c

is malignant neoplasm of the cervix uteri or cervical area.

It may present with vaginal

[1]
bleeding, but symptoms may be absent until the cancer is in its advanced stages. Treatment consists
of surgery (including p
p
  in early stages andchemotherapy and radiotherapy in advanced
stages of the disease.  
 

3 Cancer that forms in tissues of the cervix (the organ
connecting the uterus and vagina. It is usually a slow-growing cancer that may not have symptoms but can be found
with regular Pap tests (a procedure in which cells are scraped from the cervix and looked at under a microscope.
Cervical cancer is almost always caused by human papillomavirus (HPV infection.

?
Ô

    
 from cervical (uterine cervix cancer in the United States in 20103
?
New cases3 12,200
Deaths3 4,210

Pap smear screening can identify potentially precancerous changes. Treatment of high grade changes
can prevent the development of cancer. In developed countries, the widespread use of cervical screening
programs has reduced the incidence of invasive cervical cancer by 50% or more.[
   

]

Human papillomavirus (HPV infection is a necessary factor in the development of almost all cases of
cervical cancer.[1][2] HPV vaccineseffective against the two strains of HPV that currently cause
approximately 70% of cervical cancer have been licensed in the U.S, Canada, Australia and the
EU.[3][4] Since the vaccines only cover some of the cancer causing ("high-risk" types of HPV, women
should seek regular Pap smear screening, even after vaccination.[5]

Cervix in relation to upper part of vagina and posterior portion of uterus.

Cervical cancer seen on a T2 weighted saggital MR image of the pelvis.

j



  




 
  
 

 
















  















 

 








 







  


 

The cervix is another name for the neck of the womb. It is the opening to the womb from the vagina.
It is really a strong muscle. Normally it is quite tightly shut, but during labour it opens up to let the
baby out.

j





The cervix has a layer of skin-like cells on its outer surface. Cancer of these cells is called squamous
cell cervical cancer. There are glandular cells lining the inside of the cervix. The glandular cells
produce mucus. Cancer of these cells is called adenocarcinoma of the cervix.

The area where cervical cells are most likely to become cancerous is called the transformation zone.
It is the area around the opening of the cervix that leads on to the narrow passageway running up
into the womb.

! 



There are lymph nodes around the womb and cervix. The nearest large groups of lymph nodes are
in the groin (at the top of each of your thighs. The lymph nodes are part of the lymphatic system.
Tissue fluid that bathes the area containing the cancer will drain to the nearest lymph nodes. When
you have surgery for cancer, your surgeon will usually take out some lymph nodes and send them to
the lab to be checked for any cancer cells that have broken away from the tumour.

[edit]Signs and symptoms

The early stages of cervical cancer may be completely asymptomatic.[1][6] Vaginal bleeding, contact
bleeding or (rarely a vaginal mass may indicate the presence of malignancy. Also, moderate pain during
sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced
disease, metastases may be present in the abdomen, lungs or elsewhere.

Symptoms of advanced cervical cancer may include3 loss of appetite, weight loss, fatigue, pelvic pain,

back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or faeces from

This page is about the symptoms of

the vagina,[7] and bone fractures.

cervical cancer. The most common symptom of cervical

cancer is bleeding from the vagina at other times than when
you are having a period. You may have bleeding

Between periods
@

@ After or during sex

@ At any time if you are past your menopause

Some women also have

A vaginal discharge that smells unpleasant

@

@ Discomfort or pain during sex

Doctors call pain related to sex 'dyspareunia'. There are

many other conditions that cause these symptoms. Most of
them are much more common than cervical cancer. But you
should go to your doctor straight away if you have any of
these symptoms. You probably don't have cancer. But if you
do, the sooner you are treated, the more likely you are to be
cured and usually the less treatment you will need to have.

Pre-cancerous cell changes do not usually have any

symptoms. Which is why it is so important to have a
regular smear test.

]
 


The earlier a cancer is picked up, the easier it is to treat it
and the more likely the treatment is to be successful. So it is
important that you go to your GP as soon as possible if you
notice worrying symptoms. If someone you care about
needs to know how to spot cancer early, pass on a nudge
through the Cancer Research UK µDo me a favour¶
campaign - it could make all the difference.

[edit]Causes



 

About 2,800 women are diagnosed with cervical cancer in the UK each year. Overall, 2 out of every
100 cancers diagnosed in women are cervical cancers. But it is the most common cancer in women
under 35 years old.

About 4.1 million women are invited for cervical screening each year in England and about 24,000
have a severely abnormal cervical screening result. Early treatment can prevent those cervical
changes developing into cancer.

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M


 

 
Anything that increases your risk of getting a disease is called a risk factor. Different cancers have
different risk factors. This page discusses the risk factors for cervical cancer. Even if you have one
or more of the risk factors below, it does not mean that you will definitely get cervical cancer.

Back to top


 

Human papilloma virus (HPV is the major cause of the main types of cervical cancer ± squamous
cell cancer and adenocarcinoma. There are over 100 different types of human papilloma virus
(HPV. Up to 8 out of 10 people (80% in the UK are infected with the HPV virus at some time during
their lifetime. But for most people the virus causes no harm and goes away without treatment.

Some HPV types are called the wart virus or genital wart virus because they cause genital warts.
The types of this virus that cause warts are not the same types that increase the risk of cervical
cancer. But some types of HPV are considered high risk for cancer of the cervix ± they include types
16 and 18. If you have persistent or frequent infections with these high risk types of HPV, you are
more at risk of developing pre cancerous cervical cells or cervical cancer than people who have not
had these infections.

Almost all women who get cervical cancer have had past infections with HPV. As some types of
HPV are passed on from one person to another through sexual contact (including non penetrative
sexual activity this has led to women's sexual behaviour being seen as a risk factor for cervical
cancer. But, on the other hand, most women infected with these viruses do NOT develop cervical
cancer. So other factors must also be needed.

If men use a condom during penetrative sex, this reduces the risk of a woman becoming infected
with HPV. Using condoms also reduces the chance of a woman developing pre cancerous changes
in the cervix (CIN if she has HPV infection.

Vaccines to prevent HPV infection have now been licensed for use in the European Union. All girls
aged 12 or 13 in the UK are now routinely offered the HPV vaccine at school. These vaccines
protect against the strains of HPV that are most likely to cause cervical cancer. But they do not
protect against all strains. As it takes between 10 and 20 years for a cervical cancer to develop after
HPV infection, it is still important for women to carry on with cervical cancer screening. It will take
some years before the introduction of the vaccine has a major effect on reducing the number of
cases of cervical cancer. The cervical screening programme is continuing as before.

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A recent study looked at all the research results together and found that having both herpes and
HPV infection doubled the risk of squamous cell cervical cancer. This research took account of the
number of sex partners women had, as well as their use of the pill.

Another study looked at infection with HPV and chlamydia (pronounced klah-mid-ee-ah. The study
found that the risk of squamous cell cancer increased by about 80% in women with both infections.

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If you smoke, you are more likely to develop squamous cell cervical cancer. Researchers have
found cancer causing chemicals (benzyrene from cigarette smoke in the cervical mucus of women
who smoke. They think that these chemicals damage the cervix. There are cells in the lining of the
cervix called Langerhans cells that specifically help fight against disease. These cells do not work so
well in smokers.

If you have a high risk type of HPV infection and smoke, you are twice as likely to have pre
cancerous cells in your cervical screening test, or to get cervical cancer. The Langerhans cells are
less able to fight off the virus and protect the cervical cells from the genetic changes that can lead to
cancer.

  
that if you smoke you are more likely to get cervical cancer. If you have mild pre
cancerous changes in your cervical screening test, the cells are more likely to go back to normal
without any treatment if you stop smoking.

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If you have a weakened immune system, then your risk of many cancers, including cervical cancer,
is higher than average. People with HIV and AIDS, or people taking drugs to suppress their immune
systems after an organ transplant, are more at risk of developing cervical cancer if they also
haveHPV infection.

This is because a healthy immune system normally protects you from cells that have become
abnormal. Your immune system will kill off the cells and so prevent them from becoming cancerous.

Back to top


 
Research that looked at a number of studies together shows that taking the pill could increase a
woman's risk of developing cervical cancer. It is not clear why this is. The researchers took account
of other factors, such as the number of sexual partners, smoking, and most importantly, infection
withHPV. Researchers suspected that there was a link with taking the pill, but clear evidence has not
come out of the studies until now.

We thought that the pill was statistically linked to cervical cancer because women on the pill are
more likely to be sexually active and so more at risk of picking up HPV. Also, they do not necessarily
use barrier contraception (condom or cap which could prevent them picking up the human
papilloma (wart virus. But now it seems that it may actually directly increase the risk.

About 8 in 100,000 women get cervical cancer every year in the UK. The recent research suggests
that amongst women who have taken the pill for at least 5 years, that risk is doubled. But this is still
a small risk, and it is important to know that taking the pill can help to protect you against womb and
ovarian cancers.

