Cervical Cancer: Causes, Symptoms, Risk Factors, Diagnosis, Stages, Treatment, Prevention and Prognosis

It begins at the cervix, the lower end of the uterus that comes into contact with the upper vagina.

Causes and risk factors for cervical cancer include human papillomavirus (HPV) infection , having many sexual partners, smoking, taking birth control pills, and engaging in early sexual contact.

HPV infection can cause cervical dysplasia or abnormal growth of cervical cells.
Regular pelvic exams and Pap tests can detect pre-cancerous changes in the cervix.

Pre-cancerous changes in the cervix can be treated with cryosurgery, cauterization, or laser surgery.

The most common symptoms and signs of cervical cancer are:

  • Abnormal vaginal bleeding
  • Increased vaginal discharge.
  • Bleeding after going through menopause.
  • Pain during sex
  • Pelvic pain.

Cervical cancer can be diagnosed using a Pap smear or other procedures that show tissue from the cervix. Chest x-rays, CT scan, MRI, and CT scan can be used to determine the stage of cervical cancer.

Cancer of the cervix requires different treatments than cancer that begins in other
parts of the uterus.

Treatment options for cervical cancer include: Radiation therapy, surgery, and Chemotherapy.

A vaccine is available to prevent HPV infection with the most common types of HPV that are associated with cancers.

The prognosis of cervical cancer depends on the stage and type of cervical cancer, as well as the size of the tumor.

Cervical cancer occurs in nearly 13,000 women each year in the United States, leading to about 4,100 deaths. Since 1980, the incidence of cervical cancer has decreased by 45%, and the mortality (death) rate for cervical cancer has decreased by 49%.

Survival rates among African American women are lower than for any other racial or ethnic group in cervical cancer in the United States. It remains a common cause of cancer and cancer death in women in developing countries without access to cervical cancer screening (PAP) or human papillomavirus (HPV) vaccines.

Cervical cancer is different from cancer that begins in other regions of the uterus (uterine or endometrial cancer). If caught early, cervical cancer has a very high cure rate. Vaccination against HPV, which is known to cause cervical cancer, is an effective preventive measure.

Causes

Almost all cervical cancers are caused by a long-term infection with one of the HPVs. HPV infection is very common, and most people with HPV infection do not develop cancer. There are over 100 types of HPV, and only certain types have been linked to cancers.

Other types of HPV cause benign warts on the skin or on the genitals. The so-called “high risk” types of HPV have been shown to cause cancers of the cervix as well as cancers of the penis in men. HPV can also cause cancers of the mouth, throat, and anus in people of both sexes.

HPV infection spreads through sexual contact or skin-to-skin contact. Many studies have shown that HPV infection is common and that most people will become infected with HPV at some point in life. The infection usually resolves on its own.

In some women, the HPV infection persists and causes precancerous changes in the cells of the cervix. These changes can be detected by regular cervical cancer screening (known as a Pap test).

With the PAP test, a superficial sample of cells from the cervix is ​​taken with a brush or swab during a routine pelvic exam and sent to a laboratory for analysis of how the cells look.

Dysplasia is cells that appear abnormal that are not cancers but may be precancerous. Dysplasia of the cervix identified at the time of the PAP test is referred to as a squamous intraepithelial lesion (SIL).

Cervical intraepithelial neoplasia (CIN) is another term used to classify precancerous changes in the cervix that are seen in tissue samples such as biopsies. Precancerous changes in the cervix such as CIN and SIL are typically treatable, which can prevent the development of cancer.

The cervix contains two types of cells: the cells lining the outer cervix, known as squamous cells, and the cells that line the inner canal of the cervix. These inner cells have characteristics of glandular cells.

The point where squamous and glandular cells meet is known as the transition zone, and it is in this area that most cervical pre-cancers and cancers begin to grow.

Up to 90% of cervical cancers arise from squamous cells and are called squamous cell carcinomas, with most of the remainder coming from glandular cells ( adenocarcinomas ).

What are the symptoms and signs of cervical cancer?

Cervical cancer cannot produce symptoms or signs. In particular, early-stage cervical cancers, such as precancerous changes, typically do not produce symptoms. Symptoms can develop when cervical cancer cells begin to invade surrounding tissues.

Symptoms and signs of cervical cancer include:

  • Abnormal vaginal bleeding
  • Vaginal bleeding after menopause.
  • Vaginal bleeding after sex.
  • Bleeding or spotting between periods.
  • Longer or heavier menstrual periods than usual.
  • Other abnormal vaginal discharge.
  • Pain during sexual intercourse.

It is important to note that these symptoms are not specific to cervical cancer and can be caused by a variety of conditions.

Which are the risk factors?

As described above, cervical cancers are caused by infection with one of the high-risk types of HPV. However, since not everyone who is infected with HPV will develop cancer, it is likely that other factors also play a role in the development of cervical cancer.

