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What is cervical cancer?

Cervical cancer is caused by the uncontrolled growth of cells in the cervix. The cervix is the narrow bottom portion of a woman's uterus. Shaped like a cone, it connects the uterus to the vagina.

Almost all cervical cancers are caused by persistent infections with specific types of human papillomavirus (HPV). HPV is a very common sexually transmitted disease.

  • High-risk HPV—there are 14 high-risk types of HPV that can lead to cancer (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68). Two HPV types,16 and 18, cause 80% of all cervical cancers.
  • Low-risk HPV—some HPV strains cause genital warts but rarely cause cancer. HPV 6 and HPV 11 cause 90% of all genital warts but are considered "low risk" because they rarely lead to cancer.

Many HPV infections resolve without treatment—the body is able to clear the infection—but infections with high-risk HPV types that do not go away can lead to cervical cancer. It can take many years for an HPV infection to develop into cancer. An infection with high-risk HPV can cause infected cells to grow uncontrollably. Usually the immune system recognizes these cells and limits their growth, but sometimes the cells remain and become precancerous.

The earliest precancerous changes cause the cells lining the inside or outside of the cervix to appear different from normal cervical cells. These atypical, precancerous cells are more likely to progress to cancer if left untreated. If the cells become cancerous, they are initially limited to the surface lining (in situ). Without treatment, the cancer cells can become invasive by growing into the supporting tissues of the cervix and potentially spreading to other sites in the body.

There are two primary types of cervical cancer:

  • Squamous cell carcinomas occur in the flat squamous cells that cover the outside of the cervix and are the most common. According to the American Cancer Society, as many as 9 out of 10 cases of cervical cancer are squamous cell carcinomas.
  • Adenocarcinomas arise from mucus-producing gland cells of the opening of the cervix (the endocervix) and account for most other cases of cervical cancer.

A few cervical cancers are mixtures of both types.

With early detection, cervical cancer is usually treatable by surgically removing the cancer. The 5-year survival rate for women who receive treatment for early stage cervical cancer is greater than 90%. If the cancer spreads beyond the surface of the cervix, treatment may require a hysterectomy, radiation, or chemotherapy. Given time, cervical cancer can spread (metastasize) to the rest of the uterus, the bladder, the rectum, and the abdominal wall. Eventually, it can reach the pelvic lymph nodes and metastasize further, invading other organs throughout the body. Cure rates decline as cervical cancer spreads, with widespread cervical cancer usually being fatal.

The American Cancer Society estimates that more than 13,000 women in the United States will be diagnosed with cervical cancer in 2019 and about 4,250 will die from the disease. Invasive cervical cancer was once a very common disease in the U.S. Since the introduction of the Papanicolaou (Pap) smear (also called Pap test), a screening tool that allows the detection of cancerous and precancerous changes in the cervix, rates of cervical cancer in the U.S. and other industrialized nations have dropped by as much as 70%. More recently, tests that detect high-risk types of HPV have become an important addition to cervical cancer screening regimens.

However, cervical cancer is still a very serious concern in certain populations of the U.S., such as Hispanic women who are the most likely to get cervical cancer, and in developing nations where access to healthcare and screening programs are limited. According to the World Health Organization, cervical cancer is the second most common type of cancer in women living in developing nations. In these countries, about 570,000 new cases of cervical cancer were diagnosed in 2018. About 85% of cervical cancer-related deaths throughout the world occur in developing nations.

Accordion Title
About Cervical Cancer
  • Risk Factors

    As mentioned earlier, persistent infections with high-risk types of human papillomavirus (HPV) are the most significant risk factor because they cause almost all cervical cancers.

    According to the National Cancer Institute, other factors can further increase your risk of developing cervical cancer after you have become infected with HPV. These include having multiple (3 or more) full-term pregnancies, long-term oral contraceptive (birth control pill) use, and cigarette smoking.

    Increased risk for cervical cancer is also associated with:

    • Having a weakened immune system (for example, after an organ transplant or with HIV infection)
    • Being overweight
    • A diet lacking in fruits and vegetables
    • A history of exposure to DES (a drug given to some women between 1940 and 1971 to prevent miscarriage) before birth
    • A family history of cervical cancer
    • A history of chlamydia infection
  • Signs and Symptoms

    HPV infections and precancerous changes in the cervix usually do not cause any symptoms. The only way to know if either is present is to get tested.

