Cervical Cancer

Topic Overview

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This topic talks about the testing, diagnosis, and treatment of cervical cancer. For general information about abnormal Pap test results, see the topic Abnormal Pap Test.

What is cervical cancer?

Cervical cancer occurs when abnormal cells on the cervix grow out of control. The cervix is the lower part of the uterus that opens into the vagina. Cervical cancer can often be cured when it’s found early. It is usually found at a very early stage through a Pap test .

What causes cervical cancer?

Most cervical cancer is caused by a virus called human papillomavirus , or HPV. You can get HPV by having sexual contact with someone who has it. There are many types of the HPV virus. Not all types of HPV cause cervical cancer. Some of them cause genital warts , but other types may not cause any symptoms.

You can have HPV for years and not know it. It stays in your body and can lead to cervical cancer years after you were infected. This is why it is important for you to have regular Pap tests. A Pap test can find changes in cervical cells before they turn into cancer. If you treat these cell changes, you may prevent cervical cancer.

What are the symptoms?

Abnormal cervical cell changes rarely cause symptoms. But you may have symptoms if those cell changes grow into cervical cancer. Symptoms of cervical cancer may include:

• Bleeding from the vagina that is not normal, or a change in your menstrual cycle that you can't explain.
• Bleeding when something comes in contact with your cervix, such as during sex or when you put in a diaphragm.
• Pain during sex.
• Vaginal discharge that is tinged with blood.

How is cervical cancer diagnosed?

As part of your regular pelvic exam, you should have a Pap test. During a Pap test the doctor scrapes a small sample of cells from the surface of the cervix to look for cell changes. If a Pap test shows abnormal cell changes, your doctor may do other tests to look for precancerous or cancer cells on your cervix.

Your doctor may also do a Pap test and take a sample of tissue ( biopsy ) if you have symptoms of cervical cancer, such as bleeding after sex.

How is it treated?

Cervical cancer that is caught early can usually be cured. If the cancer is caught very early, you still may be able to have children after treatment.

The treatment for most stages of cervical cancer removes the cancer and makes you unable to have children. These treatments include:

• A hysterectomy and removal of pelvic lymph nodes with or without removal of both ovaries and fallopian tubes .
• Radiation therapy .
• Chemotherapy .

Depending on how much the cancer has grown, you may have one or more treatments. And you may have a combination of treatments.

It’s common to feel scared, sad, or angry after finding out that you have cervical cancer. Talking to others who have had the disease may help you feel better. Ask your doctor about support groups in your area. You can also find people online who will share their experiences with you.

Can cervical cancer be prevented?

The Pap test is the best way to find cervical cell changes that can lead to cervical cancer. Regular Pap tests almost always show these cell changes before they turn into cancer. It is important to follow up with your doctor after any abnormal Pap test result to treat abnormal cell changes. This may help prevent cervical cancer.

A vaccine called Gardasil protects against four types of HPV, which together cause most cases of cervical cancer and genital warts. You get three shots over 6 months. The vaccine is recommended for girls 11 to 12 years old. It is also recommended for females 13 to 26 years old who did not get the vaccine when they were younger.

The virus that causes cervical cancer is spread through sexual contact. The best way to avoid getting a sexually transmitted disease is to not have sex . If you do have sex, practice safer sex, such as using condoms and limiting the number of sex partners you have.

Frequently Asked Questions

Learning about cervical cancer:	What is cervical cancer? What causes it? Can I prevent it? What are the symptoms of cervical cancer? What increases my risk for cervical cancer? How common is it? Should my daughter get the HPV vaccine?
Being diagnosed:	How is cervical cancer diagnosed? What are the stages of cervical cancer? What tests will I need? Do I need to see a specialist?
Getting treatment:	What is the treatment for cervical cancer? Will I need surgery? Will I need to take medicines? Will I need radiation therapy? Are there alternative treatments?
Living with cervical cancer:	How will cervical cancer affect my daily life? Will it affect my ability to have children? Will it affect my body image and sexuality? Is cancer treatment painful? What are the side effects of treatment? When should I call my doctor? How will I feel after treatment?
End-of-life issues:	What is care at the end of life? What is hospice care?

Health Tools 

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	HPV: Should my daughter get the vaccine?
	Actionsets are designed to help people take an active role in managing a health condition.
	Cancer: Controlling cancer pain
	Cancer: Controlling nausea and vomiting from chemotherapy

Cause

Cervical cancer is caused by severe abnormal changes in the cells of the cervix . Most precancerous or cancerous cell changes occur in the cervix at the transformation zone because these cells normally undergo constant change. During this natural process of change, some cervical cells can become abnormal if you are infected with high-risk types of HPV.

