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Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)

Authors
J Michael Straughn, Jr, MD
Catheryn Yashar, MD
Section Editor
Barbara Goff, MD
Deputy Editors
Sandy J Falk, MD, FACOG
Sadhna R Vora, MD
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INTRODUCTION

More than 11,000 American women develop cervical cancer each year. However, cervical cancer is a treatable condition, and there is a good chance of cure if the cancer is found and treated in the early stages.

This article discusses the diagnosis and treatment of women with early-stage cervical cancer. A separate article discusses issues specific to the treatment of early-stage cervical cancer in women who may want to become pregnant in the future. (See "Patient education: Fertility preservation in women with early-stage cervical cancer (Beyond the Basics)".)

More detailed information about cervical cancer, written for healthcare providers, is available by subscription. (See 'Professional level information' below.)

THE CERVIX

The cervix is the bottom part of the uterus (womb). The cervix opens into the vagina (figure 1).

The cervix is composed of two main types of cells. The outer layer of the cervix is covered with cells called squamous cells. “Squamous cell carcinoma of the cervix” is the name for a cancer that affects these cells.

The cervix also includes glandular (also called columnar) cells, which line the opening canal of the cervix that leads into the uterus (the endocervical canal). These cells can also become cancerous; when they do, they are called “adenocarcinoma of the cervix.”

Although they arise from different types of cells, squamous cell carcinoma and adenocarcinoma of the cervix are treated similarly in the early stages.

CERVICAL CANCER RISK FACTORS

Most cervical cancers are caused by infection with a virus called human papillomavirus (HPV).

HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital or mouth to genital contact). HPV infection can also cause a noncancerous condition called condyloma (genital warts). (See "Patient education: Genital warts in women (Beyond the Basics)".)

HPV infection is very common. Approximately 75 to 80 percent of sexually active adults will acquire a genital HPV infection before the age of 50. There are many types of HPV, and these affect different areas of the body. Most HPV infections are temporary because the body's immune system effectively clears the infection.

Of the HPV types that infect the cervix and surrounding areas (vagina, vulva, anus), most do not cause cancer. Some HPV types cause genital warts, which do not develop into cancer. The HPV types that are high risk for causing cancer will do so only if the infection persists. Approximately 10 to 20 percent of women with a cervical HPV infection will still have the infection after two years. More information about HPV testing is available in a separate article. (See "Patient education: Cervical cancer screening (Beyond the Basics)".)

Additional risk factors for cervical cancer include cigarette smoking and a weakened immune system (caused by certain diseases, medications, or HIV/AIDS).

CERVICAL CANCER SYMPTOMS

Typically, cervical cancer develops slowly over a period of several years. In some women, the cancer does not cause any symptoms, while in others it causes abnormal vaginal bleeding or discharge. This can include bleeding between menstrual periods, bleeding after sex, or bleeding after menopause. This bleeding may be no more than a spot of blood, or it may be heavy bleeding.

Abnormal vaginal bleeding can be caused by many other conditions, not related to cancer. If you have abnormal vaginal bleeding, make an appointment to see your doctor or nurse.

CERVICAL CANCER DIAGNOSIS

Cervical cancer is usually detected by a Pap test. Often, the Pap test detects abnormal cells when they are in the precancerous stage. Treatment of precancerous cells of the cervix can prevent cervical cancer. (See "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)" and "Patient education: Follow-up of high-grade abnormal Pap tests (Beyond the Basics)".)

If a Pap test shows abnormal cells, a biopsy is done. It is the biopsy that is used to diagnose cervical cancer. A biopsy involves removing a small piece of tissue from the cervix. This is done through the vagina. The biopsy is performed during an office visit using a procedure called colposcopy. The colposcope (similar to a large magnifying lens) magnifies the view of the cervix. This allows the clinician to better see the location, extent, and degree of very small abnormalities that may not be visible with the naked eye alone. (See "Patient education: Colposcopy (Beyond the Basics)".)

The tissue obtained during the biopsy is examined with a microscope to see if cervical cancer cells are present. In some cases, more of the cervix will need to be removed for biopsy; this is done through a procedure called cervical conization or a “cone biopsy” (figure 2). This can be done in the operating room (by a surgeon using either a scalpel or a special laser) or in the office using a loop electrosurgical excision procedure (LEEP). LEEP is performed with a device that uses an electric current to remove a piece of the cervix. You will usually get the results of the biopsy one to two weeks after the biopsy is done. (See "Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)".)

