Cervical cancer

About cervical cancer | Reduce your risk | Screening | Diagnosis | Treatment | Coping with Cancer | Support Services | More information and resources | References

About cervical cancer

The cervix

The cervix is the lower part of the uterus (womb). It is sometimes called the uterine cervix.

The cervix connects the body of the uterus to the vagina (birth canal).

There are two main types of cells covering the cervix

  • squamous cells (make up the ectocervix or outer cervix) and
  • glandular cells (make up the endocervix or inner cervix).

The place where these 2 cell types meet is called the transformation zone. Most cervical cancers start in the transformation zone.1

The female reproductive system - the cervix

Image courtsey of Cancer Council Victoria

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Cervical cancer

Cervical cancer is the growth of abnormal cells in the cervix. Cervical cancer most commonly begins in the cells of the transformation zone. At diagnosis, the cancer is usually within the cervix, but sometimes it has spread to tissues around the cervix (eg the vagina) or to other parts of the body.

Certain types of human papillomavirus (HPV), have been identified as the main risk factor for cervical cancer. HPV is a common infection. The virus is so common that four out of five people will have had the virus at some time in their lives. Most people are not aware they have the virus and in most cases the body naturally clears the virus within one to two years.

There are more than 100 different types of HPV, including some that affect the reproductive system. Genital HPV is spread through genital-skin to genital-skin contact, for example during sexual activity. Cervical cancer is a result of long-term (persistent) HPV infection. It is important to remember that most women who have HPV clear the virus naturally and do not go on to develop cervical cancer.2

Cervical cancer is highly preventable. The best way to protect yourself is to be vaccinated against HPV and participate in regular cervical screening.3

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How common is it?

Cervical cancer is the twelfth most common cancer affecting women in Western Australia.4 In 2014, 113 women were diagnosed with cervical cancer. The chances of getting cervical cancer by the time you are aged 75 (lifetime risk) is 1 in 156. This means for every 156 women who reach the age of 75 one will have developed cervical cancer during their lifetime. In 2014, 24 Western Australian women died from cervical cancer.4

Learn more about cancer statistics.

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Risk factors

The main cause of cervical cancer is long-term (persistent) infection with human papillomavirus (HPV).

You can get cervical cancer at any time after you become sexually active, but your risk increases after the age of 30.

Your risk of cervical cancer is also increased by not participating in regular cervical screening. Three out of every four women who develop cervical cancer have either never had a cervical screening test or have not had one within the last five years.5

There are also a number of other known factors that increase the chances (risk) of developing cervical cancer; some of these risk factors are beyond your control, whereas others are not.6,7

Lifestyle factors are things you can change. Your risk of cervical cancer is increased8 if you:

  • are not vaccinated against HPV
  • do not participate in regular cervical screening
  • smoke

There is no strong evidence that food, nutrition and physical activity affect cervical cancer risk. However, nutritional status may affect your vulnerability to infection.8

Other risk facts that are out of your control and can increase your risk include:

  • Exposure to diethylstilboestrol: If your mother used the drug diethylstilboestrol (DES) during pregnancy to prevent a miscarriage you have an increased risk of developing cervical cancer.
  • Immunosuppression - use of immune system suppressing drugs for prolonged periods of time and HIV is a risk factor for cervical cancer.9

It is important to emphasise that having one or more of these risk factors does not mean you will get cervical cancer.

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Symptoms

Early changes in cervical cells rarely cause symptoms. If cell changes go undetected and develop into cervical cancer, the most common symptoms include:10

  • vaginal bleeding between periods
  • menstrual bleeding that is longer or heavier than usual
  • bleeding after intercourse
  • pain during intercourse
  • unusual vaginal discharge
  • vaginal bleeding after menopause
  • excessive tiredness
  • leg pain or swelling
  • low back pain

It is important to know these symptoms, but it is equally important to know cervical cancer often develops without symptoms. What's more, having these symptoms does not necessarily mean you have cervical cancer, as they may be caused by other conditions. However, if you do have any of these symptoms, or you are concerned, you should see your doctor as soon as possible.

