Cervical Cancer

f you're one of the millions of women who regularly visit their obstetricians and gynecologists for routine pelvic examinations and Pap tests, then you are part of the good news about cervical cancer. This disease is almost 100 percent curable when it is diagnosed in its early stages and treated promptly. Pap tests are the single most effective method for identifying irregularities in cervical cells that could develop into cancer. Since the 1940s, when the Pap test was first introduced, the death rate for cervical cancer has declined by nearly 75 percent.

The battle against cervical cancer is far from won, however. Approximately 13,500 women are diagnosed with cervical cancer each year. As many as 4,500 of these women will die from the disease because it was diagnosed too late for effective treatment. Sadly, many of these deaths could be prevented with regular screening and early treatment.

Cervical cancer is not as common as other cancers that affect women. Breast cancer is far more prevalent, striking approximately 180,000 women in 1992. In the same year, more than 20,000 women developed ovarian cancer, and nearly 12,000 women died from it.

Early Warning; Gradual Progression

Barely more than an inch long, the cervix is the narrow end of the uterus that opens into the upper part of the vagina. Lined with mucous membrane similar to that found inside the mouth, the cervix is made up of connective tissue. This tiny passage is laced with a network of nerves that respond to pressure by sending electrical messages to the brain and spinal cord. Several weeks prior to labor and childbirth, as pressure from the uterus grows, the cervix thins and begins to expand—or dilate—to accommodate the movement of the baby through the birth canal.

Cervical cancer usually develops over a long period of time. At the outset, formerly healthy cells in the cervix begin to develop abnormally for some reason. Here are the stages of progression.

THREE STAGES OF ABNORMAL GROWTH

Nearly half the time, the slightly abnormal cell growth called cervical dysplasia will go away on its own. But the abnormal cells can become frankly cancerous; and if they do, decisive treatment is called for immediately. Eliminating the cancer while it is noninvasive—still confined to the surface of the cervix—makes a complete cure almost a certainty. However, if the cancer is allowed to continue and become invasive—attacking deeper layers of tissue—the odds of stopping it decline rapidly.

Cervical intraepithelial neoplasia (CIN). Also called cervical dysplasia, CIN is not cancer but the first of the cellular changes that may develop into cancer in some women. A Pap test detects these abnormal changes. However, no test can predict whether CIN will develop into cancer, which is why early detection and treatment of any abnormality is so important.

Cervical dysplasia is a fairly common condition; more than 55,000 women are diagnosed with it each year. Increasingly, women are developing cervical dysplasia at younger and younger ages—during their late teens to early 20s.

Noninvasive Carcinoma. A very early form of cervical cancer is known as carcinoma in situ. It also may be called noninvasive carcinoma. This abnormality involves only the top layer of cervical cells, not deeper layers of tissue in the cervix or elsewhere in the reproductive tract. Without treatment, carcinoma in situ usually will develop into invasive cervical cancer. Carcinoma in situ occurs most often in women between 30 and 40 years of age.

Invasive Cervical Cancer. At this stage, cancer has penetrated deep into the cervix and possibly into neighboring tissues and organs. Invasive cervical cancer is nearly 100 percent curable when diagnosed early and treated promptly. However, when the disease has spread outside the reproductive tract, it can be effectively treated in only 5 percent of cases. Invasive cervical cancer occurs most frequently in women between the ages of 40 and 60.

Who's at Risk?

All women are at risk for cervical dysplasia and cervical cancer. As with many other forms of cancer, researchers are unsure of the exact cause. Several factors have been identified, however, that could increase your chances of developing cervical dysplasia and cervical cancer. These risk factors include:

Cigarette smoking. Chemicals from cigarettes and cigarette smoke have been found in the cervical tissue of women who smoke. These chemicals may damage cervical cells and weaken their ability to fight off infection, as well as make them more vulnerable to abnormal development. The exact mechanism linking cigarette smoking and cervical cancer has not been established, however.

Early sexual activity. Women who have sex at an early age may be more susceptible to cervical cancer than other women. One reason for this risk is that the developing cells in the cervix of a young woman are more fragile than the mature cervical cells of older women, and more likely to be damaged from the slight abrasions caused by frequent intercourse. Teenagers who smoke and have frequent sex double their risk.

