General Information / Anatomy / Function / Statistics

• Cervix is the neck of the uterus (womb)
• Serves as a canal between the uterus and vagina
• Second most common type of gynecological cancer in North American women
• One of the easiest to prevent, recognize and cure in its early stages because it can often be spotted in regular physical examinations using the Pap smear test
• Carcinoma in situ is a pre-malignant lesion on the cervix that has a cure rate of 100%
• Stage 1 cancers, the cure rate is 80% to 90%
• Most cervical cancer originates from the surface tissue of the cervix and then spreads to involve the entire cervix. May metastasize to pelvic sidewall lymph nodes, into the vagina, uterus and ovaries, to nearby areas of the pelvis such as the rectum and bladder. Occasionally distant metastases to the liver, lungs and bones are seen. May spread (metastasize) by the lymph system or veins, but more commonly the lymph system
• Invasive cancer of the cervix is uncommon in our province because most cases are detected in the pre-invasive stage. Some cases do appear and many of these are patients who have never had a Pap smear, or not had one for many years. A few appear despite having been screened
• For statistics, please see Statistics by Cancer Type

Symptoms / Signs

• Early stages
  • None
• Intermediate stages
  • Foul smelling vaginal discharge
  • Bleeding or spotting between periods
  • Painful intercourse
  • Bleeding after intercourse
• Advanced stages
  • Pelvic or back pain
  • Urine leakage
  • Weight loss
  • Anorexia (appetite loss)
  • Fecal matter coming from vagina
  • Kidney failure due to obstruction of ureters

Etiology / Carcinogens / Risks

Sexual History

• Squamous cell cancer of cervix occurs in women who have had sexual intercourse
• Early age of onset of sexual activity, specifically before age 18, is associated with an increased risk
• Multiple sexual partners - higher risk with more than two partners and with partners who have multiple partners
• Human papilloma virus often involved in the etiology of cervical cancer
• Smoking increases risk
• A history of genital warts (human papilloma virus) or partner who has had warts is associated with an increased risk
• Offspring of women who have had the synthetic drug Diethylstilbestrol (DES) administered during pregnancy have a small risk of developing adenocarcinoma of the cervix or vagina
• Women on immunosuppressive medication or steroids

Prevention

• Regular Pap test smears (named after Dr. Papanicolaou)
• No smoking

Diagnosis / Screening / Staging / Grading / Types

Screening

See also our Cervical Cancer Screening Program for information.

How often should the Pap test / smear screening be carried out?

The following recommendations have been approved by the Cancer Committee and subsequently by the Board of Directors of the B.C.M.A. for women who are or have been sexually active:

Note: the best time for the Pap test to be performed is between 10 and 20 days after the first day of the menstrual period. For about 2 days before a Pap test, a woman should avoid douching, or using vaginal medicines or spermicidal foams, creams, or jellies (except as directed by a physician). These may wash away or hide abnormal cells.

• Annual cervical smears for three years, and if normal
• Smears every two years until age 69
• Women with a cytologic abnormality should continue to be screened annually after investigation and treatment
• A follow-up program will be established to notify the patient's physician if a smear has not been received by the cytology service within two years of the last negative smear. The follow-up program would have an additional benefit for older women, in whom the majority of invasive cancers are seen, since many of these women are currently not having regular Pap smears and, in some instances, have dropped out of the program altogether (February, 1992)
• Over 69 years
• Women over 69 may be dropped from the regular Pap smear screening program PROVIDED all their previous smears have been entirely normal; if not at the discretion of the patient's physician
• After hysterectomy for cancer, women must continue to have Pap smears. Also, if the cervix is still present they should be continued. Otherwise, Pap smears should be discussed with the doctor
• All women who have had a hysterectomy, for reasons other than 1) significant degree of dysplasia, 2) invasive cancer or 3) carcinoma in situ (CIN 3), may be dropped from the program entirely

Who should be screened?