Other factors that may play a role in causing cervical cancer include:

• Having sex before age 16. ¹
• Having more than one sex partner, or having a sex partner who has more than one partner. ²
• Smoking or a history of smoking. Smoking seems to make HPV infections last longer. ³ One study shows that your risk of cervical cell changes may also increase if you are around someone else while they smoke ( secondhand smoke ). ⁴ Cervical cell changes are more likely to go away on their own in women who don't smoke.
• Having an impaired immune system , such as from having human immunodeficiency virus (HIV) .
• Using birth control pills for more than 5 years. This may be related to infection with HPV. ⁵

Regular Pap test screening is the single most important tool to identify cervical cell changes early before they progress to cancer.

Symptoms

Since abnormal cervical cell changes rarely cause symptoms, it is important to have regular Pap test screening. If cervical cell changes progress to cervical cancer , symptoms may develop. Symptoms of cervical cancer may include:

• Abnormal vaginal bleeding or a significant unexplained change in your menstrual cycle .
• Bleeding when something comes in contact with the cervix, such as during sexual intercourse or when you insert a diaphragm.
• Pain during sexual intercourse.
• Abnormal vaginal discharge containing mucus that may be tinged with blood.

Symptoms that may occur when your cervical cancer has progressed include:

• Anemia because of abnormal vaginal bleeding.
• Ongoing pelvic, leg, or back pain.
• Urinary problems because of blockage of a kidney or ureter .
• Leakage of urine or fecal content into the vagina because an abnormal opening ( fistula ) has developed between the vagina and the bladder or rectum.
• Weight loss.

What Happens

If cervical cancer is not treated, it may spread from the cervix to the vagina, then into deeper tissue layers of connective tissue around the uterus. As it progresses, it may spread to the pelvic lymph nodes and other pelvic organs. Advanced-stage cancer may spread to lymph nodes, to other organs in the pelvis, causing problems with kidney and bowel function, or to other organs in the body, such as the liver and lungs.

Cervical cancer is classified in stages that are determined by the size of the cancer and how far it has spread to nearby tissues and other organs, such as the lungs, the liver, or bones. Your doctor will determine the stage of your cervical cancer by gathering information from a variety of tests, including X-rays. The stage of your cancer is one of the most important factors in selecting the treatment option that is right for you. The long-term outcome (prognosis) depends on the stage of your cervical cancer.

What Increases Your Risk

The most common cause of cervical cancer is a persistent infection with a high-risk type of human papillomavirus (HPV ). HPV infection of the cervix is a sexually transmitted disease (STD) . A past HPV infection in you or your partner can cause abnormal cervical cell changes years later because the virus may remain in the body for life. HPV infection usually does not cause symptoms and often goes away without causing any problems, so you or your partner may not be aware of a current or past HPV infection.

Other risk factors that may increase your risk for cervical cancer include:

• High-risk sexual behaviors, such as having more than one sex partner, or having a sex partner who has more than one partner. Safer sex can reduce your risk.
• Having an impaired immune system . For example, women with human immunodeficiency virus (HIV) seem to: ⁶
  • Have higher rates of HPV infection.
  • Be more likely to develop cervical cell changes from HPV.
  • Be more likely to quickly develop cervical cancer from those cell changes.
• Using birth control pills for more than 5 years. This may be related to infection with HPV. ⁵
• Exposure to diethylstilbestrol (DES) before birth (prenatal exposure), though this is rare.
• Smoking or a history of smoking, and possibly exposure to secondhand smoke.

Pregnant women have the same risk of developing cervical cancer as nonpregnant women.

When To Call a Doctor

If you have been diagnosed with cervical cancer , be sure to follow your doctor's instructions about calling when you have problems, new symptoms, or symptoms that get worse.

If you are concerned about your symptoms or if you think you have an increased risk for cervical cancer, call your health professional if you have:

• Unexpected bleeding between menstrual periods.
• Menstrual periods that are irregular or 1½ to 2 times longer than normal for 3 months in a row. For example, if your menstrual periods usually last 6 days and then they last between 9 and 12 days for 3 months in a row, call your doctor.
• Severe menstrual bleeding that causes you to change a maxi-pad or super tampon every hour for longer than 8 hours.
• Unexpected bleeding after douching or sexual intercourse.
• Pain during sexual intercourse.
• Abnormal vaginal discharge containing mucus that may be tinged with blood.

Watchful Waiting

Regular Pap test screening is the most important tool in identifying and treating cervical cell changes before they progress to cervical cancer. After cervical cancer has been diagnosed, it should be treated. Watchful waiting is not appropriate.

Who To See

Health professionals who can evaluate your symptoms and your risk factors, and who can diagnose cervical cancer include:

• Gynecologists .
• Obstetricians .
• Family physicians .
• Nurse practitioners .
• Physician assistants .
• Internists .

Doctors who can manage your cancer treatment include:

• Gynecologists .
• Gynecologic oncologists .
• Radiation oncologists .
• Medical oncologists .

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

The Pap test is a routine screening test used to identify abnormal cell changes of the cervix and to screen for cervical cancer . Regular Pap test screening is the single most important tool in identifying and treating cervical cell changes before they progress to cervical cancer. If cervical cancer is suspected, your doctor will take a medical history and perform a physical exam, including a pelvic exam and a Pap test. Several follow-up tests may be needed for evaluation and treatment.