The evidence suggests that the increased risk of cervical cancer begins to drop as soon as you stop
taking the pill. After 10 years the risk is the same as if you had never taken it. The important thing to
remember is that regular screening can pick up changes in the cervix before they develop into a
cancer. Obviously, screening is now very important for women taking the pill.

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c
 
Some research suggests that women with partners who have been circumcised are less likely to get
cervical cancer. This may be because men who are circumcised are less likely to carry HPV
infection. This research took into account different factors relating to sexual behaviour.

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You will quite often hear that women who started having sex young or women who have a lot of
different sex partners are more likely to get cervical cancer. But really, this is only true because the
earlier you start having sex and the more men you have sex with, the more likely you are to pick up
an infection with a high risk (cancer causing human papilloma virus (HPV. And so then you are
more at risk of developing cervical cancer.

It is not correct to say that women who get cervical cancer have it because they were promiscuous
(slept around. After all, you could have only slept with one man and still caught the virus if he had it.
If he's had lots of partners, that will increase your risk, because it indirectly exposes you to possible
sexual infections from lots of other people.

A Cochrane review, published in 1999, found that health education can help women to reduce their
risk of cervical cancer. Teaching women about healthy sexual behaviour helped them behave in
ways that lowered their cervical cancer risk. The teaching included information about

@ How to use a condom

@ How to avoid sex when they are young
@ How to reduce their number of sexual partners
@ How to negotiate safe sex
The education helped them to protect themselves from unsafe sex and talk to their partners about
their need to do this. You can read this review of promoting healthy sexual behaviour in the
Cochrane Library. It was written for researchers and specialists so is not in plain English.

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There is no evidence at all to say that pregnancy increases the risk of cervical cancer. Abnormalities
in the cervix may become more visible during pregnancy and so be more likely to be diagnosed.
Some women may have a screening test when they are pregnant. Women who are not up to date
with their cervical screening are more likely to be offered a test when they go to the doctor because
of their pregnancy. This screening might lead to women being diagnosed with pre cancerous
changes or cervical cancer while they are pregnant. But this does not mean that the pregnancy
caused the cancer ± just that this is when it was picked up.

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Women in developing countries have a higher cervical cancer risk. This is partly because developing
countries don't have screening. It is also because women in developing countries are more likely to
have large families. Women who have had 7 or more children have double the risk of women with
only 1 or 2 children. Having your first baby early, before 17, also doubles the risk, compared to
having your first baby at 25 or older. This research also took account of HPV infection, and found
that HPV infection did not explain the increase in cervical cancer in women who had larger numbers
of children. Other similar research looked at the different types of cervical cancer. They also found a
doubling of risk of squamous cell cervical cancer with 3 or more children, compared to no children.
But they found that the risk of adenocarcinoma went up by half (50%.

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One study has shown that black women with HPV may have a lower cervical cancer risk than white
women with HPV. But we need more studies to confirm any effect of ethnic group.

Another study showed that women with a first degree relative (mother, sister or daughter diagnosed
with adenocarcinoma or squamous cell carcinoma of the cervix have double the risk of developing
cervical cancer, compared to women without a family history. But we don¶t know whether this is
linked to faulty genes, or whether it is due to common lifestyle factors. In some cases it may be that
HPV infection is passed on during pregnancy and childbirth.

Human papillomavirus (HPV infection with high-risk types has been shown to be a necessary factor in
the development of cervical cancer.[8]HPV DNA may be detected in virtually all cases of cervical
cancer.[1][8][2] Not all of the causes of cervical cancer are known. Several other contributing factors have
been implicated.[9]
[edit]
  

In the United States each year there are more than 6.2 million new HPV infections in both men and
women, according to the CDC, of which 10 percent will go on to develop persistent dysplasia or cervical
cancer. That is why HPV is known as the "common cold" of the sexually transmitted infection world. It is
very common and affects roughly 80 percent of all sexually active people, whether they have symptoms
or not. The most important risk factor in the development of cervical cancer is infection with a high-risk
strain of human papillomavirus. The virus cancer link works by triggering alterations in the cells of the
cervix, which can lead to the development of cervical intraepithelial neoplasia, which can lead to cancer.

Women who have many sexual partners (or who have sex with men who had many other partners have
a greater risk.[10][11]

More than 150 types of HPV are acknowledged to exist (some sources indicate more than 200
subtypes.[12][13] Of these, 15 are classified as high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58,
59, 68, 73, and 82, 3 as probable high-risk (26, 53, and 66, and 12 as low-risk (6, 11, 40, 42, 43, 44, 54,
61, 70, 72, 81, and CP6108.[14] Types 16 and 18 are generally acknowledged to cause about 70% of
cervical cancer cases. Together with type 31, they are the prime risk factors for cervical cancer.[15]

Genital warts are caused by various strains of HPV which are usually not related to cervical cancer.
However, it is possible to have multiple strains at the same time, including those that can cause cervical
cancer along with those that cause warts. The medically accepted paradigm, officially endorsed by the
American Cancer Society and other organizations, is that a patient must have been infected with HPV to
develop cervical cancer, and is hence viewed as a sexually transmitted disease (although many dispute
that, technically, it is the causative agent, not the cancer, that is a sexually transmitted disease, but most
[16]
women infected with high risk HPV will not develop cervical cancer. Use of condoms reduces, but does
not always prevent transmission. Likewise, HPV can be transmitted by skin-to-skin-contact with infected
areas. In males, there is no commercially available test for HPV, although HPV is thought to grow
[
   
preferentially in the epithelium of the glans penis, and cleaning of this area may be preventative.


]

[edit]c 


The American Cancer Society provides the following list of risk factors for cervical cancer3 human
papillomavirus (HPV infection, smoking, HIV infection, chlamydia infection, stress and stress-related
disorders, dietary factors, hormonal contraception, multiple pregnancies, exposure to the hormonal
drug diethylstilbestrol, and family history of cervical cancer.[10] Early age at first intercourse and first
pregancy are also considered risk factors, magnified by early use of oral contraceptives.[17] There is a
[
   

]
possible genetic risk associated with HLA-B7.

There has not been any definitive evidence to support the claim that circumcision of the male partner
reduces the risk of cervical cancer, although some researchers say there is compelling epidemiological
[18]
evidence that men who have been circumcised are less likely to be infected with HPV. However, in
men with low-risk sexual behaviour and monogamous female partners, circumcision makes no difference
to the risk of cervical cancer.[19]

[edit]Diagnosis

[edit]ÿ 
 


M 


Your doctor will suggest more tests if you've had an
abnormal smear, or if you have symptoms which could be
caused by cervical cancer. These tests are different ways of
looking at the cervical cells more closely. To find out more
about the abnormality, and to see whether you have cervical
cancer, your specialist may ask you to have one of these
tests

@ Colposcopy
 Cone biopsy
@

This may be all that you need to have done. Do remember

that the vast majority of women who have an abnormal
smear, or suspicious symptoms, do 
have cancer.
Treating abnormal pre cancerous cells will stop a cancer
from developing. Cone biopsy may successfully treat the
problem by removing the abnormal area. If your doctor sees
an obvious abnormality with the colposcope, they may treat
you there and then. But you will have to go for follow up
smears to make sure the abnormal cells don't come back.

If any of the tests do show you have an invasive cervical

cancer, you will need further tests and moretreatment.
'Invasive' means that the cancerous cells have started to
grow into the deeper layers of the cervix - for example, into
the muscle layer.

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c 
This is another examination of the cervix similar to when you
have a smear test. A doctor or specialist nurse uses a
colposcope to look at the surface of the cervix. This is really
just a large magnifying glass that they use to closely
examine the skin-like covering of the cervix. It doesn't go
inside you. But by looking through it, they can see
abnormalities that may be too small to see with the naked
eye. The doctor or specialist nurse will take a biopsy of any
abnormal areas.

For most women, this is a painless examination. It may be a

little uncomfortable because you will be in the position you
need to be in for a smear. Some people find it
uncomfortable to stay in that position for more than a couple
of minutes, but other than that, it should be fine.

You usually have colposcopy in the outpatient clinic, or in a

local community hospital. You lie on your back on the couch
in the same position as for a smear. That is, with your feet
drawn up and your knees apart. As with a smear, if you
cannot get into that position for any reason, the doctor or
specialist nurse may be able to do the examination with you
lying on your side with your knees drawn up.

The doctor or nurse puts in a speculum to open up the

vagina. And then looks through the colposcope at the
surface of the cervix. The examination takes up to 20
minutes. If they need to take biopsies, you can have some
local anaesthetic injected into the cervix first. You will be
able to go home as soon as the colposcopy is over.
If your doctor or specialist nurse finds an area of abnormal
cells, you may have treatment there and then. They may call
this 'see and treat'. It can be very convenient, as you won't
have to go back for another appointment - or have the
anxiety of waiting for it. But you can choose to come back
for treatment if you prefer.

