The cervix is the lower, narrow part of the uterus (womb). The uterus, a hollow, pear shaped organ is located in a women’s lower abdomen, between the bladder and the rectum. The cervix forms a canal that opens into the vagina, which leads to the outside of the body.

Scientists believe that some abnormal changes in cells on the cervix are the first steps in a series of slow changes that can lead to cancer years later. Cancers of the cervix are named for the type of cell in which they begin. Most cervical cancers are squamous cell carcinomas. Squamous cells are thin flat cells that form the surface of the cervix.

Over the years doctors have used different terms to refer to the abnormal changes in the cells in the cervix. One term is squamous intraepithelial lesion (SIL). The word lesion refers to an area of abnormal tissue; intraepithelial means the abnormal cells are present only in the surface layer of cells.

Changes in the cells are divided into two categories:

Low-grade SIL refers to the early changes in the size and shape and number of cells that form on the surface of the cervix. Pre- cancerous lesions also may be called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). Some lesions go away on their own; others may get larger and become high-grade lesions. This is most often seen in women ages 25 and 35, but can appear in other age groups.

High-grade SIL means that there are a large number of pre- cancerous cells. Like low-grade SIL, these pre-cancerous changes involve only cells on the surface of the cervix. These cells will not become cancerous and invade deeper tissues of the cervix for many months, perhaps years. High-grade lesions also may become moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ. They develop most often in women 30 and 40 years of age.

If abnormal cells spread deeper into the cervix, or to another organ, the disease is then called cervical cancer or invasive cervical cancer. This occurs most often in women over the age of 40.1

About 12,900 cases of cervical cancer will be diagnosed this year. Most of these will be caught early and cured, although about one third if these cases will result in the patient’s death. In certain groups of women, including women past child-bearing years, who do not regularly see a gynecologist, cervical cancer is more commonly found in advanced stages when cure is less likely.

WHO IS AT RISK?

Cervical cancer can affect any women who are or have been sexually active. Risk of cervical cancer is higher in women who have had multiple sexual partners or in women whose partners have had multiple partners. Older women and women without access to regular medical care are especially vulnerable if they do not have regular pap tests and gynecological exams. Women who have genital warts, women who smoke and those infected with the human immunodeficiency virus (HIV) are also at increased risk.

SYMPTOMS

Symptoms so not usually appear until abnormal cervical cells become cancerous and invade nearly tissue. When this happens, the most common symptom is abnormal bleeding. Bleeding may
start and stop between regular menstrual periods, or it may occur after sexual intercourse, douching, or a pelvic exam. Menstrual bleeding may last longer and be heavier than normal. Bleeding after menopause also may be a symptom of cervical cancer. Increases vaginal discharge is another sign of cervical cancer.

DIAGNOSTIC PROCEDURES

The implementation of the Pap Smear provided early detection of cervical cancer, making it a relatively rare form of cancer in the United States. It also detects cervical cancer in early stages before it spreads to other parts of the body, when it is highly curable.3 Death rates have declined 40% since the early 1970’s.

The American Cancer Society recommends that all women who have reached the age of 18 or who have been sexually active, have a Pap test and pelvic exam every year. After three or more normal exams, the Pap test can be performed less frequently at the doctor’s discretion. (American Cancer Society, Cancer Facts for Women) These tests are performed in a doctor’s office or a clinic.

In a pelvic exam, the doctor checks the uterus, vagina, ovaries, fallopian tubes, bladder and rectum. The doctor feels the organs for any abnormality in their shape or size. A Speculum is used to widen the vagina so that the doctor can see the upper part of the vagina and the cervix.

The Pap test is a simple, painless test to detect abnormal cells in and around the cervix. A woman should have this test when she is
not menstruating; the best time is between 10 and 20 days after the
first day of her menstrual period. A wooden scraper (spatula) and/ or a small brush is used to collect a sample of cells from the cervix
and upper vagina. The cells are place son a glass slide and sent to a medical laboratory to be checked for abnormal changes.

One way of describing Pap results uses the new method known as the Bethesda System Changes. This describes low-grade or high- grade SIL. This method provides more useful information than older systems, which use numbers ranging from 1 (normal) to 5 (invasive cancer). Women should ask their doctor to explain the system they use for their Pap test.

If the pelvic exam and Papa test indicate that an infection id present, the doctor will treat the infection and repeat the Pap test at a later time. If the test results suggest something more than an infection, the doctor may repeat the Pap test and do other tests to find out what the problem is.