If your biopsy shows cervical cancer, you should see a doctor who specializes in cancers of the female reproductive system (called a gynecologic oncologist).

CERVICAL CANCER STAGING

Once cervical cancer is diagnosed, the next step is to determine the stage. Staging is a system used to describe the spread of a cancer.

Cervical cancer is staged mainly based upon the results of physical examination and imaging studies. The staging process includes a complete pelvic (internal) examination of the cervix, vagina, uterus, and ovaries. Other procedures may also be performed to look inside your bladder (cystoscopy) or rectum (anoscopy) to see whether the cancer has spread to these areas. You may be asked to undergo a chest X-ray, urinary tract imaging (X-ray, computed tomography [CT] scan, or magnetic resonance imaging [MRI]), or bone X-rays to detect whether the cancer has spread outside the pelvis or to other organs.

A cervical cancer's stage is assigned based on:

The size of the cancer

How deeply the cancer has invaded into the tissue surrounding the cervix

If there are signs of cancer in the vagina, pelvis, bladder, rectum, or local lymph nodes (figure 3)

If there are signs of cancer spread to distant organs (eg, the liver, lungs, or bone)

Additional procedures may be done to see whether and where the cervical cancer has spread, although these will not change the official stage. This may include tests or procedures to evaluate spread to lymph nodes. These may include imaging tests (CT scan, positron emission tomography [PET] scan) or surgery to examine the lymph nodes.

CERVICAL CANCER TREATMENT OPTIONS

There are several options for treatment of early-stage cervical cancer. Decisions about treatment depend on the stage of the cancer, your age and health, and your and your doctor's preferences.

The most common treatment for early-stage cervical cancers is radical hysterectomy (surgical removal of the cervix, uterus, and surrounding tissues called the parametrium). The alternative is radiation therapy, which is usually given in combination with chemotherapy. Some women with the earliest stage cervical cancers can be treated with cervical conization (figure 2) or simple hysterectomy. For a simple hysterectomy, the cervix and uterus are removed, but not surrounding tissues; this is the same procedure women have for benign problems with the uterus, such as fibroids. (See "Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)" and "Patient education: Abdominal hysterectomy (Beyond the Basics)".)

It is not possible to become pregnant after having a hysterectomy or pelvic radiation therapy. In women with early-stage cervical cancer, it is sometimes possible to have a less aggressive treatment (such as cervical conization) which would allow you to carry a pregnancy. These issues are discussed separately. (See "Patient education: Fertility preservation in women with early-stage cervical cancer (Beyond the Basics)".)

Radical hysterectomy and lymph node evaluation — Radical hysterectomy is a surgical procedure that involves removing the uterus, cervix, some of the vagina, and connective tissues surrounding the cervix and uterus (parametrium) (figure 4). The ovaries do not necessarily have to be removed during a radical hysterectomy for cervical cancer; this decision depends upon your age and other factors. (See "Patient education: Abdominal hysterectomy (Beyond the Basics)", section on 'Removal of ovaries'.)

At the time of radical hysterectomy, the lymph nodes in the pelvis, and sometimes higher up in the abdomen, are removed and evaluated to check for spread of cancer.

The surgery is usually performed through an incision in the abdomen. Alternately, surgery can be done through several small incisions, either laparoscopically or robotically. The surgical approach depends on your and your surgeon's preference and other factors.

The surgery generally takes approximately three to four hours. Most women stay in the hospital for two to three days after surgery.

Some women with early-stage cervical cancer need “adjuvant” (additional) treatment in addition to surgery. This may include radiation and possibly chemotherapy. Adjuvant therapy is given if the tissue removed during the surgery shows risk factors for the cancer coming back after surgery. Risk factors include a large or deeply invasive tumor, or cancerous cells found in blood vessels or lymph vessels, at the margins (edges) of the tissue, or in lymph nodes.

Radiation therapy — Radiation therapy (RT) refers to the use of high-energy X-rays to stop the growth of the cancer. There are two ways to deliver radiation therapy: brachytherapy and external beam radiation therapy (EBRT).