LLETZ, or Large Loop Excision of the Transformation Zone

means cutting out the area of the cervix where the abnormal
cells develop (the transformation zone is the area just inside
the cervical canal. LLETZ is the most common treatment
used in the UK. It is simple and quick to carry out, works
well and can be done under local anaesthetic. It also
provides a clear tissue sample for the laboratory to examine.
There are quite a few other treatment options, including
laser, cold coagulation and cone biopsy - these can work
equally well. Look at the section on treating abnormal
smears for more about other treatments that you may have.

Sometimes the doctor or specialist nurse cannot see clearly

enough because the abnormal cells go further up into the
cervical canal than can be seen with a colposcope. If they
cannot see all the cells that are abnormal you will need to
have either a LLETZ or a cone biopsy.

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c  
This is a minor operation that you usually have under
general anaesthetic. You will probably stay in hospital
overnight.

While you are under anaesthetic the doctor cuts out a cone
of tissue from your cervix. The cone includes the whole area
of the cervical canal where there might be abnormal cells.
The cone of tissue is sent to the laboratory for examination
under the microscope.

When you wake up after the cone biopsy, you may have
some gauze packed into your vagina to help stop any
bleeding. If you have a pack, you will probably have a tube
to drain urine from your bladder as well (a catheter. This is
because the gauze pack presses on the bladder and the
tube that carries urine out of the body (the urethra. Your
nurse or doctor will take the pack out before you leave
hospital the following day. It is normal to have bleeding for
up to 4 weeks after a cone biopsy.

A 1999 Cochrane review found that immediate blood loss

and bleeding after cone biopsy is reduced by treatment with
a drug called tranexamic acid. The drug vasopressin can
also reduce bleeding. You can read this review of
preventing blood loss after cone biopsies in the Cochrane
Library. It was written for researchers and specialists so is
not in plain English.

You will probably have period type pains when you wake up.
If you do, tell your nurse and ask for some painkillers. You
can take painkillers home with you if you need to, but the
pains usually only last a couple of hours.

When you get home, try to rest as much as you can for the
first week or so. You do not have to stay in bed. But you
mustn't be too active either. Don't do any heavy housework
or carry heavy loads. It will help if you can arrange for a
relative or friend to help you for a few days, particularly if
you have children to look after. You shouldn't do any
vigorous exercise or have sexual intercourse for 4 to 6
weeks after your cone biopsy. By that time your cervix will
have healed.

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M
   



You can have a colposcopy if you are pregnant. It is
perfectly safe for you and your baby, and will not affect the
delivery. It won't affect your ability to get pregnant in future
either. In most cases, any treatment for pre cancerous cells
can be planned for after you've had the baby. Your doctor
will be very careful about taking biopsies.

Your doctor will not suggest a cone biopsy if you are

pregnant unless he or she suspects there is a cervical
cancer. Cone biopsy during pregnancy can weaken the
cervix and bring on a miscarriage. There is more information
about the effect cone biopsy might have on future
pregnancy in this section of CancerHelp UK.

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Before you leave hospital, whether after a colposcopy or a
cone biopsy, make sure you know how you will be given the
results. You may be asked to come back to the hospital for
an outpatients appointment to see the specialist to get the
results. Or they may be sent in the post.

If you have abnormal cells on your cervix, you will be asked

to come back to hospital to have them treated. There is
more about treating abnormal smears in this section of
CancerHelp UK.
If you had abnormal cells and have had a cone biopsy, the
area with the abnormal cells will usually have already been
removed. As long as the abnormal cells were completely
removed and there is no sign of cervical cancer, you will not
need any further treatment. But you will need regular smear
tests for a while to keep an eye on the area.

`


  





  " 
#"   


 $

 




This page is about the further tests your doctor may suggest
if you have been diagnosed with cervical cancer. You need
more tests to see how far the cancer has grown, whether it
has spread and to decide on the best treatment.

%


 







You have this under general anaesthetic so that your

specialist can examine you thoroughly and take biopsies if
necessary. The examination includes checking your womb,
vagina, rectum and bladder, to see if cancer has spread to
any of these areas.
 

 

Your doctor might want you to have a scan to stage your

cancer and check for cancer spread. AnMRI scan uses
magnetism to build up a picture of the body. A CT scan is a
type of computerised X-ray. You may have a PET-CT
scan which combines a CT scan and a scan that uses a low
dose of radioactive liquid. You may have blood tests to
check your general health. You may also have a chest X-ray
to check for signs of cancer in the lungs.

 


 

You may feel very anxious while waiting for the results of
your tests. It may help to talk to a close friend or relative
about how you are feeling. If you would like to talk to
someone outside your own friends and family, look in the
µcoping with cancer¶ section of CancerHelp UK for more
about counselling.

While the pap smear is an effective screening test, confirmation of the diagnosis of cervical cancer or pre-
cancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual
inspection of the cervix aided by using a dilute acetic acid (e.g. vinegar solution to highlight abnormal
cells on the surface of the cervix.[1]

Colposcopic impression, the estimate of disease severity based on the visual inspection, forms part of the
diagnosis.
Further diagnostic and treatment procedures are loop electrical excision procedure (LEEP
and conization, in which the inner lining of the cervix is removed to be examined pathologically. These are
carried out if the biopsy confirms severe cervical intraepithelial neoplasia.

This large squamous carcinoma (bottom of picture has obliterated the cervix and invaded the lower uterine segment. The
uterus also has a round leiomyoma up higher.

Micrograph of a ˜

p 

  

 , a type of cervical cancer. H&E stain.

[edit]

   
Cervical intraepithelial neoplasia, the potential precursor to cervical cancer, is often diagnosed on
examination of cervical biopsies by apathologist. For premalignant dysplastic changes, the CIN (cervical
intraepithelial neoplasia grading is used.

The naming and histologic classification of cervical carcinoma percursor lesions has changed many times
over the 20th century. The World Health Organization classification[20][21] system was descriptive of the
lesions, naming them mild, moderate or severe dysplasia or carcinoma in situ (CIS. The term, Cervical
Intraepithelial Neoplasia (CIN was developed to place emphasis on the spectrum of abnormality in these
 [21]
lesions, and to help standardise treatment. It classifies mild dysplasia as CIN1, moderate dysplasia as
CIN2, and severe dysplasia and CIS as CIN3. More recently, CIN2 and CIN3 have been combined into
CIN2/3. These results are what a pathologist might report from a biopsy.

These should not be confused with the Bethesda System terms for Pap smear (cytology results. Among
the Bethesda results3 Low-grade Squamous Intraepithelial Lesion (LSIL and High-grade Squamous
Intraepithelial Lesion (HSIL. An LSIL Pap may correspond to CIN1, and HSIL may correspond to CIN2
[21]
and CIN3, however they are results of different tests, and the Pap smear results need not match the
histologic findings.
[edit]c
 
 

This page is about the main types of fully diagnosed cervical

cancer. If you are looking for information about abnormal
smears, you need to go to either the screening page, which
has information about what smear results mean. Or the
section on treating abnormal cervical cells.

There are two main types of cervical cancer

Squamous cell cancer

@

@ Adenocarcinoma

They are named after the type of cell that becomes

cancerous. Squamous cells are the flat skin-like cells that
cover the outer surface of the cervix (the ectocervix.
Squamous cell cancer is the most common type of cervical
cancer.

Adenomatous cells are gland cells that produce mucus. The

cervix has these gland cells scattered along the inside of the
passageway that runs from the cervix to the womb (the
endocervical canal. Adenocarcinoma is a cancer of these
gland cells. It is less common than squamous cell cancer,
but has become more common in recent years. Between 1
in 10 and 1 in 20 cases of cervical cancer are
adenocarcinoma. It is treated in the same way as squamous
cell cancer of the cervix.

 





  

Very rarely, other types of cancer can occur in the cervix.
For example, lymphoma, which is a cancer of the lymphatic
system. If you have this rare cancer, then this section of
CancerHelp UK is not the right one for you. There is a
section on lymphoma and its treatment in CancerHelp UK.

Histologic subtypes of invasive cervical carcinoma include the following3[22][23] Though squamous cell
carcinoma is the cervical cancer with the most incidence, the incidence of adenocarcinoma of the cervix
has been increasing in recent decades.[1]

[
   

]
A squamous cell carcinoma (about 80-85% 
A adenocarcinoma (about 15% of cervical cancers in the UK[20]
A adenosquamous carcinoma
A small cell carcinoma
A neuroendocrine carcinoma

Non-carcinoma malignancies which can rarely occur in the cervix include

A melanoma
A lymphoma

Note that the FIGO stage does not incorporate lymph node involvement in contrast to the TNM staging for
most other cancers.
å
 


 
 


 

 

   





 
 


 
 

 !



   
It can be very difficult for GPs to decide who may have a
suspected cancer, and who may have something much less
serious that will go away on its own. With many symptoms,
it is perfectly right that your GP should ask you to wait to
see if they get better or respond to treatment (such as
antibiotics. If GPs referred everyone they saw to a
specialist immediately, the system would get jammed and
those needing urgent appointments wouldn't be able to get
them.

