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

INTRODUCTION — More than 14,000 Americans develop cervical cancer each year. However, cervical cancer is a treatable condition, and there is an excellent chance of cure if the cancer is found and treated in the early stages.

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

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

CANCER CARE DURING THE COVID-19 PANDEMIC — COVID-19 stands for "coronavirus disease 2019." It is an infection caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and has since spread throughout the world. Getting vaccinated lowers the risk of severe illness; experts recommend COVID-19 vaccination for anyone with cancer or a history of cancer.

In some cases, if you live in an area with a lot of cases of COVID-19, your doctor might suggest rescheduling or delaying medical appointments. But this decision must be balanced against the importance of getting care to screen for, monitor, and treat cancer. Your doctor can talk to you about whether to make any changes to your appointment schedule. They can also advise you on what to do if you test positive or were exposed to the virus.

THE CERVIX — The cervix is the bottom part of the uterus. 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 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. The HPV types that are high risk for causing cancer will do so if the infection persists. Approximately 10 to 20 percent of people with a cervical HPV infection will still have the infection after two years. More information about HPV testing and the HPV vaccine (to prevent infection with types of HPV known to cause cervical cancer) is available separately. (See "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)

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

CERVICAL CANCER SYMPTOMS — Typically, cervical cancer develops slowly over several years. In some cases, the cancer does not cause any symptoms, while in others it causes abnormal vaginal bleeding or discharge. This can include vaginal bleeding between menstrual periods, bleeding after sex, or bleeding after menopause. This bleeding may be spotting or 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 health care provider.

CERVICAL CANCER DIAGNOSIS — Pap testing and human papillomavirus (HPV) testing are commonly used together to screen for 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 or glandular cell abnormal Pap tests (Beyond the Basics)".)

If a Pap test shows abnormal cells, further testing is essential, as treatment of abnormal cells of the cervix can prevent cervical cancer. A biopsy of the cervix involves removing a small piece of tissue from the cervix. 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 cervical 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 either in the operating room by a surgeon using a scalpel 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 upon the results of physical examination and imaging studies. The staging process includes a complete pelvic examination of the cervix, vagina, uterus, and ovaries. A rectal examination is usually done as well. 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 computed tomography (CT) scan, positron emission tomography (PET) scan, or magnetic resonance imaging (MRI) to detect whether the cancer has spread outside the pelvis or to other organs. Additional procedures may be done to see whether and where the cervical cancer has spread, although these may not change the official stage.

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 may not change the official stage.

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 (RT), which is usually given in combination with chemotherapy. Some people 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 used to treat certain noncancer problems affecting 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 RT. In people 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 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 and fallopian tubes'.)

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.

A hysterectomy is often done through an incision in the abdomen ("laparotomy"); several smaller incisions (a "minimally invasive" approach) may be used in certain situations. Studies suggest that when done to treat cervical cancer, the laparotomy approach is associated with better outcomes for most people; a minimally invasive approach may be considered if the tumor is small (<2 cm).

Hysterectomy generally takes approximately three hours. Most people stay in the hospital for one to two days after surgery.

Some people with early-stage cervical cancer need more treatment in addition to surgery. This may include radiation and possibly chemotherapy. Additional treatment 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, in the surrounding tissues (parametria), 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 kill the cancer cells. There are two ways to deliver radiation therapy: brachytherapy (BT) and external beam radiation therapy (EBRT).

●BT is delivered through a device that is temporarily placed in the vagina and uterus, 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 in the office.

●With EBRT, the source of the radiation is outside of 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 RT may include effects on bowel or bladder function (eg, frequent urination), vaginal narrowing leading to painful sex, or menopause.

Ask your doctor or nurse about how to prevent or manage these side effects. To prevent vaginal narrowing, you may be advised to use a device called a vaginal dilator. (See 'Sexual issues after treatment' below.)

Chemotherapy — Most people who undergo EBRT for cervical cancer are given chemotherapy along with the RT (an approach termed "chemoradiation"). 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 once per week during the course of EBRT.

Support during treatment — Most people 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 health care team. Many people benefit from bringing a family member, partner, 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 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 people with early-stage cervical cancer who have standard treatment are excellent. For people with the earliest stages (stage IA) of cancer, approximately 95 percent are alive at five years after diagnosis. This means that 5 percent died, although the cause of death was not necessarily related to the cancer. For people with slightly larger cancers (stage IB1, meaning that the cancer is confined to the cervix and smaller than 2 cm), approximately 90 percent 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. Based on research findings and recommendations of expert groups, this is our general approach to cervical cancer follow-up:

●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, computed tomography (CT), CT with positron emission tomography (PET), and magnetic resonance imaging (MRI), are not recommended for routine follow-up. These may be done if you develop any 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, if you have not already gone through menopause before treatment, you may become postmenopausal (ie, stop having monthly periods and no longer have ovarian function) as a result of pelvic radiation, surgical removal of the ovaries, 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. If this happens, treatments are available that can help.

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 females (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 health care 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 health care 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) (The Basics)
Patient education: Human papillomavirus (HPV) vaccine (The Basics)
Patient education: Cervical cancer screening 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 or glandular cell abnormal Pap tests (Beyond the Basics)
Patient education: Fertility preservation in 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 females (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
Human papillomavirus infections: Epidemiology and disease associations
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
Preinvasive and invasive cervical neoplasia in patients with HIV infection
Radical hysterectomy
Human papillomavirus vaccination
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)

●Gynecologic Oncology Group

(www.gog.org)

●National Cancer Institute

1-800-4-CANCER

(www.cancer.gov)

●American Cancer Society

●The National Cervical Cancer Coalition

(www.nccc-online.org)

●The American Club of Therapeutic Radiologists (ASTRO)

(www.astro.org/Patient-Care-and-Research/Patient-Education)

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ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jennifer F De Los Santos, MD, who contributed to an earlier version of this topic review.