Tests to confirm a diagnosis of cervical cancer include:

• A colposcopy and cervical biopsy, to find out whether and where cancer cells are on the surface of the cervix.
• An endocervical biopsy (or curettage), to find out whether cancer cells are in the cervical canal.
• A cone biopsy or loop electrosurgical excision procedure (LEEP). These tests are sometimes recommended to remove cervical tissue for examination under a microscope.

If you are pregnant, a colposcopy and cervical biopsy can be done to confirm cervical cancer.

Tests to determine the extent (stage) of cervical cancer include:

• A cone biopsy or loop electrosurgical excision procedure (LEEP). These tests are sometimes recommended to determine the spread of cancer in cervical tissue.
• A cystoscopy, to look at the interior lining of the bladder and the urethra to determine whether the cancer has spread to the urinary system.
• A proctoscopy, to look at the lower part of the large intestine (colon) to determine whether the cancer has metastasized.
• An intravenous pyelogram, to see whether there is any blockage of a kidney.
• A chest X-ray, to check for cancer cells that have spread from the cervix.

Other surgeries may be done to determine the extent of cervical cancer. For more information, see the Surgery section of this topic.

Tests to guide treatment decisions include:

• A complete blood count (CBC), to check for anemia and other abnormal blood values.
• A chemistry screen, to find out how the liver and kidney are working.
• A computed tomography (CT) scan of the abdomen and pelvis, to determine which treatment choice is needed depending on the spread of cancer in the abdomen and pelvis.
• A magnetic resonance imaging (MRI) of the abdomen and pelvis. This test can also help determine which treatment will be recommended depending on the spread of cancer in the abdomen and pelvis.
• A positron emission tomography (PET). This test is sometimes used to evaluate which organs the cancer has spread to.

Early Detection

As part of your routine gynecological exam, you should have a Pap test. A Pap test is used to identify abnormal cell changes of your cervix and to screen for cervical cancer. The Pap test is the most effective screening test to prevent the development of cervical cancer. Abnormal cervical cells on a Pap test are classified according to their degree of abnormality. Treatment decisions are guided by the kind of changes seen in the cells. In North America, abnormal cells are classified using the Bethesda system (TBS). The Bethesda system or other classification systems are used in other parts of the world.

Treatment Overview

Cervical cancer detected in its early stages can be cured with treatment and close follow-up. Treatment choices for cervical cancer may include one or more of the following therapies:

• Surgery to remove the cancer
• Radiation therapy to treat the cancer itself or other organs affected by the cancer
• Chemotherapy to help make the cancer more sensitive to radiation therapy and to treat cancer that has spread (metastasized)

Your quality of life becomes a critical issue when considering treatment options. Be sure to discuss your personal preferences with your oncologist when he or she recommends treatment.

Initial treatment

The choice of treatment and the long-term outcome (prognosis) of cervical cancer depends on the type and stage of cancer. Your age, overall health, quality of life, and desire to be able to have children must also be considered. Treatment choices for cervical cancer may be a single therapy or a combination of therapies, such as:

• Cone biopsy to remove the cancer.
• Simple hysterectomy to remove the uterus and cervix.
• Modified radical hysterectomy and lymph node dissection to remove the cancer.
• Radiation therapy, which uses high-dose X-rays or implants in the vaginal cavity to kill cancer cells.
• Chemotherapy, which uses medicines to kill cancer cells.
• Radical trachelectomy to remove the cervix and the pelvic lymph nodes (lymph node dissection). But the uterus is left in place. This treatment is done less often.

Chemotherapy may be given at the same time as radiation therapy (chemoradiation). Studies show that chemotherapy given at the same time as radiation treatment (chemoradiation) improves survival rates in stages IIB, IIIA, IIIB, and IVA cervical cancer without significantly increasing the side effects of either treatment. Chemoradiation may also improve survival rates in stages IB and IIA for women with large tumors. ^{7, 8, 3} Compared with radiation alone, chemoradiation improves survival. ⁹ It is usually used as the primary therapy or after a hysterectomy.

Microinvasive squamous cell carcinoma (stage IA1) with minimal invasion into deeper cell layers is the most treatable stage with the highest survival rates. This stage is treated with a cone biopsy or loop electrosurgical excision procedure (LEEP) or simple hysterectomy. Five-year survival rates are close to 100%. ¹⁰

Most treatments for cervical cancer cause side effects. Side effects may differ, depending on the type of treatment used and your age and overall health. Your doctor can talk to you about your treatment choices and the side effects associated with each treatment.

• Side effects of chemotherapy may include loss of appetite, nausea, vomiting, diarrhea, mouth sores, or hair loss.
• Side effects of radiation therapy may include fatigue, skin irritation, or changes in your bowel or urinary habits.
• Side effects of surgery depend on the surgery used to treat the stage of your cancer.

