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Types of Cancer > Gynecologic Cancers > Cervical Cancer > Overview

Cervical Cancer: The Basics

Christopher Dolinsky, MD and Christine Hill-Kayser, MD
Affiliation: Abramson Cancer Center of the University of Pennsylvania
Last Modified: April 17, 2009

How is cervical cancer diagnosed and staged?

The most common reason for your doctor to pursue the diagnosis of cervical cancer is if you have an abnormal Pap test. Pap tests exist to find pre-cancerous lesions in your cervix. A pre-cancerous lesion means that there are abnormal appearing cancer cells, but they haven't invaded past a tissue barrier in your cervix; thus a pre-cancerous lesion cannot spread or harm you. However, if left untreated, a pre-cancerous lesion can evolve to an invasive cancer. Pap tests are reported as no abnormal cells, abnormal cells of undetermined significance, low risk abnormal cells or high risk abnormal cells. Depending on your specific case, your doctor will decide how to proceed.

A report of no abnormal cells equates to a negative test, meaning you simply need to follow-up in one year. The abnormal cells of undetermined significance can be handled in three different ways. Women can either get a repeat Pap test in 4-6 months, they can get HPV testing, or they can be referred for colposcopy. Colposcopy is a procedure done during a pelvic exam with the aide of a colposcope, which is like a microscope. By using acetic acid on the cervix and examining it with a colposcope, your doctor can look for abnormal areas of your cervix. Then, the most abnormal areas can be biopsied. A biopsy is the only way to know for sure if you have cancer, because it allows your doctors to get cells that can be examined under a microscope. Once the tissue is removed, a doctor known as a pathologist will review the specimen. Colposcopy is uncomfortable, but not painful, and can be done in your gynecologist's office. Your doctor will decide how to proceed with the workup of a Pap test showing abnormal cells of undetermined significance depending on the details of your case. If repeat Pap tests are not normal, then you will be referred for colposcopy. If you test positive for HPV, you will be referred for colposcopy. Generally, most patients with low risk abnormal cells, or high risk abnormal cells will be immediately referred for colposcopy. If you are pregnant, an adolescent, HIV positive, or post-menopausal, your doctor may have slightly different recommendations. Also, sometimes your Pap test will show cells that look abnormal but could have come from higher in your uterus. There is a chance that if this happens, you will need to have your uterine lining sampled. Talk to your doctor about your Pap test results, and what you need to do next after an abnormal Pap smear.

If you are having symptoms (bleeding/discharge) from a cervical cancer, then it can probably be visualized during a pelvic exam. Any time your doctor can see a cervical tumor on pelvic exam, it will be immediately biopsied. When abnormal appearing tissue is noticed during a colposcopy, then it needs to be biopsied as well. There are a few different ways to do a biopsy. A punch biopsy may be used to remove a small section of the cervix. A LEEP (loop electrosurgical excision procedure) is another method to do a biopsy where a thin slice of the cervix is removed. Finally, a conization or cone biopsy may be performed. A cone biopsy removes a thicker section of the cervix, and allows the pathologist to see if malignant cells have invaded underneath the surface. The cone biopsy has the added value of sometimes being able to cure a pre-cancerous lesion that is localized to a small area. Treatments for cervical cancer and pre-cancerous lesions will be discussed further in the next section.

In order to guide treatment and offer some insight into prognosis, cervical cancer is staged into different groups. There are a few different staging systems, but the most popular one for cervical cancer is the FIGO system (International Federation of Gynecologists and Obstetricians). The FIGO system is a clinical staging system which means that the cancer is staged by a doctor's physical examination and the results of a biopsy. The FIGO staging system is for invasive cervical cancers, not pre-cancerous lesions. A simplified version of the FIGO staging system is:

• Stage IA - microscopic cancer confined to the cervix
• Stage IB - cancer visible by the naked eye confined to the cervix
• Stage II - cervical cancer invading beyond the uterus but not to the pelvic wall or lower 1/3 of the vagina
• Stage III - cervical cancer invading to the pelvic wall and/or lower 1/3 of the vagina and/or causing a non-functioning kidney
• Stage IVA - cervical cancer that invades the bladder or rectum, or extends beyond the pelvis
• Stage IVB - distant metastases

