What is the cervix?

The cervix is part of a woman's reproductive system. It's in the pelvis. The cervix is the
lower, narrow part of the uterus (womb).

The cervix is a passageway:

 The cervix connects the uterus to the vagina. During a menstrual period, blood
flows from the uterus through the cervix into the vagina. The vagina leads to the
outside of the body.

 The cervix makes mucus. During sex, mucus helps sperm move from the vagina
through the cervix into the uterus.

 During pregnancy, the cervix is tightly closed to help keep the baby inside the
uterus. During childbirth, the cervix opens to allow the baby to pass through the
vagina.

What is cancer?

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the
organs of the body.

Normal cells grow and divide to form new cells as the body needs them. When normal
cells grow old or get damaged, they die, and new cells take their place.

Sometimes, this process goes wrong. New cells form when the body does not need them,
and old or damaged cells do not die as they should. The buildup of extra cells often forms
a mass of tissue called a growth or tumor.

Growths on the cervix can be benign or malignant. Benign growths are not cancer. They
are not as harmful as malignant growths (cancer).

 Benign growths (polyps, cysts, or genital warts):

o are rarely a threat to life

o don't invade the tissues around them

 Malignant growths (cervical cancer):

o may sometimes be a threat to life

o can invade nearby tissues and organs

o can spread to other parts of the body

Cervical cancer begins in cells on the surface of the cervix. Over time, the cervical cancer
can invade more deeply into the cervix and nearby tissues. The cancer cells can spread by
breaking away from the original (primary) tumor. They enter blood vessels or lymph
vessels, which branch into all the tissues of the body. The cancer cells may attach to other
tissues and grow to form new tumors that may damage those tissues. The spread of
cancer is called metastasis. See the Staging section for information about cervical cancer
that has spread.

Risk factors and causes of cervical cancer

When you get a diagnosis of cancer, it's natural to wonder what may have caused the
disease. Doctors cannot always explain why one woman develops cervical cancer and
another does not. However, we do know that a woman with certain risk factors may be
more likely than others to develop cervical cancer. A risk factor is something that may
increase the chance of developing a disease.

Studies have found a number of factors that may increase the risk of cervical cancer. For
example, infection with HPV (human papillomavirus) is the main cause of cervical
cancer. HPV infection and other risk factors may act together to increase the risk even
more:

 HPV infection: HPV is a group of viruses that can infect the cervix. An HPV
infection that doesn't go away can cause cervical cancer in some women. HPV is
the cause of nearly all cervical cancers.

HPV infections are very common. These viruses are passed from person to person
through sexual contact. Most adults have been infected with HPV at some time in
their lives, but most infections clear up on their own.

Some types of HPV can cause changes to cells in the cervix. If these changes are
found early, cervical cancer can be prevented by removing or killing the changed
cells before they can become cancer cells. The NCI fact sheet Human
Papillomaviruses and Cancer: Questions and Answers has more information.

A vaccine for females ages 9 to 26 protects against two types of HPV infection
that cause cervical cancer. The NCI fact sheet Human Papillomavirus (HPV)
Vaccines: Questions and Answers has more information.

 Lack of regular Pap tests: Cervical cancer is more common among women who
don't have regular Pap tests. The Pap test helps doctors find abnormal cells.
Removing or killing the abnormal cells usually prevents cervical cancer.

 Smoking: Among women who are infected with HPV, smoking cigarettes slightly
increases the risk of cervical cancer.

 Weakened immune system (the body's natural defense system): Infection with
HIV (the virus that causes AIDS) or taking drugs that suppress the immune
system increases the risk of cervical cancer.

a woman who has had sex with a man who has had many sexual partners may be at higher risk of developing cervical cancer. the risk of developing cervical cancer is higher because these women have a higher risk of HPV infection.  Using birth control pills for a long time: Using birth control pills for a long time (5 or more years) may slightly increase the risk of cervical cancer among women with HPV infection.) Having an HPV infection or other risk factors does not mean that a woman will develop cervical cancer. the risk decreases quickly when women stop using birth control pills. DES was given to some pregnant women in the United States between about 1940 and 1971. In both cases. Most women who have risk factors for cervical cancer never develop it. However.  DES (diethylstilbestrol): DES may increase the risk of a rare form of cervical cancer in daughters exposed to this drug before birth.  Sexual history: Women who have had many sexual partners have a higher risk of developing cervical cancer. Also. (It is no longer given to pregnant women. .  Having many children: Studies suggest that giving birth to many children (5 or more) may slightly increase the risk of cervical cancer among women with HPV infection.

A woman with any of these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible. Detection and diagnosis Doctors recommend that women help reduce their risk of cervical cancer by having regular Pap tests. A Pap test (sometimes called Pap smear or cervical smear) is a simple test used to look at cervical cells. . douching. When the cancer grows larger. or a pelvic exam o Menstrual periods that last longer and are heavier than before o Bleeding after going through menopause  Increased vaginal discharge o Pelvic pain o Pain during sex Infections or other health problems may also cause these symptoms. women may notice one or more of these symptoms:  Abnormal vaginal bleeding o Bleeding that occurs between regular menstrual periods o Bleeding after sexual intercourse. Only a doctor can tell for sure. Pap tests can find cervical cancer or abnormal cells that can lead to cervical cancer.Symptoms Early cervical cancers usually don't cause symptoms.

