Cervical cancer, which most often afflicts women in their 30s and 40s, is a relatively rare form of cancer that usually grows very slowly. The American Cancer Society estimates that each year about 13,000 new cases are diagnosed and 4,100 women die of the disease. Because widespread Pap smear testing allows the disease to be caught in its early stages, invasive cancer has become much less frequent; both the incidence rate and the death rate have declined over the past three decades.

What is cervical cancer and what causes it?

How is cervical cancer diagnosed? Does it have symptoms?

Most cervical disease in this country is diagnosed through Pap smears before it becomes cancerous. At this stage the disease usually has no symptoms, although under the microscope the cells will show abnormalities.

The classic symptom of established cervical cancer is vaginal bleeding, usually slight. It may occur after intercourse or upon severe exertion. While women with endometrial cancer often have heavy menstrual periods, women with cervical cancer seldom have that problem. Sometimes there is watery discharge, which may smell bad. Sometimes cervical cancer has no symptoms at all until it is fairly advanced.

How Cervical Cancer Develops

Cervical cancer develops gradually, starting with changes that result in atypical cells (atypia) — they are not normal but not cancerous either. They can spontaneously revert to normal. At first these changes take place only on the surface of the cervix, but they can penetrate more deeply into the cell layers as time goes on if they do not revert to normal. The atypical cells may progress to a state of precancerous change, referred to as dysplasia. When the changes are confined to cell layers above what is called the basement membrane, the condition is fully curable by local therapy. This stage is not yet cancer. In the next stages, the precancerous abnormal cells visible under a microscope have not become invasive cancerous cells with the ability to spread, but they can develop into a local condition called carcinoma in situ. You and your doctor have plenty of time to deal with these changes; they occur slowly, often over a period of years, and it is highly unusual for somebody to proceed from mild to moderate to severe dysplasia to carcinoma in situ to cancer in a matter of months. All the same, you should continue having Pap smears every year; if you do, your chances of getting invasive cancer will be almost zero. Even at the level of mild dysplasia, the cervix can heal itself spontaneously, so some doctors recommend observation only. Once moderate or severe dysplasia is diagnosed, most doctors recommend intervention.

Microinvasion is a stage of minimal penetration of the basement membrane, which falls between carcinoma in situ and stage I cancer. Though technically invasive, these cancers are still relatively easy to cure. Stage I cervical cancer is confined to the cervix and the uterus. Stage II cancer has spread locally to the top of the vagina. Stage III cervical cancer has spread a little farther, sometimes to the lower part of the vagina, toward the side walls of the pelvis, and sometimes to the ureters, which enter the bladder right next to the cervix. Stage IV cervical cancer has spread still further, perhaps involving the bladder or the rectum.

Your Pap Test

There are several systems for classifying the results of Pap tests, so the terminology can be confusing. Talk to your doctor about the precise meaning of your test results.

One system for grading Pap tests is the Bethesda System (TBS). Its categories refer to the kinds of cell changes and the extent of the cervix affected by these changes. (The ratings in parentheses refer to the former grading system which rated Pap tests in classes I-V.)

Normal: No evidence of malignant cells (class I).

Atypical cells of undetermined significance: The cells look strange (that is, abnormal) but probably are not precancerous. This category is sometimes called reactive cellular changes. The changes can be brought about by infections such as herpes, chlamydia, or yeast infection (class II).

Low-grade squamous intraepithelial lesions (SIL): These abnormal changes in the squamous cells are not invasive but can become so over time, although sometimes the abnormal cells spontaneously change back to normal cells (class III).

High-grade intraepithelial lesions: High-grade SILs are less likely than low-grade SILs to disappear without treatment and are more likely to eventually develop into cancer if they are not treated. However, treatment can cure all SILs and prevent true cancer from developing. A Pap smear cannot show for certain whether a woman has a high- or low-grade SIL (class IV).

Invasive cancer (likely to be spreading into the cervix and potentially beyond): I have never had a patient with a Pap smear that showed invasive cancer. The one such patient whom I did see during my residency (twenty-five years ago) was a woman with four children who had not had a single Pap smear since delivering her last child ten years previously (class V).

The most confusing Bethesda System category for cells of the outer cervix is atypical squamous cells of undetermined significance, which is often abbreviated as ASCUS and pronounced “ask-us.” Pathologists use the category when the Pap test fails to reveal whether the abnormal cells are due to inflammation or to a precancer.

