CERVICAL CANCER TREATMENT INFORMATION

What is the Cervix?

The cervix is the lowest portion of the uterus; it protrudes down into the vagina. The normal
cervix has an opening to allow sperm to flow into it and menstrual blood to flow out of it. While
this opening is normally very narrow, it opens to about 4 inches (10 cm.) across during labor to
allow for childbirth. There are strong cervical muscles around the cervix's bottom opening to
keep it closed. If the opening is too loose, the cervix is called "incompetent" and will cause
miscarriages. The cells that make up the cervix lining undergo a change at the opening of the
cervix, which is called the "os". The cells in the vaginal part of the cervix are called "squamous"
cells, they are resistant to abrasion and heal quickly after injury. In contrast, the cells deeper in
the cervix (and uterus) are called "columnar" cells which form glands. These glands produce
mucous. The area of change from the squamous to columnar cells is called the "squamo-
columnar junction" and is the area of the cervix where cancer most commonly arises. This is area
that is scraped for the annual "Pap" smear, to look for cancerous cells, and it can be seen by a
doctor performing a pelvic examination.
What is Cervical Cancer?

Normally the cervix has stopped growing by puberty, but it's cells will continue to divide to
replace those that die of injury or old age. While some division of cervical cells to replace old or
injured ones is normal, it is a tightly controlled process. Sometimes a abnormal cell may arise
which divides out of control. This will then form a tumor . A tumor is simply a swelling, and
does not necessarily mean cancer (obviously most swellings are not cancerous). If a tumor only
grows in it's local area, it is called "benign" and is not cancer. If, however, it has the capability to
spread to other areas of the body, then it is called "malignant" and is cancer. Cervical cancer
starts in just one single cell, but this cell quickly divides to form many similar cancer cells,
which each continue to grow. Eventually, if not cured, these cells push the normal cells out of the
way, grow a large tumor, and spread to other body areas to ultimately kill the patient. Cervical
cancer kills by anemia, infection, blockage of kidney drainage ("uremia") and general disability.

How Common is Cervical Cancer?

Each year in the U.S.A. 14,500 new patients get invasive cervical cancer and 8,000 women die
of it. "Pre-cancerous" changes in the cervix are much more common; they affect 59,000
American women per year and are shown by an abnormal "Pap smear". Some, but not all, of
these patients with "pre-cancerous" cervical changes will go on to develop frank cervical cancer.
The average age of patients is 50 years, but the disease has been seen in patients ranging in age
from 17 to 90 years. In general, cervical cancer has been on the increase in the United States, and
even more in developing countries. It currently ranks as the fifth most common cancer in
women, after lung, breast, colon and uterine cancer.

What Causes, or Increases the Risk, for Cervical Cancer?

Like any other cancer, the exact reason why one woman gets cervical cancer and another does
not is unknown . However, several things are noted to increase the risk:
1) Being Female is obviously the biggest risk factor for cervical cancer.
2) Lots of Male Sexual Partners and having children by different men, and starting to have sex at
a young age dramatically increases risk. In contrast, cervical cancer is extremely rare in women
who never were pregnant and nuns.
3) Uncircumcised Sexual Partners -- cervical cancer is very rare in the wives of circumcised
Jewish men.
4) Sexually Transmitted Viruses like the "Human Papilloma Virus" (HPV), especially types 16,
18, and 33. These are found in about 50% of patients.
5) Low Social and Financial Status may reflect more sexual promiscuity or inability to get proper
screening and treatment for the disease.
6) Immune Deficiency Diseases like AIDS. In fact, the development of cervical cancer in a HIV
positive patient is sufficient to reclassify them as full-blown AIDS. Furthermore, getting
immune-system suppressing drugs (to avoid rejecting a newly transplanted organ) also increases
the risk, especially in patients with HPV.
7) DES taken by the patient's mother, during pregnancy. DES is a hormone associated with
developing a rare type of cervical cancer called the "clear-cell" variety.
****Alcohol and Tobacco use are not linked to getting cervical cancer!

What about Screening for Cervical Cancer?

The Papaniculaou ("Pap") smear, done since 1940, is of proven value in the early detection of
cervical cancer. It is also useful after treatment to help monitor the success of therapy. A Pap
smear is done at the time of pelvic examination, it involves taking a brush and a small "spatula"
(Ayer's) to get some cells for the squamocolumnar junction of the cervix, and also any abnormal
areas. The scraping often causes slight bleeding. Too much blood in the specimen can distort the
Pap smear, so it is not advised during a menstrual period.

The American Cancer Society recommends a cancer "checkup" every three years for women
over age 20, or starting younger if she is sexually active. This includes a pelvic exam with a Pap
test every 3 years (after 2 initial "negative" tests one year apart). Those at higher risk should get
more frequent (i.e. annual) screening. The cells collected from the Pap test are examined by a
Pathologist (and often also checked by a computerized reading machine) to look for abnormal
changes. Since many of these tests are read at once, the interpretation tricky, and the results of a
wrong answer catastrophic, much publicity has surrounded misread tests. This has led
pathologists to be very cautious in reading Paps, and they are likely to reject an imperfect smear
(such as those mixed with blood) and request a re-scrape. Results take days to weeks to get.

The results are placed into one of 5 categories, called"classes":

Class I means "negative" (no suspicious cells)
Class II means mild and minimal changes (benign)
Class III means mild to moderate changes (suspicious)
Class IV means marked abnormal cells changes (very suspicious)
Class V means cancer cell are seen.
If a test is suspicious for cancer, it should be repeated every 3 to 6 months to 2 years. A Pap test
is not completely accurate in detecting cervical cancer, the "false - negative" rate (failure to pick
up an existing cancer) averages 30%. However, it remains a power-ful tool to detect cancer.
Unfortunately, only 15% of women get the proper screening. While a Pap test can help detect
cancer, no therapy is based upon a Pap test alone.