Sexually transmitted diseases (STDs). Cervical dysplasia may develop after a sexually transmitted infection. Herpes simplex virus type II, a common STD, was once suspected as a cause of cervical dysplasia. However, research has shown that this virus cannot change normal cells into abnormal ones. Although the link between a specific STD and cervical cancer has yet to be identified, these diseases are believed to increase overall risk. Indeed, the connection between HIV (the AIDS virus) and cervical cancer is so strong that women with the virus are now advised to get a Pap test every 6 months.

Women with multiple partners have a greater chance of contracting sexually transmitted diseases. Teenagers are especially at risk for STDs, including human papilloma virus (HPV) and herpes. Even a woman with only one partner can still be at risk for STDs if her partner has had many others. Several STDs, including syphilis, gonorrhea, chlamydia, and HIV are increasing at alarming rates in the U.S. teen population.

Human papilloma virus (HPV). There are 60 known types of this sexually transmitted virus, but only a few can cause cells to become cancerous. One form of HPV produces genital warts and also is suspected of causing the cellular changes that may lead to cervical cancer. Up to 90 percent of cervical cancers show evidence of HPV infection. On the other hand, many women are diagnosed with HPV but never develop dysplasia or cervical cancer. The symptoms caused by HPV can be treated, but the virus itself cannot be “cured.” Symptoms often recur after treatment. If your doctor diagnoses HPV but finds no dysplasia, aggressive treatment is not necessary.

Age. The risk of cervical cancer rises with age and, when first diagnosed, cervical cancer in older women tends to be more advanced. Ironically, few women over age 65 have Pap smears regularly. Furthermore, one research study reports that after age 44, women no longer listed the Pap smear as the major reason for visiting a physician's office. You, too, may mistakenly believe that once you reach menopause, you no longer need routine gynecological exams. In fact, nothing is further from the truth.

Income. Women in low income groups develop CIN and cervical cancer 5 times as often as women in higher economic brackets. One explanation for this discrepancy in cancer rates is that poor women are less likely to have regular access to cancer screenings and follow­up care.

Race. African­American women are twice as likely to develop cervical cancer, and to have a more advanced cancer when first diagnosed than are Caucasian women. Cervical cancer rates are also higher for Hispanic and Native American women. However, a predisposition for developing cervical cancer is not passed from mother to daughter, as with breast cancer.

Symptoms of CIN and Cervical Cancer

Cervical dysplasia and early stages of cervical cancer have no visible symptoms. An abnormal Pap test is the first indication that something may be wrong. The test itself does not confirm CIN or cervical cancer; however, it does indicate that some cervical cells are abnormal.

In more advanced cervical cancer, the most common symptom is irregular bleeding. Two­thirds of women with advanced cervical cancer experience bleeding between periods, with heavier or lighter amounts than normal menstrual flow, or are troubled by bleeding following intercourse. Eventually the bleeding becomes constant. In some women, however, cervical cancer can spread dramatically to other areas in the body before it causes any bleeding.

Pain in the pelvic area, legs, and back, and discomfort while urinating (caused by pressure from a tumor), or blood in the urine, may also indicate advanced disease.

Detecting and Treating Abnormal Cells

Because early detection greatly increases the chances that treatment for CIN or cervical cancer will be successful, it's crucial that women be screened for signs of cervical disease. The main screening method is the Pap smear. If the results of the Pap are abnormal, a series of tests can determine the reason for the problem. Here are the procedures for detecting and evaluating abnormal cervical cells.

Pap Test

This simple procedure involves scraping some cells with a cotton swab or small “cyto” brush from the mucous membranes where the cervix and vagina meet. It is in this area that cell changes begin which could lead to cervical cancer.

The cells are deposited on a glass slide and sent to a laboratory where it is examined by a cytopathologist—an expert in the study of diseased cells. The lab report will describe the type and severity of any cell changes found. Cell appearance from the Pap test will be rated as normal, or as showing mild (CIN I), moderate (CIN II), or severe dysplasia (CIN III); carcinoma in situ; or invasive cancer.

What an Abnormal Pap Test Can Mean

If your physician tells you that the results of your Pap test are abnormal, it's a good idea to ask how your results were described by the laboratory. A basic understanding of your Pap test can help explain the additional diagnostic procedures your doctor will probably recommend.

If the abnormal results are due to an infection, other diagnostic tests probably won't be needed. Infections actually are the most common cause of abnormal Pap tests. Yeast infection (or candidiasis) as well as viral infections like herpes and HPV (genital warts) can cause inflammation of cervical cells. The treatment for yeast and bacterial infections is usually antibiotics. Your doctor may recommend a follow­up Pap test within 1 to 2 months to make sure the treatment was effective.

