Medically Reviewed by Nancy R. Berman, MSN, ANP-BC, NCMP, FAANP
Michigan Healthcare Professionals
Farmington Hills, MI
Department of Obstetrics and Gynecology
Wayne State University School of Medicine
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Unlike breast cancer, cervical cancer may not be a female disease you hear about every day. However, both cervical cancer and the virus that causes most cases of cervical cancer—HPV—are prevalent and worth every woman's attention.
Cancer of the cervix is the fourth most common type of cancer found in women worldwide, after breast, lung and colon cancer. In the United States and other developed countries, cervical cancer rates are much lower; in fact, 85 percent of all cases of cervical cancer occur in developing countries.
The American Cancer Society (ACS) estimates there will be about 13,170 cases of invasive cervical cancer in the United States in 2019, and about 4,250 women will die from the disease.
Cervical cancer is a disease in which cancer cells develop in the tissues of the cervix. The cervix, the lower part of the uterus that protrudes into the vagina, connects the body of the uterus to the vagina. Nearly all cases of cervical cancer can be linked to the human papillomavirus (HPV), a sexually transmitted virus.
There are more than 150 types of HPV, and about 40 high-risk types are linked to cervical cancer. Most women who develop cervical cancer have HPV, but only a small number of women infected with HPV develop cervical cancer. Only persistent HPV infections lead to cervical cancer. Additionally, some low-risk types of HPV cause vaginal and vulvar warts. Other HPV strains cause the warts that sometimes develop on the hands or feet.
The normal cervix is a firm muscle that feels much like the tip of your nose, soft but firm. It is reddish pink, and the outside is covered with normal skin cells called squamous cells. Different cells called columnar (or glandular) cells line the cervical canal. Transformation zones (T-zones) are areas in the body where two cell types meet, and one changes to becomes the other. There is a transformation zone at the cervix, the anal canal and on the tonsils. The line where the two cell types meet—called the squamocolumnar junction (SCJ) is part of the T-zone, and the normal change process of one cell type to another creates metaplastic cells. These changing metaplastic cells are at greatest risk and where abnormal cells most commonly develop when high-risk types of HPV persist in them. Through the female lifespan, the SCJ moves further toward the canal of the cervix and eventually up in the canal. In young women, the T-zone is more exposed on the outside of the cervix (teens through 20s), which makes them more susceptible to cervical infections.
To screen for cervical cancer, health care professionals use the Pap and HPV tests. The Pap test looks for abnormal cell changes that may be mild, moderate or severe precancer or cancer. Screening is meant to find precancer cells and treat them before they progress to invasive cancer. Screening is important because the goal is to find precancer and treat it before cancer has occurred. Additionally, if cancer is present, the earlier health care professionals diagnose it, the better the chance for a cure.
The ACS reports that both incidence of and deaths from cervical cancer have declined markedly over the last several decades. This is no doubt due to more frequent detection and treatment of precancerous and cancerous lesions of the cervix from increased Pap test screening.
Because persistent infection with high-risk strains of HPV can lead to cervical cancer, many medical professionals now also test for the HPV virus in addition to using the Pap test. The U.S. Food and Drug Administration (FDA) has approved use of an HPV test for screening women ages 30 and older and, when combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.
Because the FDA has approved some HPV tests for primary HPV testing in women aged 25 and older, your health care professional may not order a Pap test initially. This is because large amounts of data find that the HPV test can identify women who may have disease that was missed by the Pap as well as identify women who have future risk as long as the high-risk type of HPV persists.
The FDA has also approved an HPV vaccine called Gardasil 9 to protect women against nine strains of HPV. These include the two most common high-risk (cancer-causing) types of HPV, strains 16 and 18, and the two most common low-risk types of HPV, 6 and 11, which cause 90 percent of genital warts. It also protects against five other high-risk types: 31, 33, 45, 52 and 58. Together these types cause most cases of cervical cancer, as well as many cancers of the vulva, vagina, anus, penis and throat.
Ideally, girls and boys should receive the HPV vaccine before they become infected with HPV (in other words, before they become sexually active). As such, the vaccine is approved for children as young as nine and is routinely recommended as a series of shots for girls and boys at age 11 or 12.
Health care professionals also recommend the vaccine for females ages 13 to 26 and males ages 13 to 21 who did not receive the vaccine when they were younger. The FDA has approved Gardasil 9 for women and men up to age 45, although health care professional usually don't give it after age 26, because it is unlikely to provide much benefit to older people. This is a decision to be made by the individual and their health care professional.
If someone is already infected with one of the HPV types in the vaccine, the vaccine will not work against that particular HPV type. It will still work against the remaining types. The vaccine creates antibodies to the HPV types in the vaccine. It does not treat existing infection.
Clinical trials have shown that the HPV vaccine is safe and close to 100 percent effective in preventing HPV strains 16 and 18, which cause 70 percent of cervical cancers. It is also 99 percent effective in preventing HPV strains 6 and 11, which cause about 90 percent of genital warts. The vaccine may come in two or three injections, depending on the age of the person being vaccinated, with patients under 15 years old requiring just two doses and over 15 years old needing three.
The HPV vaccine does not protect against all cancer-causing strains of the HPV virus, so the FDA recommends continued screening with regular Pap and HPV tests appropriate to age, according to published guidelines.
The reason screening is so important for preventing cervical cancer is because the disease usually causes no symptoms in its earliest stages. The detection and treatment of high-grade, severe lesions can prevent progression to invasive cancer. Irregular bleeding, bleeding or pain during sex or vaginal discharge may be symptoms of more advanced disease. If you experience any of these symptoms, you should discuss them with a health care professional.