Removing tissue from the cervix may cause some bleeding or other discharge. lets the pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. the Pap test is not painful. A pathologist checks the tissue under a microscope for abnormal cells. The area usually heals quickly. o Conization: The doctor removes a cone-shaped sample of tissue. The doctor or nurse scrapes a sample of cells from the cervix. Some women also feel some pain similar to menstrual cramps. o Endocervical curettage: The doctor uses a curette (a small. o Punch biopsy: The doctor uses a sharp tool to pinch off small samples of cervical tissue. abnormal cells found by a Pap test are not cancerous. The colposcope combines a bright light with a magnifying lens to make tissue easier to see. The same sample of cells may be tested for HPV infection. or cone biopsy. A colposcopy is usually done in the doctor's office or clinic. soft brush instead of a curette. It is not inserted into the vagina. A lab checks the cells under a microscope for cell changes. If you have abnormal Pap or HPV test results. round piece of cervical tissue. spoon-shaped instrument) to scrape a small sample of tissue from the cervix. o LEEP: The doctor uses an electric wire loop to slice off a thin. when treatment is more likely to be effective. Some doctors may use a thin. A conization. Most often. your doctor will suggest other tests to make a diagnosis:  Colposcopy: The doctor uses a colposcope to look at the cervix. Your doctor can suggest medicine that will help relieve your pain. . It's done in a doctor's office or clinic during a pelvic exam. The doctor may do this test in the hospital under general anesthesia. the Pap test can help find cancer early. Also.  Biopsy: Most women have tissue removed in the doctor's office with local anesthesia. For most women.Finding and treating abnormal cells can prevent most cervical cancer.

douching. who will talk to me about the next steps? When? .You may want to ask the doctor these questions before having a biopsy:  Which biopsy method do you recommend?  How will tissue be removed?  Will I have to go to the hospital?  How long will it take? Will I be awake? Will it hurt?  Are there any risks? What are the chances of infection or bleeding after the test?  For how many days afterward should I avoid using tampons. or having sex?  Can the test affect my ability to get pregnant and have children?  How soon will I know the results? Who will explain them to me?  If I do have cancer.

your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. Cancer cells use sugar faster than normal cells.  PET scan: You receive an injection of a small amount of radioactive sugar. if cervical cancer spreads to the lungs. An MRI can show whether cancer has spread. the new tumor has the same kind of cancer cells and the same name as the original tumor. and areas with cancer look brighter on the pictures. The disease is metastatic cervical cancer. feel for swollen lymph nodes. A machine makes computerized pictures of the sugar being used by cells in your body. A tumor in the liver. the cancer cells in the lungs are actually cervical cancer cells. The doctor can view these pictures on a monitor and can print them on film. For example. or by enema. and may remove additional tissue. not lung cancer. it's treated as cervical cancer. These are the stages of invasive cervical cancer: . not lung cancer. Your doctor will do a pelvic exam. if so. whether the cancer has spread and. Staging is a careful attempt to find out whether the tumor has invaded nearby tissues. or the lungs. to what parts of the body.Staging If the biopsy shows that you have cancer. by mouth. To learn the extent of disease. The contrast material makes abnormal areas easier to see. lymph nodes. It may also spread to the liver or bones. For that reason. Sometimes contrast material makes abnormal areas show up more clearly on the picture. When cancer spreads from its original place to another part of the body. The stage is based on where cancer is found. lungs. Doctors call the new tumor "distant" or metastatic disease. You may receive contrast material by injection in your arm or hand. or elsewhere in the body can show up on the CT scan.  MRI: A powerful magnet linked to a computer is used to make detailed pictures of your pelvis and abdomen.  CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your organs. the doctor may order some of the following tests:  Chest x-rays: X-rays often can show whether cancer has spread to the lungs. Cervical cancer spreads most often to nearby tissues in the pelvis.

 Stage IV: The tumor invades the bladder or rectum. one or both kidneys may not be working well. but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body. It may also have invaded the pelvic wall. Cancer cells are found only in the cervix. Stage I: The tumor has invaded the cervix beneath the top layer of cells.  Recurrent cancer: The cancer was treated.  Stage II: The tumor extends to the upper part of the vagina. It may extend beyond the cervix into nearby tissues toward the pelvic wall (the lining of the part of the body between the hips).  Stage III: The tumor extends to the lower part of the vagina. The tumor does not invade the lower third of the vagina or the pelvic wall. If the tumor blocks the flow of urine. . Or the cancer has spread to other parts of the body.

Because cancer treatments often damage healthy cells and tissues. medical oncologists. Before treatment starts. side effects are common. supportive care is available to relieve the side effects of treatment.cancer.gov/cancertopics/coping and from NCI's Cancer Information Service at 1-800-4-CANCER or LiveHelp (http://www. a surgeon who specializes in treating female cancers. Your doctor can describe your treatment choices. The choice of treatment depends mainly on the size of the tumor and whether the cancer has spread. a research study of new treatment methods. or you may ask for a referral. and to help you cope with the feelings that a diagnosis of cancer can bring. ask your health care team about possible side effects and how treatment may change your normal activities. and they may change from one treatment session to the next. chemotherapy. to control pain and other symptoms. Side effects may not be the same for each person. You and your doctor can work together to develop a treatment plan that meets your medical and personal needs.gov/help).Treatment Women with cervical cancer have many treatment options. radiation therapy. You may want to talk to your doctor about taking part in a clinical trial. Your doctor may refer you to a specialist. and radiation oncologists. or a combination of methods. You can get information about coping on NCI's Web site at http://www. Other specialists who treat cervical cancer include gynecologists. where?  May I have a copy of the report from the pathologist?  What are my treatment choices? Which do you recommend for me? Will I have . See the section on Taking Part in Cancer Research. You may want to ask the doctor these questions before treatment begins:  What is the stage of my disease? Has the cancer spread? If so. Your health care team may also include an oncology nurse and a registered dietitian.cancer. and the possible side effects. At any stage of the disease. You may want to see a gynecologic oncologist. The treatment choice may also depend on whether you would like to become pregnant someday. the expected results of each. The options are surgery.

for how long?  What is the treatment likely to cost? Will my insurance cover the cost?  How will treatment affect my normal activities?  What can I do to take care of myself during treatment?  What is my chance of a full recovery?  How often will I need checkups after treatment?  Would a clinical trial (research study) be right for me? . more than one kind of treatment?  What are the expected benefits of each kind of treatment?  What are the risks and possible side effects of each treatment? What can we do to control the side effects?  What can I do to prepare for treatment?  Will I have to stay in the hospital? If so.

