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CANCER OF THE CERVIX
What is cancer of the cervix?
Cancer of the cervix, a common kind of cancer in women, is a disease in which cancer (malignant) cells are found in the tissues of the cervix. The cervix is the opening of the uterus (womb). The uterus is the hollow, pear-shaped organ where a baby develops. The cervix connects the uterus to the vagina (birth canal).
Cancer of the cervix usually grows slowly. Before cancer cells are found on the cervix, the tissues of the cervix go through changes in which cells that are not normal begin to appear. These cells are known as dysplasia, "carcinoma-in-situ," "cervical intraepithelial neoplasia," or CIN.
Since there are usually no symptoms associated with cancer of the cervix until the later stages, it is important to have a Pap smear on a regular basis.
If cells that are not normal are found, your doctor will need to do colposcopy (look at the cervix through a magnification device) and take a sample of tissue (called a biopsy) from the cervix and look at it under a microscope to see if there are any cancer cells.
What causes cervical cancer?
It is thought that a virus called human papilloma virus (HPV) is associated with the development of abnormal cells on the cervix. It is estimated that more than 6 million women in the United States have HPV infection. Some patients with HPV infection appear to be at minimal increased risk for development of abnormal cervical cells or cervical cancer.
However, studies do suggest that the major risk factor for development of abnormal cervical cells, or invasive cancer of the cervix, is HPV infection. HPV infection far outweighs other known risk factors such as the number of children you have had, number of sexual partners, socioeconomic status, and smoking history. There are a number of types of the HPV virus. It has been shown that patients infected with types 16, 18, and 31 are more likely to have CIN, or micro-invasive cancer, on biopsy while patients with types 16 and 18 have an 11-fold risk of rapid development of high-grade dysplasia.
How fast does cancer of the cervix spread?
Cervical cancer develops slowly and in many patients (as many as 70%). Cervical dysplasia (precancer) may take 10 years to turn into an actual cancer. However, in about 10% of patients, lesions can progress from CIN to invasive cancers in under a year. There is no way to predict whose cancer will change quickly, so everyone is treated or watched closely. As the cancer progresses, it grows through the lining (skin) of the cervix into the underlying tissue and eventually outside of the cervix to neighboring structures, including muscle, bladder, and rectum.
Where else can cancer of the cervix spread?
In addition to local invasion, carcinoma of the cervix can spread to nearby lymph nodes or to distant parts of the body through the bloodstream. The spread of tumors to other areas is often a reflection of the extent of the disease in the cervix. That is, early cancers usually do not spread to other areas, while locally extensive cancers have a higher chance of being elsewhere in the body. While cancer of the cervix generally progresses in an orderly manner, occasionally a small tumor with distant metastasis is seen. For this reason, patients must be carefully evaluated for spread of the cancer elsewhere.
What are the types of cancers that affect the cervix?
A variety of different types of cancers can involve the cervix. Far and away the most common is "squamous cell carcinoma" which comprises 90% of all cancers seen. About 10% will be a type called "adenocarcinoma." Treatment is the same for both. More rare cancers include adenosqaumous, small cell, sarcoma, and lymphoma. Cancers from other organs rarely spread to the cervix, but it is possible. Only a biopsy of the cancer can tell what type of cancer it is.
What are the stages of cervical cancer?
The stage of your cervical cancer is very important because your prognosis (chance of recovery) and choice of treatment depend on the stage of your cancer (whether it is just in the cervix or has spread to other places) and your general state of health.
The stage of the cervical cancer is defined as the extent of the tumor at the time of your diagnosis. The usual initial staging studies may include the pelvic and rectal examination. Sometimes an examination under anesthesia, with or without deeper biopsies, is needed. Other studies may include a pelvic ultrasound, CAT scan or MRI scan, a telescopic examination of the bladder, a pathology report, and a chest X-ray. The stage of the cancer is the most important deciding factor in determining which treatment will be used.
The following stages are used for cancer of the cervix:
- Stage 0 or carcinoma in situ -- Stage 0 cervical cancer is very early cancer. The cancer is found only in the first layer of cells of the lining of the cervix.
- Stage I -- Cancer is found throughout the cervix, but has not spread nearby. Divided into:Stage IA: a very small amount of cancer is found deeper in the tissues of the cervixStage IB: a larger amount of cancer is in the tissues of the cervix
- Stage II -- Cancer has spread to nearby areas, but is still inside the pelvic area. Divided into:Stage IIA: cancer has spread beyond the cervix to the upper two-thirds of the vaginaStage IIB: cancer has spread to the tissue around the cervix
- Stage III -- Cancer has spread throughout the pelvic area. Cancer cells may have spread to the bones of the pelvis and/or gone into the lower part of the vagina. The cells also may have spread to block the tubes that connect the kidneys to the bladder (the ureters).
