Cervical Cancer: The Basics

Christopher Dolinsky, MD and Christine Hill-Kayser, MD

Updated By Lara Bonner Millar, MD

Affiliation: Abramson Cancer Center of the University of Pennsylvania

Last Modified: January 16, 2011

What is the cervix?

The cervix is the name for the lowest part of the uterus. The uterus is an organ that only women have,
and it is where a baby grows and develops when a woman is pregnant. During pregnancy, the uterus has
an enormous increase in size. When a woman is not pregnant, the uterus is a small, pear-shaped organ
that sits between a woman's rectum and her bladder. The cervix connects the uterus with the birth
canal (the vagina). The cervix can both be visualized and sampled by your doctor during a routine pelvic
examination in his or her office.

What is cervical cancer?

Cervical cancer develops when cells in the cervix begin to grow out of control and can then invade
nearby tissues or spread throughout the body. Large collections of cells that grow abnormally are called
tumors. Some tumors are not cancer, because they cannot spread or threaten someone's life. These are
called benign tumors. The tumors that can spread throughout the body or invade nearby tissues are
considered cancer and are called malignant tumors. Usually, cervix cancer is very slow growing, although
in certain circumstances it can grow and spread quickly.

Cancers are characterized by the cells that they originally form from. The most common type of cervical
cancer is called squamous cell carcinoma; it comes from cells that lie on the surface of the cervix known
as squamous cells. Squamous cell cervical cancer compromises about 80% of all cervical cancers. The
second most common form is adenocarcinoma; it comes from cells that make up glands in the cervix.
The percentage of cervical cancers that are adenocarcinomas has risen since the 1970s, although no one
knows exactly why. About 3% to 5% of cervical cancers have characteristics of both squamous and
adenocarcinomas and are called adenosquamous carcinomas. There are a few other very rare types like
small cell and neuroendocrine carcinoma that are so infrequent that they will not be discussed further
here.

Am I at risk for cervical cancer?

Cervical cancer is vastly more common in developing nations than it is in developed nations, and it is
fairly rare in the United States. In the U.S. in 2007, 12,280 women in the United States were diagnosed
with cervical cancer and 4,021 women in the United States died from cervical cancer. This puts cervical
cancer as the 12th most common cancer that women develop, and the 14th most common cause of
cancer death for women in the U.S. However, cervical cancer is the 2nd most common cause of cancer
death in developing nations, with about 370,000 new cases annually having a 50% mortality rate.
Decades ago, cervical cancer was the number one cause of cancer deaths in women in the U.S. There
has been a 75% decrease in incidence and mortality from cervical cancer in developed nations over the
past 50 years. Most of this decrease is attributed to the effective institution of cervical cancer screening
programs in the wealthier nations.

Although there are several known risk factors for getting cervical cancer, no one knows exactly why one
woman gets it and another doesn't. One of the most important risk factors for cervical cancer is
infection with a virus called HPV (human papilloma virus). HPV is a sexually transmitted disease that is
incredibly common in the population; most college-aged men and women have been exposed to HPV.
HPV is the virus that causes genital warts, but having genital warts doesn't necessarily mean you are
going to get cervical cancer. There are different subtypes, or strains, of HPV. Only certain subtypes are
likely to cause cervical cancer, and the subtypes that cause warts are unlikely to cause a cancer. Often,
infection with HPV causes no symptoms at all, until a woman develops a pre-cancerous lesion of the
cervix. It should be stressed that only a very small percentage of women who have HPV will develop
cervical cancer; so simply having HPV doesn't mean that you will get sick. However, almost all cervical
cancers have evidence of HPV virus in them, so infection is a major risk factor for developing it.

Because infection with a sexually transmitted disease is a risk factor for cervical cancer, any risk factors
for developing sexually transmitted diseases are also risk factors for developing cervical cancer. Women
who have had multiple male sexual partners, began having sexual intercourse at an early age, or have
had male sexual partners who are considered high risk (meaning that they have had many sexual
partners and/or began having sexual intercourse at an early age) are at a higher risk for developing
cervical cancer. Also, contracting any other sexually transmitted diseases (like herpes, gonorrhea,
syphilis, or Chlamydia) increases a woman's risk. HIV infection is another risk factor for cervical cancer,
but it may be so for a slightly different reason. It seems that any condition that weakens your immune
system also increases your risk for developing cervical cancer. Conditions that weaken your immune
system include HIV, having had an organ transplantation, and Hodgkin's disease. Another important risk
factor for developing cervical cancer is smoking. Smokers are at least twice as likely as non-smokers to
develop cervix tumors. Smoking may also increase the importance of the other risk factors for cancer.
Finally, being in a low socioeconomic group seems to increase the likelihood for developing and dying
from cervical cancer. This may be because of increased smoking rates, or perhaps because there are
more barriers to getting annual screening exams. Cervical cancer is one of the few cancers that affects
young women (in their twenties and even their teens), so no one who is sexually active is really too
young to begin screening. Additionally, the risk for cervical cancer doesn't ever decline, so no one is too
old to continue screening. Remember that all risk factors are based on probabilities, and even someone
without any risk factors can still get cervical cancer. Proper screening and early detection are our best
weapons in reducing the mortality associated with this disease.

