a person's chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a woman's risk of developing cervical cancer:

Human papillomavirus (HPV) infection. The most important risk factor for cervical cancer is infection with HPV. This virus is most commonly passed from person to person during sexual activity. There are different types, or strains, of HPV, and some strains are more strongly associated with certain types of cancers. HPV vaccines protect against certain strains of the virus. 

Immune system deficiency. Women with lowered immune systems have a higher risk of developing cervical cancer. A lowered immune system can be caused by immune suppression from corticosteroid medications, organ transplantation, treatments for other types of cancer, or from the human immunodeficiency virus (HIV), the virus that causes acquired immune deficiency syndrome (AIDS). When a woman has HIV, her immune system is less able to fight off early cancer.

Herpes. Women who have genital herpes have a higher risk of developing cervical cancer.

Smoking. Women who smoke are about twice as likely to develop cervical cancer as women who do not smoke.

Age. Girls younger than 15 rarely develop cervical cancer. The risk goes up between the late teens and mid-30s. Women over 40 remain at risk and need to continue having regular Pap test screenings.

Race. Cervical cancer is more common among black women, Hispanic women, and American Indian women.

Oral contraceptives. Some research studies suggest that oral contraceptives (birth control pills) may be associated with an increase in the risk of cervical cancer. However, more research is needed to understand how oral contraceptive use and the development of cervical cancer are connected.

Exposure to diethylstilbestrol (DES). Women whose mothers were given this drug during pregnancy to prevent miscarriage have an increased risk of cervical cancer. DES was given for this purpose from about 1940 to 1970. Women exposed to DES should have an annual pelvic examination that includes a cervical Pap test as well as a four-quadrant Pap test, in which samples of cells are taken from all sides of the vagina to check for abnormal cells.

Prevention

Cervical cancer can often be prevented by preventing precancers and having regular Pap tests. Preventing precancers means controlling possible risk factors , such as:

Delaying first sexual intercourse until the late teens or older

Limiting the number of sex partners

Avoiding sexual intercourse with people who have had many partners

Avoiding sexual intercourse with people who are obviously infected with genital warts or show other symptoms

Having safe sex by using condoms will reduce the risk of HPV infection. Condoms also protect against HIV and genital herpes.

Quitting smoking

 The Pap test is the most common test for cervical cancer. Researchers have found that combining it with a test to detect HPV provides the most accurate results. In 2003, a U.S. Food and Drug Administration (FDA) panel recommended that Pap tests and HPV tests be used together when screening for cervical cancer in women older than 29. The HPV test and HPV genotyping (testing the strain of HPV) are already being used as secondary tests for people with Pap test results that show abnormal cells to help doctors determine a woman’s risk for developing cervical cancer.

In 2006, the FDA approved the first HPV vaccine, called Gardasil, for girls and women between ages 9 and 26. The vaccine helps prevent infection from the two HPV strains known to cause most cervical cancers and precancerous lesions. The vaccine also prevents against two low-risk HPV strains that cause 90% of genital warts. In 2009, the FDA approved a second HPV vaccine, called Cervarix, for the prevention of cervical cancer in girls and women ages 10 to 25. These vaccines do not protect people who are already infected with HPV. Doctors still recommend regular Pap tests using the guidelines below for all women. 

In 2009,Screening schedule:

Starting at age 21, women should have Pap tests every two years.

After three normal Pap tests in a row, women 30 and older may have Pap tests every 3 years. Women with specific medical conditions, such as a history of abnormal Pap tests, infection with HIV, a weakened immune system, or exposure to DES, should be screened more often.

Women 30 and older may be tested for HPV with the Pap test. If both are normal, the tests are not needed for another three years.

Starting at age 65 to 70, women can stop screening if they have had three normal Pap tests in a row in the previous 10 years. However, they should continue screening if they are sexually active, have had multiple sexual partners, or have a history of abnormal Pap tests. 

In 2012, Screening guidelines:

All women should begin having Pap tests within three years of beginning vaginal sexual intercourse or by age 21, whichever comes first.

Women should be screened every three years with a conventional or liquid-based Pap test. Women 30 and older who have had three normal test results in a row can receive screening every three years. Women older than 30 may also have a Pap test and the HPV test every five years.

Women 65 or older can stop screening if their previous three Pap tests were normal and there were no abnormal test results within the previous 10 years

Screening after a hysterectomy (removal of the uterus and cervix) is not necessary unless the surgery was done to treat cervical cancer or precancer. Women who have had a hysterectomy without removal of the cervix should continue screening until age 70.