It is common to feel tired or weak for a while. The time it takes to heal after surgery is different for each woman. women no longer have menstrual periods. some women have bladder problems for a few days. it means the disease may have spread to other parts of the body. This option is for a small number of women with small tumors who want to try to get pregnant later on. The hospital stay usually is about 2 to 5 days. you should discuss the plan for pain relief with your doctor or nurse. After surgery. After a hysterectomy. You may have problems with nausea and vomiting. . your doctor can adjust the plan if you need more pain control. and you may have bladder and bowel problems. the length of the hospital stay may vary from several days to a week. With either total or radical hysterectomy. They cannot become pregnant.  Radical hysterectomy: The surgeon removes the cervix. the uterus. with a gradual return to solid food. part of the vagina. Medicine can help control your pain. You may have pain or discomfort for the first few days.  Total hysterectomy: The surgeon removes the cervix and uterus. Before surgery. After a radical trachelectomy. some tissue around the cervix. If cancer cells have reached the lymph nodes. The surgeon removes tissue that may contain cancer cells:  Radical trachelectomy: The surgeon removes the cervix. and part of the vagina. the surgeon may remove other tissues:  Fallopian tubes and ovaries: The surgeon may remove both fallopian tubes and ovaries. and the lymph nodes in the pelvis. The doctor may restrict your diet to liquids at first. Most women return to their normal activities within 4 to 8 weeks after surgery.  Lymph nodes: The surgeon may remove the lymph nodes near the tumor to see if they contain cancer. After a hysterectomy. This surgery is called a salpingo-oophorectomy.Surgery Surgery is an option for women with Stage I or II cervical cancer.

Sharing these feelings with your partner may be helpful. Some drugs have been shown to help with these symptoms. You may want to ask the doctor these questions before having surgery:  Do you recommend surgery for me? If so. menopause occurs at once. You may wish to discuss this with your doctor before surgery. Sometimes couples talk with a counselor to help them express their concerns. will I be able to get pregnant and have children? If I get pregnant later on. which kind? Will my ovaries be removed? Do I need to have lymph nodes removed?  What is the goal of surgery?  What are the risks of surgery?  How will I feel after surgery? If I have pain.When the ovaries are removed. is there a bigger chance that I could have a miscarriage?  When will I be able to resume normal activities?  How will the surgery affect my sex life? Radiation therapy . For some women. how will it be controlled?  How long will I have to be in the hospital?  Will I have any lasting side effects? If I don't have a hysterectomy. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. a hysterectomy can affect sexual intimacy. and they may be more effective if started before surgery. You may have feelings of loss that make intimacy difficult.

A radioactive substance is loaded into the tube. but doctors usually advise patients to try to stay as active as they can. For example. itching. and you can go home afterward.Radiation therapy (also called radiotherapy) is an option for women with any stage of cervical cancer. or urinary problems. no radioactivity is left in your body. Once the radioactive substance is removed. you may wish to discuss with your doctor the possible long-term effects of radiation therapy. It affects cells only in the treated area. Resting is important. vomiting. they can usually be treated or controlled. . the radiation may make the vagina narrower. diarrhea. Doctors use two types of radiation therapy to treat cervical cancer. Some women receive both types:  External radiation therapy: A large machine directs radiation at your pelvis or other tissues where the cancer has spread. It may also help to know that most side effects go away when treatment ends. You are likely to become tired during radiation therapy. Also. however. You may have dryness. Each treatment takes only a few minutes. You may need to stay in the hospital while the radioactive source is in place (up to 3 days). and tender.  Internal radiation therapy: A thin tube is placed inside the vagina. your skin in the treated area may become red. Women with cancer that extends beyond the cervix may have radiation therapy and chemotherapy Radiation therapy uses high-energy rays to kill cancer cells. Or the treatment session may last a few minutes. dry. You may lose hair in your genital area. Talk with your doctor or nurse about ways to relieve discomfort. or burning in your vagina. It also may be used after surgery to destroy any cancer cells that remain in the area. The treatment usually is given in a hospital or clinic. Internal radiation may be repeated two or more times over several weeks. your health care team can tell you about ways to expand the vagina. Radiation to the abdomen and pelvis may cause nausea. A narrow vagina can make sex or follow-up exams difficult. However. Although the side effects of radiation therapy can be upsetting. Your doctor may advise you to wait to have sex until a few weeks after radiation treatment ends. There are ways to prevent this problem. You may receive external radiation 5 days a week for several weeks. Side effects depend mainly on how much radiation is given and which part of your body is treated. especially in the later weeks of treatment. If it does occur. Women with early stage cervical cancer may choose radiation therapy instead of surgery.

Menstrual periods are more likely to return for younger women. You may want to ask the doctor these questions before having radiation therapy:  What is the goal of this treatment?  How will the radiation be given?  Will I need to stay in the hospital? If so.Another long-term effect is that radiation aimed at the pelvic area can harm the ovaries. Menstrual periods usually stop. for how long?  When will the treatments begin? How often will I have them? When will they end?  How will I feel during treatment? Are there side effects?  How will we know if the radiation therapy is working?  Will I be able to continue my normal activities during treatment?  How will radiation therapy affect my sex life?  Are there lasting side effects?  Will I be able to get pregnant and have children after my treatment is over? Chemotherapy . and women may have hot flashes and vaginal dryness. Women who may want to get pregnant after radiation therapy should ask their health care team about ways to preserve their eggs before treatment starts.