Brachytherapy is delivered through a device that is temporarily placed in the vagina, either intermittently or continuously over several days. In some cases it may be necessary for the treatment to be delivered in the hospital, while in others it may be given at home. Brachytherapy alone is adequate treatment for the earliest stage cervical cancers.

In women with more advanced disease, EBRT is generally added to brachytherapy to decrease the chance of the cancer coming back. With EBRT, the source of the radiation is outside the body. The area to be treated (referred to as the radiation "field") is designed carefully to limit the amount of radiation directed at healthy tissue. During EBRT, your body is positioned beneath the X-ray machine in the same way every day, and the radiation field is exposed to the radiation beam for a few seconds (similar to having an X-ray) once per day, five days per week for five to six weeks. This is done as an outpatient procedure, and you can usually continue your normal daily activities during treatment.

Side effects of radiation therapy — Possible short-term side effects of RT include:

Feeling tired

Needing to empty your bladder frequently

Discomfort with urination

Loose stools and feeling the need to have a bowel movement frequently

Pubic hair falling out

Discomfort with intercourse

Most of these problems resolve when treatment is completed.

Longer-term side effects can include:

Urine leakage or stool leakage through the vagina (unusual)

More frequent urination

Pain or bleeding with bowel movements

More frequent bowel movements or diarrhea, especially with certain foods

Narrowing or scarring of the vagina, which can cause pain during sex

Bowel obstruction so that food cannot pass through the bowels

Weakened pelvic bones

Menopause

If you are sexually active, ask your doctor or nurse about specific things that you can do to prevent pain during sex after treatment. This might include using a vaginal dilator during and after treatment. (See 'Sexual issues after treatment' below.)

Chemotherapy — Most women who undergo EBRT for cervical cancer are given chemotherapy along with the radiation therapy (an approach termed “chemoradiotherapy”). Chemotherapy drugs are medicines that stop or slow the growth of cancer cells.

Chemotherapy has the ability to enhance the damaging effect of RT on cervical cancer cells; when chemotherapy drugs are used in this manner, they are referred to as "radiation sensitizers." The chemotherapy is usually given in a vein (IV) once per week during the course of EBRT.

Support during treatment — Most women and families affected by cervical cancer worry about their short- and long-term health and the risk of the cancer coming back. You might continue to worry for many years after treatment ends.

It is important to talk openly and honestly with your family and healthcare team. Many women benefit from bringing a family member or friend to doctor visits; this person can help you to understand your options, ask important questions, take notes, and feel supported.

A variety of support options are available, both during and after treatment, including individual counseling, support groups, and Internet-based discussion groups. A list of reputable groups is available below. (See 'Where to get more information' below.)

CERVICAL CANCER PROGNOSIS

Every person with cancer is different, and it is difficult to predict what an individual woman should expect in the future. The chances that early-stage cervical cancer can be cured are good in most cases. When discussing chances of cure, it is important to remember that these numbers represent averages and do not necessarily predict what will happen to you.

The survival rates for women with early-stage cervical cancer who have standard treatment are excellent. In the earliest stages (IA, meaning that the cancer is confined to the cervix, only visible under a microscope, and no more than 5 mm deep and 7 mm wide) at five years after diagnosis, approximately 95 percent of women are alive. This means that 5 percent of women died, although the cause of death was not necessarily related to the cancer. For slightly larger cancers (stage IB1, meaning that the cancer is confined to the cervix, visible without a microscope, and smaller than 4 cm), approximately 90 percent of women are alive at five years after diagnosis. The chance of the cancer coming back or spreading to other organs and becoming life-threatening may increase if it has spread to the lymph nodes.

CERVICAL CANCER FOLLOW-UP

Monitoring — After cervical cancer treatment, periodic follow-up testing and examination are recommended. There is no established schedule of testing and follow-up visits. Based on research findings and recommendations of expert groups, this is our general approach to cervical cancer follow-up [1-3]:

A careful physical examination every three to four months for two years, then every six months during years 3 to 5, and annually thereafter.

Cervicovaginal cytology (Pap smear) annually.

Other tests, including blood tests, pelvic ultrasound, and magnetic resonance imaging (MRI) are not recommended for women who have no symptoms that suggest a cancer recurrence.