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Reduce Your Risk

Cervical cancer is largely preventable. Regular cervical screening and the HPV vaccinationare the best defence against this cancer.3

There are a number of things you can do to help reduce your chances (risk) of developing cervical cancer including:

In 2018 Gardasil 9 (nonavalent) replaced the Gardasil (quadravalent) vaccine used as part of the Australian immunisation porgram.  Gardasil 9 is a vaccine that protects against seven types of HPV (types 16, 18, 31, 33, 45, 52 and 58) which cause over 90% of cervical cancers in women11 and a least 90% of all HPV-related cancers in men. It also protects against two other HPV types (types 6 and 11), which cause 90% of genital warts.12

Through the National Immunisation Program, girls and boys in Australia are offered the HPV vaccine around the age of 12 or 13. In WA the vaccine is given in year 8.  It is important that parents give consent to their child (or children) to receive the vaccination.

It is also important that both boys and girls receive all of the doses to receive full and effective protection. A child who has missed a scheduled dose is eligible to receive free catch-up vaccination at their school, community health or local government vaccination clinic or from their general practitioner.

HPV vaccines are also available from health care professionals for men and women who were not vaccinated by the HPV Vaccination Program or the catch up programs. If you are interested in being vaccinated against HPV, speak with your doctor. As older men and women are not covered under the National Immunisation Program, they will need to pay for the vaccine out of pocket.

  • Participate in regular cervical screening

The National Cervical Screening Program has changed. The Pap test was replaced on 1 December 2017 with a new Cervical Screening Test. All women aged 25-74 who have ever had sex should have a Cervical Screening Test every five years. The first Cervical Screening Test is due two years after a women's last Pap test. After that, women will only need to have the test every five years if the results are normal

Regular cervical screening is the best protection against cervical cancer.  Even HPV vaccinated women need to have regular cervical screening as the HPV vaccine does not protect against all the HPV types that can cause cervical cancer.2

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To reduce your overall cancer risk you should also:

  • Achieve and maintain a healthy body weight
  • Get at least 30 to 60 minutes or more of moderate intensity physical activity on most days of the week
  • Eat well - enjoy a wide variety of nutritious foods from the five groups every day
    • Plenty of vegetables, including different types and colours, and legumes/beans
    • Fruit
    • Avoid processed meats
    • Limit your intake of red meat to 3 or 4 palm sized serves (65-100g) a week
    • Eat foods which are high in fibre
  • Avoid alcohol. If you choose to drink, limit your alcohol intake

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Screening

Screening

Screening for cancer means finding early cancer before symptoms develop. Screening does not diagnose cancer, it identifies people who need more tests to find out if cancer is present.

Early detection of cervical cancer significantly improves the chances of successful treatment.

How do I screen for cervical cancer?

During cervical cancer screening a health care provider inserts a speculum into the vagina so they can see the cervix. Then cells are collected from the cervix using a brush or spatula. This may feel slightly uncomfortable, but generally only lasts for a short time. The cells are placed into a liquid. The sample is sent to a laboratory to be examined and tested for HPV. If HPV is detected, further testing or treatment is needed.

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National Cervical Screening Program

The National Cervical Screening Program now provides routine screening every five years for women. If you're aged 25 to 74 you should have your first Cervical Screening Test two years after your last Pap test.

More information about the changes to the program is available from the National Cervical Screening Program.

What do my test results mean?

Your healthcare provider will talk to you about your Cervical Screening Test results. Possible results include:

Return to screen in five years

Your results show you do not have a HPV infection. The National Cervical Screening Program will send you a reminder to have your next Cervical Screening Test in five years.13

Return to screen in 12 months. 

Your results show you do not need further investigation but you should have a repeat test in 12 months.

This is because you have a HPV infection. It is likely to be cleared by your body within the next 12 months. The repeat test checks if the infection has gone and if so, you are safe to return to five yearly screening.

If the repeat test shows a HPV infection is still present, you may need further investigation from a specialist.

If you have a HPV infection, it does not mean you have cervical cancer. It takes about 10 to 15 years for cervical cancer to develop, and cervical cancer is a rare outcome.13

Refer to a specialist

Your results show you have:
• A type of HPV infection that requires further investigation, or,
• Abnormal cells were found that require treatment
Your healthcare provider will refer you to a specialist for a follow-up test called a colposcopy test.

It is very important you follow the instructions of your healthcare provider if you received this test result.

This result does not necessarily mean you have cervical cancer. It takes about 10 to 15 years for cervical cancer to develop, and cervical cancer is a rare outcome of a HPV infection.13

Unsatisfactory test result

An unsatisfactory test result means the laboratory cannot read your sample. This means you will need to come back for a repeat test in six to twelve weeks.