    By the time you notice nonspecific symptoms, such as increased vaginal discharge and/or abnormal bleeding between menstrual periods or after intercourse, invasive cancer has usually developed and may have already spread to nearby tissues.

    There are many conditions other than cancer that can cause abnormal vaginal bleeding and discharge. It is important that you see your healthcare provider both to determine the cause of any symptoms you may have and for regular preventive screening even if you have no symptoms.

  • Testing

    Screening tests

    • Pap smear (Pap test): the Papanicolaou (Pap) smear is widely used to screen for precancerous or cancerous changes in cervical cells. The earliest, precancerous changes cause the cells lining the inside or outside of the cervix to appear different from normal cervical cells. These changes, when present on a Pap smear, are termed "atypical cells." Atypical cells are not entirely specific for a precancerous condition, however, and can temporarily appear in response to infections or irritation of the cervix lining. Precancerous cells can become more abnormal in appearance over time and are more likely to progress to cancer if left untreated. In Pap smears, these more abnormal (intermediate) cellular changes are called low-grade or high-grade squamous intraepithelial lesions.
    • HPV test: The HPV test is primarily used to screen for cervical cancer in women 30 years of age and older and/or identify women who may be at increased risk of cervical cancer. The test determines whether a woman's cervical cells are infected with a high-risk type of human papillomavirus (hrHPV). Such an infection, if long-lasting, can cause changes in cervical cells that could lead to cervical cancer. Now that hrHPV infection is known to be the cause of most cases of cervical cancer, HPV testing has become an essential part of women's health screening.


    Recommendations

    Recommendations from U.S. Preventive Services Task Force (USPSTF) have been endorsed by the Society of Gynecologic Oncology and the American Society for Colposcopy and Cervical Pathology (ASCCP). These recommendations are mostly in agreement with current cervical cancer screening guidelines from the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society, and the American Society for Clinical Pathology (ASCP).

    The following is a summary of screening recommendations for women with average risk:

    • Women ages 30 to 65—have a discussion with your healthcare provider about the pros and cons of all three of the following screening strategies so you can decide which approach is best for you.
      • Co-testing with a Pap smear and high-risk HPV (hrHPV) test every 5 years (preferred), or
      • Pap smears alone every 3 years (acceptable), or
      • hrHPV tests alone every 5 years (considered an alternative screening strategy)
    • Women ages 21 to 29—have a Pap smear every 3 years. HPV testing also may be performed when a woman in this age group has abnormal changes on a Pap test.
    • Women younger than 21—do not have screening, regardless of sexual activity, because cervical cancer is not common in your age group. False-positive results may occur due to normal cell changes and are somewhat common. The false-positive results may generate unnecessary and costly treatment as well as emotional anxiety.
    • Women over age 65—do not have screening if you have no history of abnormal cervical changes and either of the following is true:
      • You have had three consecutive negative Pap smear or
      • You have had two consecutive negative co-tests (Pap smears plus hrHPV tests) in a row within the past 10 years, with the most recent co-test performed within the past 5 years

    You should still undergo regular cervical cancer screening even if you have been vaccinated against HPV. (See Prevention below.)

    More frequent screening is advised for women with risk factors such as exposure to DES (diethylstilbestrol) during their mother's pregnancy, a previous diagnosis of a high-grade precancerous cervical lesion or cervical cancer, HIV infection, or a compromised immune system.

    If you have had a total hysterectomy (surgical removal of the uterus and cervix) and you have no history of cervical cancer or cervical changes, guidelines suggest that you may discontinue cervical cancer screenings. However, if you have a history of cervical cancer or serious pre-cancerous cervical changes (high grade lesions), then it is recommended that you continue to be screened for cervical cancer for 20 years after your surgery.

    Diagnostic tests

    If you have a positive screening result, your healthcare practitioner may use one or both of the following diagnostic tests to follow up:

    • Colposcopy: this follow-up test involves putting a vinegar-like solution on the cervix and checking it for abnormalities using a bright light and magnifying instrument. The colposcopy may include a Schiller test, which involves placing iodine on the cervix, causing normal cells to turn brown and abnormal cells to show up as white or yellow.
    • Biopsy: if abnormal areas are found on the cervix during colposcopy, the healthcare practitioner will remove small pieces of tissue for examination by a pathologist. A biopsy and microscopic evaluation are the only way to tell for sure whether abnormal cells are cancerous, precancerous, or reactive for some other reason.
  • Staging

    If cancer is found, it will then be "staged." Staging is determining how far the cancer has spread and what body organs are affected. The process typically involves imaging studies such as a computed tomography (CT) scan.