• Cervical cytology is primarily a test for the detection of carcinoma of the cervix before symptoms appear
• All women who are or have been sexually active should have Papanicolaou smears
• All pregnant women should be screened at their first prenatal visit and 6 weeks post-partum; a pre-natal smear does not endanger the fetus. A smear should be taken prior to the commencement of oral contraceptives and regularly thereafter, as per above recommendations
• There is no evidence that oral contraceptives increase the risk of cervical cancer
• There is an extremely low incidence of cancer of the cervix in women over 70 if previous Pap smears have been normal

The technique of obtaining a specimen:

• The Pap smear is a quick procedure, which ideally should be a part of your regular pelvic exam. It will take only a few minutes
  • The patient lies in the lithotomy position (on back with legs up)
  • The doctor exposes the cervix using a speculum which allows the physician to inspect the cervix and take a Pap smear
  • A wooden spatula is usually used to take cells from the surface of the cervix. This process should not cause you any discomfort
  • The cells are then smeared on a glass slide and sent to the Central Cytology Laboratory at the B.C. Cancer Agency in Vancouver and examined by a "cytologist", (a specialist in microscopic examination of cells)

Interpretation of Pap Smear Results

• Note: After a hysterectomy, Pap smears are continued if the cervix or part of the cervix is left intact

"Negative" or "Normal"

• The majority of Pap smears are normal and no atypical cells are seen

"Atypical"

These cells are considered abnormal. An "atypical" smear falls into four categories:

• Benign Atypia - These cells are slightly abnormal, possibly as a result of inflammation, irritation, or hormonal changes of the cervix
• Dyskaryosis - In dyskaryosis the cell changes are associated with dysplasia on the surface of the cervix. Atypical smears should be repeated when requested by the laboratory. Some of these abnormalities return to "normal" without treatment. A Pap smear often is recommended three to six months later to check for further cell changes. Persistent mild dyskaryosis moderately or markedly dyskaryotic cells will result in a recommendation for a colposcopic examination
• "Suspicious Cells" - the phrase is applied to a smear that contains cells suspicious for pre-invasive cancer. The patient will usually be referred for a colposcopic examination by a gynecologist. The majority of patients found to have suspicious cells will have in situ carcinoma and the remainder dysplasia. There is no sharp dividing line between marked (severe) dysplasia and in situ carcinoma with respect to diagnosis or treatment
• "Malignant or Positive Cells" - the phrase is applied to a smear which contains cells having a malignant appearance. The patient will usually be referred to a gynecologist for a colposcopic examination or a biopsy of the cervix. Positive Pap smear results suggest "in situ carcinoma" or "invasive carcinoma"
  • "In situ carcinoma" is a cancer that is confined to the epithelium (a covering of the cervix). It has not invaded the surrounding tissue
  • "Invasive carcinoma" is cancer that has spread to neighbouring tissue
  • Both will require treatment

Diagnostic (Follow-Up) Tests After Positive PAP Smear

The following is a list of common tests and procedures used to define the type of abnormal cell change detected by a Pap smear:

• Biopsy: the removal of cervical tissue for examination under a microscope. Any suspicious lesion on the cervix should be biopsied regardless of the cytologic findings. Bite biopsies can be taken from the cervix without anesthesia
• Colposcopy: the examination of the vagina and cervix with a magnifying instrument called a colposcope. Colposcopy clinics are now available throughout the Province. The magnification of this instrument permits more accurate identification of the type and extent of the lesion present, and more precise biopsies can be taken
• For location of colposcopy clinics, contact BC Cancer Agency Gynecology secretary 604-877-6000 local 2353
• Many small lesions can be treated in outpatients under colposcopic guidance by cautery, freezing (cryotherapy), laser or loop excision (LEEP)

Done In The Hospital:

• Cone Biopsy: the surgical removal of a cone-shaped piece of cervical tissue for examination under a microscope. Also called a "conization"
• Cone biopsy may be used for diagnosis when suspicious or positive smears are obtained and no lesion can be found
• It may serve as therapy, as well, for the patient who wants to preserve her reproductive function
• Phases in the development of squamous carcinoma of the cervix
  • Dysplasia (cellular abnormality that is precancerous) may be mild, moderate or severe, also called CIN (Cervical Intraepithelial Neoplasia)
  • Carcinoma in situ (cancer cells growing on the surface of the cervix but not invading cervix)
  • Micro-invasive carcinoma