This result might happen if the number of cells collected is too small. An unsatisfactory result does not mean there is something wrong.

Talk to your healthcare provider if you have any questions about your result.13

 

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Colposcopy

A colposcopy is used to look closely at the cells of the cervix. It can help identify where abnormal or changed cells are located and what they look like.

In this procedure, the doctor puts an instrument called a speculum into your vagina to hold the walls slightly apart. Using an instrument called a colposcope, which looks like a pair of binoculars sitting on a large stand, the doctor can see the cervix magnified. The colposcope is not put into your body. The doctor will probably take a tissue sample (biopsy) during the colposcopy.

Before the test, the doctor may coat your vagina and cervix with a fluid that will help to highlight any abnormal areas. Some colposcopes are fitted with a camera connected to a TV screen, so you can watch what the doctor is doing if you'd like to.

You may experience some mild discomfort for 10 to 15 minutes while the colposcopy is performed.

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Biopsy

A biopsy is when your doctor removes a small sample of tissue and sends it to the laboratory for examination under a microscope.

To allow the cervix to heal after a biopsy and to reduce the chance of infection, you will probably be advised not to have sexual intercourse or use tampons for 2-3 days. Check with your doctor.

You may feel uncomfortable for a short time when the tissue is removed. After the biopsy, you may experience some pain similar to menstrual cramping. You can ask for medication to relieve any pain. You may also have some bleeding or other vaginal discharge for a few hours after the procedure.

Other tests may be needed to confirm your diagnosis - it is important to ask your doctor what these may be.

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What to ask your doctor or specialist?

A diagnosis of pre-cancerous cell changes or cervical cancer can be a very confusing time. It is important to find out information that is relevant to you.

There are several things you can do to help prepare for your appointment and to improve your understanding.

  • It can be helpful to write a list of questions to ask your doctor or specialist. You may need to ask for a longer appointment.
  • Take some paper and a pen so that you can write down notes and instructions
  • Take a relative or friend with you for support - it can be helpful to have an extra person to hear what is being said and write down any notes
  • It may be helpful to record your visit - make sure you ask your doctor if it's okay. Remember, many smart phones and mp3 players can make audio recordings

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Treatment

If you have been diagnosed with cervical cancer, you should expect to be cared for by a multidisciplinary team (MDT). This is a group of doctors and other health professionals who are experts in a specific cancer who work together to plan the best treatment for you. Everyone's treatment is different and depends on the type of cancer and how far the cancer has spread.

Stages of Cancer

Staging is used to determine if and how much a cancer has spread and is used to determine treatment options and survival outcomes (prognosis) for cancer patients post diagnosis.

In Australia, staging for cervical cancer is done using a system developed by the International Federation of Gynaecology and Obstetrics.  It describes cervical cancer stages as:

  • Stage 0: Abnormal cells are found only in the first layer of the cells lining the cervix.
  • Stage 1: The cancer is found only in the tissues of the cervix
  • Stage 2: The tumour has spread beyond the cervix to the vagina and tissues next to the cervix
  • Stage 3: The cancer has spread throughout the pelvic area
  • Stage 4: The cancer has spread beyond the pelvic area to nearby organs such as the bladder or rectum. The tumour may also have spread to the lung, liver or bones, although this is uncommon
  • Recurrent: If the cancer comes back after initial treatment, this is known as recurrent cancer. Cervical cancer may come back in the cervix or in another part of the body.14

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Prognosis

Prognosis means the expected outcome of a disease. The earlier cervical cancer is diagnosed and treated, the better the outcome.

You may wish to discuss your prognosis and treatment options with your doctor, but it's not possible for any doctor to predict the exact course of your cancer. Test results, the type of cancer you have, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as age, fitness and medical history are all important in assessing your prognosis.

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Types of Treatment

The type of treatment for cervical cancer depends on the stage at diagnosis and can be different for everyone. If you or someone you know has been diagnosed with cancer, you may have many questions and concerns and need more information to help you make decisions about your treatment.