As many as 20 percent of all Pap tests may be inaccurate—reporting abnormal results when nothing irregular is present. A second Pap test can help validate suspicious findings. It's important not to have a second Pap test too quickly because the cervical cells need time to repair themselves after an exam.

What's Next After an Abnormal Pap

If infection is not the cause of your abnormal Pap results, your doctor most likely will recommend further diagnostic tests for cancer. These may include colposcopy, endocervical curettage (ECC), loop electrocautery excision procedure (LEEP), or conization. Each of these diagnostic procedures will involve a biopsy (removal for microscopic evaluation) of cervical tissue. A pelvic examination is also part of the diagnostic evaluation to determine whether there are any serious abnormalities in the pelvic region.

Most primary care physicians will perform the basic diagnostic and treatment procedures for mild to moderate dysplasia. When conization is necessary, you should see a gynecologist—especially if the biopsy will be performed for treatment of invasive cancer.

THE CERVIX: STRONG, DELICATE, VULNERABLE

This tiny corridor between the uterus and the vagina must be strong enough to keep a developing baby securely in place during pregnancy, yet elastic enough to allow delivery at term. Lined with delicate mucous membrane, it is prey to infection by the human papilloma virus (HPV), a sexually transmitted disease linked to the development of cervical cancer in ways yet to be explained. If you've been diagnosed with HPV—or any other STD—you should schedule regular Pap tests to check for early signs of cancer.

Doctors generally agree that a step­by­step approach to diagnosis usually is preferable to immediate aggressive treatment. This limits the impact on the cervix as much as possible, especially before a complete biopsy has been performed. Continued or prolonged invasive treatments can erode and weaken the cervix.

Colposcopy. During this procedure, your physician inserts a viewing scope (colposcope) into the vagina to magnify the region for inspection. For this procedure, a Schiller test, a rinse of acetic acid solution applied with a cotton swab, is administered to turn abnormal areas yellow or white. Small portions of these abnormal areas can then be removed for biopsy with a special punch instrument.

A colposcopy takes about 15 minutes and is performed in your doctor's office. Although the procedure may be uncomfortable, it is not painful. You may feel some discomfort—similar to menstrual cramps—when cervical tissue is removed for biopsy.

Endocervical curretage (ECC). Often performed during a colposcopy, ECC involves scraping cells from the inner portion of the cervix. Even when the outside of the cervix appears normal through a colposcope, the inner cervix, which can't be viewed, could pose a problem. Adenocarcinoma, for example, is a form of cancer that grows in the upper portion of the cervix and is difficult to detect without an ECC. It is common in young women and spreads quickly. Together, colposcopy and ECC can reliably identify most cervical cancers.

Loop electrocautery excision procedure (LEEP) and conization. These two more extensive methods of diagnosing abnormal tissue may also be used as treatments for CIN and early invasive cervical cancer.

With LEEP, abnormal or suspicious cervical tissue is removed with a sharp wire loop and the site is cauterized—burned to eliminate any remaining abnormal tissue. With conization, a cone­shaped section of the cervix is cut with a scalpel or a laser and removed for biopsy. This procedure requires general anesthesia and usually is performed as outpatient surgery in the hospital. Most doctors suggest conization only when other diagnostic tests have revealed cancerous abnormalities. Conization helps to assess how much tissue is diseased. Because it requires removal of part of the cervix, it should be recommended only when invasive cervical cancer is suspected and a comprehensive diagnosis is necessary, and only after biopsies from other tests have indicated severe abnormalities.

Treating CIN

Hearing that your Pap test is abnormal can be upsetting. But remember that, when detected early, most abnormalities can be treated successfully. Your treatment options are determined by how much diseased tissue is present in your cervix.

One alternative in mild dysplasia (CIN I) is a “watch and wait” approach. As many as 40 percent of mild dysplasia cases will return to normal without further treatment. Frequent Pap tests may be all your physician recommends to monitor mild dysplasia. Be sure to follow through on this recommendation.

Moderate and severe dysplasia (carcinoma in situ) need more aggressive treatments that either destroy or remove the abnormal cells. These treatments include: hysterectomy (surgically removing the uterus and the cervix), cryosurgery (freezing the site with carbon dioxide or nitrous oxide), electrocautery (burning away the abnormal cells with an electric rod), laser vaporization (destroying the cells with a laser beam), excising (cutting out the diseased area), and conization.

