context: The uterine cervix is the lowest portion of a woman's uterus (womb), connecting the uterus with the vagina. Cervical cancer occurs when the cells of the cervix grow abnormally and invade other tissues and organs of the body. When it is invasive, this cancer affects the deeper tissues of the cervix and may have spread to other parts of the body (metastasis), most notably the lungs, liver, bladder, vagina, and rectum. However, cervical cancer is slow-growing, so its progression through precancerous changes provides opportunities for prevention, early detection, and treatment. Better means of detection have meant a decline in cervical cancer in the U. S. over the decades. Most women diagnosed with precancerous changes in the cervix are in their 20s and 30s, but the average age of women when they are diagnosed with cervical cancer is the mid 50s. This difference in the age at which precancerous changes are most frequently diagnosed and the age at which cancer is diagnosed highlights the slow progression of this disease and the reason why it can be prevented if adequate steps are taken. Cervical cancer begins with abnormal changes in the cervical tissue. The risk of developing these abnormal changes is associated with infection with human papillomavirus ( HPV). In addition, early sexual contact, multiple sexual partners, and taking oral contraceptives (birth control pills) increase the risk of cervical cancer because they lead to greater exposure to HPV. Forms of HPV, a virus whose different types cause skin warts, genital warts, and other abnormal skin disorders, have been shown to lead to many of the changes in cervical cells that may eventually lead to cancer. Certain types of HPV have also been linked to cancers involving the vulva, vagina, penis, anus, tongue, and tonsils. Genetic material that comes from certain forms of HPV (high-risk subtypes) has been found in cervical tissues that show cancerous or precancerous changes. In addition, women who have been diagnosed with HPV are more likely to develop a cervical cancer. Girls who begin sexual activity before age 16 or within a year of starting their menstrual periods are at high risk of developing cervical cancer. Cigarette smoking is another risk factor for the development of cervical cancer. The chemicals in cigarette smoke interact with the cells of the cervix, causing precancerous changes that may over time progress to cancer. The risk of cervical cancer in cigarette smokers is two to five times that of the general population. Oral contraceptives ("the pill"), especially if taken longer than five years, may increase the risk for cervical cancer because they reduce the use of condoms. As in many cancers, you may have no signs or symptoms of cervical cancer until it has progressed to a dangerous stage. They may include: Pain, when the cancer is advanced Abnormal vaginal bleeding (other than during menstruation) Abnormal vaginal discharge Pelvic pain Kidney failure due to a urinary tract or bowel obstruction, when the cancer is advanced The range of conditions that can cause vaginal bleeding are diverse and may not be related to cancer of the cervix. They vary based on your age, fertility, and medical history. Vaginal bleeding after menopause is never normal. If you have gone through menopause and have vaginal bleeding, see your health care provider as soon as possible. Very heavy bleeding during your period or frequent bleeding between periods warrants evaluation by your health care provider. Bleeding after intercourse, especially after vigorous sex, does occur in some women. If this occurs only occasionally, it is probably nothing to worry about. Evaluation by your health care provider is advisable, especially if the bleeding happens repeatedly. If you have vaginal bleeding that is associated with weakness, feeling faint or light-headed, or actual fainting, go to a hospital emergency department for care. As with all cancers, an early diagnosis of cervical cancer is key to successful treatment and cure. Treating precancerous changes that affect only the surface of a small part of the cervix is much more likely to be successful than treating invasive cancer that affects a large portion of the cervix and has spread to other tissues. The most important progress that has been made in early detection of cervical cancer is widespread use of the Papanicolaou test ( Pap smear) and high-risk HPV testing. A Pap smear is done as part of a regular exam. During the procedure, cells from the surface of the cervix are collected and examined for abnormalities. Diagnosis of cervical cancer requires that a sample of cervical tissue (called a biopsy) be taken and analyzed under a microscope. This would be done if the Pap smear is abnormal. There are various diagnostic tools that can be used to identify changes in the cervix. They include: Colposcopy is a procedure similar to a pelvic exam. It is usually used for a patient who had an abnormal Pap smear result but a normal physical exam. The examination uses a type of microscope called a colposcope to inspect the cervix. The entire area of the cervix is stained with a harmless dye or acetic acid to make abnormal cells easier to see. These areas are then biopsied. The colposcope magnifies the cervix by eight to 15 (depends on the colposcope) times, allowing easier identification of any abnormal-appearing tissue that may need biopsy. This procedure can usually be done in your gynecologist's office. If a biopsy under colposcopy suggests an invasive cancer, a larger biopsy is needed to fully evaluate your condition. Treatment will depend on stage of the cancer. The loop