How can I prevent cervical cancer?

Fortunately, there are several actions that women can take to decrease the risk of dying from cervix
cancer. The first of these is undergoing regular Pap testing. Pap tests will be discussed further in the next
section, but the reason that women have had such a drastic drop in cervical cancer cases and deaths in
this country has been because of the Pap test and annual screening.

Recently, two vaccines, called Gardasil and Ceravix have been developed. These vaccines have been
demonstrated to be effective in preventing infection with some strains of HPV, when given before a
person is exposed to HPV. For this reason, is the vaccines are recommended and approved for girls and
young women ages 9 – 26 years. Vaccination can also be given to boys, ages 9-26, to prevent genital
warts and further spread of HPV in women and men. HPV is also a cause of penile and anal cancers and
head & neck cancers.

For further prevention, women should try to reduce risk factors as much as possible. Don't start
smoking, and if you are already a smoker, it is time to quit. Smoking has been shown to decrease the
immune system’s ability to clear an HPV infection. Women can limit their numbers of sexual partners,
and delay the onset of sexual activity to reduce risk, as more partners increases the likelihood of
infection. Unfortunately, condoms do not protect you from developing HPV, so even though they can
protect you from other sexually transmitted diseases and HIV, they cannot help lower your risk for being
infected with HPV.

Many people are interested in preventing cervical cancer with vitamins or diets. Studies looking at beta-
carotene and folic acid for preventing cervical cancer have shown no benefit. Some people think that
anti-oxidants (like vitamin A and vitamin E) may play a role in cervical cancer prevention, but there is
currently no convincing data that would suggest so. Further studies need to be performed before any
nutritional recommendations can be made regarding cervix cancer prevention.
What screening tests are available?

Cervical cancer is considered a preventable disease. It usually takes a very long time for pre-cancerous
lesions to progress to invasive cancers and we have effective screening methods that can detect pre-
cancerous lesions that can generally be cured without serious side effects. Effective screening programs
in the United States have led to the drastic decline in the numbers of cervical cancer deaths in the last
50 years. For women who do end up with cervical cancer in developed nations, 60% of them either have
never been screened or haven't been screened in the last five years. The importance of regular cervical
cancer screening cannot be overstated.

The current hallmark of cervical cancer screening is the Pap test. Pap is short for Papanicolaou, the
inventor of the test, who published a breakthrough paper back in 1941. A Pap test is easily performed in
your doctor's office. During a pelvic examination, your doctor uses a wooden spatula and/or a brush to
get samples of cervical cells. These cells are placed on a slide, fixed, and sent to a laboratory where an
expert in examining cells under a microscope can look for cancerous changes. Many women find the
exam uncomfortable, but rarely painful. Depending on the results of the test, your doctor may need to
perform further examinations.

Although the Pap test is highly effective, it isn't a perfect test. Sometimes, the test may miss cells that
have potential to become an invasive cancer. The test shouldn't be performed when you are
menstruating; and if collection goes perfectly, even the best laboratories can miss abnormal cells. This is
why women need to have the tests performed on a regular basis.

In November 2009, the America College of Obstetricians and Gynecologists (ACOG) released updated
guidelines which recommend that women have their first Pap test at age 21. From ages 21 to 30,
screening should be done every 2 years. Women 30 years and older, who have had three consecutive
normal Paps, may decrease the screening to every three years. However, after having a new sexual
partner, these women need to go back to yearly Pap testing. The ACOG guidelines also note that women
with certain risk factors may need more frequent screening. These risk factors include being infected
with human immunodeficiency virus (HIV), being immunosuppressed, having been exposed to
diethylstilbestrol (DES) before birth, and having previously been treated for certain cervical
abnormalities or cancer.

Women aged 65 to 70 years who have had at least three normal Pap tests and no abnormal Pap tests in
the last 10 years may decide, after talking with their doctor, to stop having Pap tests. Women who have
had a hysterectomy (surgery to remove the uterus and cervix) do not need to have a Pap test, unless the
surgery was done as a treatment for a precancerous condition or cancer. Women who have had a
"subtotal or supracervical" hysterectomy still have a cervix, and need to continue Pap testing. Women
who have received the HPV vaccine should follow the same guidelines as unvaccinated women, as the
vaccine does not prevent infection with all strains of HPV.

