1. Cervical Cancer

2. New cancer diagnoses in the U.S.
Statistics:
Breast ,300
Uterus (womb) ,100
Ovary ,400
Cervix ,200
Vulva ,000
Cancer still drastically changes the lives of many women in the U.S., but with the empowerment of knowledge, more women are participating in prevention and screening activities which are reducing the risk of dying of these diseases. Cervical cancer rates are still far higher than they should be since over half of the women with this diagnosis have not had a Pap test in over three years. This educational material is designed to improve participation in screening practices through a better understanding of benefits.

3. What is cervical cancer?
It is a cancer of the female reproductive tract
It is the most common cause of cancer death in the world where Pap tests are not available
It is the easiest gynecologic cancer to prevent through screening
Where Pap tests are not available for screening, cervical cancer is the number one cancer killer of women. Cervical cancer typically affects women at younger ages than other gynecologic cancers. That’s why we urge all reproductive-age women to educate themselves and to participate in screening.
The Pap test has reduced the risk of cancer by early detection of cells destined to become cancer.

4. What is the female reproductive tract?
Vulva
Vagina
Cervix
Uterus
Fallopian tubes
Ovaries
The vulva is the female external genitalia, just outside the vagina. The vagina is located between the vulva and the bottom of the womb (the cervix). The cervix is responsible for keeping babies inside the womb until the baby is mature enough for delivery. The uterus is where the fertilized eggs implant, and it houses babies for nine months. It is also responsible for menstrual cramps through its muscular contractions. The fallopian tubes transport eggs and sperm. The ovary is responsible for monthly production of eggs as well as for hormone production.
Because there are often no symptoms with early cervical cancer and a woman cannot see her own cervix, regular cancer screening examinations are important to find early changes.

5. How common is cervical cancer?
500,000 women worldwide die of cervical cancer annually
50-60 million women in the U.S. have a Pap test each year
3-5 million women in the U.S. have an abnormal result
12,200 new cervical cancers diagnosed in the U.S. per year
4,100 deaths from cervical cancer in the U.S. per year
Most women who have cervical cancer have not had Pap tests regularly. In 2001, depending on age, 72% to 88% of U.S. women had a Pap test in the past three years. Cervical cancer is uncommon in this group of screened women.
Abnormal results of the Pap test are common and do not always mean precancer. Women should talk with their health care provider about any abnormal results. Do not be afraid. Effective treatment is available if needed.
Most cervical cancer can be prevented

6. What causes cervical cancer?
The central cause of cervical cancer is human papillomavirus or HPV:
HPV is sexually transmitted
The HPV detected today could have been acquired years ago
There are many different types of HPV
Low-risk types can cause warts
High-risk types can cause precancer and cancer of the cervix
The cause of cervical cancer is a sexually transmitted virus, called human papillomavirus. There are many HPV types and only some cause cancer. HPV infections (even high-risk types) usually go away without treatment. Low-risk HPV types can cause genital warts. The high-risk types cause most abnormal pap smears, precancer and cancer of the cervix, vagina, and vulva.

7. If I have HPV, does it mean I will get cancer?
NO!
In most cases HPV goes away
Only women with persistent HPV (where the virus does not go away) are at risk for cervical cancer
Most men and women who have HPV never know they are infected. The HPV can be detected by a DNA test. Women with infections that do not go away for years are at highest risk of precancer and cancer.
HPV testing is new, and many women will first hear about this virus when they have an abnormal Pap test or a positive HPV test. If you don’t have HPV you are at low risk for developing cervical cancer. If you test positive for HPV talk to your health care provider about the next steps. You are not alone. This is a very common infection.

8. How common is HPV?
Most men and women who have had sex have been exposed to HPV
More than 75% of sexually active women tested have been exposed to HPV by age 18-22
This is a very common virus.
Studies demonstrate that most sexually active women have had HPV at some time. In fact, HPV infection is so common in women ages 18-29, that current recommendations for screening advice against testing women in this age group.

9. Who is at risk? Women who have ever had sex
Women who have had more than one partner
Women whose partner (s) has had more than one sexual partner
Women with other sexually transmitted diseases
Most women are at risk since sex is a normal adult activity. The more partners a woman has the greater her chances of being infected with HPV. Studies show that even women who report one lifetime sexual partner have about a 10% chance of having HPV infection.
We really don’t know everything about how this virus is transmitted.