For cancer that has spread to distant organs. hearing problems. Other side effects include skin rash. chemotherapy is usually combined with radiation therapy. You may receive chemotherapy in a clinic. Your health care team will check for low levels of blood cells. loss of balance. If your levels are low. or at home. Chemotherapy uses drugs to kill cancer cells. The side effects depend mainly on which drugs are given and how much. or mouth and lip sores. If you lose your hair. Some women need to stay in the hospital during treatment. Chemotherapy kills fast-growing cancer cells. your health care team may stop the chemotherapy for a while or reduce the dose of drug. it will grow back.  Cells that line the digestive tract: Chemotherapy can cause a poor appetite. at the doctor's office. bruise or bleed easily. but it may change in color and texture.For the treatment of cervical cancer. and feel very weak and tired. Your health care team can suggest ways to control many of these problems. chemotherapy alone may be used. Most go away when treatment ends. diarrhea. but the drugs can also harm normal cells that divide rapidly:  Blood cells: When chemotherapy lowers the levels of healthy blood cells. joint pain. or swollen legs and feet. You may want to ask the doctor these questions before having chemotherapy:  Why do I need this treatment?  Which drug or drugs will I have?  How do the drugs work? . nausea and vomiting. you're more likely to get infections. There are also medicines that can help your body make new blood cells.  Cells in hair roots: Chemotherapy may cause hair loss. tingling or numbness in your hands and feet. The drugs for cervical cancer are usually given through a vein (intravenous). Your health care team can give you medicines and suggest other ways to help with these problems.

 What are the expected benefits of the treatment?  What are the risks and possible side effects of treatment? What can we do about them?  When will treatment start? When will it end?  How will treatment affect my normal activities? .

nausea. Some people worry that the doctor will be offended if they ask for a second opinion. It also can help relieve stress. a nearby hospital. However. If you get a second opinion. You can ask your doctor. You also need enough protein to keep up your strength. You need the right amount of calories to maintain a good weight. or a medical school for names of specialists. swimming. And many health insurance companies will pay for a second opinion if you or your doctor requests it. To make sure. You may find that foods don't taste as good as they used to. Nutrition and physical activity It's important for you to take care of yourself by eating well and staying as active as you can. yoga. In addition. you should discuss this delay with your doctor. Or the second doctor may suggest another approach. or mouth sores) can make it hard to eat well. There are many ways to find a doctor for a second opinion. or another health care provider can suggest ways to cope with these problems. if your activity causes you pain or other problems. It may take some time and effort to gather your medical records and see another doctor. Exercise may reduce nausea and pain and make treatment easier to handle. be sure to talk to your doctor before you start. a registered dietitian. Usually the opposite is true. The delay in starting treatment usually will not make treatment less effective. be sure to let your doctor or nurse know about it.Second opinion Before starting treatment. knowing that you've looked at your options. the doctor may agree with your first doctor's diagnosis and treatment plan. You may be uncomfortable or tired. it's not a problem to take several weeks to get a second opinion. and other activities can keep you strong and increase your energy. Most doctors welcome a second opinion. Also. vomiting. Research shows that people with cancer feel better when they stay active. you might want a second opinion about your diagnosis and treatment plan. you have more information and perhaps a greater sense of control. Whatever physical activity you choose. you may not feel like eating during or soon after treatment. Either way. Eating well may help you feel better and have more energy. Your doctor. Walking. In most cases. You can feel more confident about the decisions you make. the side effects of treatment (such as poor appetite. . a local or state medical society.

It's normal for you. If you have any health problems between checkups. or other activities. you should contact your doctor. working. Pap tests. keeping your job. and medical bills are common. . and chest x-rays. nurses. Even when the cancer seems to have been completely removed or destroyed. and your friends to have many different and sometimes confusing feelings. Checkups may include a physical exam. You may want to ask your doctor these questions after you have finished treatment:  How often will I need checkups?  How often will I need a Pap test?  What other follow-up tests do you suggest for me?  Between checkups. hospital stays. what health problems or symptoms should I tell you about? Sources of support Learning you have cervical cancer can change your life and the lives of those close to you. Here's where you can go for support:  Doctors. Your doctor will check for the return of cancer. Checkups help ensure that any changes in your health are noted and treated if needed. Concerns about treatments and managing side effects.Follow-up care You'll need regular checkups after treatment for cervical cancer. You may also worry about caring for your family. or continuing daily activities. your family. and other members of your health care team can answer questions about treatment. These changes can be hard to handle. the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment.

diagnosis.  Information specialists at 1-800-4-CANCER and at LiveHelp (http://www. Today. combinations. and radiation therapy. They can send you a list of organizations that offer services to people with cancer. A sentinel lymph node is the first lymph node to which the cancer is likely to spread.  Your doctor or a sex counselor may be helpful if you and your partner are concerned about the effects of cervical cancer on your sexual relationship.  Social workers. or members of the clergy can be helpful if you want to talk about your feelings or concerns. counselors. Clinical trials are designed to answer important questions and to find out whether new approaches are safe and effective. Doctors continue to search for new and better ways to treat cervical cancer. or emotional support. and schedules. Taking part in cancer research Doctors all over the country are conducting many types of clinical trials (research studies in which people volunteer to take part). They are testing new treatments.  Support groups also can help. You may want to talk with a member of your health care team about finding a support group. or on the Internet. Doctors also are studying surgery to remove sentinel lymph nodes. Often. doctors may be able to avoid more surgery to remove other lymph nodes. Research already has led to advances in the prevention. over the telephone. including new drugs. surgery. social workers can suggest resources for financial aid. and publications. surgeons often have to remove many lymph nodes and check each of them for cancer. Some trials are combining chemotherapy. They are studying new ways to treat cervical cancer. You and your partner may find it helps to discuss your concerns.cancer.gov/help) can help you locate programs. patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. But if the research shows that it's possible to identify the sentinel lymph node (the lymph node most likely to have cancer). Groups may offer support in person. transportation. In these groups. and treatment of cervical cancer. . services. Some are also studying therapies that may improve the quality of life for women during or after cancer treatment. home care.

It has general information about clinical trials as well as detailed information about specific ongoing studies of cervical cancer. Although clinical trials may pose some risks. NCI's Information Specialists at 1-800-4- CANCER or at LiveHelp at http://www. NCI's Web site includes a section on clinical trials at http://www.gov/help can answer questions and provide information about clinical trials. It describes how treatment studies are carried out and explains their possible benefits and risks. talk with your doctor.gov/clinicaltrials.cancer. If you are interested in taking part in a clinical trial. they may still make an important contribution by helping doctors learn more about cervical cancer and how to control it.cancer.Even if the people in a trial don't benefit directly. . researchers do all they can to protect their patients. You may want to read the NCI booklet Taking Part in Cancer Treatment Research Studies.

