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Cervical Cancer: The Basics

Christopher Dolinsky, MD and Christine Hill-Kayser, MD


Updated By Lara Bonner Millar, MD
Affiliation: Abramson Cancer Center of the University of Pennsylvania
Last Modified: January 16, 2011
What is the cervix?

The cervix is the name for the lowest part of the uterus. The uterus is an organ that
only women have, and it is where a baby grows and develops when a woman is
pregnant. During pregnancy, the uterus has an enormous increase in size. When a
woman is not pregnant, the uterus is a small, pear-shaped organ that sits between a
woman's rectum and her bladder. The cervix connects the uterus with the birth
canal (the vagina). The cervix can both be visualized and sampled by your doctor
during a routine pelvic examination in his or her office.
What is cervical cancer?

Cervical cancer develops when cells in the cervix begin to grow out of control and
can then invade nearby tissues or spread throughout the body. Large collections of
cells that grow abnormally are called tumors. Some tumors are not cancer, because
they cannot spread or threaten someone's life. These are called benign tumors. The
tumors that can spread throughout the body or invade nearby tissues are
considered cancer and are called malignant tumors. Usually, cervix cancer is very
slow growing, although in certain circumstances it can grow and spread quickly.

Cancers are characterized by the cells that they originally form from. The most
common type of cervical cancer is called squamous cell carcinoma; it comes from
cells that lie on the surface of the cervix known as squamous cells. Squamous cell
cervical cancer compromises about 80% of all cervical cancers. The second most
common form is adenocarcinoma; it comes from cells that make up glands in the
cervix. The percentage of cervical cancers that are adenocarcinomas has risen since
the 1970s, although no one knows exactly why. About 3% to 5% of cervical cancers
have characteristics of both squamous and adenocarcinomas and are called
adenosquamous carcinomas. There are a few other very rare types like small cell

and neuroendocrine carcinoma that are so infrequent that they will not be discussed
further here.
Am I at risk for cervical cancer?

Cervical cancer is vastly more common in developing nations than it is in developed


nations, and it is fairly rare in the United States. In the U.S. in 2007, 12,280 women
in the United States were diagnosed with cervical cancer and 4,021 women in the
United States died from cervical cancer. This puts cervical cancer as the 12th most
common cancer that women develop, and the 14th most common cause of cancer
death for women in the U.S. However, cervical cancer is the 2nd most common
cause of cancer death in developing nations, with about 370,000 new cases
annually having a 50% mortality rate. Decades ago, cervical cancer was the number
one cause of cancer deaths in women in the U.S. There has been a 75% decrease in
incidence and mortality from cervical cancer in developed nations over the past 50
years. Most of this decrease is attributed to the effective institution of cervical
cancer screening programs in the wealthier nations.

Although there are several known risk factors for getting cervical cancer, no one
knows exactly why one woman gets it and another doesn't. One of the most
important risk factors for cervical cancer is infection with a virus called HPV (human
papilloma virus). HPV is a sexually transmitted disease that is incredibly common in
the population; most college-aged men and women have been exposed to HPV. HPV
is the virus that causes genital warts, but having genital warts doesn't necessarily
mean you are going to get cervical cancer. There are different subtypes, or strains,
of HPV. Only certain subtypes are likely to cause cervical cancer, and the subtypes
that cause warts are unlikely to cause a cancer. Often, infection with HPV causes no
symptoms at all, until a woman develops a pre-cancerous lesion of the cervix. It
should be stressed that only a very small percentage of women who have HPV will
develop cervical cancer; so simply having HPV doesn't mean that you will get sick.
However, almost all cervical cancers have evidence of HPV virus in them, so
infection is a major risk factor for developing it.

Because infection with a sexually transmitted disease is a risk factor for cervical
cancer, any risk factors for developing sexually transmitted diseases are also risk
factors for developing cervical cancer. Women who have had multiple male sexual
partners, began having sexual intercourse at an early age, or have had male sexual
partners who are considered high risk (meaning that they have had many sexual
partners and/or began having sexual intercourse at an early age) are at a higher
risk for developing cervical cancer. Also, contracting any other sexually transmitted

diseases (like herpes, gonorrhea, syphilis, or Chlamydia) increases a woman's risk.


HIV infection is another risk factor for cervical cancer, but it may be so for a slightly
different reason. It seems that any condition that weakens your immune system
also increases your risk for developing cervical cancer. Conditions that weaken your
immune system include HIV, having had an organ transplantation, and Hodgkin's
disease. Another important risk factor for developing cervical cancer is smoking.
Smokers are at least twice as likely as non-smokers to develop cervix tumors.
Smoking may also increase the importance of the other risk factors for cancer.
Finally, being in a low socioeconomic group seems to increase the likelihood for
developing and dying from cervical cancer. This may be because of increased
smoking rates, or perhaps because there are more barriers to getting annual
screening exams. Cervical cancer is one of the few cancers that affects young
women (in their twenties and even their teens), so no one who is sexually active is
really too young to begin screening. Additionally, the risk for cervical cancer doesn't
ever decline, so no one is too old to continue screening. Remember that all risk
factors are based on probabilities, and even someone without any risk factors can
still get cervical cancer. Proper screening and early detection are our best weapons
in reducing the mortality associated with this disease.

How can I prevent cervical cancer?

Fortunately, there are several actions that women can take to decrease the risk of
dying from cervix cancer. The first of these is undergoing regular Pap testing. Pap
tests will be discussed further in the next section, but the reason that women have
had such a drastic drop in cervical cancer cases and deaths in this country has been
because of the Pap test and annual screening.