10. Who is at risk? Women who do not have Pap tests
Women with immune problems
Steroid medications
Transplanted organs
Chemotherapy
HIV
Women who smoke
The risk for cervical cancer increases with each additional factor listed.
All of our bodies have the ability to fight infections. Some of our bodies are more effective fighters of HPV than others. A weakened immune system from any cause makes the body less able to fight the virus.
Women who smoke are more likely to get cervical precancer and cancer. Tobacco may contribute to cervix cancer risk in multiple ways. First, tobacco decreases the bodies ability to fight off infections like HPV. Second, some of the carcinogenic chemicals found in tobacco are concentrated in the mucous made by the cervical glands. When a woman who smokes has an HPV infection, the carcinogens and the virus are a “double hit” for her cervix.

11. What is a Pap test?
A test which collects cells from the surface of the cervix and looks for any abnormal cells
Abnormal cells can be treated before cervical cancer develops
When cancer is detected early, it is easier to treat
When you have a Pap test, your health care provider scrapes cells from the cervix and places them on a microscope slide or into a jar containing liquid. Laboratory tests are run to find out if there are any abnormal cells.
If abnormalities are found, you will be notified to return for repeat testing. If precancer changes are found, they are easily treated, but follow-up is necessary.
Unlike mammograms, chest X-rays and the PSA test for prostate cancer, Pap tests can detect changes before cancer develops.

12. When do I need my first Pap test?
Three years after the onset of sexual intercourse
No later than age 21
Current knowledge suggests it takes at least three years for cervical cancer to develop. Since cervical cancer is sexually transmitted, you should have your first Pap test three years after you have sex or when you are 21, whichever comes first.

13. How often do I need a Pap test?
Every year until age 30
After age 30, if you have only had normal results, you may have them every two to three years after discussion with your physician and evaluation of your risk factors
The American Cancer Society recommends annual Pap tests until age 30. If the new liquid-based test is used, you can be screened every two years.
Women 30 and older may be screened every two to three years if you have three normal tests in a row. If the new combination HPV and Pap test is used, you can wait three years between tests.

14. I feel fine, so why do I need a Pap test?
A Pap test can find treatable changes of the cervix (precancer) before you have a symptom or notice a problem
Once a problem is symptomatic, it is harder to treat
The purpose of the Pap test is to find problems before symptoms occur. Once symptoms occur, the success rate for treatment goes down. It is possible to prevent cervical cancer because precancers can be detected with Pap tests and treatment started.

15. Why do I need to keep getting tested?
The test is not perfect
Changes (abnormalities) may occur since the last test
It may take many years for changes to develop or be detected
Your risk changes if you have new partners
New testing options are making Pap test more accurate. However, it is still possible for an abnormality to be missed. Repeat testing improves the odds of finding any abnormalities.
It is possible to have your first Pap test abnormality many years after you had sex with an infected partner.
Realize also that a woman’s risk can change. You may have a new sexual partner or your partner may have a new partner.

16. What is the best time to have a Pap test?
Schedule your Pap when you are not having a menstrual period
It is best to abstain from intercourse and avoid use of tampons or douches for two days before your Pap test
A routine Pap test should be performed between periods. If you are having abnormal bleeding, make an appointment as soon as possible. Keep your appointment because the bleeding may be a sign of cancer.

17. What should I expect when I have a Pap test?
Feet are placed in stirrups (foot holders)
A speculum (thin duck-billed instrument) is inserted into vagina to see the cervix
You may have brief discomfort which is usually mild
You may have some spotting afterward
Like any new experience you may wonder what will happen during your first Pap test.
If you have concerns during the test, tell your health care provider.
Even if you find a Pap test embarrassing or mildly uncomfortable, it is worth it.

18. How do I find out about my Pap test results?
You may ask to have a copy mailed to you
You may call for your results
If you have an abnormal result, it is extremely important to follow-up for the recommended testing
Even after a normal Pap test, it is still important to report any symptoms of abnormal vaginal bleeding, discharge or pain to your doctor and call to be seen right away
You can feel in control of your health by taking responsibility for knowing the results of all of your tests. Be sure you receive your results. Do not assume that a lack of a letter or phone call, means everything is ok. If you have not received your results in a reasonable amount of time, call your provider’s office.
Remember that you know your body best. If something doesn’t seem right, even if you have had a normal Pap test, make an appointment with your health care provider.