All women are at risk for cervical cancer, but several factors can increase risk, according to the ACS:
- Persistent infection with high-risk strains of HPV. Most women and men who have been sexually active have been exposed to the HPV virus, which spreads through skin-to-skin contact with an HPV-infected area. However, certain types of sexual behavior increase a woman's risk of getting an HPV infection, such as having sex at an early age, having many sexual partners and having unprotected sex.
Condoms do not completely protect against HPV because the virus spreads via skin-to-skin contact, including the skin in the genital area that may not be covered by a condom. Correct and consistent condom use is still important, however, to protect against AIDS and other sexually transmitted diseases.
- A compromised immune system related to certain illnesses such as human immunodeficiency virus (HIV) infection. Women who are HIV positive are less able to clear HPV or fight cancers like cervical cancer.
- Smoking cigarettes, which exposes the body to cancer-causing chemicals. Women who smoke are about twice as likely to develop cervical cancer. The chemicals produced by tobacco smoke may damage the DNA in cervical cells and make cancer more likely to grow there.
- Infection with chlamydia bacteria, which spreads via sexual contact and may or may not cause symptoms. Researchers don't know exactly why chlamydia infection increases cervical cancer risk, but they think it might be because active immune system cells at the site of a chlamydia infection might damage normal cells and cause them to turn cancerous.
- A diet low in fruits and vegetables. Women who don't eat many fruits and vegetables miss out on protective antioxidants and phytochemicals such as vitamins A, C, E and beta-carotene, all of which have been shown to help prevent cervical cancer and other forms of cancer. Overweight women are also more likely to develop cervical cancer.
- A family history of cervical cancer. If your mother or sister had cervical cancer, you may have a genetic tendency for the disease. This could be because some women are genetically less able to fight off HPV infection than other women.
- Exposure in utero to diethylstilbestrol (DES), a synthetic hormone that was prescribed to pregnant women between 1940 and 1971 to prevent miscarriages. For every 1,000 women whose mothers took DES when they were pregnant, about one develops clear-cell adenocarcinoma (cancer) of the vagina or cervix. For more information on DES exposure, contact the U.S. Centers for Disease Control and Prevention, toll-free: 1-800-CDC-INFO (232-4636), or online at www.cdc.gov.
- Long-term oral contraceptive use (five or more years) may very slightly increase a woman's risk of cancer of the cervix, according to some statistical evidence. However, this risk appears to go back to normal after a woman has been off birth control pills for 10 years. The ACS advises women to discuss the benefits of birth control pills versus this very slight potential risk with their health care professionals.
The death rate from cervical cancer in African-American women is nearly double that of the death rate in Caucasian women. Additionally, Hispanic women develop this cancer nearly twice as often as non-Hispanic Caucasian women. Lack of access to health services (and therefore, less screening), cultural influences and diagnosis of cancer at more advanced stages are all possible reasons for these differences.
Women of all ages are at risk of cervical cancer, but it occurs most often in women 30 and over because they are more likely to have persistent HPV infections. Regardless, it is important that even postmenopausal women continue having regular Pap tests if they still have a cervix. If a woman no longer has a cervix due to a hysterectomy to remove cervical cancer or precancer, she should continue screening with Pap tests and HPV tests. If her cervix was removed during a hysterectomy and there were no signs of cancer and no suspicious Pap tests before the surgery, then she does not need to continue screening. Women over age 65 should stop getting Pap tests if they have had adequate prior screenings: three Pap tests or two Pap tests and one for HPV resulting in negative and no abnormal results in the previous decade.
Discuss your individual screening needs with your health care professional. The guidelines for screening are for the general population. Women who are at risk due to being HIV positive, have history of DES exposure or are immunocompromised are not managed according to the general population guidelines.
The benefits of the Pap test are clear: Because of early detection and treatment of cell changes, over the last 40 years, the death rate for cervical cancer has decreased by more than 50 percent.
Although both the incidence and death rates of cervical cancer are going down, it is still a fairly common cancer in U.S. women, which may be related to the prevalence of infection with HPV. According to the CDC, approximately 79 million people are currently infected with HPV, and up to 14 million new infections occur each year.
In its earliest stages, cervical cancer usually causes no symptoms. Irregular bleeding, bleeding or pain during sex or vaginal discharge may be symptoms of more advanced disease. These symptoms don't necessarily mean you have cancer, but if you experience any of these symptoms, you should discuss them with your health care professional.
Despite the Pap test's 60-plus–year record as a safe and highly accurate screening tool for cervical cancer and precancerous abnormalities of the cervix, many women do not have regular Pap tests. Most invasive cervical cancers occur in women who have not had regular Pap tests, so clearly, the Pap test is important. Many other cases of cervical cancer are attributed to failure to follow up on screening results.
A Pap test is a simple procedure: After a health care professional places a speculum (the standard device used to examine the cervix) in the vagina, he or she takes cells from the surface of the cervix with a spatula and then with a brush or broom device puts the sample into a vial of liquid. In some settings, the Pap is still done on what is called a conventional slide, and the sample is smeared onto glass and fixed with a spray. From the liquid-based vial, a slide is made in the lab for the pathologist to read, while the remaining liquid in the vial can be used for an HPV test.
Women who have had a hysterectomy with the cervix removed should not have Pap tests if the uterus was removed for benign reasons (i.e., no cancer). Vaginal cancer is a rare disease and there is no indication to screen for it.
The slide or vial then goes to a laboratory where a cytotechnologist (a lab professional who reviews your tissue sample) and, when necessary, a pathologist (a health care professional who examines bodily tissue samples) examines the sample for any abnormalities.
Though not infallible, when done regularly, Pap tests can prevent or detect most cervical cancers. In many studies, the Pap is seen to be as low as 50 percent accurate, but by repeating the Pap over time, the detection of disease is improved. That is why women should be screened over time according to guidelines for their age group.