Telephone: 1-800-4-CANCER (1-800-422-6237) Internet NCI's Web site provides information from numerous NCI sources.gov/espanol If you're unable to find what you need on the Web site. health professionals. treatment. The following NCI services are available to help you. and ongoing clinical trials. or laser surgery. your family.  Cancer of the cervix requires different treatment than cancer that begin in other parts of the uterus. supportive care. Information specialists translate the latest scientific information into plain language. and the general public. and cancer statistics.cancer. Also.gov Spanish Web site: http://www.nih. Use the online contact form at http://www. diagnosis. genetics. Telephone NCI's Cancer Information Service (CIS) provides accurate.  The most common symptom of cancer of the cervix is abnormal bleeding.National Cancer Institute information resources You may want more information for yourself.cancer. Web site: http://www. screening. and your doctor. It has information about NCI's research programs. cauterization.cancer. as well as through TRS providers for the hearing or speech impaired.  Cancer of the cervix can be diagnosed using a Pap test or other procedures that sample the cervix tissue. It offers current information about cancer prevention.  Regular pelvic exams and Pap testing can detect precancerous changes in the cervix.gov/help. up-to-date information about cancer to patients and their families.gov.cancer. Cervix Cancer At A Glance  Risk factors for cancer of the cervix have been identified. and they will respond in English or Spanish.gov/contact or send an email to cancergovstaff@mail. contact NCI staff.  Precancerous changes in the cervix may be treated with cryosurgery. . funding opportunities. online assistance through LiveHelp at http://www. information specialists provide live. Calls to the CIS are confidential and free.

with the formation of a cavity that is marginated by the invasive tumor. Spread . In different reported series of patients with untreated carcinoma in situ who were followed up for many years. nodular-type tumors that circumferentially involve the endocervical region and large. the carcinoma-in-situ lesion may regress after the initial diagnosis. such an occurrence was reported in 17 (25%) of 67 patients who were followed up for at least 3 years. This process is usually complicated by infection that causes seropurulent discharge. with combination growth patterns being common. bulky mass that involves only the superficial aspect of the cervix and has the tendency for excessive bleeding. invasive carcinoma developed in about 30% of patients at 10 years and in about 80% of patients at 30 years. Carcinoma in situ is particularly known to precede invasive cervical cancer in most cases. friable. nodular. The nodular variety typically arises in the endocervix and grows through the cervical stroma into confluent. Infiltrative exocervical lesions tend to invade the vaginal fornices and the upper part of the vagina. Exophytic cervical cancer may result in a large. firm masses that cause the cervix and isthmus to expand. The exophytic variety is the most common growth pattern. However. The transformation from mild dysplastic to invasive carcinoma generally occurs slowly within several years. It usually arises from the exocervix and is often polypoid or papillary in form. Multiple local growth patterns of invasive cervical cancer have been described. The ulcerative growth pattern is associated with tumor necrosis and sloughing. Progression to invasive carcinoma becomes established and is considered irreversible once the malignant process extends through the basement membrane and invasion of the cervical stroma occurs. infiltrative. and ulcerative. On the other hand. Large. The infiltrative growth pattern leads to a stone-hard cervix that may be predicated to have minimal visible ulcerations or an exophytic mass. The patterns include the following: exophytic. infiltrative endocervical lesions tend to extend into the corpus and the lateral parametrium.Pathophysiology Origins and growth patterns Cancer of the cervix typically originates from a dysplastic or premalignant lesion previously present at the active squamocolumnar junction. exophytic-type tumors that originate from the endocervix and extend into the endocervical canal result in what has been referred to as a barrel-shaped cervix. although the rate of this process varies widely.

large-cell SCC (70% of cases). A tumor that extends through the posterior aspect of the cervix or corpus infrequently leads to intraperitoneal spread. nonkeratinizing. eventually. The extrauterine spread of cervical cancer occurs primarily by means of direct extension and lymphatic invasion that initially affects the contiguous tissues in the region of the laterally positioned cardinal ligament. bones. Lymphatic tumor spread usually occurs in a fairly orderly pattern or sequence that first involves the regional paracervical and parametrial lymph nodes and then the internal and external iliac lymph nodes. Adnexal metastases are uncommon intheearlystages of the disease. which are separated from the cervix by the pubovesicocervical fascia. the tumor may involve the anterior or posterior parametrium. potentially. the pelvic sidewalls. (2) moderately differentiated. the sciatic plexus is involved. and liver. pyelonephritis. or thoracic lymph nodes. the para-aortic nodes. The lateral paracervical and parametrial regions are more vulnerable to tumor invasion than the anterior and posterior parametrium because of the lack of a protective fascial covering at the lateral regions and because of the natural lymphatic drainage through the lateral paracervical tissues into the cardinal ligaments. Later. and eventually the supraclavicular nodes via the thoracic duct. respectively. into the adjacent structures. Histopathologic types Squamous cell carcinoma (SCC) accounted for 80-90% of all cervical malignancies in a large case series. Involvement of the urinary bladder and rectum can occur in advanced cases because of direct tumor extension or subsequent to invasion of the vesicouterine or uterosacral ligaments. large-cell SCC (25% of cases). The local spread of cervical cancer may progress through the parametrium to involve the ureters and. (3) direct extension into the parametrium and. and (4) spread into the regional pelvic lymph nodes and. In some patients.The main pathways for the spread of invasive cervical cancer consist of the following: (1) microscopic spread into the vaginal mucosa beyond a visible or palpable tumor. into the retroperitoneal. inguinal. A vesicovaginal fistula or rectovaginal fistula may or may not develop.15 Most of the information regarding the etiology and epidemiology of cervical cancer is derived from experience and research that are related to the most common SCC lesion. Metastasis to the para-aortic lymph nodes without involvement of pelvic lymph nodes is unusual. keratinizing. This may then be followed by spread to the common iliac nodes. and renal failure are common complications of progressive disease. and (3) small-cell undifferentiated . (2) extension into the endometrium or myometrium of the corpus. in advanced stages. The most common sites of hematogenous metastases are the lungs. The major histopathologic SCC subtypes include: (1) well- differentiated. Hydronephrosis. Hematogenous tumor spread may be a result of a lymphatic venous anastomosis or direct venous invasion.