Staging (after FIGO, 1994)

• Stage 0 - In situ, pre-invasive, intra-epithelial carcinoma
• Stage 1 - Carcinoma strictly confined to the cervix (extension to the corpus should be disregarded)
• Stage 1a - Invasive cancer identified only microscopically. All gross lesions even with superficial invasion are Stage Ib cancers. Invasion is limited to measured stromal invasion with maximum depth of 5.0 mm and no wider than 7.0 mm
• Stage Ia1 - Measured invasion of stroma no greater than 3.0 mm in depth and no wider than 7.0 mm
• Stage Ia2 - Measured invasion of stroma greater than 3 mm and no greater than 5 mm and no wider than 7 mm
• Stage Ib - Lesions of greater dimensions than Stage Ia2 whether seen clinically or not
• Stage II - The carcinoma extends beyond the cervix but has not extended to the pelvic wall; the carcinoma involves the vagina but not the lower third
• Stage IIa - No obvious parametrial involvement
• Stage IIb - Obvious parametrial involvement
• Stage III - The carcinoma has extended to the pelvic wall; on rectal examination, there is no cancer-free space between the tumour and the pelvic wall; the tumour involves the lower third of the vagina
• Stage IIIa - No extension to the pelvic wall
• Stage IIIb - Extension to the pelvic wall
• Stage IV - The carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum

Types

• Squamous cell carcinomas - approximately 75%
• Adenocarcinomas (include endocervical cell, endometrioid and clear cell carcinomas, adenosquamous carcinoma) - more difficult to diagnose

Treatment

• Treatment varies according to results of the biopsy and the severity of the precancerous changes

Cryotherapy

• Cryosurgery (extreme cold) or hot cauterization can be used for dysplastic lesions and some cases of cancer "in situ". These methods destroy the abnormal cells. Cryosurgery uses a freezing technique to do this and hot cauterization uses heat. This treatment can be done in a clinic without general anaesthetic and has no effect on a woman's fertility or the ability to bear children. There should be no change in sexual function
• Patients referred for cryotherapy should have had a colposcopic examination to determine why a Pap smear is abnormal. Cryotherapy is used to treat lesions like dysplasia and carcinoma-in-situ limited to a well-defined area of the cervix, which have been previously diagnosed by colposcopic examination
• Cryotherapy is a relatively simple and painless procedure, which can be done at most colposcopy clinics. It does not require hospitalization, anaesthesia or pain pills. It is the treatment method least likely to have any effect on future fertility or pregnancy
• The doctor first does a colposcopic examination and usually stains the lesion with an iodine preparation to outline the area to be treated. Nitrous oxide gas from a tank at the foot of the examination table passes through a hose to a probe tip that is applied to the cervix. This causes the probe tip and underlying tissue to freeze. The frozen probe is applied to the affected area of the cervix for approximately 3 - 4 minutes. You will be asked to lie quietly for a few minutes as some people have a slight flush following the procedure
• NOTE: Your appointment should be scheduled immediately following your menstrual period so that you will not menstruate for approximately 3 weeks following your cryotherapy. If you suspect you may be pregnant please inform your physician and the clinic, as cryotherapy is not performed during pregnancy
• You may feel some menstrual-like cramps during the procedure but these should subside once the procedure has been completed. If these cramps recur later in the day, an aspirin or 222 should relieve your discomfort. If pain persists for more than 24 hours, contact your doctor
• It is recommend that you DO NOT use tampons, DO NOT douche, and DO NOT have intercourse for three weeks following cryotherapy. Douching, intercourse or tampons during this time may introduce infection. You will have a watery discharge and should wear a mini-pad
• While cryotherapy is an effective treatment method in most cases, it is important that you return for follow-up visits to ensure that all the abnormal cells have been destroyed. You will have a return appointment and a Pap test. After that, you will be asked to have a repeat examination every 4 - 6 months until one year of satisfactory follow-up is completed. Thereafter we recommend routine Pap test by your family doctor every six months