New Technology for Cervical Cancer Screening and Diagnosis
Because the Pap test is sometimes associated with errors, research and development strategies are focused, to a large degree, on fine-tuning Pap test interpretation, visualization and tissue retrieval. For example, the FDA approved liquid-based Pap tests to enhance the test. These tests use a solution that helps preserve the cells scraped from the cervix (the Pap test), as well as remove mucus, bacteria and other cells from the specimen that may interfere with examining the cervical cells. Test vials preserve specimens for up to two weeks from the date of collection, giving the health care provider an opportunity to request HPV testing on a patient who has a borderline Pap result. In fact, most labs will automatically perform an HPV test on someone who has a borderline Pap result without waiting.
New technologies have been developed that help health care professionals assess a patient's tissue at the time of colposcopy, select a biopsy site and offer visualization with mobile devices. These technologies continue to be assessed as data becomes available and are not in widespread use.
In addition, the FDA has approved the HPV DNA test for use together with the Pap test to screen for precancer and cancer in women age 30 and over. A health care professional may also order an HPV DNA test for women 25 and older who have a borderline abnormal Pap test result (ASC-US) to see if more testing or treatment is required. It is preferred that all women ages 30 and older have a Pap and an HPV test every five years.
To help improve the reliability of your Pap test, schedule your appointment two weeks after your last menstrual period and refrain from doing the following for at least 48 hours before the test:
using vaginal creams, suppositories, medicines, sprays or powders
Pap Test Results
An abnormal Pap test result does not mean you have cervical cancer. It indicates there is some degree of change or abnormality in the cells that cover the surface (lining or epithelium) of the cervix. The Pap test is a screening test and not a diagnosis.
While the Pap test cannot confirm an HPV infection, it can show cell changes that suggest infection with HPV.
Pap test classifications include:
Negative for intraepithelial lesion or malignancy. This classification means there are no signs of precancerous changes, cancer or other significant abnormalities. Incidental findings such as yeast, herpes or trichomonas may be noted. Trichomonas on a Pap test is not considered absolutely diagnostic of the infection as inflammatory cells may be overidentified as trichomonads. Other specimens may show what are known as "reactive cellular changes," which is how cervical cells react to infection and other irritations.
Atypical squamous cells of undetermined significance, or ASCUS. These are cellular changes that the pathologist is not able to definitely call abnormal. Indeed, 75 percent of women with this Pap result have nothing wrong on the cervix. For the remaining 25 percent, their abnormal cells may have a severe, precancerous change. Since HPV is a necessary cause of cervical cancer, the HPV test is used to determine which women, ages 25 and older with ASC-US, need to have colposcopy. Women who test positive for HPV will have to have colposcopy, while those women with a negative result should have a repeat co-test with Pap and HPV in three years. (Screening guidelines following a negative Pap and HPV test result is to repeat both in five years' time.)
Squamous intraepithelial lesion (SIL). This change is definitely abnormal and is caused by HPV. There are two categories of SIL changes: low-grade SIL and high-grade SIL.
Low-grade SIL refers to early changes in the size, shape and number of cells on the surface of the cervix. These changes may also be called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). Most of these lesions result from an active HPV infection and return to normal on their own without treatment. Others, however, may continue to grow or become increasingly abnormal in other ways and develop into a high-grade lesion. According to the National Cancer Institute, these cell changes occur most often in women ages 25 to 35 but can appear in other age groups.
Because a Pap is a screening test and a woman may have more severe disease than the Pap found, any patient age 25 or older with SIL should have a colposcopy. In patients younger than 25, a health care professional may choose to repeat the Pap test in 12 months. Women who have a low-grade Pap plus a negative HPV test result, should have both tests repeated the following year rather than a colposcopy.
High-grade SIL. Cells in this category look very different from normal cells and are less likely to return to normal without treatment. High grade-SIL cells are more likely to develop into cancer.
Other terms for high-grade SIL are moderate or severe dysplasia (CIN 2 or CIN 3) carcinoma in situ.
Follow-up for high-grade SIL (CIN 2 or CIN 3 are the usual pathologic results after biopsy) depends on the results of the colposcopy. In most cases, it involves additional procedures, including biopsy, endocervical curettage or both to determine the degree of abnormality and rule out invasive cancer.
In most cases, cervical cancer grows slowly. Precancerous changes may not become cancerous for months or years. Once they spread deeper into cervical tissue or to other tissues and organs, the cellular abnormalities are classified as cervical cancer or invasive cervical cancer. Cervical cancer tends to occur in midlife; about half of women diagnosed with cervical cancer are between the ages of 35 and 55. It rarely occurs in women younger than 20. The development of cervical cancer requires long-term persistence of high-risk HPV. Screening young women under 21 can lead to over-response and over-treatment of transient changes that will usually go away.
A Pap test is a screening tool; other procedures are necessary to confirm Pap test abnormalities and diagnose conditions. All abnormal Pap tests should have some form of action plan. This may include a "watch and wait" approach with retesting in 12 months or, depending on the degree of abnormality, your health care provider may order other tests, including:
Colposcopy: The health care professional uses a colposcope to magnify and focus light on the vagina and cervix to view these areas in greater detail. The evaluation begins after vinegar has been applied and allowed to soak for a few minutes. Depending on these findings, your health care professional may then use one or more of the following tests:
Biopsy: This procedure involves taking a sample from the cervical surface. This is felt as a pinch and usually more than one biopsy is taken if there is abnormal tissue seen. In many cases, there is nothing to biopsy.
Endocervical curettage: Cells are scraped from inside the cervical canal using a spoon-shaped instrument called a curette to help make a more precise diagnosis. This procedure evaluates a part of the cervix that cannot be seen.