19. Do I need a Pap test if I had a hysterectomy?
If you had treatment for precancer or cancer of the cervix, you may need a Pap test
If the cervix was left in place at the time of your hysterectomy, you will still need Pap tests
Preventive health care is still important even if you do not need a Pap test
The American Cancer Society recommends that you have a Pap test four to six months after your hysterectomy if your surgery was done for moderate to severe dysplasia or cancer. If you have three normal Pap tests in a row following your hysterectomy you may discontinue Pap tests.
If you had a hysterectomy, and did not have a previous cancer or precancer, you are at very low risk. A Pap test is not recommended, but other preventive health care is still important.

20. What is new in screening and prevention?
Liquid cytology-thin layer cytology
Combination of HPV test and Pap is now available for women 30 years of age and older
Pap test computer reviews
Vaccines for HPV currently being tested
Women who are younger may have the liquid-based Pap test, which only needs to be repeated every two years. The Pap test also might be sent to a computer for confirmation of a negative result.
If you are 30 or over, there is a new test that combines the HPV DNA test with a Pap test. It tells you if the cells look normal and if high-risk HPV DNA is present. This combined test only needs to be repeated every three years if both tests are negative.
You should talk with your health care provider about these advances in cervical cancer prevention. If you decide to have one of the new screening tests, you might want to make sure it will be covered by your insurance plan. Also, not all providers offer all the tests yet.
The most exciting prospect on the horizon is a new vaccine against the most common HPV types. It is undergoing research testing now.

21. Evaluation of the Abnormal Pap Test and Treatment of Precancer

22. What is an HPV test?
A test sometimes used to determine if you need further evaluation
Cells are collected just like a Pap test
It checks for high-risk HPV
An HPV test is sometimes useful to determine if you need any further evaluation. This is particularly true for the minimally abnormal Pap tests with atypical squamous cells of undetermined significance, often abbreviated as ASC-US. The HPV test is collected just like a Pap test. In fact, if the Pap test is collected in a liquid, then the HPV test can be run on that liquid if the Pap test shows minimally abnormal results. The test checks for high-risk HPV.
The FDA approved HPV DNA test (DNA with Pap) can identify 13 different high-risk HPV types. About 90% of cervical cancers are caused by one of these 13 types.

23. What happens if I have an abnormal Pap test?
-US management options:
HPV testing
Repeat Pap
Colposcopy
ASC-H, LSIL, HSIL, AGC, AIS, cancer
Possibly endometrial biopsy for AGC
AIS / cancer: referral to gynecologic oncologist
There is a spectrum of Pap test results from “normal to “cancer or carcinoma.” In between normal and cancer, there is a range of abnormalities, such as ASC-US (the abbreviation for atypical squamous cells of undetermined significance) or LSIL (low-grade squamous intraepithelial lesions) to more significant cellular changes, such as HSIL (high-grade squamous intraepithelial lesions), AGC (atypical glandular cells) or AIS (adenocarcinoma in situ).
A Pap test is only a screening test. Additional tests are needed to determine if there is indeed a pre-cancer change or cancer.
The abnormalities called ASC-US sometimes harbor pre-cancer changes, but most often reflect inflammation, hormonal changes or an infection with the human papillomavirus. If your Pap test shows ASC-US, any of the following three management options may be chosen as the next step by you and your doctor: HPV testing, repeat Pap tests at approximately six month intervals or immediate colposcopy.
The other abnormalities are almost always caused by HPV. Thus, testing for HPV is not helpful in those cases. The more abnormal tests, such as HSIL, AGC, AIS, and cancer are also more worrisome for true pre-cancer or cancer changes. Any of these Pap test results should be followed by a colposcopy with biopsies. For AGC, an endometrial biopsy may be added. A gynecologic oncologist is a physician who specializes in the care of women with precancers or cancers and would often be consulted if the Pap test shows AIS or cancer.

24. What is a colposcopy? Colposcopy: Use of a magnifying instrument
Application of a vinegar-like solution onto the cervix
See abnormalities that can’t be seen with the naked eye
Feels like getting a Pap test, but lasts longer
Source: This is a copyrighted image of the California Family Health Council, Inc. and may not be reproduced in any way without the expressed written permission of the California Family Health Council. California Department of Health Services "What You Should Know if your Pap Test is Abnormal"- Your Colposcopy Exam, Donna Bell Sanders (Education Programs Associates 1995; Campbell, CA).
The first step in the evaluation of an abnormal Pap test is a colposcopy. Colposcopy is a test that helps find abnormal areas in the cervix. This is done in the doctor’s office. Similar to the examination for obtaining a Pap test, a speculum will be placed into the vagina. A nurse or doctor then applies a vinegar-like solution onto the cervix and examines the cervix with the colposcope, which is a magnifying lens with a strong light. If there are abnormal areas, a biopsy may be taken. .