Home treatment measures may help relieve some common side effects of cancer treatment. For more information, see the Home Treatment section of this topic.

If you have recently been diagnosed with cervical cancer, you may experience a wide variety of emotions in reaction to your diagnosis. Most women will feel some denial, anger, and grief. There is no "normal" or "right" way to react to a diagnosis of cancer. You can take steps, though, to manage your emotional reactions to learning that you have cervical cancer. Some women find that talking with family and friends is comforting, while others may need to spend time alone to understand their feelings about their disease.

If your emotions are interfering with your ability to make decisions about your health and to move forward with your life, it is important to talk with your doctor. Your cancer treatment center may offer counseling services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other women who have had similar feelings after a diagnosis such as yours can help you accept and deal with your disease.

Treatment for pregnant women

Recommended treatments are the same for pregnant women as for nonpregnant women. Treatment for early stage IA cervical cancer may be delayed until after delivery if the pregnancy is in the third trimester . A vaginal delivery may be possible. ¹

For all stages of cervical cancer, treatment will be managed by a team of doctors specializing in cancer and high-risk pregnancies. The baby does not appear to be affected by cervical cancer, but treatment for the cancer may cause problems such as an early delivery or even the loss of the baby. ¹¹ Treatment will consider the recommendations for the specific stage of cancer, the development of the baby, and the mother's preferences. ¹

What to think about during initial treatment

Depending on the extent (stage) of your cancer, surgery may be combined with radiation therapy and chemotherapy. Radiation or chemotherapy given after a surgery is called adjuvant therapy .

Some women with cervical cancer may be interested in participating in research studies called clinical trials. Clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Women who do not want standard treatments or are not cured using standard treatments may want to participate in clinical trials. These are ongoing in most parts of the United States and in some other countries for all stages of cervical cancer.

Cervical cancer progresses more rapidly, has higher recurrence rates, and has a poorer prognosis in women with human immunodeficiency virus (HIV) .

For more information about specific cervical cancer treatments, see the topics:

• Cervical Cancer—Health Professional Information [NCI PDQ].
• Cervical Cancer—Patient Information [NCI PDQ].

Ongoing treatment

After initial treatment for cervical cancer , it is important to receive follow-up care. Your emotional reactions may continue throughout the course of your treatment depending on your prognosis, the treatment methods used, and your quality-of-life decisions.

Your oncologist or gynecologic oncologist will schedule regular checkups that will include:

• A pelvic exam and Pap test every 3 months for the first 2 or 3 years.
• After the first 2 or 3 years, a pelvic exam and Pap test every 6 months until 5 years after treatment.

Follow-up tests that may be recommended by your oncologist include an abdominal and pelvic computed tomography (CT) scan to monitor whether cancer has spread to other organs in the abdomen or pelvis.

If respiratory symptoms are present, a chest X-ray may be done to determine whether cancer has spread to the lungs.

Treatment if the condition gets worse

Cervical cancer can return after treatment. About 35% of women with cervical cancer will have persistent or recurrent disease. ¹² The chance that your cancer will return depends on the stage of the initial cancer: cancer found early is less likely to come back than cancer found at a later stage. If cancer returns after treatment, it is usually within 2 years of the first diagnosis. ¹⁰ Your long-term outcome (prognosis) for recurrent cervical cancer depends greatly on how much the cancer has spread when the recurrence is diagnosed. ^{10, 7}

• Overall, fewer than 5% of women with recurrent cancer survive 5 more years even with additional treatment.
• Women who have had a radical hysterectomy and develop a recurrence that has not spread outside the pelvis have a 5-year survival rate of 30% to 40% when treated with radiation therapy. Chemotherapy may also be recommended.
• Women who develop a local recurrence that has not spread outside the pelvis may be treated with an extensive surgery called pelvic exenteration, which removes all the pelvic organs and surrounding tissue to eliminate the risk of additional recurrences.

The goal of treatment of advanced-stage cervical cancer that has spread outside the pelvis is to control symptoms, reduce complications, and increase comfort ( palliative care ). It is not intended to cure the disease. Palliative care may include:

• Radiation therapy.
• Chemotherapy medicines.
• Medicines for symptoms such as nausea or pain.

Complementary therapies

In addition to conventional medical treatment, you may wish to try complementary therapies, such as:

• Acupuncture.
• Herbs.
• Biofeedback.
• Meditation.
• Yoga.
• Visualization.
• Vitamins and nutritional supplements.

Complementary therapies are not a substitute for the standard treatment recommended for cervical cancer. Before you try any of these therapies, discuss their possible benefits and side effects with your doctor. Let him or her know if you are already using any such therapies. For more information, see the topic Complementary Medicine.

End-of-life issues

Some women with advanced-stage disease that is not curable may choose not to have cancer treatment because the time, costs, and side effects of treatment may be greater than the benefits. Making the decision about when to stop cancer treatment aimed at prolonging life and shift the focus to best supportive care can be difficult. For more information, see the topics:

• Care at the End of Life.
• Hospice Care.

