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Cervical cancer

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of cervical cancer.

Alternative Names

Dysplasia; Human papillomas virus; Pap smear

Treatment for Cervical Cancer

In contrast to CIN, cervical cancer represents true invasion of cells beyond the epithelium into surrounding tissue. Cervical cancer may be detected in a biopsy performed during colposcopy for an abnormal Pap smear, or it may be visible to the naked eye when the doctor performs a speculum exam.

Imaging Tests to Determine Extent of Tumor Spread. If invasive cancer is detected on biopsy, additional tests are performed to determine the tumor spread. The extent of the spread determines whether the cancer is operable.

An abdominal computed tomography (CT) scan is commonly used to check for spread of the disease to lymph nodes and areas around the pelvic area.

CT stands for computerized tomography. In this procedure, a thin x-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms, the computer is able to generate a 3-D image of a section through the body. CT scans are very detailed and provide excellent information for the doctor.

To find out if cancer has spread to areas around the uterus, other procedures are used. X-ray images are taken of the bladder and urinary system (known as intravenous pyelography or IVP) or of the lower intestinal tract (known as a barium enema).

Click the icon to see an image of intravenous pyelography.

Click the icon to see an image of a barium enema.

If these tests detect cancer in any of these surrounding sites, then further tests are used:

Cystoscopy is performed to examine and take tissue from the bladder for biopsy.

Click the icon to see an image of cystoscopy.

Sigmoidoscopy is used to evaluate the rectum. (Both this procedure and a cystoscopy involve the insertion of a tube with a lighting device for viewing and manipulating the internal areas.)

Click the icon to see an image of sigmoidoscopy.

Magnetic resonance imaging (MRI) is a sensitive and noninvasive procedure that is occasionally useful for locating the presence of tumors in the tissues surrounding the uterus.

Click the icon to see an image of a MRI.

Sentinel Node Biopsy. Of interest is a technique known as a sentinel node biopsy, which has been used in patients with breast cancer to help determine if cancer has spread beyond the lymph nodes. It is now being investigated for patients with early cervical cancer and may be helpful in determining which patients require lymphadenectomy (removal of the lymph nodes) in the pelvic area:

The procedure uses an injection of a tiny amount of a blue dye, into the tumor site.
These substances then flow via the lymphatic system into the so-called sentinel node . This is the first lymph node to which any cancer would spread.
The sentinel lymph node and possibly one or two others are then removed.
If they do not show any signs of cancer, it is possible that the remainder of the lymph nodes will be cancer-free, and further removal of lymph nodes becomes unnecessary.

A 2002 study reported that this technique was able to detect cancer that had spread in 87.5% of cases. More investigation is required before it can be widely used.

General Treatment Guidelines

Once diagnosed, cervical cancer (invasive disease) is classified into stages according to the extent of the abnormal cells' invasion into the lining of the cervix or its spread throughout the cervix or beyond. These classifications are used to determine treatment and outlook.

It is important for patients who have been diagnosed with cervical cancer to know the normal treatments for their particular stage, so that they may compare their doctor's suggestions with these norms.

In stage I patients, the need for more aggressive treatment is correlated with larger tumor size, any involvement of blood or lymph vessels, and deeper invasion into the supportive tissues (the stroma) around the cervix.

In later stages, a greater tumor size, older age and poor general health, and cancer involvement in the pelvic and para-aortic lymph nodes (nodes near the aorta, the major artery in the body) suggest the need for investigative or more aggressive treatments.

Stage 0 and Treatments

Stage 0 is cancer in situ confirmed by biopsy and confined to the first layer of cervical tissue (the epithelium). Treatment Options: Loop electrosurgical excision procedure (LEEP), laser therapy, conization, or cryotherapy.

Stage I (Including Locally Advanced Cancer) and Treatments

Stage I is invasive cancer, but the tumor confined is confined to the cervix. This stage is further categorized as IA and IB.

Stage IA. Five-year survival rates for stage IA can be 95% or more.

In stage IA1 cancer cells are microscopic, there is minimal invasion (less than 3 mm) into the supportive tissue around the cervix (the stroma), and the horizontal extent of the tumor is less than 7 mm. Treatment Options: Simple hysterectomy. Conization is an alternative that is sometimes possible for women who want to preserve fertility and who have a nonaggressive tumor that has spread less than 3 mm with no lymph or blood vessel involvement. Trachelectomy has been investigated for women who want to preserve fertility.
In stage IA2 there is deeper invasion (greater than 3 mm but less than 5 mm) and the horizontal extent of the tumor is less than 7 mm. Treatment Options: Radical hysterectomy with surgical lymph node removal (lymphadenectomy) is a common approach.

Note on Stage IA2 through IIA: Postoperative concurrent radiation and platinum-based chemotherapy may be considered for stages IA2 through IIA tumors if the following high risk features are found at the time of primary surgery: lymph node involvement, cancerous cells found in the margins of the tumor, and involvement of the parametrium.

