Cervical Cancer

If a growth or another abnormal area is seen on the cervix during a pelvic examination or if a Pap test detects precancerous or cancerous cells, a biopsy is done. Usually, doctors do a procedure called colposcopy using an instrument with a binocular magnifying lens (colposcope), inserted through the vagina, to examine the cervix and to choose the best biopsy site.

Two different types of test are done:

• Cervical biopsy: A tiny piece of the cervix, selected using the colposcope, is removed.

• Endocervical curettage: Tissue is scraped from inside the cervix.

These tests are similar to having a Pap test. They usually cause only mild pain and a small amount of bleeding.

If the diagnosis is not clear, a cone biopsy is done to remove a larger cone-shaped piece of tissue. Usually, a thin wire loop with an electrical current running through it is used. This procedure is called the loop electrosurgical excision procedure (LEEP). It requires only a local anesthetic. Alternative techniques are to use a scalpel (cold knife) or a laser (a highly focused beam of light). These procedures require an operating room and usually a general anesthetic.

Loop Electrosurgical Excision Procedure (LEEP)

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If cervical cancer is diagnosed, its exact size and locations (its stage) are determined. Staging begins with a physical examination of the pelvis and a chest x-ray. Usually, computed tomography (CT), magnetic resonance imaging (MRI), or a combination of CT and positron emission tomography (PET) is done to determine whether the cancer has spread to nearby tissues or to distant parts of the body. If these procedures are not available, doctors may do other imaging procedures to check specific organs, such as cystoscopy (bladder), sigmoidoscopy (colon), or IV urography (urinary tract).

Doctors usually also check for spread to the lymph nodes by doing imaging tests or a biopsy. Knowing whether cancer has spread to the lymph nodes and how many lymph nodes are involved helps doctors predict the person's outcome and plan treatment.

Stages of cervical cancer range from I (the earliest) to IV (advanced). Staging is based on how far the cancer has spread:

• Stage I: The cancer is confined to the cervix.

• Stage II: The cancer has spread outside the uterus, to the upper two thirds of the vagina or to tissues outside the uterus, but is still within the pelvis (which contains the internal reproductive organs, bladder, and rectum).

• Stage III: The cancer has spread throughout the pelvis and/or the lower third of the vagina and/or blocks the ureters and/or causes a kidney to malfunction and/or spreads to the lymph nodes near the aorta (the largest artery in the body).

• Stage IV: The cancer has spread outside the pelvis and/or to the bladder or rectum or to distant organs.

Precancerous cervical cells (cervical intraepithelial neoplasia) and cervical cancer that involves only the surface of the cervix (early stage I) are treated the same way. Doctors can often completely remove the cancer by removing part of the cervix with a cone biopsy procedure. They may use the loop electrosurgical excision procedure (LEEP), a laser, or a scalpel. These treatments preserve a woman’s ability to have children.

Removal of the uterus (hysterectomy) may be done if women are not interested in preserving their ability to have children. If some cancer remains after the cone biopsy, hysterectomy or another cone biopsy may be done.

If early-stage cancer has spread deeply into the cervix or into blood vessels or lymphatic vessels, a modified radical hysterectomy is done, and nearby lymph nodes are removed. A modified radical hysterectomy involves removing the cervix and some of the tissue next to it (called the parametrium). But unlike a standard radical hysterectomy, the modified radical hysterectomy involves removing only half of the parametrium.

Lymph nodes may be checked for spread of cancer cells with a procedure called sentinel lymph node mapping.

Another treatment option is external radiation therapy plus radioactive implants placed in the cervix to destroy the cancer (a type of internal radiation called brachytherapy).

Radiation therapy may irritate the bladder or rectum. Later, as a result, the intestine may become blocked, and the bladder and rectum may be damaged. Also, the ovaries usually stop functioning, and the vagina may narrow.

If cervical cancer involves more than the surface of the cervix but the cancer is still relatively small, treatment is typically

• Radical hysterectomy (a hysterectomy plus removal of surrounding tissues including the upper part of the vagina and ligaments) and evaluation of lymph nodes

Hysterectomy is done by making a large incision in the abdomen (open surgery) or by using a thin viewing tube (laparoscope) and specialized surgical instruments inserted through small incisions just below the navel. Research suggests that when open surgery is done, the cancer is less likely to return and women are more likely to live longer than when laparoscopic surgery is done.

If the cancer has grown or has begun to spread within the pelvis, treatment is typically

• Radiation therapy plus chemotherapy

The ovaries are usually left in place because cervical cancer is unlikely to spread (metastasize) to the ovaries.