25. What is a cervical biopsy?
Removal of a small piece of tissue from the cervix
May feel like getting a Pap test or like a menstrual cramp that lasts a few seconds
Source: TAP Pharmaceuticals, “Female Reproductive Systems.”
During a biopsy, a very small piece of tissue is removed so that a pathologist can evaluate it under a microscope to make a diagnosis. Any visible abnormality of the cervix should be biopsied to make sure of the diagnosis. Having a biopsy taken may cause some discomfort, like a menstrual cramp that lasts a few seconds.
Sometimes, your doctor will also perform an endocervical curettage, in which a little bit of tissue will be scraped from the cervical canal in order to examine it more closely under the microscope. And, at times colposcopy with biopsies and endocervical curettage is not enough to find the explanation for the abnormal Pap test and to make sure of the diagnosis. In this situation, a conization is performed, during which a larger, cone-shaped piece of tissue is removed from the cervix.
Source: A. DeCherney and M. Pernoll, Current Obstetric and Gynecologic Diagnosis and Treatment (The McGraw-Hill Companies, Inc.) 586.

26. What does the biopsy result mean?
Mildly abnormal (CIN I)
observation preferred
More abnormal (CIN II)
treatment
Precancer (CIN III)
Cancer
Gynecologic oncology consultation
The pathologist examines all tissues under the microscope. Similar to what was discussed earlier for the Pap test, biopsy results can show a broad spectrum with the two extremes being “normal” and “cancer or carcinoma”. In between, there is a range of abnormalities called CIN I to III. CIN stands for cervical intraepithelial neoplasia. CIN III is a pre-cancer change. This means the cells are highly abnormal, but do not yet invade or spread like cancer cells.
It is important to understand that treatment depends on the biopsy results, NOT the Pap test.
For CIN I management options include treatment or observation. Which route of management is right for you will depend on a number of factors. Observation is often preferred over immediate therapy since the chance that CIN I spontaneously regresses to normal is about 60%. However, about 10% will progress to more severe abnormalities. Therefore, a schedule of repeat examinations will be needed when CIN I is diagnosed, often Pap tests every six months.
CIN II and III should always be treated.
If any invasive cancer has been found, you should be seen by a gynecologic oncologist to determine what treatment you will need.

27. What are the treatment options for CIN?
Laser
Cryotherapy
Cone Biopsy
In special circumstances a hysterectomy may be recommended
If you need treatment for CIN, there are multiple treatment options such as LEEP, laser, cryotherapy, and cone biopsy. Options can be divided into two main groups: those that remove the area of abnormality (LEEP, cone biopsy) and those that destroy the area of abnormality (cryotherapy, laser vaporization). Each of those have their indications, advantages and disadvantages, but, importantly, cure rates are comparable. In special circumstances a hysterectomy may be recommended.

28. What can I expect after treatment for CIN?
Estimates of cure range from 73-90% with a single treatment
The risk for invasive cancer following treatment is about 1%
Therefore, you still need to have regular Pap tests
Minimal, if any, impact on fertility
Cryotherapy, LEEP, laser and conization are similar in their ability to treat CIN. Estimated cure rates range from 73% to 90% with a single treatment. However, 10% to 27% of patients will have future problems with CIN, making close follow-up after treatment very important. Once a patient has been treated for CIN, her risk for developing invasive cervical cancer is about 1%.
One major concern regarding treatment of cervical pre-cancers has been the potential that fertility may be decreased. Treatment of CIN could make it more difficulty to get pregnant or to carry the baby to full-term. This could happen because of cervical stenosis (scarring of the opening of the womb), decreasing cervical mucous formation or cervical incompetence (weakening of the cervix with difficulties of holding the baby inside the womb until term). However, there is little evidence that a single treatment leads to changes of either fertility or pregnancy outcomes.

29. What you can do? Take Control - Protect Yourself
1) Ask your doctor about an appropriate Pap test screening interval for you
2) Make sure that you get a Pap test at the recommended time
3) Find out how and when you will learn about the results of your Pap test
4) Follow-up! Don’t assume that no news is good news
5) Do not smoke

30. What are the symptoms of cervical cancer?
Abnormal bleeding
Between periods
With intercourse
After menopause
Unusual vaginal discharge
Other symptoms
Leg pain
Pelvic pain
Bleeding from the rectum or bladder
Some women have no symptoms
Usually women with cervical cancer have no symptoms, particularly if the cancer is small. The common symptoms of cervical cancer are:
Bleeding between periods
Bleeding or spotting after sexual intercourse
Bleeding or spotting in women who have already gone through menopause
Unusual, continuous, foul-smelling vaginal discharge
In women with more advanced cervical cancer additional symptoms may occur, such as:
Progressive and ultimately constant pelvic pain
One-sided leg pain caused by nerve involvement
A pelvic mass
Bleeding from the bladder or rectum.
It is not unusual for a woman with cervical cancer to have no symptoms.