Cone biopsy: When biopsy or endocervical curettage reveals a problem that requires further investigation, the next step may be a cone biopsy. This procedure involves removing a "cone" of tissue from around the opening of the cervical canal. In addition to diagnosing an abnormality, cone biopsy can remove the abnormal tissue in an attempt to treat the disease. A pathologist examines tissue removed during cone biopsy to be sure all the abnormal cells have been removed.
- Loop Electrocautery Excision Procedure (LEEP): This procedure removes the suspicious area with a loop device. The remaining tissue is electrocoagulated (vaporized with electrical current). LEEP is both a diagnostic test and a treatment. A pathologist examines tissue removed during LEEP to be sure all abnormal cells have been removed.
If your health care professional finds cervical cancer, he or she will conduct more tests to learn if cancer cells have spread to other parts of the body. These tests may include:
Cystoscopy to look for cancer that has spread to the bladder. The doctor examines the inside of the bladder using a lighted tube.
Proctoscopy to help determine if the cancer has spread to the rectum.
Examination of the pelvis under anesthesia to check for further spread.
Chest x-ray to see if the cancer has spread to the lungs.
Other imaging tests, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), to see if the cancer has spread to lymph nodes or other organs.
In some cases, a Pap test may report abnormal cells in a sample when, in fact, the cells in question are normal. This type of abnormal report is known as a false positive.
When a Pap test fails to detect an abnormality that is present, the result is called a "false negative." Even under the best of conditions, there is always a small possibility of a false negative. Several factors may contribute to a false negative Pap test:
When irregular cells are located high in the cervical canal, they are difficult to get to or scrape under normal Pap test procedures.
Menstrual blood and inflammatory cells can mask abnormal cells; these cells would not be visible to the cytotechnologist.
An inadequate sample—not enough cells were collected during the Pap test.
Human error, in which the person reviewing the slide misinterpreted abnormal cells as normal.
The addition of HPV testing has improved screening results for women whose high-risk HPV may have been missed by a Pap test previously. It can also help identify women with future risk as long as the virus persists.
Screening Guidelines for Cervical Cancer
The ACS, the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists generally agree on the following guidelines for early detection and prevention of cervical cancer, but always talk with your health care professional about what's best for you:
All women should begin screening at age 21.
Women ages 21 to 29 should have a Pap test every three years. Women 25 and older should not have an HPV test unless it is needed because of an abnormal Pap test result. Ordering an HPV test alone, without a Pap test, is FDA-approved for women 25 and older.
Women ages 30 to 65 should have both a Pap test and an HPV test every five years, a Pap test alone every three years or an HPV test alone every five years. (Expert organizations have some variances in preference for type of tests and frequency; talk with your health care professional about what's best for you).
Women over age 65 who have been screened with normal results in the past 10 years and have had three negative Pap tests or two co-tests of negative Pap and one HPV with no abnormal results should stop getting screened. Women who have been treated for cervical precancer should continue to be screened for 20 years after treatment.
Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer, should not be screened.
- Women who have received the HPV vaccine should still follow the screening guidelines for their age group.
Women in special populations including HIV-positive, immunocompromised, and DES-exposed may need more frequent screenings. Talk to your health care professional about what's right for you.
To plan your treatment, your health care professional needs to know the stage of the disease. The following stages are used for cervical cancer:
Stage 0 or carcinoma in situ. This is very early cancer. The abnormal cells are found only in the first layer of cells of the lining of the cervix and do not invade the deeper tissues of the cervix.
Stage I cancer involves the cervix but has not spread.
Stage IA indicates a very small amount of cancer that is only visible under a microscope and is found in the deeper tissues of the cervix.
Stage IB indicates a larger amount of cancer is found in the tissues of the cervix that can usually be seen without a microscope.
Stage II cancer has spread to nearby areas but is still inside the pelvic area.
Stage IIA cancer has not spread into the tissues next to the cervix, called the parametria. The cancer may have spread to the upper part of the vagina.
Stage IIB cancer has spread to the tissue around the cervix.
Stage III cancer has spread throughout the pelvic area. Cancer cells may have spread to the lower part of the vagina. The cells also may have spread to block the tubes that connect the kidneys to the bladder (the ureters).
Stage IV cancer has spread to other parts of the body.
Stage IVA cancer has spread to the bladder or rectum (organs close to the cervix).
Stage IVB cancer has spread to other organs such as the lungs or liver.
The best treatment plans for cervical cancer take into account several factors: the location of abnormal cells, the results of colposcopy, your age and whether you want to have children in the future. Basically, treatment involves destroying or removing the abnormal cells. Three basic approaches are used alone or in various combinations:
Surgery is used to remove the cancer. Various surgical techniques may be used, including:
Electrosurgery (electric current is passed through a metal rod that touches, vaporizes and destroys abnormal cells)
Conization (a biopsy used as a treatment)
Simple hysterectomy (removal of the cervix and uterus)
Radical hysterectomy (removal of cervix, upper vagina, uterus and ligaments that support them)
Trachelectomy (removal of the cervix and upper part of the vagina, but not the body of the uterus). This procedure allows women to be treated without losing their ability to have children.
Pelvic exoneration, a more extensive operation sometimes used to treat recurrent cervical cancer. This procedure involves removing all the same organs and tissues as a radical hysterectomy and includes pelvic lymph node dissection. The bladder, vagina, rectum and part of the colon may also be removed depending on where the cancer has spread.
Radiation therapy (using high-dose X-rays or other high-energy rays to kill cancer cells) treats both early and advanced-stage diseases. Sometimes your health care professional will use it alone or in combination with surgery. A common way to receive radiation is externally, just like an X-ray. Another procedure, called brachytherapy, involves having the radioactive source placed inside your body; it continues to emit energy for a specific time. In most stages of cervical cancer, radiation should be used with chemotherapy.
Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill or infused into the body with a needle inserted into a vein. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body and can kill cancer cells outside the cervix. Combination chemotherapy is constantly evolving, with the goal of improving response to treatment. Chemotherapy with platinum can also make radiation more effective, depending on the stage of the cancer.
Based on the stage of your cancer, treatment regimens usually include the following:
Stage 0 cervical cancer is sometimes called carcinoma in situ or CIN 3 and is precancer. Treatment may be one of the following: cold knife conization; laser surgery; loop electrocautery excision procedure (LEEP); cryosurgery; and surgery to remove the abnormal area. Hysterectomy is not recommended for women with precancer of the squamous cells. When precancer impacts cells that are higher up in the cervical canal and involve the glandular cells, then a hysterectomy is recommended for women who are done with childbearing. Because those cells are not as easily evaluated after treatment, there is more risk of disease left behind or recurrence. The precancerous changes or the stage 0 cancer can recur in the cervix, vagina or, rarely, the anus, so close follow-up is very important.
Stage I cervical cancer treatments depend on how deep the tumor cells have invaded the normal tissue.
Stage IA cancer is divided into stage 1A1 and stage 1A2.
For stage 1A1, there are a few options. If you still want to be able to have children, your doctor will remove the cancer with a cone biopsy and then closely follow you to see if the cancer returns. If you are through having children or the cone biopsy doesn't remove all the cancer, your doctor may remove your uterus (simple hysterectomy). If the cancer has invaded your lymph nodes or blood vessels, treatment will involve a radical hysterectomy and removal of the pelvic lymph nodes. If you still want to have children, you may be able to have a radical trachelectomy (surgery to remove the cervix and pelvic lymph nodes) instead of a radical hysterectomy.
Stage 1A2 involves three treatment options: radical hysterectomy and removal of lymph nodes in the pelvis; brachytherapy with or without external beam radiation; or, if you still want to have children, radical trachelectomy combined with removal of pelvic lymph nodes.
If the cancer has spread to the parametria or to any lymph nodes, your doctor will recommend radiation therapy and possibly chemotherapy. If the pathology report reveals that some of the cancer may have been left behind, you may be treated with pelvic radiation combined with chemotherapy and, possibly, brachytherapy.
Stage IB cancer is divided into stage 1B1 and 1B2.
For pelvic stage 1B1, treatment may involve radical hysterectomy and removal of lymph nodes or para-aortic lymph nodes (lymph nodes higher up in the abdomen), possibly combined with radiation therapy and/or chemotherapy; high-dose internal and external radiation; or, if you still want to be able to have children, radical trachelectomy combined with the removal of pelvic and some para-aortic lymph nodes.
For stage 1B2, the standard treatment is chemotherapy and radiation therapy to the pelvis combined with brachytherapy. In some cases, treatment may involve a radical hysterectomy combined with removal of pelvic and some para-aortic lymph nodes. If your doctor finds cancer in the removed lymph nodes, he or she may recommend radiation therapy after surgery, possibly with chemotherapy as well. And some doctors recommend starting with a combination of radiation and chemotherapy as a first option, followed by a hysterectomy.
Stage IIA cervical cancer treatment depends on the size of the tumor. If the tumor is larger than four centimeters, treatment may include brachytherapy and external radiation. Treatment may also include chemotherapy with cisplatin. Some doctors recommend removing the uterus after radiation. If the cancer is smaller than four centimeters, treatment may involve a radical hysterectomy and removal of pelvic and some para-aortic lymph nodes. If the removed tissue reveals cancer, treatment will also include a combination of radiation and chemotherapy, possibly with brachytherapy as well.
For stage IIB cancer, treatment may include internal and external radiation therapy combined with cisplatin chemotherapy or cisplatin plus fluorouracil.
Stage III and IVA: Most health care professionals combine these two groups in terms of prognosis and treatment. The treatment for these two groups includes combined internal and external radiation therapy with cisplatin chemotherapy or cisplatin plus fluorouracil. If the cancer has spread to the lymph nodes, especially if it has spread to lymph nodes in the upper part of the abdomen (para-aortic lymph nodes), the cancer may have spread to other areas of the body. Some doctors will check the lymph nodes with surgery, a CT scan or an MRI. If lymph nodes appear enlarged, they will be biopsied. If the para-aortic lymph nodes are indeed cancerous, the doctor may want to do further tests to see if the cancer has spread to other areas of the body.
Stage IVB cancer treatments often include chemotherapy and/or radiation therapy. Cancer at this stage is not usually considered curable, so treatments are more to relieve symptoms caused by the cancer than to treat the cancer itself.
Recurrent cervical cancer may require radiation therapy combined with chemotherapy. Sometimes immunotherapy or targeted therapy is used to slow cancer growth. If the cancer has come back outside of the pelvis, a woman may choose to go into a clinical trial of a new treatment and/or use chemotherapy or radiation therapy to ease symptoms. If the recurrence is limited to the pelvis, radical pelvic surgery may be recommended.
Getting regular Pap and HPV tests to look for precancerous changes at the early stages is the best way to prevent cervical cancer. Most women who develop invasive cervical cancer have not had regular Pap tests or have never been screened. Reducing or eliminating risk factors associated with the development of cervical cancer can also help prevent it:
Don't smoke cigarettes.
Use condoms correctly and consistently to protect yourself from sexually transmitted diseases. Note, however, that while condom use will decrease the risk of HPV infection, it can't prevent it entirely because HPV can infect cells anywhere on the skin in the genital area.