Stage IB and Locally Advanced Cancer. Five-year survival rates for stage IB can be 80% to 90% with either radiation or surgery. Survival rates are lower if lymph nodes are involved.

In stage IB1 the tumor is typically visible (not usually microscopic) and diameter may be up to 4 cm. Treatment Options: Radical hysterectomy with pelvic lymph node removal (lymphadenectomy). Primary radiation can be used instead of surgery in patients who are poor surgical candidates or who do not plan on being sexually active.
In stage IB2 the tumor is more than 4 cm and considered "bulky." Treatment Options: Relapse rates after surgery are higher than in stage 1B1. Primary treatment with radiation therapy with concurrent platinum-based chemotherapy is reasonable. Some women in stage IB may be given combinations of radiation and surgery, although the benefits of such combinations are unclear for most women, particularly given a higher risk for severe side effects.

Note on Locally Advanced Cervical Cancer: Stages IB2 through IVA are often referred to collectively as locally advanced cancer and are frequently treated similarly. In addition to standard treatments, notably radiotherapy with concurrent platinum-based chemotherapy, experimental approaches for some women with locally advanced cervical cancer employ radiation therapy with hyperthermia (high heat often provided by ultrasound) and neoadjuvant (preoperative) chemotherapy and radical surgery.

Stage II and Treatments

Stage II invasive cancer extends beyond the cervix, but not does not involve the pelvic side wall. This stage is further categorized as IIA and IIB.

Stage IIA. Cure rates for stage IIA can be as high as 75 - 80% with either radiation or radical hysterectomy. Survival rates are lower if lymph nodes are involved. In stage IIA the upper two thirds of the vagina are involved but not the parametrium (the connective tissue between the pelvic floor and upper part of the cervix). Treatment Options: Same as stage IB1 above unless tumor is bulky. In this latter case, treatment is the same as stage IB2.

Stage IIB. For stage IIB 5-year survival rates are about 60%. In stage IIB the cancer has spread to the parametrium. Treatment Options: Radiation therapy with concurrent cisplatin-based chemotherapy.

Stage III and Treatments

In stage III invasive cancer with tumor extending to the lower third of the vagina (stage IIIA) or to the side walls of the pelvis (stage IIIB). The kidney may be affected. Treatment Options: Radiation therapy with concurrent cisplatin-based chemotherapy. Five-year survival rates are about 40%.

Stage IV and Treatments

In stage IV invasive cancer with tumor spread beyond the pelvis or to the mucosal lining of the bladder or rectum. Five-year survival rates are less than 20%.

Stage IV. In stage IVA the cancer involves the inner lining of the bladder or rectum. Treatment Options: Radiation therapy with concurrent cisplatin-based chemotherapy.

Stage IVB. In stage IVB, the cancer has metastasized beyond the pelvis. Treatment Options: Radiation therapy to relieve symptoms and chemotherapy (usually cisplatin or carboplatin combined with other drugs such as topotecan). Platinum-based chemotherapy yields short-lived response in 20% of patients. Clinical trial participation is reasonable.

Recurrent or Persistent Cancer and Treatments

Cervical cancer may recur locally in the lymph nodes near the cervix, or it may metastasize to distant sites, such as the lung or bones, or it may appear both locally and in distant locations.

Treatment Options: Pelvic exenteration if cancer has spread to only local areas. (This involves removal of the cervix, uterus, vagina, and perhaps bladder, lower colon, or rectum. It is an aggressive surgical approach that may lead to cure in a small percentage of patients with recurrent cervical cancer.) Radiotherapy is another option if it is technically possible, generally if patients did not have it previously. If cancer has metastasized, platinum-based chemotherapy is reasonable. Other drugs may be useful under certain circumstances.

Treatment of Pregnant Women with Cervical Cancer

Only 1% of cervical cancers occur during pregnancy or shortly afterwards. To diagnose the condition, a cervical biopsy, in which a small amount of tissue is removed for diagnosis, can be performed anytime during the pregnancy. However, a cone biopsy, which removes larger amounts of tissue, is typically delayed until after the first trimester to reduce the risk of abortion. The options may be as follows:

If the abnormality is diagnosed as dysplasia or even carcinoma in situ, treatment is sometimes delayed until a few weeks after the mother gives birth, and vaginal delivery may still be possible. The risks and benefits of this approach, however, should be discussed with the doctor.
If early-stage cancer is diagnosed in the late second or third trimester, a woman may sometimes be able to delay treatment until the baby is delivered. A Cesarean section is the preferred delivery method. The cancer treatment of choice is started shortly afterward.
More locally advanced invasive cancer is nearly always treated, particularly if is diagnosed within the first 20 weeks of the pregnancy.

Review Date: 9/1/2006
Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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