INTRODUCTION

More than 10,000 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 the treatment of early stage cervical cancer in women who want to become pregnant in the future. (See "Patient information: Cervical cancer treatment for women who desire future pregnancy; early stage cancer".)

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 SYMPTOMS

Typically, cervical cancers develop slowly over a period of several years. In some women, the cancer does not cause any symptoms initially while in others it causes abnormal vaginal discharge or bleeding. 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.

Abnormal bleeding can also be caused by a number of 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 diagnosed with a cervical biopsy. A biopsy involves removing a small piece of tissue. The biopsy is performed during an office visit using a procedure called colposcopy. (See "Patient information: Colposcopy".)

The tissue obtained during the biopsy is analyzed with a microscope to see if cervical cancer cells are present. In some cases, a larger biopsy called cervical conization is needed (figure 1).

If a 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 its stage. Staging is a system used to describe the aggressiveness and spread of a cancer. 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, or local lymph nodes (figure 2)
• If there are signs of cancer spread to other organs

Cervical cancer stages range from stage 0 (cancer has not invaded through the first layer of the cervix) to stage IV (the cancer has spread to distant organs, such as the liver). In general, lower stage cancers are less aggressive and require less treatment than higher stage cancers.

CERVICAL CANCER TREATMENT OPTIONS

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

The most common treatment for early stage cervical cancers is radical hysterectomy (surgical removal of the cervix and uterus). The alternative is radiation therapy, which is usually given in combination with chemotherapy. Patients with the earliest stage cervical cancers can be treated with cervical conization or simple hysterectomy alone. (See "Patient information: Treatment of abnormal Pap smears".) for information about conization and (see "Patient information: Abdominal hysterectomy" for information about simple hysterectomy).

It is not possible to become pregnant after having hysterectomy or radiation therapy. In women with early stage cervical cancer, it is sometimes possible to have a less aggressive treatment, which would allow you to carry a pregnancy. These issues are discussed separately. (See "Patient information: Cervical cancer treatment for women who desire future pregnancy; early stage cancer".)

Radical hysterectomy — Radical hysterectomy is a surgery that involves removing the uterus, cervix, and some of the vagina (figure 3). The ovaries do not necessarily have to be removed during a hysterectomy; this decision depends on your age and other factors. (See "Patient information: Abdominal hysterectomy", section on 'Removal of ovaries'.)

The surgery is usually performed through an incision in the abdomen (figure 4). Alternately, surgery can be done through several small incisions using a laparoscope. The surgical approach depends on your surgeon's preference and other factors.

The surgery generally takes 2.5 to four hours. Most women stay in the hospital for two to three days after surgery.

If abnormal or cancerous cells are found at the margins (edges) of the tissue or lymph nodes that are removed, or if the tumor has other features that increase the risk that the cancer will come back, further (adjuvant) treatment is recommended. This generally includes both radiation therapy and chemotherapy.

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 or external beam radiation therapy (EBRT).

Brachytherapy — Brachytherapy delivers radiation from a device that is temporarily placed inside the vagina. This delivers a high dose of radiation to the area where cancer cells are most likely to be found, hopefully minimizing the effects of radiation on healthy tissues.

There are two types of vaginal brachytherapy: low dose rate and high dose rate.

• Low dose rate brachytherapy uses a device that delivers radiation through the vagina for two or three days, 24 hours per day. You stay in the hospital during this treatment.
• High dose rate brachytherapy also uses a device that delivers radiation through the vagina. However, the device is placed in the vagina for only for a few minutes at a time once a day, and treatment is generally repeated three to five times. This treatment is generally given as an outpatient, and women who get high dose rate brachytherapy do not have to stay in the hospital overnight. You can usually continue your normal daily activities during treatment.

External beam radiation therapy (EBRT) — With external beam radiation therapy (EBRT), the source of the radiation is outside the body, and 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, and you can usually continue your normal daily activities during treatment.

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 [1].

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

Most of these problems resolve when treatment is completed.

Longer term side effects can include:

• Urine leakage
• Pain or bleeding with bowel movements
• Narrowing or scarring of the vagina, which can cause pain with sex

If you are sexually active, ask your doctor or nurse about specific things that you can do to prevent pain with 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 during the radiation therapy (an approach termed chemoradiotherapy). Chemotherapy drugs are medicines that stop or slow the growth of cancer cells.

Chemotherapy also has the ability to enhance the damaging effect of radiation therapy 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.

CERVICAL CANCER FOLLOW UP

Monitoring — After cervical cancer treatment, periodic follow-up testing and examination are recommended. Expert groups recommend the following [2]:

• An exam every three months for one year, every four months for one year, every six months for three years, and then once per year. This usually involves a physical exam and Pap test (cervical cytology).
• Annual chest x-ray (there are few data to support the benefit of annual chest x-rays and many doctors do not recommend them).

Sexual issues after treatment — Vaginal changes after cervical cancer treatment may include shortening, narrowing, and decreased vaginal lubrication. These physical changes impact sexual satisfaction because they may lead to pain during intercourse, lack of interest in sex, difficulty having an orgasm, and decreased frequency of sexual activity. If the vagina is severely narrowed, use of vaginal dilators may help.

Using a vaginal moisturizer or lubricant during intercourse can relieve some of these bothersome symptoms. Counseling for sexual and/or psychological difficulties may also be helpful. (See "Patient information: Sexual problems in women".)

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/clinical_trials/learning/
• www.cancer.gov/clinical_trials/
• http://clinicaltrials.gov/

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 every four months 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

Patient information: Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL)
Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)
Patient information: Cervical cancer treatment for women who desire future pregnancy; early stage cancer
Patient information: Colposcopy
Patient information: Treatment of abnormal Pap smears
Patient information: Abdominal hysterectomy
Patient information: Sexual problems in women

Professional level information

Cervical intraepithelial neoplasia: Definition, incidence, and pathogenesis
Clinical trials of human papillomavirus vaccines
Epidemiology of human papillomavirus infections
Invasive cervical cancer: Epidemiology, clinical features, and diagnosis
Invasive cervical cancer: Management of early stage disease (FIGO IA, IB1, nonbulky IIA1) and special circumstances
Invasive cervical cancer: Management of stages IB2, bulky IIA2, and locally advanced disease
Invasive cervical cancer: Staging
Management of adenocarcinoma and neuroendocrine carcinoma of the cervix
Management of recurrent or disseminated squamous cell cervical cancer
Overview of AIDS-defining malignancies in HIV infection
Overview of preventive medicine in adults
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
Patient information: Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL)
Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)

The following organizations also provide reliable health information.

• American Society of Clinical Oncology

       (www.cancer.net/portal/site/patient)

• 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.ncc-online.org)

Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com Cancer Forum

      (http://cancer.about.com/forum)

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