Cancer of the cervix is most likely to occur in women between the ages of 30 and 55. Each year about 15,700 new cases of cervical cancer are diagnosed in the U.S. and nearly 5,000 American women die of the disease. Yet virtually all cervical cancer deaths can be prevented by getting routine Pap smears, practicing safe sex, and not smoking. Cervical cancer is slow-growing and almost 100 percent curable when it is caught early -- before it has spread beyond the cervix.
Who Is At Risk?The main risk factors for cervical cancer are linked to sexual habits. Sexually transmitted diseases (STDs) may affect your cells in a way that makes them more likely to undergo changes that can lead to cancer. These diseases include certain types of human papilloma virus (HPV), herpes, gonorrhea and chlamydia. Adolescent females who begin to have sexual relations before the age of 18 are more likely to develop cervical cancer than are women who delay having sexual intercourse. Using latex condoms and a spermicide that contains nonoxynol-9 may help prevent the spread of HPV and other STDs. But even this dual protection is not 100% effective. HPV can be on the scrotum, thigh and other places not covered by condoms. Smoking is another risk factor for developing cervical cancer.
There is evidence that poor eating habits can also contribute to developing cervical cancer. Some studies suggest that a low level of folic acid (one of the B vitamins) in the blood increases a woman's risk for the disease. Foods rich in folate include leafy green vegetables, legumes, oranges and wheat germ. Since most women only manage to get 200 micrograms (mcg) of folic acid in their diet, experts suggest taking a multi vitamin which contains 400 mcg.
Husbands who cheat on their wives risk giving them cervical cancer. The disease is linked to certain strains of the human papillomavirus (HPV), which is spread during sexual intercourse. The Human Papillomavirus (HPV) has been found to be present in 93 percent of all cases of cervical cancer or dysplasia.
The Pap Test: Your Best DefenseFortunately, cervical cancer is a slow-growing disease that can be diagnosed early. Your best weapon against cancer of the cervix is to get an annual Pap test. Named for its developer, George N. Papanicolaou, the Pap Smear can detect not only cervical cancer, but precancerous cells as well. In fact, the Pap catches an estimated 95 percent of cervical cancers at a very early stage and is credited with the steep dip in incidence and death from cervical cancer in the U.S. over the past several decades. Incidence rates declined from 14.2 per 100,000 in 1973 to 8.3 per 100,000 in 1993. In addition, deaths from cervical cancer were nearly cut in half (48 percent) between 1973 and 1993.
The Pap screening test can be done by your gynecologist or family physician during a regular pelvic exam. Using a spatula, brush or cotton swab, the physician rubs the entire surface of cervix (the opening to the uterus or womb) to gather cells. A cell sample from inside the cervical canal is also taken with a cotton swab. At most, you may feel a slight discomfort. The cells are then sent to a lab for microscopic analysis.
What Should I Do To Prepare For a Pap Test?To help boost the reliability of the Pap smear, do not douche or use a feminine deodorant for a few days before the test, do not have sex the night before the test, and schedule your appointment while you are not menstruating.
Who Should Get Regular Pap Tests?The American Cancer Society's recommendations on the frequency of Pap test screening are: All women who are or who have been sexually active or who have reached age 18 should have an annual Pap test and pelvic examination. After a woman has had three or more consecutive, annual exams with normal findings, the Pap test may be performed less frequently in a low-risk woman at the discretion of the physician.
Women should continue to have Pap test once a year if they have any of the following high-risk factors:
- Women who began intercourse before the age of 18
- Women who have had multiple sex partners or whose male sexual partners have had multiple partners
- Women with current or prior human papillomavirus infection or venereal warts or both
- Women with current or prior herpes simplex virus infections
- Women who are immunosuppressed
- Smokers and abusers of other substances, including alcohol
- Women who have a history of cervical dysplasia or cervical cancer or endometrial, vaginal, or vulvar cancer
- Women whose mothers were given the drug diethylstilbestrol (DES) during pregnancy
What Do the Results Mean?A negative Pap smear means that your results are normal. A positive Pap smear can be a sign of changes in the cells on your cervix. But interpreting a Pap smear is not always easy. When a lab finds abnormalities, a doctor has no way of knowing which abnormal cells will progress to cervical cancer and which will vanish on their own. As a result, physicians sometimes recommend surgery for conditions that don't require it.