- Stage IV -- Cancer has spread to other parts of the body. Divided into:Stage IVA: cancer has spread to the bladder or rectum (organs close to the cervix)Stage IVB: cancer has spread to faraway organs such as the lungs
Recurrent -- Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the cervix or in another place.
Some doctors will use a newer or more descriptive staging system for cervical cancer. It is called the TNM classification.
TNM Definitions
Primary tumor (T)
Tis: Carcinoma in situ or pre-cancerous changes seen
- T1: The carcinoma is strictly confined to the cervix T1a: Microscopic invasion of cervix (very early) T1b: All other cases of T1
- T2: The carcinoma extends beyond the cervix but has not extended to the pelvic wall T2a: Minimal involvement outside of cervix T2b: Obvious involvement of area around cervix
- T3: The carcinoma has extended to the pelvic wall. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower third of the vagina. All cases with obstructed or nonfunctioning kidney are included, unless they are known to be due to another cause. T3a: No extension to pelvic wall T3b: Extension to pelvic wall or blocked or nonfunctioning kidney
- T4: The carcinoma has extended to distant areas or has clinically involved the mucosa of the bladder or rectum. T4a: Spread of the growth to adjacent organs
Nodal involvement (N)
- NX: Not possible to assess the regional nodesN0: No involvement of regional nodesN1: Evidence of regional node involvement
Distant metastasis (M)
- MX: Minimum requirements to assess the presence of distant metastasis cannot be metM0: No (known) distant metastasisM1: Distant metastasis present
What is the treatment for cervical cancer?
The treatment of cervical cancer is dependent on the stage of the cancer and the health of the patient. Three kinds of treatment are used:
- Surgery - taking out the cancer in an operation.
- Radiation therapy - using high-dose x-rays or other high-energy rays to kill cancer cells.
- Chemotherapy - using drugs to kill cancer cells.
Surgical Treatment for Cervical Dysplasion or Abnormal Cells on the Cervix
Your doctor may use one of several types of surgery for dysplasion of the cervix:
- Cryosurgery kills the cells by freezing them.
- Diathermy kills the cells by heat from electrical or magnetic currents.
- Laser surgery uses a narrow beam of intense light to destroy the abnormal cells.
If the cancer is confined to the superficial layers of the cervix, a standard hysterectomy is curative. For more deeply invasive cancers, radical hysterectomy is used. A radical hysterectomy is an operation in which the cervix, uterus, and part of the vagina are removed. Lymph nodes in the area may also be removed (this is called lymph node dissection). (Lymph nodes are small bean-shaped structures that are found throughout the body. They produce and store cells that fight infection.)
If the cancer has spread outside the cervix or the female organs, your doctor may take out the lower colon, rectum, or bladder (depending on where the cancer has spread), along with the cervix, uterus, and vagina. This is called an exenteration. You may need plastic surgery to make an artificial vagina after this operation.
Radiation therapy uses x-rays or other high-energy rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation). Radiation may be used alone or in addition to surgery.
Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells outside the cervix.
If the cancer has come back (recurred) in the pelvis, your treatment may be one of the following:
- Surgery to take out the lower colon, rectum, or bladder (depending on where the cancer has spread) along with the cervix, uterus, and vagina (exenteration).
- Radiation therapy and chemotherapy.
If the cancer has come back outside of the pelvis, the treatment is dependent on your specific situation.
What is the prognosis for a patient with cervical cancer?
The prognosis for this disease is markedly affected by the extent of disease at the time of diagnosis. Among the major factors that influence prognosis are stage, volume and grade of tumor, histologic type, lymphatic spread, and vascular invasion. In a large study of patients with clinical stage IB disease, the factors that predicted most prominently for lymph node metastases and disease-free survival were capillary-lymphatic space involvement by tumor, increasing tumor size, and increasing depth of stromal invasion, with the latter being most important and reproducible. Once your cancer has been staged and surgically removed (if that is the best treatment) your physician will be able to provide you with more information.
Thomas G. Stovall, M.D.
Dr. Stovall is a Clinical Professor of Obstetrics and Gynecology at the University of Tennessee Health Science Center in Memphis, Tennessee and Partner of Women's Health Specialists, Inc.
Date Published: 2004-03-04
7800 Wolf Trail Cove, Germantown, TN 38138
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