Hysterectomy

This operation is sometimes recommended to treat CIN III (preinvasive cancer). But with other treatment options available, hysterectomy may not be the first choice for most women, especially if they are still interested in having children. This operation is major surgery with unique risks and benefits. It should be discussed carefully with your physician.

Long-term effects. Hysterectomy has significant consequences. When the uterus is removed, a woman no longer menstruates. If the ovaries are left intact, they continue to produce hormones until natural menopause occurs. But if they are removed during hysterectomy, menopausal symptoms such as hot flashes, vaginal dryness, and night sweats will suddenly begin. Hormone replacement therapy can prevent or minimize these symptoms. Although sexual function should not be impaired beyond the effects of vaginal dryness, some women describe changes in sexual sensation following a hysterectomy. In some cases, the vagina is slightly shortened.

For many women, a hysterectomy is an emotional issue. Regardless of whether a woman still wants to, or is able to, have children, removal of the uterus can affect her identity as a female. This is a legitimate issue to consider and to come to terms with when deciding whether to have the operation.

Recovery from hysterectomy takes between 4 and 6 weeks, although many women feel fatigued for longer periods. Actual hospitalization is normally several days to a week.

Electrocautery, Cryosurgery, and Laser Vaporization

These treatments destroy the abnormal cells on the surface of the cervix, allowing eventual growth of new healthy cells. The procedures can be performed in the physician's office, usually with no anesthesia.

Electrocautery often causes more pain during and after the procedure than newer methods, and it leaves more scar tissue on the cervix. For these reasons, it is used less frequently now than in the past. Still, it is effective in treating CIN I and II.

Cryosurgery and laser surgery cause cramp­like pain during the procedures and some vaginal discharge for several weeks afterwards. Bleeding may follow laser treatment. After either procedure, some women will need a second treatment to ensure all the abnormal tissue has been destroyed.

Advantages and Disadvantages. The area affected by cryosurgery in particular can be difficult to control. This can result in the destruction of either too much or not enough tissue, depending on the size of the probe. Laser surgery is slightly more likely than cryosurgery to destroy the diseased tissue the first time, but often is more expensive. Other benefits of laser treatment include its precision—it destroys only diseased tissue—and its reach—it can be directed at abnormalities farther inside in the cervix that are inaccessible to cryosurgery and electrocautery.

Follow­up. After electrocautery, cryosurgery, or laser treatment, nothing should be inserted into the vagina for several weeks. This means no tampons, douching, or intercourse. Pap smear and colposcopy should be performed in 4 months to determine whether the treatments were successful. Pap smears may not return to normal for some time following these treatments because of the trauma to the cervical cells. To be certain, Pap testing should continue at 6­month intervals until you and your physician are comfortable with the status of your lab reports.

Excision

This is both a treatment method (it removes damaged tissue) and a diagnostic tool. Excised tissue can be biopsied. The edges of the diseased area also can be evaluated to ensure that all the abnormal cells have been removed. This type of assessment is more difficult with methods such as cautery and vaporization that completely destroy the tissue.

If It's Cervical Cancer

If a biopsy confirms that abnormal cells are either preinvasive (CIN III or carcinoma in situ) or invasive cancer, your physician will want to move quickly to determine the extent and location of the disease. You may be referred—or want to consider referral—to a gynecologist who specializes in the treatment of cancer of the reproductive system.

Frequently, when advanced disease is suspected, larger portions of tissue must be removed for an accurate biopsy to help determine treatment. Dilation and curretage (D & C), a procedure in which the cervix is dilated and the sides of the cervical canal and uterus are scraped with a small spoon-shaped instrument, is another diagnostic procedure the doctor may use.

Other tests are used to determine if the disease has spread from the cervix to other parts of the body. This process of assessment is called staging and includes a comprehensive pelvic exam, performed under anesthesia, blood and urine tests, and a chest x­ray. Computed tomography scans (CT or CAT scans), ultrasound, and magnetic resonance imaging (MRI scans) of the bones, liver, and spleen are other diagnostic tests used to identify diseased areas.

Treating Cervical Cancer

Preinvasive cancer (carcinoma in situ) can be treated with the same procedures described for cervical dysplasia. However, conization or hysterectomy are more frequently recommended to prevent the disease from spreading. Without treatment, carcinoma in situ usually develops into invasive cancer. Untreated, invasive cervical cancer will travel to other pelvic structures, then invade the lymph nodes located in the groin, then finally spread into the lungs, liver, and bones. Your doctor may refer to cancer that has spread beyond the pelvis and groin as metastasis.