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose cervical cancer:

Pap test. The doctor gently scrapes the outside of the cervix and vagina and takes samples of the cells for testing.

Improved Pap test methods have made it easier for doctors to find cancerous cells. Traditional Pap tests can be hard to read because cells can be dried out, covered with mucus or blood, or clump together on the slide.

The liquid-based cytology test (often referred to as ThinPrep or SurePath) transfers a thin layer of cells onto a slide after removing blood or mucus from the sample. Because the sample is preserved, other tests (such as the HPV test mentioned in the Prevention section) can be done at the same time.

Computer screening (often called AutoPap or Focal Point) uses a computer to scan the sample for abnormal cells.

Pelvic examination. In this examination, the doctor feels a woman’s uterus, vagina, ovaries, fallopian tubes, cervix, bladder, and rectum to check for any unusual changes. A Pap test is often done at the same time.

HPV typing. An HPV test is similar to a Pap test, where the test is done on a sample of cells from the patient’s cervix. The doctor may test for HPV at the same time as a Pap test or after Pap test results show abnormal changes to the cervix. Certain strains of HPV, such as HPV 16, are seen more often in women with cervical cancer and may help confirm a diagnosis. Many women have HPV but do not have cervical cancer, so HPV testing alone is not an accurate test for cervical cancer.

If the Pap test showed some abnormal cells, and the HPV test is also positive, the doctor may suggest one or more of the following diagnostic tests:

Colposcopy. The doctor may do a colposcopy to check the cervix for abnormal areas. A special instrument called a colposcope (an instrument that magnifies the cells of the cervix and vagina, similar to a microscope) is used. The colposcope gives the doctor a lighted, magnified view of the tissues of the vagina and the cervix. The colposcope is not inserted into the woman’s body and the examination is not painful, can be done in the doctor's office, and has no side effects. It can be done on pregnant women.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). If the lesion is small, the doctor may remove all of it during the biopsy. There are several types of biopsies:

One common method uses an instrument to pinch off small pieces of cervical tissue.

Sometimes, the doctor wants to check an area inside the opening of the cervix that cannot be seen during a colposcopy. To do this, the doctor uses a procedure called endocervical curettage (ECC). Using a small, spoon-shaped instrument called a curette, the doctor scrapes a small amount of tissue from inside the cervical opening.

A loop electrosurgical excision procedure (LEEP) uses an electrical current passed through a thin wire hook. The hook removes tissue for examination in the laboratory. A LEEP may also be used to remove a precancer or an early stage cancer.

Conization (a cone biopsy) removes a cone-shaped piece of tissue from the cervix. Conization may be done as treatment to remove a precancer or an early stage cancer.

The first three procedures are usually done in the doctor's office using a local anesthetic to numb the area. There may be some bleeding and other discharge and, for some women, discomfort similar to menstrual cramps. Conization is done under a general or local anesthetic and may be done in the doctor's office or the hospital.

If the biopsy indicates that cervical cancer is present, the doctor will refer the woman to a gynecologic oncologist, who specializes in treating this type of cancer. The specialist may suggest additional tests to see if the cancer has spread beyond the cervix.

Pelvic examination. The specialist may re-examine the pelvic area while the patient is under anesthetic to see if the cancer has spread to any organs near the cervix, including the uterus, vagina, bladder, or rectum.

X-ray. An x-ray is a way to create a picture of the structures inside of the body using a small amount of radiation. An intravenous urography is a type of x-ray that is used to view the kidneys and bladder.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Cystoscopy. This procedure allows the doctor to view the inside of the bladder and urethra (canal that carries urine from the bladder) with a thin, lighted, flexible tube called a cystoscope. The person may be sedated as the tube is inserted in the urethra. A cystoscopy is used to determine whether cancer has spread to the bladder.

Proctoscopy (also called a sigmoidoscopy). This procedure allows the doctor to see the colon and rectum with a thin, lighted, flexible tube called a sigmoidoscope. The person may be sedated as the tube is inserted in the rectum. A proctoscopy is used to see if the cancer has spread to the rectum.

Laparoscopy. This procedure allows the doctor to see the abdominal area with a thin, lighted, flexible tube called a laparoscope. The person may be sedated as the tube is inserted through an incision in the body.

After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

Stages

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor and where is it located?(Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body?(Metastasis, M)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail. The Roman numerals in parentheses are stages used in another widely used staging system from the Federation Internationale de Gynecologie et d'Obstetrique, or FIGO.

TX: The primary tumor cannot be evaluated. More tests may be needed.

T0: There is no primary tumor.