Because the physical exam is so important for staging a cervical cancer, your doctors may want to do the most thorough examination while you are under anesthesia. Another important test is called intravenous pyelography (IVP), which takes an x-ray of your kidneys after you receive a dye given by vein to allow evaluation of your kidney function. Other times, your doctors will want the results of other radiologic tests to better characterize your specific cancer. Tests like CAT scans (3-D x-rays) or MRIs (like a CAT scans but done with magnets) can examine the cervix and localized lymph nodes. X-rays may be taken of your bones and/or chest. Sometimes, your doctors may want to have a look in your bladder and do a cystoscopy, in which a lighted scope is inserted through your urethra into your bladder. You may get also get a proctosigmoidoscopy, which uses a lighted scope to examine your rectum and colon. Each patient is an individual so the specific tests people get will vary; but overall, your doctors want to know as much about your particular tumor as possible so that they can plan the best available treatments.

What are the treatments for cervical cancer?

Pre-cancerous lesions

Women who have pre-cancerous lesions demonstrated on biopsy after colposcopy have a few different options how to proceed. A woman may decide on a specific option depending on whether or not she plans to have children in the future, her current health status and life expectancy, and her concerns about the future and the possibility of having a cancer come back. You should talk to your doctor about you fears, concerns and preferences. Sometimes, women with low grade lesions may choose to not have any further treatment, especially if the biopsy removed the entire lesion. If you decide to do this, you will need frequent pelvic exams and Pap tests. There are several; different ways to remove pre-cancerous lesions without removing the entire uterus (and thus preserving a woman's ability to have a baby in the future). Women can have cryosurgery (freezing off the abnormal lesion), a LEEP (the same type of electrosurgical procedure used for biopsies), a conization (the thicker type of biopsy that gets tissue under the surface), or have the cells removed with a laser. Your doctor can discuss the benefits and drawbacks of each of these modalities. Women who do not have any plans to have children in the future and are particularly worried about their chances of getting an invasive cancer may elect to have a hysterectomy (a surgery that removes your uterus and cervix). This procedure is much more invasive than any of the previous treatment modalities, but can provide peace of mind to women finished with childbearing.

Surgery

Surgery is generally only employed in early stage cervical cancers. The purpose of surgery is to remove as much disease as possible, but it usually isn't used unless all of the cancer can be removed at the time of surgery. Cancers that have a high chance of already being in the lymph nodes are not treated with surgery (lymph nodes are small, pea-sized pieces of tissue that filter and clean lymph, a liquid waste product). There are a few different types of surgeries that can be performed. The earliest stage IA tumors can sometimes be treated with only a hysterectomy (removal of the uterus and cervix). Bigger stage IA, stage IB, and occasionally stage IIA tumors can be treated with more extensive hysterectomies coupled with lymphadenectomies (procedures that remove lymph nodes in the pelvis). Depending on the amount of disease, your surgeon may have to remove tissues around the uterus, as well as part of the vagina and the fallopian tubes. One of the benefits of surgery in young women is that sometimes their ovaries can be left, so that they do not go through menopause at an early age. Higher stage disease is usually treated with radiation and chemotherapy, but sometimes surgery is employed if cervical cancer comes back after it has already been treated. A pelvic exenteration is reserved for recurrent cervical cancers. A pelvic exenteration is a major surgery in which the uterus, cervix, fallopian tubes, ovaries, vagina, bladder, rectum and part of the colon are removed. This surgery is not commonly employed, but is occasionally used for recurrent cancers.

Radiotherapy

Radiation therapy has proven very effective in treating cervical cancer. Radiation therapy uses high energy x-rays to kill cancer cells. Radiation therapy is another option besides surgery for early stage cervical cancer; and when advanced stage cervical cancer needs to be treated, it is usually done with radiation therapy. Surgery and radiation have been shown to be equivalent treatments for early stage cervical cancers, and radiation helps avoid surgery in patients who are too ill to risk having anesthesia. Radiation has the benefit of being able to treat all of the disease in the radiation field; thus lymph nodes can be treated as well as the primary tumor in the course of the same treatment.