According to guidelines developed by The American College of Obstetricians and Gynecologists and the National Cancer Institute, mild changes in cells (dysplasia) can be treated less aggressively because the risk of cancer is low. Another reason for caution: some surgical treatments may cause future miscarriages in women of childbearing age.
Up and Coming: A New Cancer Test
As good as the Pap test is, two new studies indicate that a newer test is even better at detecting cervical cancer. The DNA test detects genetic material from types of the human papilloma virus (HPV) which cause most cases of cervical cancer (the Pap test, by contrast, looks for cancerous or precancerous changes in cervical cells). Women can use the DNA test at home by using a cotton swab to collect a sample of vaginal cells, which is then sent to a lab for analysis. How precise is the DNA test? When women in a South African study used the test themselves, it found 66 percent of their cervical cancers, as compared with 68 percent detected by Pap smears. When the DNA test was used by doctors both in South Africa and Costa Rica, about 84 percent of cancers and precancerous conditions were identified.
The DNA test is most useful for women over 40. Most younger women who have HPV don't develop cancer, so the test may cause too many false alarms. However, when HPV is found in a woman over 40, it means her body couldn't fight off the infection and she's more likely to develop cervical cancer. The DNA test will probably not be used for routine screening until larger studies are completed.
What Are the Different Types of Abnormalities?Here are the range of results that may be reported to your doctor and the possible treatments:
Dysplasia or Neoplasia indicates a change in the cells on the surface of the cervix. It does not necessarily signal cancer, and a woman who gets such a result may only have to have a repeat Pap test.
Atypical Squamous Cells of Undetermined Significance (ASCUS) indicates mild cellular changes that the pathologist can't distinguish between the benign and neoplasia. A doctor will probably suggest a repeat Pap in six months.
Low-Grade Squamous Intraepithelial Lesion (LSIL): Potentially precancerous changes have been found. This is the most confusing category, and follow-up--either a Pap test in four to six months or colposcopy--is at the doctor's discretion.
High-Grade Squamous Intraepithelial Lesions (HSIL), also known as moderate or severe dysplasia or carcinoma in situ (CIS): This category requires surgical treatment to remove the lesions if the severity is confirmed by biopsy.
Squamous cell carcinoma: a cancerous lesion. The cure rate is high if caught early. Treatment choices include radical hysterectomy, radiation therapy and chemotherapy.
What Are the Diagnostic Techniques and Treatment Options?If a Pap test is abnormal, the doctor must decide whether to simply follow up with a repeat test in four to six months or do a colposcopy. A colposcope is an instrument equipped with a magnifying glass and a light. The physician uses it to closely examine suspicious areas on the cervix. When a lesion is found, a biopsy (removal of a small piece of cervical tissue) can be done. If the biopsy is normal (negative), another Pap test may be recommended in four to six months to determine if there are precancerous cells still present.
If the doctor decides that a mild form of dysplasia should be removed, several surgical techniques may be considered:
- Cauterization destroys abnormal tissue using heat, electricity or chemicals. It can be done in a physician's office or in a hospital on an outpatient basis. Usually, no anesthesia is necessary. Cauterization is considered very safe. However, occasionally it causes scarring that makes future Pap smears difficult to interpret.
- Cryosurgery destroys tissue by application of extreme cold in the form of liquid nitrogen. This procedure can also be done in the physician's office.
- Laser surgery uses a high-energy beam of light to burn away the dysplasia. There is little or no damage to surrounding tissue, and the area heals quickly. This is usually an outpatient hospital or office procedure.
- A cone biopsy may be done if advanced dysplasia is present. In this procedure, a cone-shaped wedge of the cervix is removed and analyzed. This is a major surgical procedure done with general anesthesia in a hospital. If the tissue analysis shows that all abnormal tissue was removed, no further treatment may be required.