among women younger than 35 years.4% of all new cancers in women.14 The histologic patterns include well-differentiated mucinous adenocarcinoma. small-cell carcinoma that are similar to neuroendocrine tumors occurring elsewhere. In developed countries. and a clear-cell pattern that contains glycogen but no mucin. There is a relatively higher incidence of poorly differentiated and more aggressive histologic subtypes of cervical adenocarcinoma that are associated with a poorer prognosis than SCC. and metastatic tumors. Pure adenocarcinomas arise from endocervical-type cells and constitute 5-20% of all cervical malignancies.14 These account for 15% of all cancers in women.150 cases of invasive cervical cancer were diagnosed in 2007.14 The estimated total number of new cases is 371. The associated lifetime risk of invasive cervical cancer in such countries is about 3%. . Other common sources of metastases include the ovary. Miscellaneous uncommon or rare cancers of the cervix include variants of SCC and adenocarcinomas. which is associated with a distinctly poor prognosis.14 In particular. A trend toward an absolute increase in the incidence of adenocarcinoma has been observed during the past 20-30 years. sarcoma. Most metastases are from the endometrium.carcinoma (about 5% of cases). melanoma.200 per year worldwide or 9. Many of these lesions may simulate endometrial adenocarcinoma. and in some patients with extensive or bulky cervical involvement. and breast. colon. in which 78% of worldwide cervical cancers occur.8 The incidence of carcinoma in situ is estimated to be about 4 times that of invasive cancer. This disparity is attributed to the lack of effective screening programs in developing countries that have a high incidence of cervical cancer. after cancers of the endometrium and the ovary. invasive cervical cancer is the most common genital female malignancy and the second most common malignancy in women. Invasive cervical cancer is more common in economically disadvantaged developing countries.8% of all cancers in women. the incidence more than doubled between 1970 and the mid-1980s. determining the true origin of the lesion may be difficult.8 International Worldwide.1%. after breast cancer. and it is associated with a lifetime risk of about 1. Frequency United States Invasive cancer of the cervix is the third most common genital malignancy in women.13. the disease accounts for 4. lymphoma. Metastasis to the cervix is typically found in the setting of a patient whose site of origin of the primary malignancy is already known clinically. papillary adenocarcinoma.13. mixed carcinomas.13 The American Cancer Society estimated approximately 11.

The cervix enters the vagina through the anterior vaginal wall. and the cervix. The cervix is in the most caudal position and is a relatively narrow. and the 5-year survival rate is lower. and it is uncommon in women younger than 25 years.14 Mortality/Morbidity The prognosis of cervical cancer is relatively good in low-risk countries. the Caribbean.000 deaths per year occur worldwide as a result of cervical cancer. it is separated from the urinary bladder by fatty tissue . Anatomy The uterus is a pear-shaped muscular organ with thick walls and a flattened hollow cavity. the incidence in black women is 50% higher. invasive cervical cancer is second only to breast cancer as a leading cause of worldwide cancer-related mortality in women. Anteriorly. Race Compared with non-Hispanic white women. The supravaginal segment is posteriorly covered by the peritoneum in the region of the posterior cul-de-sac (pouch of Douglas or rectovaginal pouch). with a reported 5-year survival rate of 72% for all stages combined.8 However. The uterine corpus and cervix are externally demarcated from each other by a subtle constriction called the isthmus. Southeast Asia. It consists of the corpus. or neck. and sub-Saharan Africa.8 The 5-year survival rate is reportedly about 48% in developing countries.Reported global cancer statistics show that the incidence is highest in Latin America.5% of all cancer deaths in women. southern Asia. In the United States. where patients are likely to seek medical attention when the cancer is more advanced.8 The rate in Hispanic women is over twice that of non-Hispanic white women. these account for 8.14 The 5-year survival rate for early invasive cancer is about 92%.8 The presence of metastatic adenopathy is an important factor in the prognosis of cervical cancer. or body.8 Age Cervical carcinoma in situ is most commonly detected in women aged 25-34 years. forming an oblique attachment line that separates it into a supravaginal segment and a lower intravaginal segment (portio vaginalis and exocervix). Invasive cervical cancer is most frequently diagnosed in women older than 50 years. cylindrical segment of the uterus that measures approximately 2-4 cm in length. and that for preinvasive cervical cancer is nearly 100%. an estimated 3670 women died from cervical cancer in 2007. and they are internally demarcated by a slight narrowing of the endocervical canal called the internal os. Approximately 190.

the extraperitoneal connective tissue through which the vasculature reaches the cervix. Abnormal vaginal discharge is a presenting symptom in about 10% of patients. The vaginal segment projects into the vaginal vault and consists of about one third of the anterior aspect and one half of the posterior aspect of the cervix. At the vaginal surface of the cervix is the external os. Pelvic or abdominal pain and urinary or rectal symptoms occur in advanced cases. irregular menses. In some case series and in geographic regions where endometrial cancer is not common. heavy menstrual flow. The mucosa of the endocervical canal forms branching intramucosal folds called the plicae palmatae. The cervical stroma is primarily composed of collagenous connective tissue with a small amount of interspersed stratified muscle fibers (about 10% of the stromal tissues) and a small amount of elastic tissue. However. postmenopausal bleeding is the most common presenting symptom of cervical cancer. lines the endocervical surface. the discharge may be watery. or mucoid. The transition from endocervical to endometrial glands is the histologic landmark for the internal os. The cervix has a rich network of lymphatics that drain principally into the paracervical lymph nodes and subsequently to the hypogastric and external iliac nodes (of which the obturator nodes are the innermost component). painless metrorrhagia. Approximately 90% of SCCs arise from the squamocolumnar junction. The exocervix (portio vaginalis) is covered by stratified squamous epithelium that is essentially identical to the vaginal epithelium.16 Approximately 80-90% of patients with cervical cancer experience a form of abnormal vaginal bleeding such as postmenopausal bleeding. the external os may be oval or almost linear. Presentation Early cervical cancer is usually asymptomatic. it is connected to the broad ligament and the parametrium. The usually spindle-shaped endocervical canal extends from the external os to the internal os. A single layer of columnar epithelium. Laterally. and as many as 20% of patients who have invasive cervical cancer are asymptomatic when the disease is diagnosed by means of a Papanicolaou (Pap) smear/test or routine clinical examination. where it joins the endometrial cavity. The squamocolumnar junction is located at the exocervix in young individuals and gradually migrates into the endocervical region with age as the exocervical lips atrophy. as compared with the predominantly muscular uterine corpus. or postcoital bleeding. supported by a basement membrane.without being covered by the uterovesical pouch of the peritoneum. purulent. The cervix has a preponderance of fibrous tissue. Preferred Examination . circular aperture. The pelvic lymphatics drain into the common iliac and the para-aortic lymph nodes. which is generally a small.