    Stages of cervical cancer include:

    • Stage 0—the cancer is found only in the cells covering the cervix.
    • Stage I—the cancer has grown into (invaded) the cervix, but it is not growing outside the uterus.
    • Stage II—the cancer has grown beyond the cervix and uterus and may have spread to the upper vagina. It has not spread (metastasized) to the walls of the pelvis or the lower part of the vagina.
    • Stage III—the cancer has spread to the lower part of the vagina or the walls of the pelvis. It has not spread to lymph nodes or to other areas of the body.
    • Stage IV—the most advanced stage of cancer; it has spread to other areas of the body, such as the lungs, lymph nodes or bones.


    Staging is a very important part of the diagnostic process. Treatment options and patient prognosis depend in large part on the stage of the cancer.

  • Prevention

    For most women, the best approach to preventing cervical cancer includes:

    • Vaccination against HPV
    • Lifestyle practices that reduce your risk for HPV infection
    • Regular cervical cancer screening (see Screening Tests)

    Vaccination against HPV

    Vaccination may prevent most cancers and other health problems caused by HPV. The American Academy of Pediatrics (AAP) and the U.S. Centers for Disease Control and Prevention (CDC) recommend that both girls and boys receive the HPV vaccine series when they are 11 to 12 years old. (Vaccination can be started as early as 9 years of age.)

    The vaccine is also recommended for:

    • Boys and men up to 21 years of age and women up to 26 years of age who did not receive or complete the vaccination series when they were younger.
    • Young men who have sex with men through age 26 and transgender people through age 26.
    • People aged 22-26 who have weakened immune systems, such as those who are HIV-positive, have had an organ transplant, or have had long-term treatment with steroids.

    In October 2018, the U.S. Food and Drug Administration (FDA) approved expanded use of the HPV vaccine to include women and men aged 27 through 45 years, but this use is not yet included in formal recommendations. If you fall into this group, you may want to talk to your healthcare provider about receiving the vaccine.

    Since May 2017, the only vaccine used in the U.S. protects against nine HPV types:16, 18, 6 and 11, 31, 33, 45, 52 and 58 (HPV 9-valent vaccine). Of the 32,500 cancers that HPV has caused every year, about 30,000 (90%) are caused by strains that could have been prevented by the 9-valent HPV vaccine. The vaccine may be given in a series of 2 or 3 shots. For more information about dosing schedules, see the CDC website. Even if you have been vaccinated against HPV, you should still undergo regular cervical cancer screening.

    The FDA and CDC state that the HPV vaccine is considered safe but is most effective if given before an initial exposure to the virus. The AAP and CDC both recommend that young people who are sexually active still receive the vaccination, as those already infected with one type of HPV infection may benefit from the protection against other types included in the vaccine.

    Lifestyle practices that reduce your risk

    Although some risk factors for cervical cancer, such as a family history of cervical cancer or exposure to DES before birth, cannot be prevented, there are a number of lifestyle choices you can make to reduce your risk. These include:

    • Don't smoke, or if you do smoke, quit.
    • Limit your number of sexual partners. Although monogamy (having sex with only one partner) will not keep you from becoming infected with HPV if either of you has ever had sex with someone who was infected, limiting your number of sex partners will reduce your risk of infection.
    • Use condoms. Using condoms may reduce the risk of spreading HPV, but only the skin that is covered by or comes in contact with the condom is protected from HPV. The virus can infect any uncovered skin or mucous membranes on the genitals, groin, thighs, anus, rectum and in the mouth.
  • Treatment

    Treatment of cervical cancer depends on the stage of the disease. If the cancer is either limited to the lining of the cervix or contained within the cervix, then treatments generally include removing (surgery), freezing (cryotherapy) or burning (laser technology) abnormal cells or tissues.

    Interventions for more invasive cervical cancer may include surgery to remove the cervix and uterus (hysterectomy), additional surgery to remove other affected tissue and organs, radiation treatments to destroy any remaining cancerous cells, and/or chemotherapy.

    As methods, treatments, and therapeutic drugs are constantly evolving, you should talk to your healthcare practitioners and work with them as well as a gynecologic oncologist (a doctor who specializes in cancer of the reproductive organs) to choose a treatment plan that is best for you. Depending on the diagnosis, you may wish to talk to your healthcare practitioner about participating in a clinical trial.

    For more on treatment, see the links under Related Content below.

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