If during surgery, doctors discover that cancer has spread outside the cervix, hysterectomy is not done, and radiation therapy plus chemotherapy is recommended.

When cervical cancer has spread further within the pelvis or has spread to other organs, the following treatment is preferred:

• Radiation therapy plus chemotherapy

Doctors may use positive emission tomography with computed tomography (PET-CT) to determine whether lymph nodes are involved and thus determine where radiation should be directed. External radiation (directed at the pelvis from outside the body) is used to shrink the cancer and treat cancer that may have spread to nearby lymph nodes. Then radioactive implants are placed in the cervix to destroy the cancer (a type of internal radiation called brachytherapy).

Chemotherapy is usually given with radiation therapy, often to make the tumor more likely to be damaged by radiation therapy.

The main treatment for extensive spread or recurrence of cervical cancer is

• Chemotherapy

However, chemotherapy reduces the cancer’s size and controls its spread in almost half of women treated, and the beneficial effect is usually only temporary. Adding another medication (such as monoclonal antibodies used to treat several types of cancer; this is called immunotherapy) may extend survival by a few months.

If the cancer remains in the pelvis after radiation therapy, doctors may recommend surgery to remove some or all pelvic organs (called pelvic exenteration). These organs include the reproductive organs (vagina, uterus, fallopian tubes, and ovaries), bladder, urethra, rectum, and anus. Which organs are removed and whether all are removed depends on many factors, such as the cancer's location, the woman's anatomy, and her goals after surgery. Permanent openings—for urine (urostomy) and for stool (colostomy)—are made in the abdomen so that these waste products can leave the body and be collected in bags.

A sentinel lymph node is the first lymph node that cancer cells are likely to spread to. There may be more than one sentinel lymph node. These nodes are called sentinel lymph nodes because they are the first to warn that cancer has spread.

A sentinel lymph node dissection involves

• Identifying the sentinel lymph node (called mapping)

• Removing it

• Examining it to determine whether cancer cells are present

To identify sentinel lymph nodes, doctors inject a blue or green dye and/or a radioactive substance into the cervix near the tumor. These substances map the pathway from the cervix to the first lymph node (or nodes) in the pelvis. During surgery, doctors then check for lymph nodes that look blue or green or that give off a radioactive signal (detected by a handheld device). Doctors remove this node (or nodes) and send it to a laboratory to be checked for cancer. If the sentinel lymph node or nodes do not contain cancer cells, no other lymph nodes are removed (unless they look abnormal).

For women with early-stage cervical cancer, sentinel lymph node dissection is an alternative to removing lymph nodes in the pelvis. Cervical cancer spreads to the lymph nodes in only 15 to 20% of women with early-stage cancer. Sentinel lymph node dissection may help doctors limit the number of lymph nodes that need to be removed, sometimes to only one. Removing lymph nodes often causes problems such as accumulation of fluids in tissues, which can cause persistent swelling (lymphedema), and nerve damage.

Treatment with radical hysterectomy, chemotherapy, and/or radiation therapy usually makes it impossible for women to become pregnant or to carry a pregnancy to term. However, if being able to have children is important, a woman should talk to her doctor and get as much information as possible about how treatment affects fertility and whether they are eligible for treatments that do not make future pregnancy impossible.

A cone biopsy (conization) may be an option for women who have low-risk, early-stage cervical cancer and who wish to preserve their ability to have children. Before this procedure, doctors check to see whether the cancer has spread to lymph nodes in the pelvis. If the cancer has not spread, doctors may completely remove the cancer by removing part of the cervix during a cone biopsy.

If women with early-stage cervical cancer wish to preserve their ability to have children, a different cancer treatment called radical trachelectomy (a fertility-preserving treatment) may be possible. Doctors remove the cervix, the tissue next to the cervix, the upper part of the vagina, and the lymph nodes in the pelvis. To remove these tissues, doctors may do one of the following:

• Do open surgery

• Use a laparoscope inserted through a small incision just below the navel, then thread instruments through the laparoscope, sometimes with robotic assistance (laparoscopic surgery)

• Remove the tissues through the vagina (vaginal surgery)

Then the uterus is re-attached to the lower part of vagina. Thus, women still can become pregnant. However, babies must be delivered by cesarean.

Trachelectomy appears to be as effective as radical hysterectomy for many women with early-stage cervical cancer.

If premenopausal women are having radiation therapy, doctors discuss options for protecting the ovaries to avoid causing premature menopause. Before radiation therapy of the pelvis, ovaries may be moved outside the radiation field (oophoropexy) to avoid exposing them to radiation.