Conization can make it difficult for a woman to become pregnant, or it can leave her with a tendency to miscarry. Tell your doctor if you become pregnant and you have had a cone biopsy.
What If It's Cancer?After being treated for dysplasia it is usually recommended that a woman have a Pap smear twice a year for the next two years and once a year after that to make sure there is no recurrence.
If a biopsy shows cancer is present, the physician may do a conization and a dilation and curettage (D&C). In this procedure, the uterine lining is gently scraped for tissue samples to find out whether the cancer has spread beyond the cervix. Then the doctor will determine the stage of the disease.
Treating Cervical CancerWhich treatment method is used depends largely on how far the cancer has spread Here are the treatment options:
- Surface cancer (carcinoma in situ). The cure rate for localized cervical cancer is nearly 100 percent. The same methods used to treat cervical dysplasia can be used to treat cancer that remains on the surface of the cervix. These procedures include cauterization, cryosurgery, laser surgery and conization. Sometimes radiation therapy is advised after conization to keep cancer cells from growing and multiplying. In some cases, a second conization may be necessary, or perhaps a hysterectomy.
- Invasive cancer. When cancer spreads to the uterus, a radical hysterectomy is usually done. This involves removal of the uterus, upper vagina, lymph nodes, and fallopian tubes. Sometimes the ovaries are left ion young women so that estrogen production will not be cut off.
For women with locally advanced or invasive cancer, meaning that the tumor on the cervix is large or has spread to nearby lymph nodes or other parts of the pelvis, a combination of radiation treatment and chemotherapy is now recommended rather than the standard treatment of only surgery and radiation. In early 1999, the National Cancer Institute announced that radiation and chemotherapy given together reduces death rates from the disease by 30 percent to 50 percent.
Biological therapy can also be used to treat cancer that has spread from the cervix to other parts of the body. This type of treatment aims to improve the way the body's immune system fights disease. Interferon is the most common form of biological therapy for cervical cancer. It can be used in combination with chemotherapy.
New Technology Helps Boost Accuracy of Pap ScreeningThe Pap smear screening test has reduced deaths from cervical cancer by about 70 percent over the past 50 years. Still, there's a significant error rate, and poor-quality samples are to blame for most of the mistakes. To improve the rate of detection, the Food and Drug Administration (FDA) approved the ThinPrep Pap test.
With standard pap smears, a doctor scrapes cells from a woman's cervix and then smears them on a slide. However, up to 80 percent of the cells are thrown away and up to 40 percent of all slides are obscured by impurities such as blood and mucus. With the ThinPrep, a broomlike device gathers the cells, but then they're rinsed in a vial of preservation fluid, which is sent to a lab where a machine filters out the impurities and applies a thin layer of cells to a slide. This system creates a much clearer, higher quality specimen. How much better is the new test? In one clinical trial, 40 positive cases were diagnosed with the conventional Pap smear and 67 cases with the Thin Prep--that's a 68 percent increase in finding abnormal cells.
A new computer system called Papnet may also help detect abnormalities that the Pap test misses. Until the development of this screening tool, physicians had no way to double-check the work of cytologists, who look at hundreds of thousands of Pap smears daily to find abnormal cells. Cytologists put slides containing the cervical cells under a microscope and scan them for suspicious signs. But abnormalities can be hidden by inflammation, or the cytologist may simply miss one of the tiny cells. Papnet's technology scans slides previously deemed normal by a cytologist. The computer then selects possible abnormalities, which can be displayed on a monitor for review by a technician for a final evaluation. There has been some confusion regarding the intended use of Papnet. The FDA has approved it for laboratory use as a quality control measure to rescreen slides that seem normal. It has not been approved for initial interpretation of Pap tests. A similar technology, the Autopap system, relies on a computerized microscope to screen cell samples.
All three of these technologies improve the accuracy of the Pap test, but they don't completely eliminate the occurance of false-negative results (failure to detect existing cervical cancer or precancer). The techniques add to the cost of a Pap test and my not be covered by medical insurance.