Additionally, the FDA has approved an HPV vaccine called Gardasil 9 to protect against nine strains of HPV. These include the two most common high-risk (cancer-causing) types of HPV, strains 16 and 18, and the two most common low-risk types of HPV, 6 and 11, which cause 90 percent of genital warts. It also protects against five additional types: 31, 33, 45, 52 and 58. Together, these types cause about 90 percent of cervical cancer, as well as many cancers of the vulva, vagina, anus, penis and throat.
HPV vaccines should be given before an infection occurs, ideally, before a girl or boy becomes sexually active. The vaccine is approved for children as young as nine and is routinely recommended as a series of shots for girls and boys at age 11 or 12.
Vaccinations also are recommended for females ages 13 to 26 and males ages 13 to 21 who did not receive the vaccine when they were younger. Gardasil 9 is approved for women and men up to age 45, though is typically not recommended after age 26, because it is likely to provide much benefit to older people.
If someone is already infected with one of the HPV types in the vaccine, the vaccine will not work against that particular HPV type. (It will still work against the remaining types.) Recommendations vary depending on your personal circumstances, so talk with your health care professional.
Clinical trials have shown that the vaccine is safe and close to 100 percent effective in preventing HPV strains 16 and 18, which cause 70 percent of cervical cancers. It is also 99 percent effective in preventing HPV strains 6 and 11, which cause about 90 percent of genital wart cases. Two or three injections may be needed, depending on the age of the person being vaccinated.
The vaccine does not protect against all cancer-causing strains, so the FDA recommends continued screening with regular Pap tests.
HPV screening of women ages 30 and over is also an important part of preventing potential complications of cervical cancer. The easiest way to screen for HPV is with the HPV test which checks for the virus itself. The Pap test can identify cervical cancer in its earliest stage but can also find abnormal precancerous cells and signs of an active HPV infection.
In conjunction with the Pap test, the HPV test can be used in women over age 30 to help detect HPV infection. Because it specifically tests for the types of HPV that are most likely to cause cervical cancer, when combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.
The American Cancer Society (ACS), the U.S. Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG) generally agree on the following guidelines for early detection and prevention of cervical cancer, though there are some differences among the organizations, so always talk with your health care professional about what's best for you:
All women should begin screening at age 21.
Women ages 21 to 29 should have a Pap test every three years. Women 25 and older should not have an HPV test unless it is needed because of an abnormal Pap test result. Ordering an HPV test alone, without a Pap test, is FDA-approved for women 25 and older.
Women ages 30 to 65 should have both a Pap test and an HPV test every five years; or a Pap test alone every three years; or an HPV test alone every five years. Talk with your health care professional about what's best for you.
Women over age 65 who have been screened previously with normal results in the previous 10 years—three Pap tests or two Pap and one HPV test and no abnormal results—should stop getting screened. Women with cervical precancer should continue to be screened until they have completed 20 years of follow-up.
- Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened. Many women who have had a hysterectomy do not know if they still have their cervix. It should not be assumed that the cervix was removed along with the body of the uterus. If the cervix was left behind, screening should continue according to guidelines.
Women who have received the HPV vaccine should still follow the screening guidelines for their age group.
Women in special populations including HIV positive, immunosupressed and DES-exposed are not included in the guidelines for the general population.
Facts to Know
The American Cancer Society estimates that in 2019, about 13,170 cases of invasive cervical cancer will be diagnosed in the United States and about 4,250 women will die from the disease.
The death rate from cervical cancer in African-American women is nearly double that of Caucasian women. The highest rate of cervical cancer is in underdeveloped countries.
Both incidence and deaths from cervical cancer have declined markedly over the last several decades, due to more frequent detection and subsequent treatment of pre-invasive and cancerous lesions of the cervix from increased Pap screening.
The five-year survival rate for early invasive cancer of the cervix is 92 percent. The survival rate falls steadily as the cancer spreads to other areas.
Changes in cervical cells are classified by their degree of abnormality. If your test is abnormal, ask your health care professional to discuss how your abnormalities were described. Many abnormalities return to normal with no treatment, so your health care professional may want to wait and perform another Pap test in one year or Pap and HPV if age over 25. Overtreating mild dysplasia can harm the cervix. However, if the Pap results reveal atypical squamous cells of undetermined significance (AS-CUS), then HPV testing is routinely done in women 25 and older. If no high-risk types are identified, then no further testing in needed. You should repeat the Pap and HPV test in one year. If the Pap reveals ASC-US and the HPV test is positive, your health care professional will order a colposcopy. Colposcopy also is needed if any other more serious changes are shown by the Pap results. Further screening and treatments will depend on the results of the colposcopy. CIN 1 should not be treated, but the Pap and HPV test will be repeated in 12 months. For CIN 2-3, further treatment is needed to remove the abnormal cells.
The primary risk factor for cervical cancer is infection with certain types of the human papillomavirus (HPV). Together, HPV 16 and HPV 18 account for about 70 percent of cervical cancer cases. However, it is important to note that not every HPV infection with high-risk strains is destined to become cervical cancer. Only infections that persist are likely to develop precancerous cell changes if untreated.
Rates of low-grade squamous intraepithelial lesion (low-grade SIL), usually caused by an active HPV infection, peak in both black and white women between the ages of 25 and 35. However, the number of cases of invasive cervical cancer increases with age, as does the chance of dying from cervical cancer.
Women who had first sexual intercourse at an early age or who have had many sexual partners have a higher-than-average risk of developing cervical cancer.
The majority of cervical cancers develop through a series of gradual, well-defined precancerous lesions. During this usually lengthy process, the Pap test can usually detect abnormal cells, leading to an earlier and more successful treatment. The addition of HPV testing has improved detection of precancerous changes as it is more accurate than the Pap. The HPV test can identify women who may have disease that the Pap missed. Additionally, women who have a risk of developing precancer in the future are identified and followed more closely.
