Cervical Cancer

How cervical cancer develops

HPV is a very common virus passed through sexual contact. Most people get it at some point, and the immune system clears most infections within 1 to 2 years. When a high-risk type persists, it can change the cells of the cervix:

1. HPV infection
2. Precancerous changes (cervical intraepithelial neoplasia, CIN 1 to 3, or high-grade squamous intraepithelial lesions)
3. Invasive cancer

This usually takes 10 to 20 years, giving a long window in which screening can find and remove abnormal cells. See cervical dysplasia.

Types

• Squamous cell carcinoma: most cases, from the outer surface of the cervix
• Adenocarcinoma: from glandular cells in the cervical canal, harder to detect on Pap tests
• Rare mixed and other types

Risk factors

• persistent high-risk HPV infection (the essential factor)
• never or rarely having screening
• smoking, which roughly doubles risk
• weakened immunity, including HIV and organ transplant medicines
• long-term use of oral contraceptives (small increase that falls after stopping)
• many full-term pregnancies or first pregnancy at a young age
• chlamydia infection
• in utero exposure to DES (a rare historical risk)

Symptoms

Early cervical cancer and precancer usually cause no symptoms. As it grows, symptoms can include:

• bleeding after sex
• bleeding between periods or periods that are heavier or longer
• bleeding after menopause
• watery, pink or foul-smelling vaginal discharge
• pain during sex
• pelvic pain

Advanced cancer may cause back or leg pain, leg swelling, problems urinating or with bowel movements, blood in urine, tiredness and weight loss.

These symptoms are far more often caused by infection, polyps or hormonal changes, but they should always be checked.

Screening

US Preventive Services Task Force recommendations for people with a cervix at average risk:

Self-collected vaginal HPV samples are now an accepted option in many settings. People with HIV, weakened immunity or previous high-grade changes need more frequent screening. Vaccinated people still need screening.

If a screening result is abnormal

You will usually be offered a colposcopy: a magnified look at the cervix with a vinegar solution to highlight abnormal areas, and biopsies. High-grade precancer is treated with a LEEP (loop electrosurgical excision procedure) or a cone biopsy, which removes the abnormal area and prevents most cancers.

Diagnosis and staging

If cancer is suspected:

• biopsy of the cervix
• pelvic examination, sometimes under anesthesia
• MRI of the pelvis to measure local spread
• CT or PET-CT to look for spread to lymph nodes or other organs

Staging uses the FIGO system:

Treatment

Treatment is planned by a gynecologic oncology team.

Early-stage cancer

• Cone biopsy or trachelectomy (removing the cervix but keeping the uterus) for very small tumors, preserving fertility in selected cases
• Hysterectomy with removal of pelvic lymph nodes for many stage I cancers

Locally advanced cancer

• Chemoradiation: external beam radiation plus weekly cisplatin chemotherapy, followed by internal radiation (brachytherapy)
• Immunotherapy such as pembrolizumab added to chemoradiation for some high-risk locally advanced cancers

Advanced or recurrent cancer

• chemotherapy combinations, often with bevacizumab and immunotherapy
• targeted treatments such as tisotumab vedotin
• palliative radiotherapy and supportive care

Side effects

Possible long-term effects include early menopause, infertility, vaginal narrowing and dryness, bladder and bowel changes, and leg swelling (lymphedema). Support with vaginal dilators, hormone therapy where appropriate and pelvic floor therapy helps.

Prevention

HPV vaccination

The CDC recommends routine HPV vaccination at age 11 to 12 (it can start at 9), with catch-up through age 26. Some adults 27 to 45 may benefit after discussion with a clinician. Countries with high vaccination rates have seen dramatic falls in precancer and cancer. See HPV.

Other steps

• regular screening as recommended
• not smoking
• condoms, which reduce but do not eliminate HPV transmission
• follow-up of abnormal results

Outlook

Cervical cancer found early has an excellent outlook: 5-year survival for localized disease is over 90% in US data. Survival is lower for cancer that has spread. Most cervical cancer deaths occur in people who were never or rarely screened.

Frequently asked questions

What are the early signs of cervical cancer?

Early cervical cancer often has no symptoms, which is why screening matters. When symptoms occur, the first are often bleeding after sex, bleeding between periods or after menopause, and unusual watery or bloody discharge.

What causes cervical cancer?

Almost all cervical cancers are caused by long-lasting infection with high-risk types of human papillomavirus (HPV), especially types 16 and 18. Smoking, weakened immunity and lack of screening increase the risk that an infection progresses to cancer.

How often should I get screened for cervical cancer?

In the US, people with a cervix should have a Pap test every 3 years from 21 to 29, then an HPV test every 5 years (or a Pap test every 3 years) from 30 to 65. People at higher risk may need more frequent tests.

Can the HPV vaccine prevent cervical cancer?

Yes. The HPV vaccine protects against the HPV types that cause most cervical cancers and is most effective when given before any sexual activity, ideally at age 11 to 12. Vaccinated people still need regular screening.

Is cervical cancer curable?

Yes, especially when found early. Precancerous changes are almost always curable with a simple procedure, and early-stage cancer has very high cure rates with surgery or chemoradiation. Advanced cancer is harder to cure but can be treated.