What are the Symptoms of Cervical Cancer?

Early cervical cancer commonly has no symptoms, which is why screening is necessary to detect
it. The most common actual symptoms are:
1) Bleeding into the vagina; the surface of the cervix is very soft and tumors bleed easily. In fact,
if a woman has new vaginal bleeding after menopause, the total chance of gynecologic cancer is
about 30%, with 15% having cervical cancer. In pre-menstrual women, a chance is often seen in
bleeding during periods, being more bleeding, spotting between periods, or after sexual
intercourse.
2) Vaginal Discharge, often of a yellow or green color and foul smelling. This alone is more
likely an infection, but must be investigated.
3) Cervical Pain, noted when a tampon, finger or penis is inserted into the vagina. On physical
exam, this "cervical motion tenderness" is suspicious for infection or cancer. With more
advanced disease, there can be general pelvic pains.
4) Urinary Symptoms are seen with advancing disease, as the tumor invades into the vagina, and
eventually can close off the kidney's urinary drainage. This is called "uremia" and is the most
common cause of death from cervical cancer.
5) Signs of Spread to other areas of the body include lymph gland enlargement in the groin or
collarbone area (Virchow's node) or left armpit (Irishe's node). Advanced spread may give bone,
liver, lung, bowel and brain abnormalities.

How Is Cervical Cancer Detected and Evaluated?

When screening or symptoms suspicious for cervical cancer occur, the doctor must confirm the
diagnosis. The only certain way to do this is to get a piece of the tumor (that is a "biopsy" ) and
submit it to a pathologist for analysis. A pathologist is a physician who specializes in diagnosing
disease from tissue specimens. All patients will have a Pap test, and then further workup if
suspicion remains. These tests may be done:
1) Colposcopy means examining the cervix with a special lens that magnifies the surface 40
times. The outer cervix can be painted with an iodine solution which highlights abnormal areas.
Biopsies are taken of these abnormal areas. Colposcopy can only see surface cells, not ones
inside the cervical canal.
2) Cone Biopsy means cutting out a thin "cone" of the cervical canal for evaluation. This
procedure is done with a "cold" (instead of hot) knife since heat can distort the findings. If a very
thin cancer is found, this procedure can be both diagnostic and curative, since the cancer is being
cut out. This is also called "conization."
3) Exam Under Anesthesia is done for any larger cervical cancer, to ascertain how large it is and
if it has spread. General anesthesia relaxes the pelvic muscles so the doctor can feel deep
structures. A proctoscope is inserted up the rectum and a cystoscope up the urethra to look for
spread to these areas.
4) Hysterectomy ( surgical removal of the uterus and cervix) is both diagnostic and therapeutic
for tumors that are too large to completely remove with a "conization." Sometimes a
hysterectomy may be done for a smaller cancer if the woman has no further desire for child-
bearing. Also, if the woman has symtpoms from scar tissue or benign growths in the uterus
("endometriosis") hysterectomy may be appropriate. The various types of hysterectomy are
discussed under "treatment".
5) Routine Blood Tests prior to any surgery include Complete Blood Count (CBC) to look for
anemia and infection, and Chemistry Panel (SMA) which checks blood serum minerals, liver and
kidney function. Blood tests for clotting are done (PT/PTT).
6) Radiologic Tests include regular Chest X-rays, and often a CT scan of the pelvis and
abdomen. CT scan helps tell how large a mass is, and what structures it has invaded into. It can
tell if lymph glands are enlarged (> 1 cm.) which suggests the cancer has spread to them. It can
help tell (but not conclusively) how deeply the cancer penetrates into the cervical and uterine
muscle. CT scan of the abdomen detects metastasis >1cm. to liver, lung, lymph glands, etc. CT
scan is standard for any "larger" tumor of the cervix. Magnetic Resonance Imaging (MRI) is an
optional test which does not use radiation, it is the best scan to tell how far the cancer has spread
into the soft-tissues of the pelvis. Other elaborate tests like bone scan or liver-spleen scan are
only used for symptoms in these areas.

What are the Types of Cervical Cancer?

There are several types of cervical cancer, and the treatment may differ by type:
1) Squamous Cell Carcinoma is the most common type, accounting for about 85% of cervical
cancer. It arises on the more "outer" portion of the cervix which protrudes into the vagina. It is
truly the "classic variety" cervical cancer.
2) Adenocarcinoma accounts for about 10% of cases and is increasing. It starts on the more
"inner" portion of the cervix, from the same type of cells lining the uterus. "Clear cell" cancer is
a subtype of adenocarcinoma.
3) Mixed types account for 4% and include "adenosquamous" (with elements of both
adenocarcinoma and squamous cell carcinoma) and "Glassy cell" cancer.
4) Rare Types (less than 1%) include the "neuroendocrine" cancers (Carcinoid and Small cell )
which are similar to the same named cancers of the lung and digestive tract, lymphomas (arising
from immune cells) and sarcomas (arising from the fat, cartilage or muscle cells). Cancer may
spread to the cervix from other areas.

Cervical cancer is one of the most common types or cancer in young women and comes in many
varieties. Fortunately, recent research has helped improve survival and give more hope than ever
before for those stricken with cervical cancer.

It is crucial to be educated about the disease, so you can make the proper treatment choices to
increase the likelihood of a happy outcome. Selecting the right treatment can literally make the
difference between life and death. It is important to have the peace-of-mind of knowing that you
have done everything possible to fight a cervical cancer problem successfully.