There are particular symptoms that mean your GP should

refer you to a specialist straight away. NICE (National
Institute for Health and Clinical Excellence have produced
guidelines for GPs to help them decide which patients need
to see a specialist urgently. These Government guidelines
on referrals for cervical cancer were revised in June 2005.
And in Scotland, SIGN (Scottish Intercollegiate Guidlines
Network produced their own guidelines in 2008.

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M

    


The NICE guidelines say your GP should examine you
internally if you have

@ A change in your menstrual cycle

@ Bleeding after sex

@ Bleeding if you are past your menopause

@ An abnormal discharge from your vagina

The GP should do a full internal examination of your vagina,

using a speculum so that they can see the cervix properly.
Most of these symptoms are related to abnormal bleeding.
This is the most common symptom of cervical cancer.
Bleeding is considered abnormal if you have it

@ Between periods
@ After or during sex

@ At any time if you are past your menopause

The NHS Cervical Screening Programme aims to pick up

and give treatment for abnormal cervical smears before they
develop into cancer. Screening detects about 40 out of
every 100 women (40% diagnosed with cervical cancer.

The SIGN guidelines for Scotland state that if you have not
yet had your menopause, and you have any of these
symptoms, or your cervix is inflamed or bleeding on contact,
then you should be tested first to see if you have Chlamydia.
Chlamydia is a sexually transmitted infection which can
cause some of the same symptoms. If you are past your
menopause and you have bleeding, your GP should do an
internal pelvic examination. Post menopausal bleeding can
also be a symptom of womb cancer.

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According to Department of Health guidelines, you should
ideally get an appointment within 2 weeks for an urgent
referral. The symptoms that need urgent referral to a
specialist for possible cancer of the cervix are

@ Any visible sign of cancer of the cervix that your GP

sees when examining you internally
@ One or more episodes of heavy bleeding from the
vagina after the menopause in women who are not on
hormone replacement therapy (HRT
@ Bleeding that is persistent or unexplained after stopping
HRT for 6 weeks or more
@ Repeated bleeding after sex for no apparent reason
@ Repeated bleeding between periods for no apparent
reason
The guidelines make it clear that you should have a
specialist referral with these symptoms, not just a smear
test. They also say that an earlier negative smear is not a
good reason for delaying a referral if you have signs of
cervical cancer.

If your GP can feel a lump in your lower tummy (pelvis, and

it doesn't feel like fibroids, they can decide to refer you for
an urgent ultrasound scan. If an urgent scan is not available,
they should refer you straight to a specialist.

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" 



 
If you are concerned that your GP is not taking your
symptoms as seriously as you think he or she should, you
could print this page and take it along to an appointment.
Ask your GP to talk it through with you and then you may be
able to decide together whether you need to see a specialist
and if so, how soon.

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M
      

If you see a specialist they will want to examine you and
may do several tests. There is information about the type
of tests that you may need in the diagnosing cervical
cancer section of CancerHelp UK.

[edit]


Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO staging
system, which is based on clinical examination, rather than surgical findings. It allows only the following
diagnostic tests to be used in determining the stage3 palpation, inspection, colposcopy,
endocervical curettage,hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-
ray examination of the lungs and skeleton, and cervical conization.

The TNM staging system for cervical cancer is analogous to the FIGO stage.

A Stage 0 - full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in
situ
A Stage I - limited to the cervix
A IA - diagnosed only by microscopy; no visible lesions
A IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread
A IA2 - stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less
A IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of
more than 7 mm
A IB1 - visible lesion 4 cm or less in greatest dimension
A IB2 - visible lesion more than 4 cm
A Stage II - invades beyond cervix
A IIA - without parametrial invasion, but involve upper 2/3 of vagina
A IIB - with parametrial invasion
A Stage III - extends to pelvic wall or lower third of the vagina
A IIIA - involves lower third of vagina
A IIIB - extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney
A Stage IV - extends outside the vagina
A IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis
 A IVB - distant metastasis

Stage 1-A1 young women - conization wis clear margin. Parous women - hysterectomy.

Stage 1-A2 laproscopic lymphadenectomy + vaginal trechelectomy + post operative radiotherapy.

Stage 1B & 2A 1. Wertheim's hysterectomy . 2- schauta vaginal hysterectomy + laparoscopic

lymphadenectomy 33 primary radiotherapy 43 combined surgery & radiotherapy.


 #ÿ$%& 



M

 
Your doctor will use tests to help stage your cancer. The
stage of a cancer tells the doctor how far it has spread. It is
important because treatment is often decided according to
the stage of a cancer. Doctors use different systems to
stage cancers. The system usually used for cervical cancer
numbers the different stages from 1 to 4. There is
more about staging cancers in the about cancer section.

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c
 
'c"(
Carcinoma in situ means that some of the cells of the cervix
have cancerous changes. But the abnormal cells are all
contained within the surface layer of the cervix. Carcinoma
in situ is not a cancer but in some women the changes will
develop into a cancer after some years. It is important to
have treatment as soon as possible for carcinoma in situ. As
long as the affected area is removed, cancer can be
prevented. Carcinoma in situ can be found during cervical
screening tests and we have information about abnormal
screening results on the cervical screening page of
CancerHelp UK.

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 )
Stage 1 means that the cancer is just in the neck of the
womb. It is often divided into

Stage 1A
@

@ Stage 1B

These days, stage 1A and 1B are both divided into two

smaller groups

@Stage 1A1 and stage 1A2

@ Stage 1B1 and stage 1B2

In stage 1A the growth is so small it can only be seen with a

microscope (or colposcope. Stage 1A1 means the cancer
has grown less than 3 millimetres (mm into the tissues of
the cervix, and it is less than 7mm wide. Stage 1A2 means
the cancer has grown between 3 and 5 mm into the cervical
tissues, but it is still less than 7mm wide.

In stage 1B the cancerous areas are larger, but the cancer

is still only in the tissues of the cervix and has 
usually
spread. It can usually be seen without a microscope, but not
always. In stage 1B1 the cancer is no larger than 4
centimetres (cm. In stage 1B2 the cancer is larger than
4cm across.
Stage 1 cervical cancer is generally treated
with surgery or radiotherapy. But if you have stage 1B2
cervical cancer, your doctor may suggest combined
chemotherapy and radiotherapy.

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 #
In stage 2 cervical cancer, the cancer has begun to spread
outside the neck of the womb into the surrounding tissues.
But it has not grown into the muscles or ligaments that line
the pelvis (pelvic wall, or to the lower part of the vagina.
Stage 2 can be divided into

@ Stage 2A
 @ Stage 2B
In stage 2A the cancer has spread down into the top of the
vagina.

Stage 2A is now divided into

@ Stage 2A1
@ Stage 2A2

In stage 2A1 the cancer is 4 cm or less. In stage 2A2 the

cancer is more than 4 cm.

In stage 2B there is spread up into the tissues around the

cervix.
Stage 2A cervical cancer may be treated
with surgery or radiotherapy or both.

Stage 2B cervical cancer is usually treated with

combined radiotherapy and chemotherapy. Research
studies have shown that this combined treatment can
improve the survival rates of stage 2 cervical cancer.

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 $
In stage 3 cervical cancer, it has spread away from the
cervix and into surrounding structures in thepelvic area. It
may have grown down into the lower part of the vagina and
the muscles and ligaments that line the pelvis (pelvic wall.
And it may have grown up to block the tubes that drain the
kidneys (the ureters. It can be divided into

@ Stage 3A
@ Stage 3B

Stage 3A is when the cancer has spread to the lower third of

the vagina but not the pelvic wall.

Stage 3B means the tumour has grown through to the pelvic

wall or is blocking one or both of the tubes that drain the
kidneys.
This stage is usually treated
with radiotherapy and chemotherapy. We know from
research that this combined treatment can improve the
survival rates of stage 3 cervical cancer.

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 %
Stage 4 cervical cancer is advanced cancer. The cancer has
spread to other body organs outside the cervix and womb. It
can be divided into

@ Stage 4A
@ Stage 4B
Stage 4A is when the cancer has spread to nearby organs
such as the bladder or rectum (back passage.

If the cancer has spread to organs further away, such as the

lungs, your doctor may call it stage 4B.
This stage of cancer may be treated
with surgery, radiotherapy, chemotherapy or a combination
of these treatments. Some women may choose just to have
treatment to control symptoms at this stage

[edit]Prevention

[edit]

] 
p


[24]
Gardasil, is a vaccine against HPV types 6, 11, 16 & 18 which is up to 98% effective.

Cervarix has been shown to be 92% effective in preventing HPV strains 16 and 18 and is effective for
[25]
more than four years.

Together, HPV types 16 and 18 currently cause about 70% of cervical cancer cases. HPV types 6 and 11
cause about 90% of genital wart cases. HPV vaccines have also been shown to prevent precursors to
[26][27]
some other cancers associated with HPV.