31. Clinical staging of cervical cancer
The clinical stage is the extent of cancer at the time of diagnosis. Staging is necessary so that physicians can accurately communicate with each other about the disease. This allows doctors to discuss treatment options, to consider enrollment in clinical trials and to compare the outcomes in efforts to improve quality of care. Clinical staging is completed before treatment begins.
Cervical cancer can be broken into 4 general groups.
Stage I
Stage IA cancers are cancers with minimal invasion that can only be detected microscopically.
Stage IB cancers are those that involve only the cervix. The cancers that are larger than 4 cm are classified as stage IB2.
Stage II
A stage IIA cervix cancer indicates that there has been spread of the cancer to involve both the cervix and upper portion of the vagina.
A cancer is defined as stage IIB if there is extension of the cancer into the tissue next to the cervix.
Stage III
A stage IIIA cervical cancer has involvement of the lower vagina and a IIIB has extension of the cancer towards the pelvic sidewall.
Stage IV
Stage IV cancers involve the bladder, rectum, lungs or other organs.
Source: “FIGO Annual Report on The Results of Treatment in Gynaecological Cancer” Journal of Epidemiology and Biostatistics, (2001) vol. 6 no. 1, page 14.

32. What is a cervical conization?
Removes a cone-shaped piece of tissue
Often allows for diagnosis and treatment
Performed with local anesthesia in the office or under general anesthesia in the operating room
A cervical conization is often used to diagnose or exclude the presence of a very small cervical cancer. This procedure is performed in the operating room with or without general anesthesia where a cone shaped segment of the cervix is removed.
Alternatively a large cervical excisional biopsy can be performed in the office under local anesthesia.
The risks associated with a cervical conization are bleeding, infection and infertility.
Source: TAP Pharmaceuticals,
“Female Reproductive Systems.”

33. What is a radical hysterectomy?
Treatment option for early stage cancer
Not the same as the usual hysterectomy
Surgical removal of the uterus, cervix and upper vagina with the surrounding tissues
Lymph nodes are removed
Removal of the ovaries is not required
If a hysterectomy must performed for the treatment of cervical cancer, a radical hysterectomy is usually performed. This involves removal of the uterus along with a portion of the surrounding support tissue and a portion of the upper vagina. The lymph nodes in the pelvis and sometimes those near the aorta are removed.
The radical nature of the procedure results in a few more complications when compared to a simple hysterectomy. The most common changes are noted in the function of the bladder (you can’t tell when your bladder is full, so you must watch the clock to know when to go), shortening of the vagina and constipation.
A radical hysterectomy does not require removal of the ovaries.

34. What is radiation with chemotherapy (chemoradiation)?
Standard of care for advanced cancer
Treatment requires:
External radiation
Internal radiation
Low dose chemotherapy given at the same time
For some women, treatment with chemoradiation is a better option than surgery. This is most often true with advanced cancer.
Radiation is composed of two portions, external and internal radiation. A very low dose of chemotherapy is administered at the same time as the external radiation. This low dose of chemotherapy makes the radiation therapy more effective.
External radiation is usually given in small doses five days a week for about five weeks. Fatigue, nausea, diarrhea, and skin or vaginal irritation are common side effects.
For internal radiation, a radiation cylinder is placed inside the vagina where it delivers radiation treatment directly to the cervix. This procedure can last several hours to a full day in the hospital. Two to three treatments may be necessary.

35. Cervical cancer: What is the chance of survival after treatment?
FIGO Stage
5-Year Survival
Stage I
81-96%
Stage II
65-87%
Stage III
35-50%
Stage IVA
15-20%
The survival rate five years after diagnosis varies depending upon the stage of cervical cancer. The risk increases with higher stages of disease. However, there are treatment options for everyone.

36. Re-establishing Wellness
Restoring wellness is a gradual process
Some women find strength from:
Friends and family
Support groups
Spiritual work
Counseling
Exercise
The challenges and the journey are different for each woman with cervical cancer