Tis: This stage is called carcinoma (cancer) in situ, which means that the cancer is found only in the layer of cells lining the cervix and has not spread deeper into the cervix.

T1/FIGO I: The carcinoma is found only in the cervix.

T1a/FIGO IA: Invasive carcinoma was diagnosed only by microscopy (viewing cervical tissue or cells under a microscope). Note: Any tumor found macroscopically (large enough to be recognized by imaging tests or to be seen or felt by the doctor) is called stage T1b or FIGO IB.

T1a1/FIGO IA1: There is a cancerous area of 3.0 millimeters (mm) or smaller in depth, and 7.0 mm or smaller in length.

T1a2/FIGO IA2: There is a cancerous area larger than 3.0 mm but not larger than 5.0 mm in depth, and 7.0 mm or smaller in length.

T1b/FIGO IB: In this stage, the doctor can see the lesion, and the cancer is found only in the cervix, or there is a microscopic lesion (one able to be seen using a microscope) that is larger than a stage T1a2/FIGO IA2 tumor (see above). The cancer may have been found because of a physical examination, laparoscopy, or other imaging methods.

T1b1/FIGO IB1: The tumor is 4.0 centimeters (cm) or smaller.

T1b2/FIGO IB2: The tumor is larger than 4.0 cm.

T2/FIGO II: The cancer has grown beyond the uterus but not to the pelvic wall or to the lower third of the vagina.

T2a/FIGO IIA: The tumor has not spread to the tissue next to the cervix, also called the parametrial area.

T2a1/FIGO IIA1: The tumor is 4.0 cm or smaller.

T2a2/FIGO IIA2: The tumor is larger than 4.0 cm.

T2b/FIGO IIB: The tumor has spread to the parametrial (tissue surrounding the uterus) area.

T3/FIGO III: The tumor extends to the pelvic wall, and/or involves the lower third of the vagina, and/or causes hydronephrosis (swelling of the kidney) or a nonfunctioning kidney.

T3a/FIGO IIIA: The tumor involves the lower third of the vagina, but it has not grown into the pelvic wall.

T3b/FIGO IIIB: The tumor has grown into the pelvic wall and/or causes hydronephrosis or nonfunctioning kidneys.

T4/FIGO IVA: The tumor has spread to the mucosa (lining) of the bladder or rectum and grown beyond the pelvis.

Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the cervix are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): The tumor has not spread to the regional lymph nodes.

N1/FIGO IIIB: The tumor has spread to the regional lymph node(s).

Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.

M0 (M plus zero): There is no distant metastasis.

M1/FIGO IVB: There is distant metastasis.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

       

Stage 0: The tumor is called carcinoma in situ. In other words, the cancer is found only in the first layer of cells lining the cervix, not in the deeper tissues (Tis, N0, M0). Carcinoma in situ is not considered to be an invasive cancer.

Stage I: The cancer has spread from the cervix lining into the deeper tissue but is still just found in the uterus. It has not spread to lymph nodes or other parts of the body (T1, N0, M0). This stage may be described in more detail (see below).

Stage Ia: T1a, N0, M0

Stage Ia1: T1a1, N0, M0

Stage Ia2: T1a2, N0, M0

Stage Ib: T1b, N0, M0

Stage Ib1: T1b1, N0, M0

Stage Ib2: T1b2, N0, M0

Stage II: The cancer has spread beyond the cervix to nearby areas, such as the vagina or tissue near the cervix, but it is still inside the pelvic area. It has not spread to lymph nodes or other parts of the body (T2, N0, M0). This stage may be described in more detail (see below).

Stage IIa: T2a, N0, M0

Stage IIa1: T2a1, N0, M0

Stage IIa2: T2a2, N0, M0

Stage IIb: T2b, N0, M0

Stage III: The cancer has spread outside of the cervix and vagina but not to the lymph nodes or other parts of the body (T3, N0, M0).

Stage IIIa: The cancer has spread to the lower part of the vagina but not to other parts of the body (T3a, N0, M0).

Stage IIIb: The cancer may have spread as far as the pelvic wall and to lymph nodes but not to other parts of the body (T1, T2, or T3a; N1, M0). If it has spread to the pelvic wall, it is called stage IIIb regardless of whether there is cancer in the lymph nodes (T3b, any N, M0).

Stage IVa: The cancer has spread to the bladder or rectum and may or may not have spread to the lymph nodes, but it has not spread to other parts of the body (T4, any N, M0).

Stage IVb: The cancer has spread to other parts of the body (any T, any N, M1).

Recurrent. Recurrent cancer is cancer that comes back after treatment. It may come back in the cervix or in another place. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

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