Pap tests, like other early detection tests, are not 100 percent accurate. When performed properly, the Pap test detects a significant majority of cervical cancers—usually in the early stages when the likelihood of a cure is the greatest.
Questions to Ask
Review the following Questions to Ask about cervical cancer so you're prepared to discuss this important health issue with your health care professional.
What is my risk for developing cervical cancer? How can I limit my risks?
What should I do before getting a Pap test to make sure the test is as accurate as possible?
Are you sending my Pap test to a board-certified lab? Does a board-certified pathologist oversee this lab?
Do I need the HPV test?
How will I be informed of the results?
If I have abnormal cells on Pap test or a positive HPV test, what next steps are necessary?
I was diagnosed with human papillomavirus (HPV). How often do I need pelvic exams and Pap tests?
I am so afraid to find out I may have cancer that I'm afraid to come in for a Pap test or pelvic exam. What should I do?
What is a colposcopy and why do you recommend it? Will it hurt?
Can cervical cancer be cured? How? Can it come back after it's been treated?
What experience do you have in treating cervical cancer? Have you had specialty training in gynecological oncology?
Will I have to be checked for cancer for the rest of my life?
What are the risks that my daughter will have cervical cancer too?
My Pap test was abnormal—what should I do?
Don't panic. There are many things that can produce an abnormal result. To improve the reliability of the test, schedule your appointment two weeks after your menstrual period and refrain from having intercourse or using vaginal contraceptives or douches for at least 48 hours before the test. Return for further testing if your health care professional recommends it.
I've already gone through menopause. Should I continue to have Pap tests?
Current guidelines suggest that if you are age 65 or older and have had adequate prior screening (three Pap tests or two rounds of Pap and HPV testing in the previous 10 years and no abnormal results) and are not otherwise at high risk for cervical cancer, you can stop having Pap tests. Annual pelvic exams are still recommended.
My health care professional has recommended a hysterectomy for invasive cervical cancer. How do I know if this is the right thing to do?
There are a number of diagnostic steps your health care professional should take before surgery, including a colposcopy and biopsy. Treatment regimens are always your choice and should be discussed thoroughly with your health care professional. Additionally, you should seek a second opinion from a gynecological oncologist before undergoing any surgical procedure. A gynecological oncologist is an obstetrician-gynecologist who has had special training in the care of women with cancers of the cervix, ovary, uterus and vulva.
Is it true that there are new tests to replace the Pap test?
There are several new technologies, but most are designed to improve the reliability of the Pap test, which is still the most widely used screening test to detect changes in cervical cells. Pap tests, like other early detection tests, are not 100 percent accurate. Still, when performed properly, the Pap test detects a significant majority of cervical cancers—usually in the early stages when the likelihood of a cure is the greatest.
How often should I have a Pap test? What about the HPV test?
The American Cancer Society, the American College of Obstetricians and Gynecologists, and the U.S. Preventive Services Task Force recommend that screenings begin at age 21. Women ages 21 to 29 should have a Pap test every three years. They should not have an HPV test unless it is needed because of a borderline abnormal Pap test result in women 25 and older. Women ages 30 to 65 should have both a Pap test and an HPV test every five years; or a Pap test alone every three years; or in women 25 and older, an HPV test alone every three or five years.
However, women who are at an increased risk for developing cervical cancer (those with new or multiple sexual partners, family history of the disease or other risk factors) should be screened more frequently. Women who have abnormal Pap test results or a positive HPV test should discuss subsequent tests and follow-up with their health care professionals.
Women who are 65 or older and have had adequate prior screening and are not at high risk for cervical cancer may stop screening for cervical cancer altogether.
Women who have had a total hysterectomy (removal of the uterus and cervix) may also stop screening unless the hysterectomy was performed because of cervical cancer or precancer-related reasons, or you have a history of abnormal Pap tests. If the hysterectomy was performed to treat cervical cancer, more frequent Pap screenings may be recommended.
Talk to your health care provider about what is best for you, based on your medical history.
I've avoided going to the health care professional for years and never even had a Pap test. What can I expect when I have the test?
A Pap test is a simple procedure. After a health care professional places a speculum (the standard device used to examine the cervix) into your vagina, he or she takes cells from the surface of the cervix, then smears them onto a glass slide or into a liquid. A sample is taken from the T-zone with a tiny wooden or plastic spatula or a tiny brush. The cell sample then goes to a laboratory, where a cytotechnologist (a lab professional who reviews your Pap test) and, when necessary, a pathologist (a physician who examines bodily tissue samples) examines the sample for any abnormalities.
I have cervical cancer and my health care professional has not recommended chemotherapy. Isn't chemotherapy always needed to treat cancers?
Depending on the stage of your cancer, sometimes radiation alone is the recommended treatment. In some cases, treatment combines radiation with chemotherapy, called chemoradiation.
I heard that a Pap test can be reported as a false negative. What does that mean?
When a Pap test fails to detect an existing abnormality, the result is referred to as a false negative. Several factors can contribute to a Pap test reporting a false negative:
When irregular cells are located high in the cervical canal and are difficult to access under normal Pap test procedures
When menstrual blood masks abnormal cells; these cells would not be visible to the cytotechnologist
An inadequate sample—when not enough cells were collected during the Pap test
Human error, where the person reviewing the slide misinterpreted abnormal cells as normal
I haven't had a Pap test in several years because I don't have health insurance and can't afford it. Are there any options for me?
The National Breast and Cervical Cancer Early Detection Program provides breast and cervical cancer screening services to underserved women throughout the country, including 13 American Indian/Alaska Native organizations. Services are either free or provided on a sliding scale based on your income. For information about access in your area, call 1 (800) CDC-INFO (232-4636) or go to www.cdc.gov/cancer/nbccedp.