Prevention

You can treat early cervical cell changes (dysplasia), which can reduce your risk for cervical cancer . You can also reduce your risk factors for abnormal cell changes.

Have regular Pap test screening

The Pap test is the most effective screening test for cervical cancer. Pap tests done at regular intervals almost always detect cervical cell changes before the changes become cancerous. Regular screening for and treatment of cervical cell abnormalities can prevent the abnormal cell changes from developing into cancer. It is important to follow up with your doctor after any abnormal Pap test result.

Quit smoking

Women who smoke have a higher risk of developing cervical cell changes that can lead to cervical cancer. ^{13, 4} The reason for this is not fully understood, but quitting smoking may decrease this risk. Not smoking has many other health benefits. Nonsmokers have a lower risk of other cancers and heart disease. Being around secondhand smoke may also increase your risk of developing cell changes that can lead to cervical cancer. ^{13, 4}

Vaccine

An HPV vaccine (What is a PDF document?) (Gardasil) protects against four types of HPV, which together cause most cases of cervical cancer and genital warts. Three shots are given over 6 months. Gardasil is recommended for girls 11 to 12 years old. The immunization is also recommended for females 13 to 26 years old who did not receive it when they were younger. It can be given to girls as young as 9 years old. Studies show that the vaccine is safe and works well to help prevent cervical cancer and genital warts. ¹⁴

For more information see:

Should my daughter get the HPV vaccine?

Reduce your risk of a sexually transmitted disease (STD)

Sexually transmitted diseases (STDs) often cause abnormal Pap tests and can lead to other serious health problems. Preventing an STD is easier than treating an infection after it occurs. The most common cause of cervical cancer is infection with a high-risk type of the human papillomavirus (HPV) . Since the HPV virus may remain in body cells for life, abnormal cervical cell changes that cause cervical cancer can be the result of either you or your partner having had an HPV infection years earlier. HPV infection usually does not cause symptoms, so you or your partner may not be aware of a current or past HPV infection.

To reduce your risk:

• Talk with your partner about STDs before beginning a sexual relationship. Find out if he or she is at risk for an STD. Remember that it is quite possible to be infected with an STD without knowing it. Some STDs, such as HIV , can take up to 6 months before they are detected in the blood.
• Be responsible.
  • Avoid sexual contact if you have symptoms of an STD or are being treated for an STD.
  • Avoid all intimate sexual contact with anyone who has symptoms of an STD or who may have been exposed to an STD.
• The fewer sex partners you have in your lifetime, the better it is for your health. Your risk for an STD increases if you have several sex partners, or if your sex partner has more than one partner.
• Use male or female condoms to reduce the risk of getting an STD. Using male condoms when you have sex has been shown to reduce your risk of getting HPV. ¹⁵ Female condoms may help also, although there has been less study of this type of protection.

Not having sexual contact is the only certain way to prevent exposure to STDs. Sexually transmitted diseases such as human papillomavirus (HPV) can be spread to or from the genitals, anus, mouth, or throat during sexual activities.

Home Treatment

During medical treatment for any stage of cervical cancer , you can use home treatment to help manage the side effects of cervical cancer or cancer treatment. Home treatment may be all that is needed to manage the following common problems. If your doctor has given you instructions or medicines to treat these symptoms, be sure to follow them. In general, healthy habits such as eating a balanced diet and getting enough sleep and exercise can help control your symptoms.

Home treatment for:

• Nausea or vomiting includes watching for and treating early signs of dehydration , such as a dry mouth, sticky saliva, and reduced urine output with dark yellow urine. Older adults can quickly become dehydrated from vomiting. Nausea and vomiting caused by chemotherapy usually require medical treatment. Your doctor may also prescribe medicines to control nausea and vomiting. For more information on how to deal with these side effects, see:

  Cancer: Controlling nausea and vomiting from chemotherapy.

• Diarrhea includes resting your stomach and being alert for signs of dehydration. Check with your doctor before using any nonprescription medicines for your diarrhea.
• Constipation includes making sure that you drink enough fluids and include fruits, vegetables, and fiber in your diet each day. Do not use a laxative without consulting your doctor.

Other issues that may arise include:

• Sleep problems. If you find you have trouble sleeping, some tips for managing sleep problems may be helpful, such as having a regular bedtime, getting some exercise during the day, and avoiding caffeine late in the day.
• Fatigue. If you feel as though you do not have any energy and tire easily, try some measures to manage fatigue, such as getting extra rest, eating a balanced diet, and reducing your stress.
• Urinary problems, which can be caused by both cervical cancer and its treatment. It may help to eliminate caffeinated drinks from your diet and to establish a schedule of urinating every 3 to 4 hours, regardless of whether you feel the need.
• Hair loss. Hair loss may be unavoidable, but using mild shampoos and avoiding damaging hair products will reduce irritation of your scalp.

Many women with cervical cancer face emotional issues as a result of their disease or its treatment.