Certain risk factors have been identified that increase a woman’s risk for developing
cervical cancer :

  • Smoking
  • HIV infection.
  • Suppression of the immune system.
  • Past or current chlamydial infection .
  • Overweight.
  • Long-term use of oral contraceptives (although the risk returns to normal when the contraceptive pills are stopped).
  • Having three or more full-term pregnancies.
  • Have a first full-term pregnancy before age 17.
  • Poverty.
  • Family history of cervical cancer.

What are cervical cancer screening guidelines?

The US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) recommend that all women between the ages of 21 and 65 receive exams every three years.

A Pap smear obtained during a routine pelvic exam is the typical screening procedure, but when a Pap smear is combined with an HPV test, screening every five years is acceptable for women 30 and older.

Women who have had a total hysterectomy for a benign condition no longer have a cervix and therefore do not need to be screened for cervical cancer. However, women who have had a subtotal hysterectomy still have a cervix and should be examined according to guidelines.

Certain special conditions and situations can change the frequency of screening, such as a history of abnormal Pap smears.

Diagnosis

As described above, Pap tests are done to detect cervical cancer. If abnormal cells are found on the Pap smear, a colposcopy procedure is performed.

Colposcopy uses a lighted microscope to examine the outer surface of the cervix during a pelvic exam.

If abnormal areas are seen, a small tissue sample (biopsy) is taken to be examined by a pathologist to look for precancerous changes or cancer. Colposcopy does not require special anesthesia and is similar to a Pap smear in terms of discomfort.

The transformation zone of the cervix cannot always be well visualized during colposcopy. In this case, a sample of cells may be taken from the inner canal of the cervix, known as an endocervical curettage or scraping.

Another option is conization, or the removal of a conical portion of the cervix around the cervical canal. This tissue can be removed with a fine loop of wire that is heated by an electrical current, known as a loop electrosurgical excision procedure (LEEP), also called a large loop excision of the transformation zone (LLETZ).

LEEP is done in the doctor’s office with a local anesthetic. Another possibility is to have the cone-shaped tissue fragment removed in an operating room under general or regional anesthesia, referred to as a conization cold knife.

After a conization or biopsy procedure, the pathologist studies the tissue to determine whether precancerous changes (referred to as grades 1-3 cervical intraepithelial neoplasia, depending on its extent) or cancer are present.

If cancer is present, depending on the size and extent of the tumor, other tests may be done to help determine the extent to which the tumor has spread. These additional tests may include chest x-rays or CT or MRI scans.

A cystoscopy (examination of the inside of the urinary bladder using a thin, lighted scope) or proctoscopy (examination of the rectum) may be necessary. An exam under anesthesia allows the doctor to perform a manual pelvic exam without causing pain to help determine the extent of the cancer’s spread within the pelvis.

What are the stages of cervical cancer?

The stage of any cancer refers to the extent to which it has spread in the body at the time of diagnosis. Staging of cancers is an important part of determining the best treatment plan.

Both the FIGO (International Federation of Gynecology and Obstetrics) system and the AJCC (American Joint Committee on Cancer) have developed systems for cervical cancer staging. Both systems are based on tumor grade, extent to any lymph nodes, and distant extent.

Cervical cancer is classified into stages 0 through IV, with many subcategories within each numerical stage.

In general, the stages of cervical cancer are as follows:

  • Stage 0: This stage is not a true invasive cancer. Abnormal cells are only
    found on the surface of the cervix, as in CIN 3. This stage is not included in the
    FIGO system and is known as carcinoma in site (CIS).
  • Stage I: There is a small amount of tumor present that has not spread to any
    lymph nodes or distant sites.
  • Stage II: Cancer has spread beyond the cervix and uterus, but does not invade
    the pelvic walls or the lower part of the vagina.
  • Stage III: The cancer has grown in the lower part of the vagina or in the walls of the pelvis.
    The tumor may be blocking the ureters (tubes that carry urine from the kidneys to the
    bladder). There is no spread to other sites in the body.
  • Stage IV: This is the most advanced stage, in which the cancer has spread to the bladder or
    rectum, or to sites in other areas of the body.

Which is the treatment?

Treatment for cervical cancer depends on many factors, including the stage of the cancer when it is diagnosed. Surgery, radiation therapy, chemotherapy, and selective therapy are common methods of treatment for cervical cancer.

Different types of doctors can be involved in the treatment team, including:

  • Gynecologic oncologist, a physician who specializes in treating cancers of the female reproductive organs, including surgery to remove the cancers.
  • Radio oncologist, a doctor who uses radiation to treat different types of cancer.
  • An oncologist who specializes in the use of chemotherapy and other medical treatments to treat cancer.

What are the treatment methods for cervical cancer?

Surgery is often done to remove cancer, especially in early-stage tumors. A hysterectomy (removal of the uterus) can be done, but other procedures that preserve the ability to carry a pregnancy can be done in young women with small tumors.

Both a cone biopsy (removal of the inside of the cervix where most tumors start) and a trachelectomy (removal of the upper vagina and cervix) are options that can be used for small tumors to preserve fertility.

With more advanced cancers, a procedure known as a pelvic exenteration removes the uterus, surrounding lymph nodes, and parts of other organs that surround the cancer, depending on its location.

