Frequently Asked Questions About Cervical Cancer
Q. What is the difference between precancerous conditions and cancer of the cervix?
A. Cells on the surface of the cervix sometimes appear abnormal but not cancerous. Scientists believe that some abnormal changes in cells on the cervix are the first step in a series of slow changes that can lead to cancer many years later. That is, some abnormal changes are precancerous, and they may become cancerous with time.
Over the years, doctors have used different terms to refer to abnormal changes in the cells on the surface of the cervix. One term now used is squamous intraepithelial lesion (SIL). (The word lesion refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells.) Changes in these cells can be divided into two categories:
Low-grade SIL (LSIL) refers to early changes in the size, shape and number of cells that form the surface of the cervix. Some low-grade lesions go away on their own. However, with time, others may grow larger or become more abnormal, forming a high-grade lesion. Precancerous low-grade lesions also may be called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). Such early changes in the cervix most often occur in women between the ages of 25 and 35 but can appear in other age groups as well.
High-grade SIL (HSIL) means that the precancerous changes are more severe; they look very different from normal cells. Like low-grade SIL, these precancerous changes involve only cells on the surface of the cervix. The cells will not become cancerous and invade deeper layers of the cervix for many months, perhaps years. Nevertheless, HSIL on a Pap smear may be associated with malignancy of the cervix. Therefore, a proper diagnostic evaluation (with a microscope to look more closely at the cervix, known as a colposocpe) is necessary. This usually begins with a colposcopic evaluation of the cervix. High-grade lesions also may be called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ. They develop most often in women between the ages of 30 and 40, but can occur at other ages as well.
If abnormal cells spread deeper into the cervix or to other tissues or organs, the disease is then called cervical cancer, or invasive cervical cancer. The average age of cervical cancer patients is 50.
Q. How do I read my Pap smear results so that I can understand them?
A. The following table will help you to better understand your Pap smear results:
Within Normal Limits
No abnormal cells detected.
Return for pelvic exam and Pap test in one year.
Atypical Cells of Uncertain Significance
Some cells show a few changes, or mild atypia. These changes might be due to a type of infection or Human Papillomavirus (HPV)
There is not one standard management plan for a patient with an ASCUS Pap smear. The appropriate follow-up and testing will depend on the patient's personal history. Nevertheless, appropriate evaluation usually includes a repeat Pap smear and/or colposcopic examination. Testing for the presence or absence of HPV can also be used to determine the next step for a woman with an ASC-US Pap smear.
Low Grade Squamous Intraepithelial Lesions
CIN I (mild dysplasia)
Some normal cells are changed into abnormal cells. These cells could change into cancer in the future. These changes also are called mild dysplasia.
Colposcopy is performed after an LGSIL Pap smear. In specific circumstances, repeat Pap smear in a few months may be warranted depending on the patient's personal history.
High Grade Squamous Intraepithelial Lesions
CIN II (moderate dysplasia)
CIN III (severe dysplasia)
CIS (carcinoma in situ)
This also is called moderate to severe dysplasia.
Colposcopic evaluation is necessary after an HSIL Pap smear is discovered. A biopsy may be done to determine the amount of abnormality. Treatment involves removal of abnormal cells.
Cancer cells are present.
Biopsy to confirm Pap tests and determine treatment. The diagnosis of cervical cancer must be made by a biopsy. The Pap smear is only a screening test.
Q. How can I detect cervical cancer early?
A. Most precancerous conditions of the cervix could be detected and treated before cancer develops if all women had pelvic exams and Pap tests regularly. This way, most invasive cancers could be prevented. Any invasive cancer that does occur would likely be found at an early, curable stage.
Q. What is my doctor checking when he or she does my pelvic exam?
A. In a pelvic exam, the doctor checks the uterus, vagina, ovaries, fallopian tubes, bladder and rectum. The doctor feels these organs for any abnormality in their shape or size. A speculum is used to widen the vagina so that the doctor can see the upper part of the vagina and the cervix.