HPV vaccines are targeted at girls and women of age 9 to 26 because the vaccine only works if given
before infection occurs; therefore, public health workers are targeting girls before they begin having sex.
 [5] [28]
The vaccines have been shown to be effective for at least 4 to 6 years, and it is believed they will be
[29]
effective for longer, however the duration of effectiveness and whether a booster will be needed is
unknown.

The use of the vaccine in men to prevent genital warts, anal cancer, and interrupt transmission to women
or other men is initially considered only a secondary market.

The high cost of this vaccine has been a cause for concern. Several countries have or are considering
programs to fund HPV vaccination.
[edit]c  
Condoms offer some protection against cervical cancer.[30] Evidence on whether condoms protect against
HPV infection is mixed, but they may protect against genital warts and the precursors to cervical
cancer.[30] They also provide protection against other STDs, such as HIV and Chlamydia, which are
associated with greater risks of developing cervical cancer.

Condoms may also be useful in treating potentially precancerous changes in the cervix. Exposure to
semen appears to increase the risk of precancerous changes (CIN 3, and use of condoms helps to
cause these changes to regress and helps clear HPV.[31] One study suggests
that prostaglandin in semen may fuel the growth of cervical and uterine tumours and that affected women
may benefit from the use of condoms.[32][33]
[edit]


Carcinogens from tobacco increase the risk for many cancer types, including cervical cancer, and women
who smoke have about double the chance of a nonsmoker to develop cervical cancer.[34][35]
[edit]*



å

  
 

Higher levels of vegetable consumption were associated with a 54% decrease risk of HPV persistence.[36]



There is weak evidence to suggest a significant deficiency of retinol can increase chances of cervical
dysplasia, independently of HPV infection. A small (n~=500 case-control study of a narrow ethnic group
(native Americans in New Mexico assessed serum micro-nutrients as risk factors for cervical dysplasia.
Subjects in the lowest serum retinol quartile were at increased risk of CIN I compared with women in the
highest quartile.[37]

However, the study population had low overall serum retinol, suggesting deficiency. A study of serum
retinol in a well-nourished population reveals that the bottom 20% had serum retinol close to that of the
[38]
highest levels in this New Mexico sub-population.

c

Risk of type-specific, persistent HPV infection was lower among women reporting intake values of vitamin
C in the upper quartile compared with those reporting intake in the lowest quartile.[39]

Ô

HPV clearance time was significantly shorter among women with the highest compared with the lowest
serum levels of tocopherols, but significant trends in these associations were limited to infections lasting
</=120 days. Clearance of persistent HPV infection (lasting >120 days was not significantly associated
with circulating levels of tocopherols. Results from this investigation support an association of
micronutrients with the rapid clearance of incident oncogenic HPV infection of the uterine cervix.[40]

A statistically significantly lower level of alpha-tocopherol was observed in the blood serum of HPV-
positive patients with cervical intraepithelial neoplasia. The risk of dysplasia was four times higher for an
alpha-tocopherol level < 7.95 mumol/l.[41]
å 

Higher folate status was inversely associated with becoming HPV test-positive. Women with higher folate
status were significantly less likely to be repeatedly HPV test-positive and more likely to become test-
negative. Studies have shown that lower levels of antioxidants coexisting with low levels of folic acid
increases the risk of CIN development. Improving folate status in subjects at risk of getting infected or
already infected with high-risk HPV may have a beneficial impact in the prevention of cervical
[42][43]
cancer.

However, another study showed no relationship between folate status and cervical dysplasia.[37]
c

 

The likelihood of clearing an oncogenic HPV infection is significantly higher with increasing levels
of lycopenes.[44] A 56% reduction in HPV persistence risk was observed in women with the highest
plasma [lycopene] concentrations compared with women with the lowest plasma lycopene
concentrations. These data suggests that vegetable consumption and circulating lycopene may be
protective against HPV persistence.[36][39][45]
[edit]

] 
p  
M   

Cervical screening is very important because we can stop cervical cancer from developing in the first
place. This is one of the few cancers that is preventable because pre cancerous cell changes can be
picked up before they have a chance to develop into a cancer. Cervical cancer screening has been
available in the UK since 1967.
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M

 

 
The screening test involves a nurse or doctor taking a small sample of cells from the surface of your
cervix. They do this by putting an instrument called a speculum inside your vagina and then scraping
the cervix with a small brush. They put the brush and cells into a small pot of liquid and send it to the
laboratory. This is called liquid based cytology. In the lab, your sample is put under a microscope.
The cells are examined and any abnormal ones reported.

In the past, cells used to be collected from the cervix using a wooden spatula and the cells were
spread onto a glass slide. This was called a cervical smear or PAP smear.

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M  
+
If you are between the ages of 25 and 60 in the UK, you will be contacted every 3 to 5 years and
asked to go for a cervical screening test. The exact age groups for screening vary between the
different countries of the United Kingdom. In England, women between 25 and 64 years are
screened. Currently in Northern Ireland and Wales, women between 20 and 64 are screened. From
January 2011, women in Northern Ireland will be invited for their first cervical screen at age 25. In
Scotland, women between 20 and 60 are invited for screening. There is information about why the
screening age varies further down this page.

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M
  



 
The screening interval is the time between smears. This used to vary between health authorities. But
research reported in 2003 by Cancer Research UK showed that the screening interval should be
decided by age. We can pick up the most cancers by screening women every 3 years if they are 25
to 49 years old and every 5 years if they are between 50 and 64.

For women between 25 and 49, 3 yearly screening prevents 84 cervical cancers out of every 100
that would develop without screening. 5 yearly screening will only prevent 73 cancers out of 100. So
the guidelines now recommend screening women 3 yearly if they are under 50.

It is acceptable and safe for women of 50 or more to have 5 yearly smears. Screening 3 yearly
doesn't give any extra protection for this age group. This is probably because abnormal cells develop
more slowly in women over 49.
The NHS in England have adopted these recommendations. So if you are between 25 and 49 and
live in England, your health authority will offer you 3 yearly cervical screening. Northern Ireland will
be bringing in these recommendations from 2011.

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M
 
 


You can have a smear test at

@ Your GP surgery
@ A well woman clinic
@ A family planning clinic
@ A genito urinary clinic (clinic for problems with the genital or urinary organs
@ An antenatal clinic if you are pregnant
@ A private health clinic
@ A voluntary organisation clinic, such as Marie Stopes
You can ask for a female nurse or doctor to do your cervical screening test. All clinics will have
women available to chaperone a male doctor. But if you only want a woman to take the smear, you
may have to make an appointment to go back at a later date. So if you are concerned about this, it is
best to mention it when you originally make your appointment.

  
- you should try to make your screening appointment for the middle of your menstrual
cycle. In other words, between periods. It is more difficult for your doctor to see the cervix and take a
sample of cells if you have your period when you go. You may get an inadequate result and have to
go back for another test.

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You take off your underwear and lie on your back on a couch. You have to lie with your knees drawn
up and spread apart. If this position is difficult for you to get into, you can ask your nurse to take the
test when you are lying on your side with your knees drawn up.

The test may be a little uncomfortable because of the position you have to get into. It shouldn't hurt.
It can be more uncomfortable if you are very tense. Try to relax. Taking a few deep breaths should
help. Breathe in and out deeply through your mouth several times.

To make sure that the womb feels a normal size and is in the right position you may need a vaginal
examination. Your doctor will not necessarily do this every time you have a screening test. The
doctor or a specially trained nurse puts on a disposable glove and puts two fingers inside your
vagina. Then, with the other hand, the doctor or nurse presses down on your abdomen gently to feel
your womb.

To take the sample of cells, the doctor or nurse puts an instrument called a speculum inside your
vagina. The speculum has two arms that spread the sides of your vagina apart so that the doctor or
nurse can see the cervix clearly. Then they scrape the surface of your cervix with a small brush. This
collects a sample of cells from the outer layer of the cervix. As soon as the doctor or nurse takes the
sample, they will put it into a pot of liquid, and send it to the laboratory. The test is then over and you
can get down from the couch.

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,-  

The NHS screening programme now uses liquid based cytology (LBC to preserve the cells taken in
cervical screening tests. The doctor or nurse collects the cells from the cervix using a very small
brush. The head of the brush is broken off into a small pot of liquid, or the cells rinsed off into the
pot, instead of putting the cells onto a slide, as used to be done with a PAP smear. The cells are
preserved better with LBC, so the results of the smear test are more reliable.

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The lab will automatically send the results back to the surgery or clinic where you had the test. Your
surgery may not contact you if the test is normal. But they should if there is anything wrong. Or if the
test could not be read properly for some reason. Just to make sure, it is best to contact your GP or
clinic for your own result. Ask them when the results should be back. Then you can ring if you
haven't heard.