• Finding out that you have cancer and going through treatment is stressful. Managing stress may include expressing your feelings to others. Learning relaxation techniques may also be helpful. Relaxation techniques, such as meditation, and support groups may be helpful.
• Your feelings about your body and your sexuality may change following treatment for cancer. It may help to talk openly with your partner about your feelings and to discuss your concerns with your doctor. Your doctor may be able to refer you to organizations that can offer additional support and information.

Not all forms of cancer or cancer treatment cause pain. If pain occurs, many options are available to relieve it. If your doctor has given you instructions or medicines to treat pain, be sure to follow them. Home treatment for pain such as a nonsteroidal anti-inflammatory drug (NSAID) or an alternative therapy like biofeedback may improve your physical and mental well-being. Be sure to discuss any home treatment you use for pain with your doctor. For more information on how to deal with pain from cancer or cancer treatment, see:

Cancer: Controlling cancer pain.

Some women with advanced-stage disease may choose not to have treatment because the time, costs, and side effects of treatment may be greater than the benefits. Making the decision about when to stop medical treatment aimed at prolonging life and shift the focus to end-of-life care can be difficult. For more information, see the topics:

• Care at the End of Life.
• Hospice Care.

Medications

Chemotherapy is used to shrink cervical cancer and decrease tumor growth. Chemotherapy may be used to treat later stages (stages II, III, and IV) of cervical cancer. It may be used alone or in combination with radiation (chemoradiation). Compared with radiation alone, chemoradiation improves survival. ⁹ It is usually used as the primary therapy or after a hysterectomy.

Chemotherapy medicines may be taken by mouth (orally) or injected into a vein (intravenous, or IV). Chemotherapy is called a systemic treatment because the medicines enter the bloodstream and travel through the body to kill cancer cells.

Extensive research and clinical trials have studied the different chemotherapy medicines used to treat cervical cancer. Some medicines are used routinely, and some are used in combination with others for greater effectiveness. Your oncologist will discuss and recommend chemotherapy treatment specific to your condition.

Medication Choices

The most common chemotherapy medicines used for initial treatment or with radiation treatment in stage IIA, IIB, IIIA, IIIB, and IVA include:

• Cisplatin.
• Fluorouracil (5-FU).

For advanced stage (stage IVB) cervical cancer or recurrent cervical cancer, the most common chemotherapy medicines used are:

• Mitomycin.
• Paclitaxel.
• Ifosfamide.

Topotecan has been approved to use with cisplatin for advanced cervical cancer. These drugs may be used when surgery or radiation cannot be done or are not likely to work. They can also be used for cervical cancer that has returned or spread to other organs.

What To Think About

Most chemotherapy will cause some side effects.

Chemotherapy may be given after surgery to try to kill any cancer cells that may remain, which is called adjuvant therapy .

Studies show that chemotherapy given at the same time as radiation treatment (chemoradiation) improves survival rates in stages IIB, IIIA, IIIB and IVA cervical cancer without significantly increasing the side effects of either treatment. Chemoradiation may also improve survival rates in stages IB and IIA for women with large tumors. ^{8, 3} Compared with radiation alone, chemoradiation improves survival. ⁹ It is usually used as the primary therapy or after a hysterectomy.

Cisplatin is the medicine most often used in chemoradiation for cervical cancer.

Surgery

Surgery to remove cervical cancer may be an option when the cancer is confined to the cervix or uterus . The type of surgery performed depends on the location and extent of cervical cancer and your desire to be able to have children.

Surgery Choices

Surgery for very early stages of cervical cancer that preserves your ability to have children includes:

• A cone biopsy or loop electrosurgical excision procedure (LEEP), which removes a wedge of cervical tissue that contains the cancer.
• Radical trachelectomy and laparoscopy for pelvic lymph node dissection, which removes the cervix and area lymph nodes , but not the uterus. Radical trachelectomy is not commonly used.

Surgery for most stages of cervical cancer does not preserve your ability to have children. Surgeries include:

• Hysterectomy with or without removal of the ovaries , to remove the cervix and related organs where recurrence would be most likely to occur.
• Modified radical hysterectomy with pelvic lymph node dissection. A radical hysterectomy usually includes removal of part of the vagina, the uterus, the ovaries, and the fallopian tubes . This removes the most likely sites of cancer and may reduce the risk of recurrence.

What To Think About

If surgery is part of your treatment, you also may be given radiation therapy , chemotherapy , or combination chemoradiation. These treatments may be given before or after surgery to try to destroy any cancer cells that may remain. Radiation, chemotherapy, or chemoradiation given before a surgery to help control or reduce the size of the tumor is called neoadjuvant therapy . Using these therapies after a surgery when only microscopic areas of cancer may still be present is called adjuvant therapy .

Compared with radiation alone, chemoradiation improves survival if it is used either before or after a hysterectomy. ⁹

Side effects from surgery can include difficulty with urination or problems with bowel habits, such as constipation or diarrhea. Your ability to have or enjoy sexual intercourse may also be affected.