electrosurgical excision procedure ( LEEP) technique uses an electrified loop of wire to take a sample of tissue from the cervix. This procedure can often be performed in your gynecologist's office. A conization (removal of a portion of the cervix) is performed in the operating room while you are under anesthesia. It can performed with a LEEP, with a scalpel (cold knife conization) or a laser. In this procedure, a small cone-shaped portion of your cervix is removed for examination. LEEP or cold knife conization procedures result in tissue samples in which the types of cells and how much they have spread to underlying areas can be more fully determined. They can be used to diagnose problems or to treat known problems. Precancerous changes Over the years, different terms have been used to refer to abnormal changes in the cells on the surface of the cervix. These changes are now most often called squamous intraepithelial lesion ( SIL). " Lesion" refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells. Changes in these cells can be divided into two categories: Low-grade SIL ( LGSIL): Early, subtle changes in the size and shape of cells that form on the surface of the cervix are considered low grade. These lesions may go away on their own, but over time, they may become more abnormal, eventually becoming a high-grade lesion. LGSIL is also called mild dysplasia or cervical intraepithelial neoplasia 1 ( CIN 1). These early changes in the cervix most often occur in women ages 25 to 35 years, but can appear in women of any age. High-grade SIL ( HGSIL): A large number of precancerous cells, which look very different from normal cells, constitute a high-grade lesion. Like low-grade SIL, these precancerous changes involve only cells on the surface of the cervix. These lesions are also called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ. They develop most often in women ages 30 to 40 years, but can occur at any age. Precancerous cells, even high-grade lesions, usually do not become cancerous and invade deeper layers of the cervix for many months, perhaps years. Invasive cancer If abnormal cells spread deeper into the cervix or to other tissues or organs, the disease is then called cervical cancer, invasive cervical cancer, or metastatic cancer. Cervical cancer occurs most often in women aged 40 years or older. If the biopsy results show invasive cancer, a series of tests may be performed, all designed to see whether the cancer has spread and, if so, how far. They include: A chest X-ray to see if the cancer has spread to the lungs Blood tests can indicate whether the liver is involved; a CT scan may be necessary if results are not definitive. Special X-rays known as an IVP or a CT scan can be used to look at the urinary tract; the bladder and urethra are evaluated by cystoscopy. The vagina is examined by colposcopy; the rectum is evaluated by a procto signoidoscopy and barium enema. Lymph nodes are evaluated by CT scans, MRI scans, or PET scans; the MRI is superior to the CT scan and the PET scan is superior to both. These tests are used to "stage" the cancer. By finding out how far it has spread, your health care providers can make a reasonable guess about your prognosis and the kind of treatment you will need. Cervical cancer is staged from stage 0 (least severe) to stage IV (metastatic disease, the most severe). Staging is based on size and depth of the cancerous lesion, as well as degree of spread. Treatment for precancerous lesions differs from that of invasive cervical cancer. Precancerous lesions Choice of treatment for a precancerous lesion of the cervix depends on a number of factors, including whether the lesion is low or high grade, whether you want to have children in the future, your age and general health, and your preference and that of your health care provider. If you have a low-grade lesion ( CIN I, as detected by a Pap smear), you may not need further treatment, especially if the abnormal area was completely removed during biopsy. You should have regular Pap smears and pelvic exams, as scheduled by your doctor. When a precancerous lesion requires treatment, LEEP conization, cold knife conization, cryosurgery (freezing), cauterization (burning, also called diathermy), or laser surgery may be used to destroy the abnormal area while minimizing damage to nearby healthy tissue. Treatment for precancerous lesions may cause cramping or other pain, bleeding, or a watery vaginal discharge. In some cases, you may choose to have a hysterectomy for precancerous changes, particularly if abnormal cells are found inside the opening of the cervix or you have severe or recurring dysplasia. This surgery is more likely to be done if you do not plan to have children in the future. Diagnostic procedures, such as LEEP and cold knife conization, sometimes themselves may treat the cervical precancer, as well. Both involve taking tissue to evaluate. If the evaluation finds abnormal cells, but the cells do not extend into where the tissue was cut, only follow-up may be needed. If there is uncertainty about whether all of the precancerous cells have been removed using LEEP or cold knife conization procedures, further treatments may be necessary. Cryocautery may be used in some cases. In this procedure, a steel instrument is cooled to subzero temperatures by immersion in liquid nitrogen or a similar liquid. This ultracooled instrument is then applied to the surface of the cervix, freezing cells. They eventually die and are sloughed off, to be replaced by new cervical cells. Tissue may also be removed by laser ablation. In this procedure, a laser beam is applied to either