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M

 

 
There are several different results you can have after a screening test. Some of the results are due
to problems with the test rather than because there are any abnormal cells. You could be told you
need a repeat smear because yours could not be read properly (sometimes called having an
'inadequate smear'. This could be because

@ There were not enough cells in the sample

@ You have an infection which meant the cells could not be seen clearly enough
@ You were having a period and there is too much blood to see the cells clearly
 @ The cervix was inflamed and so the cells could not be seen clearly enough
In all these cases, you will just be asked to go back and have another smear. If you have an
infection, you will be given some treatment and then asked to have another smear in a couple of
months.

You may be told your test result was 'borderline'. This means that cell changes were seen but that
they were so near normal that they are probably nothing to worry about and will go back to normal
on their own. You will need to go for a repeat test (probably in 6 months, but won't need any more
tests unless your repeat test shows that the cell changes are still there or have got worse.

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c

 
Cervical erosion is a condition often picked up by cervical screening tests. You may hear it called an
ectropion. It has nothing to do with cervical cancer. It means that glandular cells, which are only
normally seen inside the cervical canal, can be seen on the surface of the cervix. The cervix often
looks a little inflamed in this area. An erosion is nothing to worry about. It is common in teenagers, in
pregnancy, and in women on the pill. It can cause slight bleeding, especially after sex. Usually the
condition goes away by itself without any treatment.

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Abnormal results can be reported in two different ways. In the UK, if you have abnormal cells you
are most likely to be told you have

@ Mild or slight cell changes (mild dyskaryosis

@ Moderate cell changes (moderate dyskaryosis
@ Severe cell changes (severe dyskaryosis
More rarely your smear test result may say CIN 1, CIN 2, or CIN 3 instead of mild, moderate or
severe. CIN stands for cervical intraepithelial neoplasia. This just means cervical cell changes. This
classification is not strictly accurate as CIN can only really be diagnosed with a biopsy. But the
smear results do indicate that you probably have

@ CIN 1 if you have mild cell changes

@ CIN 2 if you have moderate cell changes
@ CIN 3 if you have severe cell changes
The three grades of CIN relate to the thickness of the skin covering the cervix that is affected. CIN 1
means one third of the thickness of the skin covering the cervix has abnormal cells. CIN 3 means the
full thickness of the skin covering the cervix has abnormal cells. Both the level of cell abnormality
(mild, moderate or severe and the CIN level will be taken into account when deciding whether you
need treatment.

All these results mean that cells have been found on your test that were pre cancerous. This  

  

. It means that some of the cells were slightly abnormal and
that if they were left untreated, they could go on to develop into cervical cancer.

  
- we are talking about the test as screening for cervical cancer here. Screening means
testing healthy women. If you have symptoms of cervical cancer, you may be given a liquid based
cytology test as part of the tests used to investigate your symptoms. This is a very different situation
to having the test as a routine screening test.

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c"*)
If you have mild cell changes or CIN 1 your doctor will either suggest a colposcopy straight away or
ask you to come back for another liquid based cytology test in 6 months time. Sometimes these
slightly abnormal cells can go back to normal by themselves. But you should definitely go for your
repeat test. You can't assume that the cells will go back to normal. If your next test is abnormal, you
will then definitely have a colposcopy to check it out further. You may need some treatment.

If the next test is normal, you will still need a further smear in 6 months. The NHS guidelines say that
you should have three normal 6 monthly tests, one after the other, before it is safe for you to go back
to regular screening.

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c"*#
$
If you have moderate or severe cell changes, or CIN 2 or 3, you will need treatment to get rid of the
abnormal cells. There is more about treatment for an abnormal smear in this section of CancerHelp
UK. You usually only need treatment once. Then you have follow up tests. If you do have an
abnormal test and have successful treatment you are very unlikely to get cervical cancer (provided
you continue being screened. If you do not have treatment, you are very much at risk from cervical
cancer.

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c
 
'c"(
CIN 3 is sometimes called 'carcinoma in situ'. This sounds like cancer, but it isn't. It means that some
of the cells look cancerous. But they are all contained within the skin covering the cervix. It will not
be a true cancer until the cells break through the top layer of skin covering the cervix and spread into
the tissue underneath. You must have treatment as soon as possible if you have carcinoma in situ.
As long as the affected area is removed, cancer can be prevented.

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9 out of 10 test results are normal. About 1 in 20 shows borderline or mild cell changes. In most of
these women, the cells will go back to normal by themselves. So the women will usually have repeat
tests every 6 months until they do. They will only go on to have treatment if the cells don't go back to
normal.

1 in 100 tests shows moderate cell changes. 1 in 200 shows severe changes. These women will go
on to have colposcopy to investigate further.

Less than 1 in 1,000 tests shows an invasive cancer. If you have an invasive cancer your doctor or
nurse will refer you to a specialist very quickly.

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You may have heard various news reports in the past about women being recalled for cervical
screening tests because the system went wrong. And even about some women dying from cervical
cancer because their tests were not checked properly and so they missed out on the treatment they
needed. But this is very, very rare. As a result of these few mistakes, the screening system has been
tightened up even further.

Now all the samples are examined in the laboratory by trained technicians looking down
microscopes. Because people can make mistakes, two different people now check all smear tests.
The abnormal cells that were missed in the past were all in health authorities who didn't make sure
two people checked their samples. And in some cases because technicians were not trained or
supervised properly. So you can feel reassured that if there are abnormal cells in your screening test
they are highly likely to be found and treated so that they cannot develop into a cancer.

Lastly, always make sure you get your result. If you do not get the result, there is always the tiny
chance that the test was reported as abnormal but that this result was not sent back to you or your
GP.
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M

  

#.

/% 

c






Early cervical cancer means cancer that is Stage 1A or 1B,

or Stage 2A.

j
 



 





For some very early cervical cancers, it may be possible to

treat the cancer with a cone biopsy or an operation to
remove just the cervix. This operation is called a radical
trachelectomy. This type of treatment is not possible for
everyone. If it is very important for you to be able to have
children, your specialist will do it if they can. But your doctor
cannot guarantee that you will be able to have children
afterwards.

j

 
 



Early cervical cancer can usually be cured with surgery or

radiotherapy or both. Surgery usually means that you have
your womb and cervix completely removed (hysterectomy.
Radiotherapy involves having treatment to the womb, cervix
and surrounding tissues. Sometimes specialists recommend
radiotherapy after surgery to lower the risk of the cancer
coming back. For stage 1B or stage 2A cervical cancer, your
specialist may suggest combined chemotherapy and
radiotherapy.

Ú 
 
 



If you have to choose between hysterectomy and

radiotherapy, it can be hard to decide which to have. There
are benefits and drawbacks to both. There is more
information about these treatments on CancerHelp UK,
understanding more about the different treatments will help
you make the choice.

c







Advanced cervical cancer means stage 2B or above. It is

sometimes possible to cure advanced cervical cancer even
if it has come back after treatment (recurrent cervical
cancer. Whether your cancer can be cured will depend on
how much cancer there is, and where it has spread to.
Unfortunately, it is not usually possible to cure cervical
cancer that is stage 4B. That is cervical cancer that has
spread to another body organ such as the lungs or liver.
   
 


#


Advanced cervical cancer can be treated with surgery or

radiotherapy, or chemotherapy. You may have a
combination of treatments. Your specialist will discuss which
treatment is best for your individual situation. If you have
already had radiotherapy for cervical cancer, you may not
be able to have any more.


The original cervical cancer screening programmes across the UK screened women from 20 to 64.
The screening programme in England now starts at 25 because cervical cancer is very rare before
this age. But changes in the cervix are quite common in younger women. So screening younger
women can lead to unnecessary treatment and worry.

There is still more evidence coming in about the exact age groups we should screen. In Wales,
Scotland and Ireland, they are still screening from age 20 until more evidence comes in, including
from their own screening programmes. Another complication is that liquid based cytology has been
introduced over the last few years. If you make more than one major change at a time to any health
programme, you won't necessarily know which change is responsible for improvements in your
service. In Wales, for example, they decided to stick with the original screening age, and introduce
LBC fully before making any more changes.

Just make sure you begin having regular smears as soon as you are 25 if you are sexually active. If
you are under 25 and are at all concerned, talk to your GP or go to a well woman clinic.

In England, Wales and Northern Ireland, the screening programme stops at 64. This is because
women who have had 

 


are very unlikely to go on to develop
cervical cancer after this age. The NHS guidelines say that if your last 3 cervical screening tests
were normal when you are 64, there is no need to have any more. But many older women have not
had enough tests. One of the reasons the UK cervical screening programme has not cut the number
of cases of cervical cancer as quickly as it was hoped is because there are so many older women
who have never had tests.
So, if you are over 64 and your last 3 tests were normal, you will not be asked to come and have any
more. If you are over 64 and have had abnormal tests, you will continue to be invited for regular
tests in the normal way. In Scotland, the screening programme stops at 60.

"   
 
 


      

  

 unless you have never been sexually active. Ask at your GP surgery or well woman clinic.

  
- if you are over 64 and have not had 3 normal tests in a row, you should carry on
having regular tests until you do. Make sure you ask at your GP or well woman clinic if you think you
should continue to have regular screening tests.