The Bethesda System is not the only classification method for reporting Pap test results. An earlier system referred to dysplasia, which literally means “abnormal growth.” Changes in cervical cells were classified by degree, as showing mild dysplasia, moderate dysplasia, or severe dysplasia.

Another term you may hear is cervical intraepithelial neoplasia (CIN). The “intra-epithelial” means that the changes are in the epithelium or outer layer of the cervix; these changes are not deep, they are not invasive cancer. The word “neoplasia” connotes unusual cell changes but in this context does not imply invasive cancer. While CIN is definitely not cancer, it is often classified in grades, as is cancer: CIN 1 means mild dysplasia, CIN 2 is moderate dysplasia, and CIN 3 is severe dysplasia.

Some physicians refer to severe dysplasia as carcinoma in situ. I dislike using that terminology, because the word “carcinoma” makes people anxious. Carcinoma in situ and severe dysplasia are essentially the same thing: the “in situ” means that the carcinoma is not invasive. If you take care of it, you should be cured, and unless you have human immunodeficiency virus infection, you should never have to worry about the disease again.

Who is at high risk for cervical cancer?

Does genital herpes increase the risk of cervical cancer?

People used to think that genital herpes set you up for cervical cancer, because data showed that women with herpes had a higher incidence of cervical cancer. The current thinking is that the risk factors are similar. Women with herpes are likely to have multiple sex partners, early intercourse, and several children, all of which put these women into a high-risk category for cervical cancer. But the herpes virus itself does not seem to be the culprit.

Are abnormalities of the cervix forerunners of Acquired immunodeficiency syndrome?

While human immunodeficiency virus-positive women are at increased risk for cervical cancer, women with cervical dysplasia are not necessarily at higher risk for Acquired immunodeficiency syndrome. Cervical dysplasia is much more common than Acquired immunodeficiency syndrome, and the vast majority of women with cervical dysplasia do not have Acquired immunodeficiency syndrome. If you do have cervical dysplasia and are worried about Acquired immunodeficiency syndrome, have an human immunodeficiency virus test.

What should you do if your Pap smear is abnormal?

If your Pap smear shows a mild abnormality, your doctor may recommend repeating the test in a few months. Often the immune system will “fix” the questionable cells, making them revert to normal. If the next smear, say three months later, is still abnormal, your gynecologist will probably suggest looking at your cervix with a colposcope, a sort of giant microscope. The procedure can be done in the doctor’s office without anesthesia.

Through the colposcope abnormal tissue really looks different from normal tissue, with different blood-vessel patterns and cells that vary in shape, size, and perhaps density. During the procedure your doctor will snip off (biopsy) bits of the most irregular-looking tissue and send them to a pathologist, who will examine them under a regular microscope and tell your gynecologist what is going on. Sometimes the problem will turn out to be an inflammation that is not linked to cancer, or an infection with the condyloma virus, that caused an abnormal Pap smear but no worrisome cellular changes. The biopsy will probably be a little uncomfortable, but not as much so as an endometrial biopsy.

What is the treatment for precancerous cervical changes?

If the changes in your cervical cells are only mildly abnormal your doctor may suggest watchful waiting, examination under the colposcope, plus more frequent Pap smears to make sure that the cells revert to normal. Laser surgery, cryosurgery, or the loop electrical excision procedure are other possibilities. Some women, who have severe dysplasia and painful menstrual periods, opt for a hysterectomy if they have finished their families, but few women end up with a hysterectomy because of dysplasia.

Cryosurgery And Laser Surgery

Cryosurgery is surgery that involves freezing. The physician takes an instrument that looks like a wand and places it against the abnormal area on the cervix. Compressed nitrous oxide gas flows through the tip of the wand, making it very cold and freezing the cells, until the abnormal area becomes a little iceball on the cervix. The frozen area is allowed to thaw and is then refrozen, a process that kills the superficial cells, which are sloughed off. The body generates new, healthy cells with no abnormalities.

Laser surgery too kills the superficial cells so that the body sloughs them off. It utilizes heat rather than cold and actually vaporizes the diseased cells. Both cryosurgery and laser surgery can be done in an outpatient setting or in a physician’s office.

Cone Biopsy of Cervical Cancer

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