or when no gross cervical lesion is visualized and endocervical disease is suspected. Conization is usually contraindicated in patients with overt cancer because of the increased risk of hemorrhage and treatment complications.Medical procedures The American Cancer Society guidelines for the early detection of cervical cancer recommend screening with an annual conventional Pap smear (or every 2 y with the newer liquid-based Pap test) and a pelvic examination in all women approximately 3 years after they begin having vaginal intercourse but no later than age 21 years. Except in pregnant patients. etc) should be screened annually. the Pap test may be performed less frequently (usually every 2-3 y). a visible lesion is detected. An alternative is for women older than age 30 years to be screened every 3 years with either the conventional or liquid-based Pap test. Nonetheless.17 Women with certain risk factors (eg. the Pap smear is only a screening tool. and samples of any suspicious areas in all 4 quadrants of the cervix or vagina should be obtained. In this location. Punch biopsy of any gross cervical lesion should be performed. when the endocervical curettage samples show dysplastic fragments. as opposed to a definitive diagnostic procedure. No gross cervical abnormality may be visualized during the speculum pelvic examination if the tumor is small or if it is located in the endocervix. when the colposcopic biopsy findings suggest microinvasive cancer. some fairly large tumors may escape inspection.17 In women aged 30 years and older. and the test is generally accepted to be effective in reducing the incidence and mortality rate of cervical cancer. or exophytic. at the discretion of the physician. and it may be ulcerative. colposcopy-directed biopsy and endocervical curettage are advised when a cervical lesion is suspected on the basis of the clinical findings or if the Pap smear reveals a precancerous lesion or malignant cells. Conization biopsy is used to evaluate a subclinical tumor when the colposcopic results are insufficient or inadequate. plaquelike.19 Screening for cervical intraepithelial neoplasia (CIN) with the Pap smear allows the early detection of preinvasive disease. Dysplasia and carcinoma in situ may be managed with cold-knife conization or with other excision or ablation methods such as . human immunodeficiency virus [HIV] infection. As many as one third of the cancers are endocervical. Curettage of the endometrium may also be performed if tumor extension in a superior direction is suspected. Colposcopy is usually adequate for the evaluation of the exocervix and of a segment of the endocervix near the transition of the squamous and columnar epithelium. in most patients. in addition to the HPV deoxyribonucleic acid (DNA) test.18. However. and it has a 15- 25% false-negative rate in the detection of cervical dysplasia. after 3 consecutive normal results. prenatal diethylstilbestrol [DES] exposure. The National Comprehensive Cancer Network (NCCN) and American Society for Colposcopy and Cervical Pathology have similar guidelines. or they might be appreciated only with bimanual rectovaginal examination.

34. and these procedures are performed for only specific indications that are based on the symptoms or clinical findings.31.40. and cryotherapy.37 Consequently. loop electrosurgical excision procedures (LEEP). .23. as well as provide a worldwide standardized classification that allows various medical centers to compare results.35. Pretherapeutic evaluation of the extent of disease20. Barium enema examination.26.33.49.45.42.29 MRI has excellent soft-tissue contrast resolution. pelvic sidewall. chest radiography.51. and intravenous urography (IVU) or cross-sectional imaging (computed tomography [CT] scanning or magnetic resonance imaging [MRI]).32. and both are significantly superior to US. the gynecology literature mostly recommends the use of CT scanning for the pretreatment evaluation of cervical cancer.25 The pretreatment evaluation of patients with cervical cancer includes physical examination.22. or when the tumor is endocervical. the additional information provided with the excellent soft-tissue contrast resolution of MRI often has no significant effect on clinical decision making or on the choice of therapy.33. which exceeds that of CT scanning and ultrasonography (US).38. MRI is significantly more valuable than CT and US in the assessment of the size of the tumor.0 cm) because of the low probability of parametrial invasion and nodal metastasis.24. IVU and cross-sectional imaging are not routinely performed because of their relatively low yield.laser conization. particularly in early disease.30. laser vaporization.44.26. Cervical conization may eventually prove tobetherapeutic in many patients.46.39.54 In general. and proctosigmoidoscopy have a low yield.43 CT scanning and MRI are approximately equivalent. in the detection of enlarged lymph nodes. Despite the advantages of MRI. US is not suited for staging of the full extent of the tumor spread because of the inability of this technique to adequately depict all the potential sites of metastasis or the anatomic regions that contain lymph nodes.27 IVU is not needed when cross-sectional imaging is performed because both modalities are similarly accurate in depicting urinary obstruction and because cross-sectional imaging has the additional ability to depict a gross tumor that involves the urinary tract.0 cm.53 Reportedly.41. radioisotope bone scanning.50 Overall. when the size of the tumor cannot be adequately evaluated during the clinical examination. CT scanning and MRI are not warranted in patients with small-volume early disease (stage Ib disease and a cervical tumor diameter <2. In early-stage disease with a small tumor confined to the cervix.36. bladder. the depth of the cervical invasion.28. cystoscopy. CT scanning and MRI are more accurate staging modalities than US. Imaging with CT scanning or MRI is appropriate when the cervical tumor is larger than 2.48.21. Furthermore. and the locoregional extent of the disease (direct invasion of the parametrium. Clinical staging The International Federation of Gynecology and Obstetrics (FIGO) believes that any staging system should be universally feasible and applicable.47. or rectum).52.