The Pap test is a simple, painless test to detect abnormal cells in and around the cervix. A woman should have this test when she is not menstruating; the best time is between 10 and 20 days after the first day of her menstrual period. For about two days before a Pap test, she should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician), which may wash away or hide any abnormal cells.
Women should have regular checkups, including a pelvic exam and Pap test, at age 21 and every three years thereafter. Those who are at increased risk of developing cancer of the cervix should be especially careful to follow their doctor's advice about checkups. Women who have had a hysterectomy (surgery to remove the uterus, including the cervix) should not undergo a Pap test (except if the hysterectomy was done for CIN II or CIN III). Hwoever, a yearly pelvic examination is still recommended.
Q. What are the symptoms of cancer of the cervix?
A. Precancerous changes of the cervix usually do not cause pain. In fact, they generally do not cause any symptoms and are not detected unless a woman has a pelvic exam and a Pap test.
Symptoms usually do not appear until abnormal cervical cells become cancerous and invade nearby tissue. Symptoms may include:
- Abnormal bleeding (bleeding may start and stop between regular menstrual periods)
- Bleeding after intercourse, douching or pelvic exam
- Menstrual bleeding that lasts longer or is heavier than usual
- Bleeding after menopause
- Increased vaginal discharge
These symptoms may be caused by cancer or by other health problems. Only a provider can tell for sure. It is important for a woman to contact her provider if she is having any of these symptoms.
Q. How is cancer of the cervix diagnosed?
A. The pelvic exam and Pap test allow the doctor to detect abnormal changes in the cervix. If these exams show that an infection is present, the doctor treats the infection and then repeats the Pap test at a later time. If the Pap test or exam suggests something other than an infection, the doctor may repeat the Pap test and do other tests to find out what the problem is.
The Pap smear is only a screening test and does not give a final diagnosis. A diagnosis and subsequent treatment is based on biopsy results, which are usually obtained after an abnormal Pap smear is discovered.
Colposcopy is the method to check the cervix for abnormal areas. This procedure is most commonly performed after an abnormal Pap smear. The doctor applies a vinegar solution to the cervix and then uses an instrument much like a microscope (called a colposcope) to look closely at the cervix.
These procedures can be done in the doctor's office.
Biopsy – The doctor may remove a small amount of cervical tissue to be evaluated by a pathologist. In one type of biopsy the doctor uses an instrument to pinch off small pieces of cervical tissue.
Loop Electrosurgical Excision Procedure (LEEP) – Another method used to do a biopsy. In this procedure, the doctor uses an electric wire loop to remove a thin, round piece of the cervix.
These types of biopsies may be done in the doctor's office using local anesthesia.
Endocervical Curettage (ECC) – The doctor may want to check inside the opening of the cervix. The doctor uses a curette (a small, spoon-shaped instrument) to scrape tissue from inside the cervical opening.
These procedures for removing tissue may cause some bleeding or other discharge. However, healing occurs quickly. Women often experience some pain similar to menstrual cramping, which can be relieved with medicine.
Cone Biopsy – This procedure requires either local or general anesthesia and may be done in the doctor's office or in the hospital. This procedure allows for evaluation and treatment of precancerous lesions. The cone biopsy also may provide the diagnosis of an invasive cervical cancer.
D&C – In a few cases, it may not be clear whether an abnormal Pap Test or a woman's symptoms are caused by problems in the cervix or in the endometrium (the lining of the uterus). In this situation, the doctor may do a dilatation and curettage (D&C). The doctor stretches the cervical opening and uses a curette to scrape tissue from the lining of the uterus as well as from the cervical canal. Like conization, this procedure requires local or general anesthesia and is done in the hospital.