Treatment of pre-cancerous / abnormal cervical cell changes

If you have had a colposcopy done, and biopsy taken that has confirmed a high-grade cervical abnormality, your doctor will recommend treatment to assist in ensuring these cell changes do not progress to cervical cancer. The type of treatment depends on your individual situation, but regardless of the type of treatment this can usually be done easily and successfully. Ask your doctor to discuss the recommended treatment options with you. Common treatment options include:

  • Laser
  • Wire loop excision (also referred to as Loop Electro Surgical Excisional Procedure or LEEP)
  • Cone biopsy

Treatment for cervical cancer

Treatment for cervical cancer may be one, or a combination of the following:

Surgery is common for women who have small tumours found only within the cervix. The type of surgery will depend on the stage of the cancer. Types of surgery include:15

  • Trachelectomy (removal of the cervix)
  • Hysterectomy (removal of the uterus and may also include removal of the cervix)
  • Removing lymph nodes
  • Bilateral salpingo-oophorectomy
  • Ovarian transposition or relocation
  • Pelvic exenteration

Cancer Australia provides an excellent overview of each of these types of surgery.

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Chemotherapy uses anti-cancer drugs to help destroy cancer cells that may have spread to other areas of your body. Chemotherapy reduces the chance of the cancer coming back.

Radiation therapy uses x-rays to destroy cancer cells that may be left behind after surgery. You may experience some pain or discomfort after each treatment, although the treatment itself is painless. Radiation therapy does not make you radioactive and does not cause hair loss. It is usually given over a 5 to 6 week period. Radiation therapy can also be used to reduce the size of the cancer and to relieve pain or other symptoms.

Complementary therapies work alongside medical treatments and some have been shown to improve quality of life or reduce pain. There is no evidence that these therapies can cure or prevent cancer.

It is important to know that some complementary therapies have not been tested for side effects, may work against your medical cancer treatment and may be expensive. Let your doctor know about all complementary therapies you are thinking of using.

For more information about complementary therapies visit Memorial Sloan-Kettering Cancer Centre's About Herbs, Botanicals and Other Products.

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More information and resources

P: 13 15 56 (cost of a local call)
E: cervicalscreening@health.wa.gov.au

 

References

  1. American Cancer Society. What is cervical cancer? http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-what-is-cervical-cancer (accessed 21 May 2013)
  2. National Cervical Screening Program. HPV (human papillomavirus). http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/hpv (accessed 21 May 2013)
  3. Ackermann S, Renner SP, Fasching PA, et al. Awareness of general and personal risk factors for uterine cancer among healthy women. Eur J Cancer Prev 2005 Dec;14(6):519-24
  4. Threlfall TJ, Thompson JR. (2015) Cancer incidence and mortality in Western Australia, 2014. Department of Health, Western Australia, Perth: 2015. Statistical Series Number 103
  5. Cervical Screening NSW. Why have a Pap test/Pap smear? http://www.csp.nsw.gov.au/why-have-a-pap-test (accessed 21 May 2013)
  6. American Cancer Society. Cervical Cancer. http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-risk-factors (accessed 21 May 2013)
  7. Cancer Australia. Risk Factors. http://canceraustralia.gov.au/affected-cancer/cancer-types/gynaecological-cancers/cervical-cancer/awareness/risk-factors (accessed 21 May 2013)
  8. World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. 2007.
  9. Blitz S, Baxter J, Raboud J, et al. Evaluation of HIV and highly active antiretroviral therapy on the natural history of human papillomavirus infection and cervical cytopathologic findings in HIV-positive and high-risk HIV-negative women. J Infect Dis 2013; 208: 454-462.
  10. Cancer Australia. Cervical Cancer Awareness. 2012. http://canceraustralia.gov.au/affected-cancer/cancer-types/gynaecological-cancers/cervical-cancer/awareness (accessed 21 May 2013)
  11. Munoz N, Bosch FX, de Sanjose S, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med 2003; 348: 518-527.
  12. The Cancer Council Australia. The HPV Vaccine. http://www.hpvvaccine.org.au/about-the-vaccine/vaccine-background.aspx (accessed 21 May 2013)
  13. Australia Government Department of Health. National Cervical Screening Program; 2017. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/healthcare-providers (accessed 5 December 2017)
  14. Cancer Australia. Staging and grading of cervical cancer. http://canceraustralia.gov.au/affected-cancer/cancer-types/gynaecological-cancers/cervical-cancer/diagnosis/staging-and-grading-cervical-cancer (accessed 21 May 2013)
  15. Cancer Australia. Cervical Cancer Treatment: Surgery. Canberra: Australian Government; 2013. http://canceraustralia.gov.au/affected-cancer/cancer-types/gynaecological-cancers/cervical-cancer/treatment/surgery (accessed 20 August 2013)

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