Surgery and radiation therapy are equally successful treatment options for invasive cervical cancer. Chemotherapy does not work as well against cervical cancer as it does against other forms of the disease, but doctors do prescribe it to treat recurrent cervical cancer.

Surgery

Surgery is used to treat cancer when the disease is confined to the cervix. Options include total hysterectomy (removal of the cervix and uterus); radical hysterectomy (removal of the cervix, uterus, upper vagina, and the lymph nodes in the area); surgical removal of the tumor; or, if a woman wants to preserve her ability to carry a child, merely conization. The choice of procedure depends on a woman's age and overall health as well as the size of the tumor.

The consequences of hysterectomy have already been touched on. But, as serious as this surgery is, both medically and emotionally, it may be the best option for treating cervical cancer. It's important to discuss the risks and benefits of the procedure, as well as the long­term consequences, with your doctor.

Radiation Therapy

Radiation therapy, which destroys the ability of cells to grow and divide, can be used alone or in combination with surgery to treat large tumors and cancers that have grown beyond the cervix. Two forms of radiation therapy are employed: internal radiation, in which radioactive implants are placed directly into the cancerous site, and external radiation, in which a machine directs high doses of radiation into the diseased tissue.

Internal radiation, called brachytherapy, destroys less of the healthy tissue around the cancer and causes fewer side effects than external radiation. Radioactive implants are inserted through the vagina, into the cervix and the uterus. Internal radiation is not always possible if the disease or earlier surgery has dramatically altered the region.

External radiation can be administered on an outpatient basis and is normally given 5 days a week for several weeks. Internal radiation usually requires a short hospital stay; the implant is left in place for 2 to 3 days.

Side Effects. The side effects of radiation therapy are uncomfortable and can be emotionally distressing. Radiation kills normal tissue, and the body reacts negatively to this aggressive treatment. Radiation for cervical cancer destroys the ovaries. Side effects may also include diarrhea, nausea, vomiting, bladder irritation and painful urination, weight loss and loss of appetite, fatigue, loss of vaginal sensation (when the vagina is included in the radiation field), and skin reactions. These side effects vary among women undergoing this treatment and those symptoms directly related to radiation usually disappear after treatment. Because the ovaries are destroyed, radiation also brings on the symptoms of menopause such as hot flashes, vaginal dryness, and night sweats.

Follow­up care. After treatment for cervical cancer, Pap tests are recommended every 2 months for the first year, every 4 months during the second year, every 6 months in the third and fourth year after surgery, and once a year thereafter. Pap tests can be inconclusive or inaccurate if a woman has received radiation therapy because radiation causes changes in cellular structure. For these women, biopsies are a better test. Three months after the tissue damage from treatment has healed, a biopsy should reveal only normal cells.

The Odds of a Cure

Not all cervical cancer responds to radiation therapy. In addition, disease returns in approximately one­third of all women treated for advanced cancer, usually within 2 years after therapy. Recurring cancer after treatment with radiation is most commonly found in the cervix, the uterus, upper vagina, and the pelvic wall. Cancer that returns after hysterectomy usually is found in the upper part of the vagina, where the cervix used to be located.

These symptoms indicate possible recurrence: weight loss, unexplained swelling in one or both legs, bloody vaginal discharge, pain in the thigh or buttock. When advanced cancer recurs in the pelvic area, prognosis is generally favorable. If the cancer has spread to locations beyond the pelvic area, however, the chances for recovery are less favorable.

Good Reasons For Optimism

A discussion of cervical cancer should not end on a pessimistic note. There is overwhelming evidence that when the disease is diagnosed early and treated effectively, a woman has every reason to expect complete recovery.

The key word here is “early.” That's why every woman needs to make a commitment to have regular Pap tests and take other steps to prevent CIN and cervical cancer. Yearly Pap tests should begin at age 18, or whenever a woman becomes sexually active.

Using condoms during sex can help prevent sexually transmitted diseases such as AIDS, as well as other infections that may contribute to the development of cervical cancer. Quitting smoking not only improves overall health but also reduces risk of CIN and cervical cancer.

Most important, be an informed consumer. Know your options when considering treatment for dysplasia or cervical cancer. Open a dialogue with your doctor. Find out exactly why he or she is recommending certain treatments or tests. When reviewing the consequences of major surgery or radiation, don't lose sight of the risk inherent in inaction. Stay well­informed and you'll make the choice that's best for you and your family.

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