The federal Affordable Care Act, approved in 2010, also makes more low-income women eligible for Medicaid coverage, particularly single women who are not currently covered.
Additionally, Medicare provides 100 percent coverage for a Pap test and pelvic examination once every 24 months. If you are at high risk for cervical or vaginal cancer, or if you are of childbearing age and have had an abnormal Pap test in the preceding 36 months, Medicare covers these tests every 12 months.
For women who do have health insurance but were still concerned about screening costs, the federal Affordable Care Act makes free screenings available to many women. If you have a health insurance plan that began on or after March 23, 2010, Pap tests and many other preventive screenings must be covered (when performed by a network provider) without you being required to pay a co-payment or coinsurance or deductible.
Give yourself the best odds after treatment for cervical cancer or precancerous conditions
If you smoke, look seriously for opportunities or resources to quit. Smoking exposes your body to cancer-causing chemicals that promote the growth of cervical cancer. The chemicals produced by tobacco smoke may damage the DNA in cells of the cervix and make cancer more likely to occur there. Also avoid drinking excessive alcohol and follow the dietary recommendations of your cancer care team. Assuming there's no reason for you to avoid these foods, eat plenty of dark green leafy vegetables, red, orange or yellow vegetables and whole grains. This will help you heal faster and give you a better chance of recovering completely. Exercise as soon as your condition permits. Know your recommended medical follow-ups and keep up with them.
Face your fertility issues
If you're concerned about your ability to have children, make this clear to your cancer care team. Ask how the medical and surgical procedures necessary for your care will affect your fertility. If you have early cervical cancer, it may be possible for you to be treated with a cone biopsy, a surgical procedure that allows most women to remain fertile. If your fertility can't be spared, you're entitled to your feelings and consideration from others. A good counselor or support group may help. You can also consider looking into newer options, such as ovarian tissue banking.
Reclaim your sex life
During this stressful time, it is normal for you to be less interested in sex than before. Counseling can help you and your partner adjust and stay physically intimate in other ways as you return to intercourse at your own pace. If you are experiencing vaginal dryness, hormone creams and lubricating gels can help. To keep your vagina elastic and flexible after radiotherapy, use a vaginal dilator and talk to your partner about having regular sex. This won't make the cancer worse or hurt your partner. Make sure that penetrative sex is very gentle at first.
If you're going to have a hysterectomy...
Ask your surgeon whether your ovaries will also be removed and research this decision carefully. It is not always a good idea to remove your ovaries, especially if you are young, because it will cause you to go into sudden menopause. Studies also have shown increased risk of lung cancer, coronary artery disease and even premature death from other causes in young women who have their ovaries removed.
Also ask whether you'll be having abdominal laparoscopic surgery with or without robotic assistance or surgery through the vagina, since the procedures have different recovery rates. Arrange for help at home; you'll be glad later, even if you don't need it for long. Freeze your favorite meals ahead of time, and prepare the room in which you'll be resting after surgery with reading materials and pictures or posters on the wall. Also have a supply of sanitary pads for post-operative drainage and large-size, comfortable panties.
After your hysterectomy...
Cooperate when you're asked to get up and walk after surgery. You'll recover faster and won't have as many problems with gas. Once you're home, don't lift heavy objects or walk up stairs too soon after surgery. If you've had an abdominal incision, edema (swelling) may make your abdomen look like it sags; with time, this will subside. Stick to a healthy, nutritious diet, not a weight-loss diet, while recovering from surgery. After your surgeon has cleared you for normal activity, exercise to tighten your muscles, build up strength and endurance and improve sleep.
Organizations and Support
American Cancer Society (ACS)
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
American Institute for Cancer Research
Address: 1759 R Street, NW
Washington, DC 20009
Association of Cancer Online Resources, Inc.
Address: 173 Duane Street, Suite 3A
New York, NY 10013
Cancer Care, Inc.
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Cancer Support Community
Address: Gilda's Club Worldwide
48 Wall Street, 11th Floor
New York, NY 10005
Corporate Angel Network
Address: Westchester County Airport
One Loop Road
White Plains, NY 10604
Foundation for Women's Cancer
Address: 230 W. Monroe, Suite 710
Chicago, IL 60606
Address: The Arnold & Sydell Miller Family Campus 23300 Commerce Park
Beachwood, OH 44122
Mautner Project - The National Lesbian Health Organization
Address: 1875 Connecticut Ave., NW Suite 710
Washington, DC 20009
Hotline: 1-866-MAUTNER (1-866-628-8637)
Memorial Sloan-Kettering Cancer Center, New York
Address: 1275 York Ave
New York, NY 10065
National Cancer Institute (NCI)
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615
National Cervical Cancer Coalition (NCCC)
Address: 6520 Platt Ave., #693
West Hills, CA 91307
National Coalition for Cancer Survivorship (NCCS)
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
National Comprehensive Cancer Network
Address: 275 Commerce Dr, Suite 300
Fort Washington, PA 19034
Native American Cancer Research
Address: 3022 South Nova Rd.
Pine, CO 80470-7830
Prevent Cancer Foundation
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Women's Cancer Resource Center
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Johns Hopkins Patients' Guide to Cervical Cancer
by Colleen McCormick, Robert Giuntoli
A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker, Rachel L. Parker
Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd, Dana Rowett
The HPV Vaccine Controversy: Sex, Cancer, God, and Politics: A Guide for Parents, Women, Men, and Teenagers
by Shobha S. Krishnan
National Cancer Institute
H. Lee Moffitt Cancer Center & Research Institute
Address: 12902 Magnolia Drive
Tampa, FL 33612
Medline Plus: Cervical Cancer
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894