Radiation therapy for cervical cancer either comes from an external source (outside of the patient, known as external beam radiation) or an internal sourc (inside the patient, known as brachytherapy). External beam radiation therapy requires patients to come in 5 days a week for up 6-8 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. With all cervical cancers above stage IB, the standard approach with radiotherapy is to use external beam radiation coupled with internal brachytherapy. Brachytherapy (also called intracavitary irradiation) allows your radiation oncologist to "boost" the radiation dose to the tumor site. This provides an added impact to the tumor, while sparing your normal tissues. This is done by inserting a hollow, metal tube with two egg shaped cartridges into your vagina. Then a small radioactive source is placed in the tube and cartridges. A computer has calculated how long the source needs to be there, but usually for what is called low dose rate (LDR) brachytherapy, you will need to have the source in for a few days. This procedure is done in the hospital, because for those few days you have to remain in bed. Another type of brachytherapy, called high dose rate (HDR) brachytherapy, uses more powerful sources that only stay in for a few minutes. Although this option usually sounds more appealing to patients, there is debate as to which type is more effective and some institutions favor one over the other. Talk to your radiation oncologist about your options and your doctor’s opinions as to HDR versus LDR for cervical cancer treatment.

Another use of radiation is for palliation - meaning that patients with very advanced cases of cervical cancer are treated with the intent of easing their pain or symptoms, rather than trying to cure their disease.

Sometimes, women with early stage are treated with surgery, but after the results of the surgery, it becomes clear that they will need radiation as well. In any setting, radiation is often combined with chemotherapy, and, depending on your case, your doctor will decide on the best possible treatment arrangement for your lifestyle and wishes.

Chemotherapy

Despite the fact that tumors are removed by surgery or treated with radiation, there is always a risk of recurrence because there may be microscopic cancer cells left in the body. In order to decrease a patient's risk of a recurrence, she may be offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. Practically all patients who are in good medical condition and receiving radiation for stage IIA or higher cervical cancer will be offered chemotherapy in addition to their radiation. It may even be offered for earlier stage cases depending individual aspects of the patient and her disease. There have been many studies that demonstrate the usefulness of adding chemotherapy to radiation in terms of decreasing mortality from cervical cancer.

There are many different chemotherapy drugs, and they are often given in combinations for a series of months. Depending on the type of chemotherapy regimen you receive, you may get medication every week or few weeks; and you usually have to go to a clinic to get the chemotherapy because many of the drugs have to be given through a vein. The most commonly employed regimens use a drug called Cisplatin, but other drugs like 5-FU, Hydroxyurea, Ifosfamide, and Paclitaxel may also be employed. There are advantages and disadvantages to each of the different regimens that your gynecologic oncologist or medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your lifestyle.

Follow-up testing

Once a patient has been treated for cervix cancer, she needs to be closely followed for a recurrence. At first, you will have follow-up visits fairly often. The longer you are free of disease, the less often you will have to go for checkups. Your doctor will tell you when he or she wants follow-up visits, Pap tests, and x-rays or scans depending on your case. Your doctor will also do pelvic exams regularly during your office visits. It is very important that you let your doctor know about any symptoms you are experiencing and that you keep all of your follow-up appointments.

Clinical trials are extremely important in furthering our knowledge of this disease. It is through clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your doctor about participating in clinical trials in your area.

This article is meant to give you a better understanding of cervical cancer. Use this knowledge when meeting with your physician, making treatment decisions, and continuing your search for information. You can learn more about cervical cancer on OncoLink through the related links to the left.

References

• The American Cancer Society All About Cervical Cancer Overview www.cancer.org.
• Bosch FX et al. (2002) The causal relation between human papillomavirus and cervical cancer. Journal of Clinical Pathology. 55(4):244-65, 2002 Apr.
• Jemal, A. et. al (2002). Cancer Statistics, 2002. Ca: a Cancer Journal for Clinicians 52 (1):23-47
• Mandelblatt JS et al. (2002) Benefits and Costs of Using HPV Testing to Screen for Cervical Cancer. JAMA. 287(18):2372-81, 2002 May 8.
• National Cancer Institute. What You Need To Know About Cervix Cancer. www.cancer.gov.
• Rubin, P. and Williams, J.P., (Eds): Clinical Oncology: A Multidisciplinary Approach for Physicians and Students 8th ed. (2001). W.B. Saunders Company, Philadelphia, Pennsylvania.
• Sawaya GF et al. (2001) Clinical practice. Current approaches to cervical-cancer screening. New England Journal of Medicine. 344(21):1603-7, 2001 May 24.
• Vetter KM and Geller SE. Moving forward: human papillomavirus vaccination and the prevention of cervical cancer. (2007). Journal of Women’s Health, 16(9): 1258-68.
• Wright, TC Jr. et al. ASCCP Sponsored Consensus Conference. (2001) Consensus Guidelines for the management of women with cervical cytological abnormalities. JAMA. 287(16):2120-9, 2002 Apr 24.