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Cancer Of The Cervix

Alternate Names

  • cervical cancer
  • cervical tumor
  • cervical carcinoma
  • Female reproductive organs

Definition

The cervix is the passage at the lower end of the uterus which opens into the vagina. It is the part of the uterus that dilates to allow the baby to pass into the birth canal during the birth process.

What is going on in the body?

Cervical cancer is a relatively common cancer of the reproductive system that occurs most often among women aged 40 to 55.
Even though the cervix is located at the top of the woman's vagina, its cells act very much like skin cells. These cells are exposed to a variety of toxins, viruses, and bacteria through sexual activity, hygienic practices, and instrumentation.
However, it is infection with human papillomavirus (HPV, see below) that may cause abnormal and potentially precancerous changes of the cervix called cervical dysplasia.
Each stage of cervical dysplasia is judged by the thickness of the layer of abnormal cells. The earliest change that can be seen with a microscope is called mild dysplasia. If not treated, these precancerous changes may disappear on their own, but may progress to become moderate and then severe.
The fourth, most severe, stage of dysplasia is called carcinoma in situ (CIS). This is when the cancer cells are in each layer of the skin on the surface. After this occurs, cancer cells may invade deeper layers of the cervix or spread to nearby sites. At that point, a woman has what is called invasive cervical cancer.

Risks

What are the causes and risks of the disease?

Cervical cancer is now known to virtually always be an end result of infection with HPV.
HPV is almost always acquired through sexual activity and is the most common sexually transmitted infection in the United States. According to the Centers for Disease Control and Prevention (CDC) approximately fifty percent of sexually active men and women will acquire HPV at some time in their lives.
The earlier the onset of sexual activity, the more sexual partners, and the more partners that one's partner has had in the past, the more likely a person is to become infected with HPV.
Sometimes HPV infection goes away on its own. However, it can also persist for months to years. In this case, the woman is more likely to have the cell damage to the cervix referred to as dysplasia. Of the more than 100 known viral types of HPV, a few - two in particular—are likely to persist and cause dysplasia.
Once a woman has dysplasia, her risk of progressing through the remaining stages to cancer is increased if she does not have regular screening examinations, and if she smokes. The reason why smoking increases risk of cervical cancer is not known.

Prevention

What can be done to prevent the disease?

Recently, a vaccine for HPV has been developed and is now on the market in the U.S. At this time, it is recommended by the CDC for young women ages 11 through 26. It is most effective if given before a young woman becomes sexually active.
The vaccine is administered in three doses over a period of six months. However, no vaccine is effective 100% of the time, and HPV vaccine does not protect against all the viral types.
Therefore, a woman can further reduce her risk of HPV, and thus of cervical cancer, by waiting to have intercourse until she is married or ready for commitment to one faithful, lifelong partner.
Fortunately, cancer of the cervix can also be avoided by early detection and treatment of the precancerous stages of the disease - the earlier the better.
Cervical dysplasia can be detected by a pelvic examination that includes a Pap smear. Most phyisicians recommend women start to have Pap smears and pelvic exams when they reach the age of 18 or sooner, if they have become sexually active - while other physicians recommend virginal women can wait until age 21 to begin these exams.
Identification of early warning signs of cervical cancer is also important. A woman should see her healthcare professional and may need to be treated if she has any of the following signs or symptoms:
  • vaginal discharge that does not seem normal
  • vaginal bleeding between periods
  • bleeding with intercourse
  • painful intercourse, known as dyspareunia

Diagnosed

How is the disease diagnosed?

Cancer of the cervix, and its associated precancerous stages, are diagnosed with a pelvic examination that includes a Pap smear.
During a pelvic exam, the cervix, vagina, and vulva are checked for signs of changes. To do a Pap smear, a professional uses a small spatula and a brush to gently scrape cells from the cervix. These cells are sent to a lab for testing. If abnormalities are found, the Pap smear may be repeated in 3 months.
Alternately, the healthcare professional may do the following additional tests:
  • colposcopy, a procedure in which a special microscope allows the professional to closely examine the cervix, vagina, and vulva
  • cervical biopsy, a procedure in which small tissue samples are taken from the cervix. This procedure is generally done in a healthcare professional's office.
  • LEEP ,a procedure where a larger piece of tissue is taken for examination and sometimes treatment. This procedure is usually done in the office with local anesthetic which makes it painless.
  • cold cone biopsy, a procedure in which a large tissue sample is taken from the cervix. This procedure is normally done in an operating room under general anesthesia. The cone biopsy often removes all of the precancerous tissue.
Tissue that is removed for a cervical biopsy is examined under a microscope and used to determine the stage of the cancer. Following are the stages of cervical cancer:
  • stage 1A, in which the tumor is in the uterus and cervix only, and has invaded less than 5 millimeters (usually visible only with a microscope)
  • stage 1B, in which the tumor is in the uterus and cervix only but has invaded 6 or more millimeters
  • stage 2, in which the tumor has spread to the vagina
  • stage 3, in which the tumor has invaded the side wall of the pelvis
  • stage 4, in which the tumor has spread to the rectum, bladder, and distant organs

Long Term Effects

What are the long-term effects of the disease?