Other Treatment

Radiation therapy is the standard treatment for certain stages of cervical cancer and often is used in combination with surgery.

Radiation therapy is the use of high-energy X-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from radiation material (radioisotopes) in thin plastic tubes inserted through the vagina into the cervical area where the cancer cells are found (intracavitary brachytherapy).

The two forms of brachytherapy used to treat cervical cancer include low-dose-rate (LDR) brachytherapy and high-dose-rate (HDR) brachytherapy. LDR brachytherapy has been used the most in the past, but HDR brachytherapy takes less time and can be done on an outpatient basis. Both LDR and HDR appear to work about the same. ¹⁶

Studies show that chemotherapy given at the same time as radiation treatment (chemoradiation) improves survival rates in stages IIB, IIIA, IIIB and IVA cervical cancer without significantly increasing the side effects of either treatment. Chemoradiation may also improve survival rates in stages IB and IIA for women with large tumors. ^{8, 3} Compared with radiation alone, chemoradiation improves survival. ⁹ It is usually used as the primary therapy or after a hysterectomy.

What to think about

Radiation may cause many side effects, including diarrhea and irritation of the bladder (radiation cystitis). Your ability to have or enjoy sexual intercourse may also be affected because radiation may cause changes to the cells lining the vagina (mucosa), making intercourse difficult or painful. A series of vaginal dilators, starting with a small one and progressing to a larger size, may be used after radiation therapy. Using the dilators can make the vaginal opening larger and help make sex less difficult or painful.

Radiation to treat cervical cancer may thin the bone and increase the risk of fractures in the pelvic area, including hip fractures. You can take steps to prevent thinning of the bone ( osteoporosis ), such as getting enough calcium and vitamin D. Also, try to prevent falls, which can lead to fractures. ¹⁷ For more information, see the topic Osteoporosis.

Radiation therapy may also be used to manage the symptoms that occur with incurable cervical cancer: this is called palliative care .

Other Treatment Choices

In addition to conventional medical treatment for cervical cancer , you may wish to try complementary therapies, such as:

• Acupuncture.
• Herbs.
• Biofeedback.
• Meditation.
• Yoga.
• Guided imagery.
• Vitamins and nutritional supplements.

Complementary therapies are not a substitute for the standard treatment recommended for cervical cancer. Before you try any of these therapies, discuss their possible benefits and side effects with your doctor. Let him or her know if you are already using any such therapies. For more information, see the topic Complementary Medicine.

What To Think About

The combination of conventional medical treatment and complementary medicine is an approach sometimes termed integrative medicine, in which conventional and complementary therapies work together for the best outcome. Complementary therapies are not a substitute for the standard treatment recommended for cervical cancer.

Other Places To Get Help

Organizations

American Cancer Society (ACS)
Phone:	1-800-ACS-2345 (1-800-227-2345)
TDD:	1-866-228-4327 toll-free
Web Address:	www.cancer.org
The American Cancer Society (ACS) conducts educational programs and offers many services to people with cancer and to their families. Staff at the toll-free numbers have information about services and activities in local areas and can provide referrals to local ACS divisions.
American College of Obstetricians and Gynecologists (ACOG)
409 12th Street SW
P.O. Box 96920
Washington, DC  20090-6920
Phone:	(202) 638-5577
E-mail:	resources@acog.org
Web Address:	www.acog.org
American College of Obstetricians and Gynecologists (ACOG) is a nonprofit organization of professionals who provide health care for women, including teens. The ACOG Resource Center publishes manuals and patient education materials. The Web publications section of the site has patient education pamphlets on many women's health topics, including reproductive health, breast-feeding, violence, and quitting smoking.
National Cancer Institute (NCI)
NCI Publications Office
6116 Executive Boulevard
Suite 3036A
Bethesda, MD  20892-8322
Phone:	1-800-4-CANCER (1-800-422-6237) 9:00 a.m. to 4:30 p.m. EST, Monday through Friday
TDD:	1-800-332-8615
E-mail:	cancergovstaff@mail.nih.gov
Web Address:	www.cancer.gov (or https://cissecure.nci.nih.gov/livehelp/welcome.asp# for live help online)
The National Cancer Institute (NCI) is a U.S. government agency that provides up-to-date information about the prevention, detection, and treatment of cancer. NCI also offers supportive care to people with cancer and to their families. NCI information is also available to doctors, nurses, and other health professionals. NCI provides the latest information about clinical trials. The Cancer Information Service, a service of NCI, has trained staff members available to answer questions and send free publications. Spanish-speaking staff members are also available.
National Women's Health Information Center
8270 Willow Oaks Corporate Drive
Fairfax, VA  22031
Phone:	1-800-994-9662 (202) 690-7650
Fax:	(202) 205-2631
TDD:	1-888-220-5446
Web Address:	www.womenshealth.gov
The National Women's Health Information Center (NWHIC) is a service of the U.S. Department of Health and Human Services Office on Women's Health. NWHIC provides women's health information to a variety of audiences, including consumers, health professionals, and researchers.
Women's Cancer Network
230 West Monroe
Suite Suite 2528
Chicago, IL  60606
Phone:	312-578-1439
E-mail:	info@thegcf.org
Web Address:	www.wcn.org
The Women's Cancer Network provides information about cancers of the female reproductive tract (ovary, endometrium, cervix, vulva, and vagina) for women and their families. Their goal is to help women understand more about the disease, learn about treatment options, and have access to new or experimental therapies. This Web site was developed by The Gynecologic Cancer Foundation, a non-profit organization with a mission to help people learn how to prevent, diagnose, and treat cancers of the female reproductive tract.