HPV testing is frequently done along with the Pap test. HPV testing can theoretically find the vast
majority of women who are at risk for developing cervical cancer. The subtype of HPV predicts how
likely it is to lead to a cervical cancer. The DNA of cervical cells can be tested to identify high-risk types of
HPV that may be present. The FDA has approved HPV DNA tests for follow-up testing of women with
abnormalities on a pap test. HPV DNA tests are also approved for general cervical cancer screening of
women over the age of 30 when done together with a Pap test. Talk to your doctor about your options
and the availability of HPV testing in your area. There are currently no approved tests to detect HPV
infections in men.

What are the signs of cervical cancer?

Unfortunately, the early stages of cervical cancer usually do not have any symptoms. This is why it is
important to have screening Pap tests. As a tumor grows in size, it can produce a variety of symptoms
including:

* abnormal bleeding (including bleeding after sexual intercourse, in between periods, heavier/longer
lasting menstrual bleeding, or bleeding after menopause)

* abnormal vaginal discharge (may be foul smelling)

* pelvic or back pain

* pain on urination

* blood in the stool or urine

Many of these symptoms are non-specific, and could represent a variety of different conditions;
however, your doctor needs to see you if you have any of these problems.

Follow-up testing
Once a patient has been treated for cervix cancer, she needs to be closely followed for a recurrence. At
first, you will have follow-up visits fairly often. The longer you are free of disease, the less often you will
have to go for checkups. Your doctor will tell you when he or she wants follow-up visits, Pap tests, and/
or scans depending on your case. Your doctor will also do pelvic exams regularly during your office visits.
It is very important that you let your doctor know about any symptoms you are experiencing and that
you keep all of your follow-up appointments.

Clinical trials are extremely important in furthering our knowledge of this disease. It is through clinical
trials that we know what we do today, and many exciting new therapies are currently being tested. Talk
to your doctor about participating in clinical trials in your area.

This article is meant to give you a better understanding of cervical cancer. Use this knowledge when
meeting with your physician, making treatment decisions, and continuing your search for information.
You can learn more about cervical cancer on OncoLink through the related links to the left.

Prevention

Cervical cancer can often be prevented by preventing precancers and having regular Pap tests.
Preventing precancers means controlling possible risk factors, such as by:

* Delaying first sexual intercourse until the late teens or older

* Limiting the number of sex partners

* Avoiding sexual intercourse with people who have had many partners

* Avoiding sexual intercourse with people who are obviously infected with genital warts or show other
symptoms
 * Having safe sex by using condoms will reduce the risk of HPV infection. Condoms also protect
against HIV and AIDS.

* Quitting smoking

The Pap test is the most common test for cervical cancer. Researchers have found that combining it with
a test to detect HPV provides the most accurate results. In 2003, a U.S. Food and Drug Administration
(FDA) panel recommended that Pap tests and HPV tests be used together when screening for cervical
cancer in women older than 29. The HPV test and HPV genotyping (testing the strain of HPV) are already
being used as secondary tests for people with Pap test results that show abnormal cells to help doctors
determine a woman’s risk for developing cervical cancer.

In 2006, the FDA approved the first HPV vaccine, called Gardasil, for girls and women between ages 9
and 26. The vaccine helps prevent infection from the two HPV strains known to cause most cervical
cancers and precancerous lesions. The vaccine also prevents against two low-risk HPV strains that cause
90% of genital warts. In 2009, the FDA approved a second HPV vaccine, called Cervarix, for the
prevention of cervical cancer in girls and women ages 10 to 25. These vaccines do not protect people
who are already infected with HPV. Doctors still recommend regular Pap tests using the guidelines
below for all women. Learn more about HPV vaccination for cervical cancer.

In 2009, the American College of Obstetricians and Gynecologists updated its guidelines for cervical
cancer to recommend the following screening schedule:

* Starting at age 21, women should have Pap tests every two years.

* After three normal Pap tests in a row, women 30 and older may have Pap tests every 3 years.
Women with specific medical conditions, such as a history of abnormal Pap tests, infection with HIV, a
weakened immune system, or exposure to DES, should be screened more often.

* Women 30 and older may be tested for HPV with the Pap test. If both are normal, the tests are not
needed for another three years.
 * Starting at age 65 to 70, women can stop screening if they have had three normal Pap tests in a row
in the previous 10 years. However, they should continue screening if they are sexually active, have had
multiple sexual partners, or have a history of abnormal Pap tests.

The American Cancer Society and the U.S. Preventive Task Force recommend the following screening
guidelines:

* All women should begin having yearly Pap tests within three years of beginning vaginal sexual
intercourse, but no later than age 21.

* Women should be screened yearly with a conventional Pap test or every two years with liquid-based
tests. Women 30 and older who have had normal test results in a row can receive screening every two
to three years. Women older than 30 may also have a Pap test and the HPV test every three years.

* Women 70 or older can stop screening if their previous three Pap tests were normal and there were
no abnormal test results within the previous 10 years.

* Screening after a hysterectomy (removal of the uterus and cervix) is not necessary unless the
surgery was done to treat cervical cancer or precancer. Women who have had a hysterectomy without
removal of the cervix should continue screening until age 70.