Radiation therapy is another common treatment for cervical cancer. External beam radiation therapy (radiation therapy given from an external source of radiation) and brachytherapy (radiation therapy that involves inserting radioactive sources near the tumor for a fixed period of time) have been used for cervical cancer.

These two types of therapy have also been used together. If radiation therapy is given as the main cancer treatment, it is often combined with chemotherapy.

Side effects of radiation therapy include fatigue, diarrhea, skin changes, nausea, vomiting, bladder irritation, vaginal irritation and discharge, and sometimes menstrual changes or early menopause, if the ovaries are exposed to radiation.

Chemotherapy may be recommended along with radiation therapy (chemo radiation) for some stages of cervical cancer. It can also be given before or after radiation treatment.

Chemotherapy drugs commonly used for cervical cancer include cisplatin and 5-fluorouracil. Chemotherapy may also be the treatment of choice for cervical cancer that has come back after treatment.

Side effects of chemotherapy include nausea, fatigue, vomiting, hair loss, and mouth ulcers.

Targeted therapy refers to drugs that have been specifically developed, or targeted, to disrupt cellular processes that promote cancer cell growth.

Bevacizumab (avastn) is an example of targeted therapy. It is a drug that inhibits the ability of tumors to make new blood vessels, which is required for tumor growth. This kind of targeted therapy is sometimes used for advanced cervical cancers.

Prevention

Cervical cancer can often be prevented with vaccination and modern screening techniques that detect pre-cancerous changes in the cervix.

The incidence of cervical cancers in the developed world decreased significantly after the introduction of the Pap test to detect precancerous changes, which can be treated before they progress to cancer.

Also, vaccines are available against the common types of HPV that cause cervical cancer. Gardasil and Gardasil 9 are HPV vaccines.

The original studies with Gardasil proved to be very effective in preventing infection with four common types of HPV (6, 11, 16, and 18) in young people who were not previously infected with HPV. Gardasil 9, a newer version of the vaccine, was approved in December 2014 and provides immunity to nine types of HPV (6, 11, 16, 18, 31, 33, 45, 52, and 58).

Vaccination must occur prior to sexual activity to provide the full benefit of the vaccine. The CDC recommends that girls ages 11 to 12 receive the HPV vaccine, and young women ages 13 to 26 should receive the vaccine if they did not receive any or all doses when they were younger.

Gardasil is also approved for use in males 9 to 26 years old, and the CDC recommends Gardasil for all boys aged 11 or 12 years, and for males aged 13 to 21 years who did not receive the full series of three vaccines. Men can get the vaccine until they are 26 years old.

What kind of support is available for women with cervical cancer?

As with any cancer diagnosis, emotional support from family, friends, clergy, a counselor, or support group can help you and your family learn about the disease and cope with the diagnosis and its effects. treatment.

Every woman is different, and different women are comfortable with different types of support systems. For those who prefer a more organized form of support, patient and family support groups are offered by cancer treatment centers, hospitals and clinics, and national advocacy organizations.

Your place of worship may also provide cancer support groups. There are even online support groups for those who prefer this option.

The following is only a partial list of sources for emotional and coping support
for those with cervical cancer:

  • American Cancer Society (ACS) Cancer Survivors Network.
  • I Can Cope (Online) is an online course sponsored by the ACS to cope with cancer.
  • The National Cancer Information Center provides information and support to people facing cancer 24 hours a day, 365 days a year. Trained cancer information specialists are available via phone (1-800-227-2345), email, or live chat.
  • The National Cervical Cancer Coalition offers online support groups and resources for coping.
  • ACS Guide to Sexuality for Women with Cervical Cancer, During and After Treatment.

Prognosis and survival rate

As with most cancers, the outlook (prognosis) is better for cancers found early than for advanced cancers. The prognosis for cancers is often reported in five-year survival rates.

Currently, survival rates for cervical cancer are based on patients who were diagnosed years ago, so these rates may be different for people diagnosed today and receiving modern treatments.

It is also important to note that many people with cancer live well beyond five years, and these rates include death from any cause, not just the cancer being studied.

The five-year survival rates by stage for cervical cancer are as follows:

  • Etapa I: 80% -93%.
  • Stage II: 58% -63%.
  • Stage III: 32% -35%.
  • Stage IV: 15%-16%.

Survival rates are based on examinations of large groups of people and do not reflect the expected outcome or course for an individual patient. Many other factors, including the general health and response of a cancer to treatment, can affect the prognosis for a specific patient.

What research is being done on cervical cancer?

Research is ongoing, not only to improve methods of treating cervical cancer, but also to improve methods of treating pre-cancers and detecting early and treatable cancers.

Pharmacological treatments, including the application of anti-viral drugs to the cervix, are being studied as an alternative or adjunct to surgical treatment of pre-cancerous changes in the cervix. For existing cancers, new targeted therapies are always being studied.

HPV vaccine testing continues to determine whether vaccines can help a woman’s immune system fight an existing HPV infection. Clinical trials are an option for many cancer patients.

Clinical trials are research studies that involve real patients, looking for new treatments or combination of treatments for a condition. Your doctor can help you decide if a clinical trial may be right for you.