The widespread introduction of the Papanicolaou test, or  for cervical cancer screening has
been credited with dramatically reducing the incidence and mortality of cervical cancer in developed
countries.[6] Pap smear screening every 3±5 years with appropriate follow-up can reduce cervical cancer
incidence by up to 80%.[46] Abnormal Pap smear results may suggest the presence of cervical
intraepithelial neoplasia (potentially premalignant changes in the cervix before a cancer has developed,
allowing examination and possible preventive treatment. If premalignant disease or cervical cancer is
detected early, it can be monitored or treated relatively noninvasively, with little impairment of fertility.

Cervical cancer screening is typically recommended starting three years or more after first sex, or starting
[47][48][
   

]
at age 21 to 25. Recommendations for how often a Pap smear should be done vary from
once a year to once every five years, in the absence of abnormal results.[46] Guidelines vary on how long
to continue screening, but well screened women who have not had abnormal smears can stop screening
about age 60 to 70.[47][48][49]

To take a Pap smear, the vagina is held open with a speculum, the loose surface cells on the cervix are
scraped using a specially shaped spatula and a brush, and the cells are spread on a microscope slide. At
a laboratory the slide is stained, examined for abnormal cells and findings are reported.

Until recently the Pap smear has remained the principal technology for preventing cervical cancer.
However, following a rapid review of the published literature, originally commissioned by NICE,[50] liquid
based cytology has been incorporated within the UK national screening programme. Although it was
probably intended to improve on the accuracy of the Pap test, its main advantage has been to reduce the
[51]
number of inadequate smears from around 9% to around 1%. This reduces the need to recall women
for a further smear.

Automated technologies have been developed with the aim of improving on the interpretation of smears,
normally carried out by cytotechnologists. Unfortunately these on the whole have proven less useful;
although the more recent reviews suggest that generally they may be no worse than human
[52]
interpretation.
The HPV test is a newer technique for cervical cancer triage which detects the presence of human
papillomavirus infection in the cervix. It is more sensitive than the pap smear (less likely to produce false
negative results, but less specific (more likely to produce false positive results and its role in routine
screening is still evolving. Since more than 99% of invasive cervical cancers worldwide contain HPV,
[15]
some researchers recommend that HPV testing be done together with routine cervical screening. But,
given the prevalence of HPV (around 80% infection history among the sexually active population others
suggest that routine HPV testing would cause undue alarm to carriers, more unnecessary follow-up
testing and treatment. HPV testing along with cytology significantly increases the cost of screening.

Various experimental techniques, such as visual inspection using acetic acid, sometimes with special
lights (speculoscopy, or taking pictures for expert evaluation (cervicography have been evaluated as
adjuncts to or replacements for Pap smear screening, especially in countries where Pap smear screening
is prohibatively expensive. There are efforts to develop low cost HPV tests which might be used for
primary screening of older women in less developed countries.

[edit]Treatment









If you have surgery for early cervical cancer you will usually
need to have surgery to remove your womb (hysterectomy.
For some very early cervical cancers, it is possible to have a
radical trachelectomy.

& 

 

In this operation, your surgeon will try to remove all of the

cancer, but leave the internal opening of the cervix. This is
then stitched closed, leaving a small opening to allow the
flow of your period to escape. The idea is that the stitch will
support a pregnancy until the baby can be born by
caesarean section. This operation can only be done if you
have a small stage 1 cervical cancer.

Before the operation, your surgeon will not be able to

promise you that trachelectomy is possible. If they find that
the cancer has spread further, you may need to have a
hysterectomy after all. Your surgeon may also need to
remove some lymph nodes from around your womb. This is
usually done with a laparoscope (so it is sometimes called
keyhole surgery.



 

Hysterectomy means removal of your womb. It is quite a big

operation. You will be in hospital for about a week and
recovering at home for at least another month. Sometimes a
hysterectomy can be done using keyhole surgery. You
recover more quickly after keyhole surgery, and only stay in
hospital for 2-3 days.

# 





Radiotherapy uses high energy waves to treat cancer. For

cervical cancer most women have chemotherapy alongside
their radiotherapy treatment.
  
 
 



You can have radiotherapy for cervical cancer externally or

internally. External treatment means the beams are directed
at your body from a machine. Internal radiotherapy means a
radioactive source is put into your vagina and up into the
womb. This gives an extra boost of treatment to the cancer
itself and the area close by. Usually you have both these
treatments for early cervical cancer.

You have external radiotherapy in the hospital radiotherapy

department, usually once a day, five days a week. Your first
visit will be to plan your treatment. Marks are made on your
skin to help the radiographer line the machine up for your
treatment each day. External radiotherapy for early cervical
cancer usually lasts for three or five weeks. It takes just a
few minutes, and does not hurt. It does not make you
radioactive.

Internal radiotherapy takes one to five days, depending on

the type of treatment. You may stay in hospital or have it as
an outpatient. You usually have internal radiotherapy within
1 or 2 weeks of finishing external radiotherapy.
c






 

Radiotherapy to the pelvic area usually causes a few side

effects. These can be diarrhoea, irritable bladder (or
radiation cystitis, feeling sick, bleeding from the vagina after
internal radiotherapy, and soreness and redness of your
vulva or back passage.

Tell your doctor or nurse if you are having side effects.

Medication is available to help control diarrhoea. With
cystitis, drinking plenty will help. If you do feel sick, you can
have anti sickness medicine before each treatment.

!




 

If you have not already had the menopause, the

radiotherapy usually stops the production of sex hormones
by the ovaries. Your periods will gradually stop and you will
get the symptoms of the menopause. You can take
hormone replacement therapy (HRT after treatment for
cervical cancer.

Radiotherapy also makes your vagina become less stretchy

and narrower. To try to prevent or minimise this, it is
important to start using vaginal dilators after your treatment.
Dilators are cone shaped objects, made of plastic or metal.
They come in different sizes. You put the dilator into your
vagina gently for 5 to 10 minutes about 3 times a week. This
will stretch the vagina and help to stop it from narrowing.

Some women have long term bowel or bladder side effects

after radiotherapy. And sometimes one or both legs may
swell. This is called lymphoedema.

c






Chemotherapy uses anti cancer or 'cytotoxic' drugs to

destroy cancer cells. You may have it as part of your
treatment when you are first diagnosed, or for cancer that
has come back. Chemotherapy can shrink advanced
cervical cancer and may help to relieve symptoms. Giving
chemotherapy at the same time as radiotherapy is now
thought to be the best choice of treatment for certain stages
of cervical cancer. This is called chemoradiation.

  




Most chemotherapy drugs are injections, although some are

available as tablets. Generally, a course of chemotherapy
takes a few days every 3 or 4 weeks. You have 3 or 4
weeks rest after each treatment, then another few days of
chemotherapy injections. This is usually repeated six or
more times. If you are having chemoradiation, you usually
have treatment once a week for 5 or 6 weeks while you are
having your course of radiotherapy.

c




 

Chemotherapy does have side effects. Which ones you get

depends on which drug and dose you have, and your
individual reaction. The most common side effects are
feeling sick, diarrhoea, hair loss or thinning, sore mouth or
mouth ulcers, and feeling tired. You may also have a drop in
the number of blood cells. Some side effects may be more
severe if you have chemotherapy at the same time as
radiotherapy.

Microinvasive cancer (stage IA is usually treated by hysterectomy (removal of the whole uterus including
part of the vagina. For stage IA2, the lymph nodes are removed as well. An alternative for patients who
desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP
[53]
or cone biopsy.

If a cone biopsy does not produce clear margins,[54] one more possible treatment option for patients who
want to preserve their fertility is a trachelectomy.[55] This attempts to surgically remove the cancer while
preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. It is
a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered
a standard of care,[56] as few doctors are skilled in this procedure. Even the most experienced surgeon
cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as
the extent of the spread of cancer is unknown. If the surgeon is not able to microscopically confirm clear
margins of cervical tissue once the patient is under general anesthesia in the operating room, a
hysterectomy may still be needed. This can only be done during the same operation if the patient has
given prior consent. Due to the possible risk of cancer spread to the lymph nodes in stage 1b cancers and
some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the uterus
for pathologic evaluation.
[57] [58]
A radical trachelectomy can be performed abdominally or vaginally and there are conflicting opinions
[59]
as to which is better. A radical abdominal trachelectomy with lymphadenectomy usually only requires a
two to three day hospital stay, and most women recover very quickly (approximately six weeks.
Complications are uncommon, although women who are able to conceive after surgery are susceptible to
[60]
preterm labor and possible late miscarriage. It is generally recommended to wait at least one year
[61]
before attempting to become pregnant after surgery. Recurrence in the residual cervix is very rare if the
[56]
cancer has been cleared with the trachelectomy. Yet, it is recommended for patients to practice vigilant
prevention and follow up care including pap screenings/colposcopy, with biopsies of the remaining lower
uterine segment as needed (every 3±4 months for at least 5 years to monitor for any recurrence in
addition to minimizing any new exposures to HPV through safe sex practices until one is actively trying to
conceive.