Recently, two vaccines, called Gardasil and Ceravix have been developed. These
vaccines have been demonstrated to be effective in preventing infection with some
strains of HPV, when given before a person is exposed to HPV. For this reason, is the
vaccines are recommended and approved for girls and young women ages 9 26
years. Vaccination can also be given to boys, ages 9-26, to prevent genital warts
and further spread of HPV in women and men. HPV is also a cause of penile and
anal cancers and head & neck cancers.

For further prevention, women should try to reduce risk factors as much as possible.
Don't start smoking, and if you are already a smoker, it is time to quit. Smoking has
been shown to decrease the immune systems ability to clear an HPV infection.

Women can limit their numbers of sexual partners, and delay the onset of sexual
activity to reduce risk, as more partners increases the likelihood of infection.
Unfortunately, condoms do not protect you from developing HPV, so even though
they can protect you from other sexually transmitted diseases and HIV, they cannot
help lower your risk for being infected with HPV.

Many people are interested in preventing cervical cancer with vitamins or diets.
Studies looking at beta-carotene and folic acid for preventing cervical cancer have
shown no benefit. Some people think that anti-oxidants (like vitamin A and vitamin
E) may play a role in cervical cancer prevention, but there is currently no convincing
data that would suggest so. Further studies need to be performed before any
nutritional recommendations can be made regarding cervix cancer prevention.
What screening tests are available?

Cervical cancer is considered a preventable disease. It usually takes a very long


time for pre-cancerous lesions to progress to invasive cancers and we have effective
screening methods that can detect pre-cancerous lesions that can generally be
cured without serious side effects. Effective screening programs in the United States
have led to the drastic decline in the numbers of cervical cancer deaths in the last
50 years. For women who do end up with cervical cancer in developed nations, 60%
of them either have never been screened or haven't been screened in the last five
years. The importance of regular cervical cancer screening cannot be overstated.

The current hallmark of cervical cancer screening is the Pap test. Pap is short for
Papanicolaou, the inventor of the test, who published a breakthrough paper back in
1941. A Pap test is easily performed in your doctor's office. During a pelvic
examination, your doctor uses a wooden spatula and/or a brush to get samples of
cervical cells. These cells are placed on a slide, fixed, and sent to a laboratory
where an expert in examining cells under a microscope can look for cancerous
changes. Many women find the exam uncomfortable, but rarely painful. Depending
on the results of the test, your doctor may need to perform further examinations.

Although the Pap test is highly effective, it isn't a perfect test. Sometimes, the test
may miss cells that have potential to become an invasive cancer. The test shouldn't
be performed when you are menstruating; and if collection goes perfectly, even the
best laboratories can miss abnormal cells. This is why women need to have the
tests performed on a regular basis.

In November 2009, the America College of Obstetricians and Gynecologists (ACOG)


released updated guidelines which recommend that women have their first Pap test
at age 21. From ages 21 to 30, screening should be done every 2 years. Women 30
years and older, who have had three consecutive normal Paps, may decrease the
screening to every three years. However, after having a new sexual partner, these
women need to go back to yearly Pap testing. The ACOG guidelines also note that
women with certain risk factors may need more frequent screening. These risk
factors include being infected with human immunodeficiency virus (HIV), being
immunosuppressed, having been exposed to diethylstilbestrol (DES) before birth,
and having previously been treated for certain cervical abnormalities or cancer.

Women aged 65 to 70 years who have had at least three normal Pap tests and no
abnormal Pap tests in the last 10 years may decide, after talking with their doctor,
to stop having Pap tests. Women who have had a hysterectomy (surgery to remove
the uterus and cervix) do not need to have a Pap test, unless the surgery was done
as a treatment for a precancerous condition or cancer. Women who have had a
"subtotal or supracervical" hysterectomy still have a cervix, and need to continue
Pap testing. Women who have received the HPV vaccine should follow the same
guidelines as unvaccinated women, as the vaccine does not prevent infection with
all strains of HPV.

HPV testing is frequently done along with the Pap test. HPV testing can theoretically
find the vast majority of women who are at risk for developing cervical cancer. The
subtype of HPV predicts how likely it is to lead to a cervical cancer. The DNA of
cervical cells can be tested to identify high-risk types of HPV that may be present.
The FDA has approved HPV DNA tests for follow-up testing of women with
abnormalities on a pap test. HPV DNA tests are also approved for general cervical
cancer screening of women over the age of 30 when done together with a Pap test.
Talk to your doctor about your options and the availability of HPV testing in your
area. There are currently no approved tests to detect HPV infections in men.
What are the signs of cervical cancer?

Unfortunately, the early stages of cervical cancer usually do not have any
symptoms. This is why it is important to have screening Pap tests. As a tumor grows
in size, it can produce a variety of symptoms including:

* abnormal bleeding (including bleeding after sexual intercourse, in between


periods, heavier/longer lasting menstrual bleeding, or bleeding after menopause)
* abnormal vaginal discharge (may be foul smelling)
* pelvic or back pain
* pain on urination
* blood in the stool or urine

Many of these symptoms are non-specific, and could represent a variety of different
conditions; however, your doctor needs to see you if you have any of these
problems.
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/ 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.

Prevention

Cervical cancer can often be prevented by preventing precancers and having


regular Pap tests. Preventing precancers means controlling possible risk factors,
such as by:

* 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 AIDS.

* 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 womans 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. Learn more about HPV
vaccination for cervical cancer.

In 2009, the American College of Obstetricians and Gynecologists updated its


guidelines for cervical cancer to recommend the following 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.

The American Cancer Society and the U.S. Preventive Task Force recommend the
following screening guidelines:

* All women should begin having yearly Pap tests within three years of beginning
vaginal sexual intercourse, but no later than age 21.

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

* Women 70 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.