0 cm in diameter. IVU. A meticulous. The major categories of the FIGO classification are as follows:  Stage 0 – Carcinoma in situ  Stage I – Invasive carcinoma that is strictly confined to the cervix  Stage II – Locoregional spread of the cancer beyond the uterus but not to the pelvic sidewall or the lower third of the vagina  Stage III – Cancerous spread to the pelvic sidewall or the lower third of the vagina. pelvic sidewalls. biopsy. The examinations permitted by FIGO for consideration in the clinicodiagnostic staging include palpation. without spread to the pelvic sidewall . and may not be an option in countries where the economic resources and surgical expertise are limited. and the quality of the imaging interpretation is not uniform or ensured. rectum. is not indicated for patients with advanced disease. cystoscopy. only clinical staging fulfills these criteria. and radiographic evaluation of the lungs and skeleton. Any suspected tumor invasion of the rectum or bladder should be confirmed by means of endoscopically guided biopsy. hysteroscopy. the technology and imaging techniques are variable. and bladder. and therefore. proctoscopy. colposcopy.According to FIGO. the staging classification of cervical cancer should be entirely based on findings from the pretreatment clinical evaluation. uterosacral ligaments. endocervical curettage. bimanual rectovaginal examination of the pelvis should be performed (preferably with the patient under anesthesia) to evaluate potential sites of locoregional tumor spread such as the parametrium. o Stage Ib2 – The primary tumor is greater than 4.  Stage IIa cervical carcinoma – Spread into the upper two thirds of the vagina without parametrial invasion  Stage IIb cervical carcinoma – Extension into the parametrium but not into the pelvic sidewall  Stage IIIa cervical carcinoma – Extension into lower one third of the vagina. Surgicopathologic staging is not available or feasible in patients with early disease who are receiving radiation therapy. Costly CT scanning and MRI examinations are generally not readily available worldwide.55 The physical examination is one of the most valuable components of the clinical staging process. inspection.0 cm in diameter. and/or hydronephrosis or a nonfunctioning kidney that is incident to invasion of the ureter  Stage IV – Cancerous spread beyond the true pelvis or into the mucosa of the bladder or rectum The FIGO stages are further categorized as follows:  Stage Ia cervical carcinoma – Preclinical invasive carcinoma that can be diagnosed only by means of microscopy  Stage Ib cervical carcinoma – A clinically visible lesion that is confined to the cervix uteri o Stage Ib1 – The primary tumor is not greater than 4.

and the detection of enlarged lymph nodes in the para-aortic. The use of intravenous iodinated contrast material for CT imaging is associated with a risk of significant allergic reactions (including fatal anaphylaxis).  Stage IIIb cervical carcinoma – Extension into the pelvic sidewall and/or causes a nonfunctioning kidney or hydronephrosis due to invasion of the ureter  Stage IVa cervical carcinoma – Extension of the tumor into the mucosa of the bladder or rectum  Stage IVb cervical carcinoma – Spread of the tumor beyond the true pelvis and/or by metastasis into distant organs The strict FIGO clinical staging guidelines do not include the status of the lymph nodes. any additional information that is revealed by cross-sectional imaging or surgery is primarily used for planning treatment regimens. Extended clinical staging with cross-sectional imaging (CT scanning and/or MRI) and surgicopathologic staging. and patient or respiratory motion. once the clinical stage is assigned on the basis of the clinical pretreatment workup results (in compliance with the FIGO guidelines). and complications due to its extravasation into the soft tissues at the injection site. including pelvic and abdominal retroperitoneal lymphadenectomy. Each has been proven to be superior to the conventional FIGO clinical staging system in determining the full extent of the tumor spread. although the presence of metastatic adenopathy is an important factor in treatment planning and in the prognosis. the stage should not be altered as a result of subsequent findings. Extended clinical staging with cross-sectional imaging (CT scanning and/or MRI) includes the status of the lymph nodes in the assessment of the extent of the disease. However. the incidence of lymph node metastases increases and the prognosis deteriorates with increased volume of the primary tumor. The detection of enlarged pelvic lymph nodes is considered equivalent to pelvic sidewall tumor extension (stage III). paracaval. in each stage. The major limitations of the FIGO clinical staging system are encountered in the estimation of the size of the primary tumor. MRI is contraindicated in patients who have vital metallic biomedical devices or metallic objects in strategic anatomic regions. provide additional diagnostic value. The size of the tumor is significant because. or inguinal regions is considered extrapelvic tumor spread (stage IV). Instead. nephrotoxicity. Other limitations occur in the evaluation of tumor extension into the parametrium and pelvic sidewalls and in the detection of metastatic lymphadenopathy or distant metastasis. an extremely large body habitus. and they should not be used to revise the assigned clinical stage. Limitations of Techniques CT scanning uses ionizing radiation and the CT image quality is degraded by metallic prostheses. MRI is more costly and less readily available than CT scanning and requires long image acquisition times. The image quality is degraded by . particularly when the tumor is endocervical.

US is operator dependent. or skin lesions. drains. which are likely to occur during the long image acquisition time. No effective gastrointestinal (GI) contrast material is currently available for MRI. a short range of target penetration with high-frequency transducers. The image quality is degraded by a large body habitus. and occasional patient intolerance of the transvaginal or transrectal approach. Claustrophobia deters some patients from undergoing MRI. and visualization of portions of the pelvis and abdomen is precluded by bowel gas and bony structures. dressings. Transvaginal US and transrectal US (TRUS) probes have inherent limitations.artifacts that are related to respiratory motion and bowel peristalsis. including a small field of view. . The transabdominal approach is also influenced by the degree of bladder filling and is impeded by the presence of surgical incisions.

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