Early stages (IB1 and IIA less than 4 cm can be treated with radical hysterectomy with removal of the
lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis
and brachytherapy (internal radiation. Patients treated with surgery who have high risk features found on
pathologic examination are given radiation therapy with or without chemotherapy in order to reduce the
risk of relapse.

Larger early stage tumors (IB2 and IIA more than 4 cm may be treated with radiation therapy
and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvantradiation therapy,
or cisplatin chemotherapy followed by hysterectomy.

Advanced stage tumors (IIB-IVA are treated with radiation therapy and cisplatin-based chemotherapy.

On June 15, 2006, the US Food and Drug Administration approved the use of a combination of two
chemotherapy drugs, hycamtin and cisplatin for women with late-stage (IVB cervical cancer
[62]
treatment. Combination treatment has significant risk of neutropenia, anemia,
and thrombocytopenia side effects. Hycamtin is manufactured by GlaxoSmithKline.

c


   
 "

Outlook means your chances of getting better. Your doctor

may call this your prognosis. With cervical cancer, the likely
outcome depends on how advanced the cancer is when it is
diagnosed (the stage.

We have included quite detailed information about the likely

outcome of different stages of cervical cancer. The statistics
we use are taken from a variety of sources, including the
opinions and experience of the experts who check every
section of CancerHelp UK. They are intended as a general
guide only. For the more complete picture in your case,
you¶d have to speak to your own specialist.

We include statistics because people ask for them, but not

everyone wishes to read this type of information.

 
#




    

No statistics can tell you what will happen to you. Your

cancer is unique. The same type of cancer can grow at
different rates in different people. The statistics cannot tell
you about the different treatments people may have had, or
how that treatment may have affected their prognosis. There
are many individual factors that will affect your treatment
and your outlook.
dit]Prognosis

Prognosis depends on the stage of the cancer. With treatment, the 5-year relative survival rate for the
earliest stage of invasive cervical cancer is 92%, and the overall (all stages combined 5-year survival
rate is about 72%. These statistics may be improved when applied to women newly diagnosed, bearing in
mind that these outcomes may be partly based on the state of treatment five years ago when the women
[63]
studied were first diagnosed.

With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are
alive 5 years after diagnosis. Only 25 to 35% of women with stage III cancer and 15% or fewer of those
[64]
with stage IV cancer are alive after 5 years.

According to the International Federation of Gynecology and Obstetrics, survival improves when
[65]
radiotherapy is combined with cisplatin-based chemotherapy.

As the cancer metastasizes to other parts of the body, prognosis drops dramatically because treatment of
local lesions is generally more effective than whole body treatments such as chemotherapy.

Interval evaluation of the patient after therapy is imperative. Recurrent cervical cancer detected at its
earliest stages might be successfully treated with surgery, radiation, chemotherapy, or a combination of
the three. Thirty-five percent of patients with invasive cervical cancer have persistent or recurrent disease
after treatment.[66]

Average years of potential life lost from cervical cancer are 25.3 (SEER Cancer Statistics Review 1975-
2000, National Cancer Institute (NCI. Approximately 4,600 women were projected to die in 2001 in the
US of cervical cancer (DSTD, and the annual incidence was 13,000 in 2002 in the US, as calculated by
SEER. Thus the ratio of deaths to incidence is approximately 35.4%.

Regular screening has meant that pre cancerous changes and early stage cervical cancers have been
detected and treated early. Figures suggest that cervical screening is saving 5,000 lives each year in the
UK by preventing cervical cancer.[67] About 1,000 women per year die of cervical cancer in the UK.

[edit]Epidemiology

Age-standardized death from cervical cancer per 100,000 inhabitants in 2004.[68]

no data
less than 2.4

2.4-4.8
4.8-7.2
7.2-9.6
9.6-12
 12-14.4

14.4-16.8
16.8-19.2
19.2-21.6

21.6-24
24-26.4
more than 26.4

Worldwide, cervical cancer is twelfth most common[69] and the fifth most deadly cancer in women.[70] It
affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year.[71] Approximately
80% of cervical cancers occur in developing countries[72] Worldwide, in 2008, it was estimated that there
were 473,000 cases of cervical cancer, and 253,500 deaths per year.[73]

In the United States, it is only the 8th most common cancer of women. In 1998, about 12,800 women
were diagnosed in the US and about 4,800 died.[6] In 2008 in the US an estimated 11,000 new cases
were expected to be diagnosed, and about 3,870 were expected to die of cervical cancer.[63] Among
gynecological cancers it ranks behind endometrial cancer and ovarian cancer. The incidence and
mortality in the US are about half those for the rest of the world, which is due in part to the success of
screening with the Pap smear.[6] The incidence of new cases of cervical cancer in the United States was 7
per 100,000 women in 2004.[74] Cervical cancer deaths decreased by approximately 74% in the last 50
years, largely due to widespread Pap smear screening.[69] The annual direct medical cost of cervical
cancer prevention and treatment is prior to introduction of the HPV vaccine was estimated at $6 billion.[69]

In the European Union, there were about 34,000 new cases per year and over 16,000 deaths due to
cervical cancer in 2004.[46]

In the United Kingdom, the age-standardised (European incidence is 8.5/100,000 per year (2006. It is
the twelfth most common cancer in women, accounting for 2% of all female cancers, and is the second
most common cancer in the under 35s females, after breast cancer. The UK's European age-
standardised mortality is 2.4/100,000 per year (2007 (Cancer Research UK Cervical cancer statistics for
the UK.[75] With a 42% reduction from 1988-1997 the NHS implemented screening programme has been
highly successful, screening the highest risk age group (25±49 years every 3 years, and those ages 50±
64 every 5 years.

In Canada, an estimated 1,300 women will be diagnosed with cervical cancer in 2008 and 380 will die.[76]

In Australia, there were 734 cases of cervical cancer (2005. The number of women diagnosed with
cervical cancer has dropped on average by 4.5% each year since organised screening began in 1991
(1991±2005.[77] Regular two-yearly Pap tests can reduce the incidence of cervical cancer by up to 90% in
Australia, and save 1,200 Australian women dying from the disease each year.[78]
[edit]History

A 400 BCE - Hippocrates3 cervical cancer incurable

A 1925 - Hinselmann3 invented colposcope
A 1928 - Papanicolaou3 developed Papanicolaou technique
A 1941 - Papanicolaou and Trout3 Pap smear screening
A 1946 - Ayer3 Aylesbury spatula to scrape the cervix, collecting sample for Pap smear
A 1976 - Zur Hausen and Gisam3 found HPV DNA in cervical cancer and warts
A 1988 - Bethesda System for reporting Pap results developed
A 2006 - First HPV vaccine FDA approved

Epidemiologists working in the early 20th century noted that cervical cancer behaved like a sexually
transmitted disease. In summary3

1. Cervical cancer was common in female sex workers.

2. It was rare in nuns, except for those who had been sexually active before entering the convent.
(Rigoni in 1841
3. It was more common in the second wives of men whose first wives had died from cervical cancer.
4. It was rare in Jewish women.[79]
5. In 1935, Syverton and Berry discovered a relationship between RPV (Rabbit Papillomavirus and
skin cancer in rabbits. (HPV is species-specific and therefore cannot be transmitted to rabbits

This led to the suspicion that cervical cancer could be caused by a sexually transmitted agent. Initial
research in the 1940s and 1950s put the blame on smegma (e.g. Heins  p1958.[80] During the 1960s
and 1970s it was suspected that infection with herpes simplex virus was the cause of the disease. In
summary, HSV was seen as a likely cause[81] because it is known to survive in the female reproductive
tract, to be transmitted sexually in a way compatible with known risk factors, such as promiscuity and low
socioeconomic status. Herpes viruses were also implicated in other malignant diseases,
including Burkitt's lymphoma, Nasopharyngeal carcinoma, Marek's disease and the Lucké renal
adenocarcinoma. HSV was recovered from cervical tumour cells.

A description of human papillomavirus (HPV by electron microscopy was given in 1949, and HPV-DNA
was identified in 1963.[
   

]
It was not until the 1980s that HPV was identified in cervical cancer
[82]
tissue. It has since been demonstrated that HPV is implicated in virtually all cervical cancers.[4] Specific
viral subtypes implicated are HPV 16, 18, 31, 45 and others.

In work that was initiated in the mid 1980s, the HPV vaccine was developed, in parallel, by researchers
at Georgetown University Medical Center, the University of Rochester, theUniversity of Queensland in
 [83]
Australia, and the U.S. National Cancer Institute. In 2006, the U.S. Food and Drug
Administration (FDA approved the first preventive HPV vaccine, marketed by Merck & Co. under the
trade name Gardasil.

[edit]Society and culture

According to a survey, only 40% of American women had heard of human papillomavirus (HPV infection
and only 20% had heard of its link to cervical cancer.[84
?