Related Information

• Abnormal Pap Test
• Complementary Medicine
• Early Disease Detection
• Genital Warts (Human Papillomavirus)

References

Citations

1. Guintoli RL II, Bristow RE (2008). Cervical cancer. In RS Gibbs et al., eds., Danforth's Obstetrics and Gynecology, 10th ed., pp. 971–988. Philadelphia: Lippincott Williams and Wilkins.
2. Cannistra SA (2007). Gynecologic cancer. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 10. New York: WebMD.
3. Eifel PJ, et al. (2004). Pelvic irradiation with concurrent chemotherapy versus pelvic and para-aortic irradiation for high-risk cervical cancer: An update of Radiation Therapy Oncology Group Trial (RTOG) 90-01. Journal of Clinical Oncology, 22(5): 872–880.
4. Trimble CL, et al. (2005). Active and passive cigarette smoking and the risk of cervical neoplasia. Obstetrics and Gynecology, 105(1): 174–181.
5. Moreno V, et al. (2002). Effect of oral contraceptives on risk of cervical cancer in women with human papillomavirus infection: The IARC muticentric case-control study. Lancet, 359(9312): 1085–1092.
6. Chirenje ZM (2005). HIV and cancer of the cervix. Best Practice and Research Clinical Obstetrics and Gynaecology, 19(2): 269–276.
7. Waggoner SE (2003). Cervical cancer. Lancet, 361: 2217–2225.
8. Thigpen T (2003). The role of chemotherapy in the management of carcinoma of the cervix. Cancer Journal, 9(5): 425–432.
9. Sundar S, et al. (2008). Cervical cancer, search date November 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.
10. Janicek MF, Averette HE. (2001). Cervical cancer: Prevention, diagnosis, and therapeutics. CA, A Cancer Journal for Clinicians, 51: 92–114.
11. Holschneider CH (2007). Premalignant and malignant disorders of the uterine cervix. In AH DeCherney et al., eds., Current Diagnosis and Treatment Obstetrics and Gynecology, 10th ed., pp. 833–854. New York: McGraw-Hill Medical Publishing Division.
12. American College of Obstetricians and Gynecologists (2002, reaffirmed 2006). Diagnosis and treatment of cervical carcinomas. ACOG Practice Bulletin No. 35. Obstetrics and Gynecology, 99(5): 855–867.
13. National Cancer Institute (2008). Cervical Cancer (PDQ): Prevention—Health Professional Version. Available online: http://www.nci.nih.gov/cancertopics/pdq/prevention/cervical/healthprofessional.
14. U.S. Food and Drug Administration (2006). FDA licenses new vaccine for prevention of cervical cancer and other diseases in females caused by human papillomavirus. FDA News. Available online: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01385.html.
15. Winer RL, et al. (2006). Condom use and the risk of genital human papillomavirus infection in young women. New England Journal of Medicine, 354(25): 2645–2654.
16. Lertsanguansinchai P, et al. (2004). Phase III randomized trial comparing LDR and HDR brachytherapy in treatment of cervical carcinoma. International Journal of Radiation Oncology Biology Physics, 59(5): 1424–1431.
17. Baxter NN, et al. (2005). Risk of pelvic fractures in older women following pelvic irradiation. JAMA, 294(20): 2587–2593.

Other Works Consulted

• American Cancer Society (2007). Cancer Facts and Figures for African Americans 2007–2008. Atlanta: American Cancer Society. Available online: http://www.cancer.org/downloads/STT/CAFF2007AAacspdf2007.pdf.
• Eifel PJ, et al. (2008). Cancer of the cervix, vagina, and vulva. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 8th ed., vol. 1, pp. 1496–1540. Philadelphia: Lippincott Williams and Wilkins.
• Kaferle JE, Malouin JM (2001). Evaluation and management of the AGUS Papanicolaou smear. American Family Physician, 63(11): 2239–2244.
• Sawaya GF, et al. (2000). Frequency of cervical smear abnormalities within 3 years of normal cytology. Obstetrics and Gynecology, 96(2): 219–223.

Credits

Author	Bets Davis, MFA
Editor	Maria Essig
Editor	Susan Van Houten, RN, BSN, MBA
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer	Kevin Holcomb, MD - Gynecologic Oncology
Last Updated	September 5, 2008