If abnormal cells are found early and treated, it may be possible to avoid removing the uterus so that a woman can still have children. Unfortunately, once cervical cancer occurs, more aggressive measures may be needed.
If the cancer is found early and treated early, there is an excellent chance of cure. If left untreated, it may spread to nearby areas or more distant sites in the body.

Other Risks

What are the risks to others?

Cervical cancer is not contagious per se.
However, HPV can be transmitted during sexual activity from a woman to her sexual partner(s) as well as vice versa.

Treatments

What are the treatments for the disease?

If dysplasia or carcinoma of the cervix is found before it has turned into frank cancerf, the cancer may be removed by several means including the following:
  • Cryosurgery, a procedure where a circular metal instrument is placed on the cervix and freezes the abnormal cells so they are killed. This is usually done in the office.
  • LEEP procedure, where the abnormal tissue is cut from the cervix using electrocautery which minimizes bleeding. This is usually done in the office with local anesthesia.
  • cone biopsy, a procedure in which a portion of the center of the cervix is removed. This procedure is also used to diagnose the cancer. During the diagnostic cold cone biopsy, the cancer is often completely removed.
  • hysterectomy, or surgical removal of the uterus and cervix
If the cancer has invaded deeper layers of the cervix, more extensive treatment may be involved, such as the following:
  • modified radical hysterectomy. During this type of surgery, the uterus, cervix, upper vagina, and surrounding tissue are removed. Depending on the extent of the cancer and a woman's age, the ovaries may be left in place.
  • radiation therapy, which is sometimes used before or after surgery to shrink the tumor cells further
  • radiation therapy and chemotherapy together. Sometimes a woman will not tolerate surgery well because of her age or other medical conditions. In this instance, radiation therapy may be used alone or with chemotherapy.
  • biological response modifiers, BRMs, which are substances that help to help strengthen the immune system's fight against cancer or infection. Interferon is a BRM that is sometimes used in treatment of cervical cancer, often in combination with chemotherapy.
For the rare patient who has failed treatments and now has distant disease to other parts of the body (usually to the lymph nodes, bones and lungs), radiation to painful areas in the bones and chemotherapy may palliate or control symptoms for a period of time.

Side Effects

What are the side effects of the treatments?

Possible side effects and complications of hysterectomy are as follows:
  • inability to control urination
  • sexual problems
  • psychological stress
  • swelling in the legs
  • bleeding that requires a blood transfusion
  • reaction to anesthesia
Chemotherapy may cause a wide variety of side effects, including hair loss, fatigue, decreased ability to fight infections, and nausea. Radiation therapy may cause fatigue and damage to surrounding organs. This may lead to diarrhea or more frequent painful urination. Biological response modifiers such as interferon may cause flu-like symptoms, including body aches, nausea, and fatigue.

After Treatment

What happens after treatment for the disease?

The outcome for a woman with cervical cancer depends on many factors, such as the following:
  • the woman's overall health
  • the woman's age when she was first diagnosed
  • the type and growth of specific cancer cells
  • how far the disease has spread
  • the technical success of the procedure
After treatment, the chance that a woman will live for 5 more years depends on the stage of the cancer. Survival rates for the various stages are as follows:
  • stage 1A, 95-100%
  • stage 1B, 80-90%
  • stage 2, 65 - 85%
  • stage 3, 30% to 50%
  • stage 4, less than 30%

Monitor

How is the disease monitored?

After treatment, a woman will be closely followed for signs that the cancer of the cervix has come back.
  • A pelvic exam and Pap smear, if the cervix is intact, will be done every 3 months for at least 2 years and then every 6 months after that.
  • Because cancer tends to come back at the same spot or spread to the lungs and liver, chest X-rays and liver function tests are done once a year.
  • If a woman has had a hysterectomy, the top of the vagina is cuffed, or closed. Colposcopy may be done at follow-up visits to examine the vaginal cuff.
Any new or worsening symptoms should be reported to the healthcare provider.

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