Q. How are precancerous conditions of the cervix treated?
A. All treatments directed toward precancerous conditions of the cervix should be based on a biopsy (since a Pap smear alone is not adequate to make the diagnosis). Treatment for a precancerous lesion of the cervix depends on a number of factors. These factors include whether the lesion is low or high grade, whether the woman wants to have children in the future, the woman's age and general health, and the preference of the woman and her doctor. A woman with a low-grade lesion may not need further treatment, especially if the abnormal area was removed during biopsy, but she should have a Pap test and pelvic exam regularly by a physician with expertise in this area. When a precancerous lesion requires treatment, the doctor may use:
- Cryosurgery (freezing)
- Cauterization Burning (also called diathermy)
- LASER Surgery (to destroy abnormal area without harming nearby healthy tissue
- LEEP (Loop Electrosurgical Excision Procedure, a larger biopsy to remove the precancerous tissues)
- Conization (Cone Biopsy, larger biopsy to remove the precancerous tissues)
Treatment for precancerous lesions may cause cramping or other pain, bleeding or a watery discharge. Rarely, a hysterectomy is performed to treat percancerous conditions of the cervix, since removeal of the uterus and cervix is considered to be unnecessary in the great majority of cases of precancerous conditions of the cervix unless other gynecologic problems exist. Women are likely to benefit from pretreatment evaluation by a gynecologic oncologist if they have:
- A suspicious visible growth of the cervix suspicious for cancer
- A Pap smear report demonstrating invasive carcinoma
- A biopsy report confirming invasive carcinoma
Q. How is cancer of the cervix treated?
A. The choice of treatment for cervical cancer depends on the location and the size of the tumor, the stage (extent) of the disease, the woman's age and general health, and other factors.
Gynecologic oncologists have expertise in the diagnostic evaluation and treatment of patients with cervical carcinoma. They also have surgical expertise in the procedures of radical hysterectomy, lymphnode removal, pretreatment surgical staging procedures, and exenterations for patients with recurrent cervical cancer. Gynecologic oncologists work closely with oncologists when this is the primary treatment modality. During that time, they function as the patient's primary care oncologist and continue to direct their care after the radiation therapy is finished.
Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Blood and urine tests are usually done. The doctor also may do a thorough pelvic exam in the operating room with the patient under anesthesia to better define the location of the cancer.
As part of the examination under anesthesia, the doctor may perform a cystoscopy, where the doctor looks inside the bladder with a thin, lighted instrument. Also may be performed is proctosigmoidoscopy where a lighted instrument is used to check the rectum and the lower part of the large intestine. Because cervical cancer may spread to the bladder, rectum, lymph nodes or lungs, the doctor also may order x-rays or tests to check these areas. For example, the woman may have a series of x-rays of the kidneys and bladder, called a computed tomography (CT) or an intravenous pyelogram (IVP). The doctor also may check the intestines and rectum using a barium enema. To look for lymph nodes that may be enlarged because they contain cancer cells, the doctor may order a CT scan, a series of x-rays put together by a computer to make detailed pictures of areas inside the body. Other procedures that may be used to check organs inside the body are ultrasonography and MRI.
Q. Is a second opinion important?
A. Before starting treatment, you may want a second pathologist to review the diagnosis and another specialist to review the treatment plan. Some insurance companies require a second opinion; others may cover second opinion if the patient requests it. It may take a week or two to arrange for a second opinion. This short delay will not reduce the chance that treatment will be successful.
A gynecologic oncologist is usually in the best position to offer a patient an expert opinion on the diagnosis and management of cervical cancer. At The James, patients also have their case presented at the gynecologic oncology multidisciplinary tumor board. This is a meeting where gynecologic oncologists, radiation oncologists and gynecologic pathologists meet to discuss the diagnostic and treatment options for a patient with or suspected to have a gynecologic cancer.
Q. What can I do to prepare for treatment?
A. Here are some questions you may want to ask your doctor before treatment begins:
When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often it helps to make a list of questions. Taking notes will help you remember what the doctor says. You may also want to have a family member/friend with you when you talk to the doctor to assist you in taking notes, asking questions or just to listen. You do not need to ask all your questions or remember all the answers at one time. There will be other opportunities to ask the doctor to explain things and to get more information.