Other tests include:

Colposcopy – The doctor applies a vinegar-like solution to the cervix and then uses an instrument much like a microscope (called a colposcope) to look closely at the cervix. The doctor may then coat the cervix with an iodone solution (a procedure called Schiller Test). Healthy cells turn brown; abnormal cells turn white or yellow.

The doctor may remove a small amount of cervical tissue for examination by a pathologist, in a procedure called a biopsy. There are two types commonly used. In the first, the doctor uses an instrument to pinch off small pieces of cervical tissue. The other method is called a loop electro surgical excision procedure (LEEP). In this procedure the doctor uses an electric wire loop to slice off a thin, round piece if tissue.

Local anesthesia is used in both of these procedures.

The doctor may want to check inside the opening of the cervix. In a procedure called endocervical curettage (ECC), the doctor uses a curettage (a small, spoon-shaped instrument) to scrape tissue from inside the cervical opening.

A conization, or cone biopsy, is a procedure done by the doctor to remove a larger, cone shaped sample of tissue. The pathologist can see whether the abnormal cells have invaded tissue beneath the surface of the cervix. This may be done in the doctor’s office or at a hospital under local or general anesthesia.

In a few cases, it may not be clear whether an abnormal Pap or a woman’s symptoms are caused by a problem in the cervix or the endometrium. The doctor may perform a Dilation and Curettage (D and C) in which the cervical opening is stretched and a curette is used to scrape tissue from the lining of the uterus as well as the cervical canal.

TREATMENTS

Pre-cancerous Conditions

Treatment depends on a number of factors, including whether the lesion is low or high grade, whether the women wants to have children in the future, the women’s age and general health, and the preference of the women and her doctor.

A woman with a low-grade lesion may not need further treatment, but should have a Pap test and pelvic exam regularly.
If a pre-cancerous lesion requires treatment, the doctor may use procedures such as cryosurgery (freezing), cauterization (burning) or laser surgery to destroy the abnormal area without harming healthy tissue.

A woman may have a hysterectomy, particularly if abnormal cells are found inside the opening of the cervix. This surgery is likely to be done when the woman does not want to have children in the future.

STAGING

Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Blood and urine tests are usually done. The doctor may also do a thorough pelvic exam in the operating room with the patient under general anesthesia. During this exam, the doctor may perform procedures called cytoscopy and proctosigmoidoscopy.

In cytoscopy, the doctor looks inside the bladder with a thin, lighted instrument. Proctosigmoidoscpopy is a procedure in which a lighted instrument is used to examine the rectum and lower part of the large intestine. Because cervical cancer can spread to the bladder, rectum, lymph nodes, or lungs, the doctor may also order x-rays to check these areas. A computerized tomography or CAT scan, is a series of x-rays put together by a computer to make detailed pictures of areas inside the body, which may be used to look for enlarged lymph nodes. Ultrasound (A procedure in which sound waves (called ultrasound) are bounced off tissues and the echoes produce a picture (sonogram). A MRI (magnetic resonance imaging) may also be used.

TREAMENTS FOR CERVICAL CANCER

Most often treatment involves surgery or radiation therapy. Sometimes chemotherapy or biological therapy is used. A team of specialists, who may include a gynecological oncologist and radiation oncologist, often treats patients.

Following are explanations of the various treatments used:

Surgery might be used as a local therapy to remove abnormal tissue in or near the cervix.

Radiation Therapy, also called radiotherapy, uses high-energy rays to damage cancer cells and stop them from growing. This is local therapy and affects cancer cells only in the treated area. A woman receiving external radiation therapy goes to the hospital or clinic each day for treatment. Usually treatments are given 5 days a week for 5 -6 weeks.

Internal radiation, or implant radiation, uses a capsule containing radioactive material placed directly into the cervix. The implant emits cancer-killing rays close to the tumor while sparing most of the healthy tissue around it. It is usually left in place for 1 to 3 days, and the treatment may be repeated several times over the course of 1 to 2 weeks. The patient stays in the hospital while the implants are in place.

Chemotherapy is the use of drugs to kill the cancer cells. It is most often used when cervical cancer has spread to other parts of the body. Anticancer drugs may be given by injection into a vein or by mouth. Either way, it is a systemic treatment, meaning that drugs flow through the body in the bloodstream.

Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment period and so on. Most patients receive this treatment on an outpatient basis.

Biological therapy is a treatment using substances to improve the way the body’s immune system fights disease. It may be used to help treat cancer that has spread to other parts of the body. Interferon is the most common biological therapy for this disease, and may be used with chemotherapy. Most patients receive this treatment on an outpatient basis.