Sexual issues after treatment — Changes after cervical cancer treatment may include vaginal shortening or narrowing, and decreased vaginal lubrication. In addition, women who were premenopausal before treatment may become postmenopausal (ie, stop having monthly periods and no longer have ovarian function) as a result of pelvic radiation or chemotherapy. These physical changes impact sexual satisfaction because they may lead to pain during intercourse, difficulty having intercourse because of narrowing or shortening of the vagina, lack of interest in sex, and difficulty having an orgasm.

Using a vaginal moisturizer or lubricant during intercourse can relieve some of these bothersome symptoms. Your doctor may also discuss the use of hormonal therapy to alleviate some of your symptoms, but this may depend on your age at diagnosis as well as other factors. If you have radiation therapy, you may be taught how to use a vaginal dilator (a device that is placed in the vagina several times a week) to prevent shortening or narrowing. Counseling for sexual and/or psychological difficulties may also be helpful. (See "Patient education: Sexual problems in women (Beyond the Basics)".)

CLINICAL TRIALS

Progress in treating cervical cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials, or read about clinical trials at:

www.cancer.gov/clinicaltrials/

http://clinicaltrials.gov/

Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Cervical cancer (The Basics)
Patient education: Human papillomavirus (HPV) vaccine (The Basics)
Patient education: Pap tests (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)
Patient education: Follow-up of high-grade abnormal Pap tests (Beyond the Basics)
Patient education: Fertility preservation in women with early-stage cervical cancer (Beyond the Basics)
Patient education: Colposcopy (Beyond the Basics)
Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)
Patient education: Abdominal hysterectomy (Beyond the Basics)
Patient education: Sexual problems in women (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention
Clinical trials of human papillomavirus vaccines
Epidemiology of human papillomavirus infections
Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis
Management of early-stage cervical cancer
Management of locally advanced cervical cancer
Invasive cervical cancer: Staging and evaluation of lymph nodes
Management of recurrent or metastatic cervical cancer
HIV infection and malignancy: Epidemiology and pathogenesis
Preventive care in adults: Recommendations
Preinvasive and invasive cervical neoplasia in HIV-infected women
Radical hysterectomy
Recommendations for the use of human papillomavirus vaccines
Virology of human papillomavirus infections and the link to cancer
Small cell neuroendocrine carcinoma of the cervix
Invasive cervical adenocarcinoma

The following organizations also provide reliable health information.

American Society of Clinical Oncology

(www.cancer.net/cervical)

The Gynecologic Cancer Foundation

     (www.thegcf.org)

National Comprehensive Cancer Network

     (www.nccn.com)

Gynecologic Oncology Group

     (www.gog.org/gynecologiccancerinformation.html)

National Cancer Institute

     1-800-4-CANCER
     (www.cancer.gov)

American Cancer Society

     1-800-ACS-2345
     (www.cancer.org)

The National Cervical Cancer Coalition

     (www.nccc-online.org)

[1,2,4-8]

ACKNOWLEDGMENT

The authors and editors would like to recognize Dr. Jennifer De Los Santos, who contributed to previous versions of this topic review.

Literature review current through: Nov 2016. | This topic last updated: Tue Mar 22 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
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  1. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  2. American College of Obstetricians and Gynecologists.. ACOG practice bulletin. Diagnosis and treatment of cervical carcinomas. Number 35, May 2002. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 2002; 78:79.
  3. Elit L, Fyles AW, Devries MC, et al. Follow-up for women after treatment for cervical cancer: a systematic review. Gynecol Oncol 2009; 114:528.
  4. Nag S, Chao C, Erickson B, et al. The American Brachytherapy Society recommendations for low-dose-rate brachytherapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2002; 52:33.
  5. Benedet JL, Bender H, Jones H 3rd, et al. FIGO staging classifications and clinical practice guidelines in the management of gynecologic cancers. FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet 2000; 70:209.
  6. Green J, Kirwan J, Tierney J, et al. Concomitant chemotherapy and radiation therapy for cancer of the uterine cervix. Cochrane Database Syst Rev 2005; :CD002225.
  7. Keys HM, Bundy BN, Stehman FB, et al. Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J Med 1999; 340:1154.
  8. Rotman M, Sedlis A, Piedmonte MR, et al. A phase III randomized trial of postoperative pelvic irradiation in Stage IB cervical carcinoma with poor prognostic features: follow-up of a gynecologic oncology group study. Int J Radiat Oncol Biol Phys 2006; 65:169.

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.