Laser Therapy

• Laser therapy with carbon dioxide (CO2) Laser
  • A beam of intense light is produced from a mixture of carbon dioxide, helium and nitrogen gases fired by electricity. Diseased cells are instantly evaporated, with little damage to surrounding healthy tissue, done in a clinic. No effect on a woman's sex life or ability to bear children
  • A cone biopsy can sometimes be done with the laser
• Laser therapy or surgery is a technique whereby a high-energy light beam is used for treatment. Laser is the acronym for Light Amplification by Stimulated Emission of Radiation. You should not be alarmed by the "radiation" as this is not radiation like that present from x-rays, etc.
• Laser therapy may be used to treat areas of abnormal cells or lesions on the cervix, vagina and vulva. Lesions such as dysplasia and carcinoma in situ of these structures that are well defined and have been assessed by prior colposcopic examination may be suitable for this treatment
• The advantage of laser therapy is that it is extremely precise and produces minimal tissue effects on surrounding normal tissue. This in turn leads to more rapid healing in comparison to other treatment methods. It is also the least likely to have any effect on future fertility or pregnancy
• Patients should have had a prior colposcopic exam to assess the degree and extent of any lesion or Pap test abnormality. Most treatments on the cervix can be carried out in a matter of a few minutes without the need for any anaesthetic. If extensive areas are to be treated, then these are usually done under a local or general anaesthetic and the patient is admitted to hospital for this procedure
• Your appointment should be scheduled immediately following your menstrual period so that you will not menstruate for approximately three weeks following your treatment. If you suspect you may be pregnant, please inform your physician and the clinic, as we would try to avoid laser therapy in pregnancy if at all possible
• During treatment, you may experience a sensation of heat or warmth but this passes rapidly as the procedure is completed. Also, on occasion, a pinprick sensation or menstrual-like cramps may be felt but these subside once the procedure is completed. If these cramps occur later in the day, then aspirin or a similar mild pain medication can be used to relieve your discomfort. If pain persists for more than 24 hours or increases, then you should contact your doctor
• Following treatment, there is usually a bloodstained, watery vaginal discharge. This discharge may last 7 - 10 days and will gradually decrease over this period of time. If, however, the amount of bleeding increases to a point where it is heavier than a normal period, you may try inserting a tampon for pressure. If this does not control the problem, contact your doctor of the clinic
• It is recommend that you DO NOT use tampons, DO NOT douche and DO NOT have intercourse for three weeks following laser therapy as these may introduce infection. If you are taking birth control pills, continue taking these as you have been doing
• Follow up: It is advised that you attend for three visits over the course of the next year so that we can assess the cervix to be sure that we have removed all of the abnormal tissue. The follow-up visits will usually be quick, short visits at which time the cervix will be examined with the colposcope and a Pap smear taken
• Biopsies are not routinely performed unless an abnormality is noted which requires further investigation. If, after the completion of these three post-treatment visits, all Pap smears are negative and the cervix is normal in appearance, then we would recommend you see your own family doctor for Pap smears twice a year

Cone Biopsy

• May be used as a diagnostic technique but also as a method of treatment when precancerous changes are too far up the cervical canal to be reached by other methods
• Conization - cone shaped sample of tissue is removed from the cervix under general anesthetic or with laser and local anesthetic, depending on the shape of the cervix - usually requires hospital day surgery
• With cone biopsy, there is a small risk (approx. 5%) of interfering with fertility or the ability to carry a pregnancy

Loop Electrosurgical Excision

• The use of fine wire loop electrode to excise the lesion is also used
• Done in office or clinic under local anesthesia

Hysterectomy

• For women who do not want more children or who have other gynecological problems, the surgical removal of the cervix, uterus and sometimes the fallopian tubes is performed

Radiation

• May be recommended in cases of invasive cervical cancer or where surgery is contraindicated

Chemotherapy

• May be used together with radiotherapy in cases of locally advanced disease. This tactic has been shown to improve the outcome compared to radiotherapy alone. Chemotherapy can also be of help to those with metastatic (more widespread) disease as well as recurrent tumours
• Not usually used

Revised April 2000

March 2007 We are currently reviewing and updating these pages. If you have any questions about your cancer and its treatment, please discuss with your oncologist or physician. Thank you.