specific areas of cervical tissue or a whole layer of tissue at the surface of the cervix. The laser destroys these cells, leaving healthy cells in their place. The success of cryocautery or laser ablation procedures is determined by a follow-up exam and Pap smear. Neither procedure is used to obtain tissue samples for evaluation; they only destroy the abnormal tissue. Therefore, the margins or edges cannot be inspected to make sure the cancer has not spread. Invasive cancer The most widely used treatments for invasive cervical cancer are surgery and radiation therapy. Chemotherapy or biological therapy also is sometimes used. If a biopsy shows that cancerous cells have invaded through a layer called the basement membrane, which separates the surface layers of the cervix from other underlying layers, surgery is usually required. The extent of the surgery varies, depending on the stage of the cancer. In cervical cancer, surgery removes cancerous tissue in or near the cervix. If the cancer is only on the surface of the cervix, the cancerous cells may be removed or destroyed by using methods similar to those used to treat precancerous lesions, such as the LEEP or a cold knife conization. If the disease has invaded deeper layers of the cervix but has not spread beyond the cervix, an operation may remove the tumor but leave the uterus and the ovaries. If the disease has spread into the uterus, hysterectomy -- removal of the uterus and cervix -- is usually necessary. Sometimes, the ovaries and fallopian tubes also are removed. In addition, lymph nodes near the uterus may be removed to check for spread of the cancer. Hysterectomy is also sometimes done to prevent spread of the cancer. Radiation therapy (or radiotherapy) is also used to treat cervical cancer at some stages. Radiation therapy uses high-energy rays to damage cancer cells and stop their growth. Like surgery, radiation therapy is local therapy; the radiation affects cancer cells only in the treated area. Radiation may be applied externally or internally. Some women receive both kinds. External radiation comes from a large machine, which aims a beam of radiation at your pelvis. Treatments, which take only a few minutes, usually are given five days a week for five to six weeks. At the end of that time, an extra dose of radiation called a "boost" may be applied to the tumor site. Because of safety concerns and expense of equipment, radiation therapy generally is offered only at certain large medical centers or hospitals. Internal or implant radiation comes from a capsule containing radioactive material which is placed directly in the cervix. The implant puts cancer-killing rays close to the tumor while sparing most of the healthy tissue around it. There are two types of implant radiation, also called brachytherapy. With low dose rate brachytherapy the implant is usually left in place for one to three days The treatment may be repeated several times over the course of 1-2 weeks. You stay in the hospital while the implants are in place. Another type is high dose rate brachytherapy. This form may be performed as an outpatient. During this treatment the implant is inserted for several minutes then removed. The therapy is performed several times over a series of weeks, each treatment usually at least a week apart. Chemotherapy is the use of powerful drugs to kill cancer cells. In cervical cancer, it is used most often when the cancer is locally advanced or has spread to other parts of the body. Just one drug or a combination of drugs may be given. Anticancer drugs used to treat cervical cancer may be given via an IV line or by mouth. Either way, chemotherapy is systemic treatment, meaning that the drugs flow through the body in the bloodstream. They can kill cancer cells anywhere in the body. Chemotherapy is given in cycles: each cycle comprises a period of intensive treatment followed by a recovery period. Treatment usually consists of several cycles. Most patients have chemotherapy as an outpatient (in an outpatient clinic at the hospital, at the doctor's office, or at home). Depending on which drugs are given and your general health, however, you may need to stay in the hospital during treatment. Treatment for invasive cervical cancer usually involves a team of specialists. The team generally includes a gynecologic, oncologist and a radiation oncologist. These doctors may decide to use one treatment method or a combination of methods. You may choose to take part in a clinical trial (research study) to evaluate new treatment methods. Such studies are designed to improve cancer treatment. Participating in a clinical trial has both benefits and risks. Self-treatment is not appropriate for cancer. Without medical treatment, the cervical cancer will continue to grow and spread. Eventually, vital body organs will not be able to function properly because the cancer will take their oxygen and nutrients, crowd them out, or injure them. The result is very often death. Although self-treatment is inappropriate, there are things you can do to reduce the physical and mental stresses of cervical cancer and its treatment. Maintaining good nutrition is one of the best things you can do. You may lose your appetite during treatment for cervical cancer. Common side effects of chemotherapy include nausea, vomiting, and sores inside the mouth. However, if you take in enough calories and protein, you will maintain your strength and energy and better tolerate the side effects of treatment. Your cancer specialist (oncologist) or gynecologist may be able to recommend a nutritionist who can provide suggestions for keeping up your calorie and protein intake. The following lifestyle changes may help keep you stronger and more comfortable during treatment: Engage in mild physical activity to keep up your energy level. Make sure it doesn't wear you out. Get enough rest at night, and take naps if needed. Quit smoking. Avoid alcohol. You may not be able to drink alcohol with some of the medications you are taking. Be sure to ask your health care provider. Regular pelvic exams and Pap smears are important for every woman. These tests are no less important for a woman who has been treated for precancerous changes or for cancer of the cervix. Follow-up care should include a full pelvic exam, Pap smear, and other tests as indicated on a regular schedule recommended by your gynecologist. These precautions are necessary to allow early detection should the cancer return. Cervical cancer treatment may cause side effects many years later. For this reason, you should continue to have regular checkups and should report any health problems that appear. The key to preventing invasive cervical cancer is to detect any cell changes early, before they become cancerous. Regular pelvic exams and Pap tests are the best way to do this. How often you should have a pelvic exam and Pap test depends on your individual situation, but here are guidelines: Make sure you get a Pap test to check for cervical cancer every 3 years if you are 21 or older. If you are 30-65, you can get both a Pap test and human papillomavirus ( HPV ) test every 5 years. Older than that, you may be able to stop testing if your doctor says you are low risk. Women of any age who've had ahysterectomywith removal of the cervix and no history of cervical cancer or precancers do not need to be screened, according to the guidelines. If you are sexually active and have a higher risk for STDs, get tests for chlamydia, gonorrhea, and syphilis yearly. Take an HIV test at least once, more frequently if you're at risk. Avoidance of HPV infection is important in the prevention of precancerous and cancerous changes of the cervix. Prevention measures include: Abstinence from sex is recommended as one way to prevent the transmission of HPV. Likewise, barrier protection, such as condom use, may reduce the risk of HPV infection, although this has not yet been fully studied. Vaccines to protect women from cervical cancer and men from HPV are now available: Gardasil is approved for use in males and females ages 9 to 26. It protects against two strains of HPV (types 16 and 18) that account for the development of 70% of cervical cancers and over 50% of precancerous lesions of the cervix, vulva, and vagina. Gardasil protects against the types of HPV (6 and 11) which are associated with over 90% of the cases of genital warts. Gardasil 9 can also be used in males and females ages 9 to-26. It prevents infection by the same HPV types as Gardasil plus HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58. Collectively, these types are implicated in 90% of cervical cancers. Cigarette smoking is another risk factor for cervical cancer that can be prevented. Quitting smoking may decrease your chances of developing the disease. For cervical cancer, the survival rate is close to 100% when precancerous or early cancerous changes are found and treated. The prognosis for invasive cervical cancer depends on the stage of the cancer when it is found. The stage of a cancer is a measure of how far it has progressed, namely, what other organs or tissues have been invaded. For the earliest stage of cervical cancerâstage 0 â more than 90% of women survive at least five years after diagnosis Stage I cervical cancer patients have a five-year survival rate of 80 â 93%. Women with stage II cervical cancer have a five-year survival rate of 58 â 63%. The survival rate for women with stage III cervical cancer is anywhere from 32 â 35% Sixteen percent or fewer women with stage IV cervical cancer survive five years. Health care providers who treat cancer often use the term "remission" rather than "cure." Although many women with cervical cancer recover completely, medical professionals sometimes avoid the word "cure," because the disease can recur. Living with cervical cancer presents many new challenges for you and for your family and friends. You will probably have many worries about how the cancer will affect you and your ability to "live a normal life," that is, to care for your family and home, to hold your job, and to continuing the friendships and activities you enjoy. Many people feel anxious and depressed. Some people feel angry and resentful; others feel helpless and defeated. For most people with cancer, talking about their feelings and concerns can help. Your friends and family members can be very supportive. They may be hesitant to offer support until they see how you are coping. Don't wait for them to bring it up. If you want to talk about your concerns, let them know. Some people don't want to "burden" their loved ones, or they prefer talking about their concerns with a more neutral professional. A social worker, counselor, or member of the clergy can be helpful if you want to discuss your feelings and concerns about having cancer. Your gynecologist or oncologist should be able to recommend someone. Many people with cancer are helped profoundly by talking to other people who have cancer. Sharing your concerns with others who have been through the same thing can be remarkably reassuring. Support groups of people with cancer may be available through the medical center where you are receiving your treatment. The American Cancer Society also has information about support groups all over the U. S.