Cervical Cancer

Cervical Cancer

By Victor Montour

The American Cancer Society has the following to say about cervical cancer. Cervical cancer can often be found early and sometimes even prevented entirely, by having regular Pap tests. If detected early, cervical cancer is one of the most successfully treatable cancers.

What is cervical cancer?

Cervical cancer starts in cells lining the cervix. The cervix is the lower part of the uterus (womb). It is sometimes called the uterine cervix. The body of the uterus (the upper part) is where a fetus grows. The cervix connects the body of the uterus to the vagina (birth canal). The part of the cervix closest to the body of the uterus is called the endocervix. The part next to the vagina is the exocervix (or ectocervix). The 2 main types of cells covering the cervix are squamous cells (on the exocervix) and glandular cells (on the endocervix). The place these cell types meet is called the transformation zone. The exact location of the transformation zone changes as you age and with childbirth. Most cervical cancers start in the cells in the transformation zone.

These cells do not suddenly change into cancer. Instead, the normal cells of the cervix gradually develop pre-cancerous changes that turn into cancer. Doctors use several terms to describe these pre-cancerous changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia. These changes can be detected by the Pap test and treated to prevent cancer from developing.

Cervical cancers and cervical pre-cancers are classified by how they look under a microscope. There are 2 main types of cervical cancer: squamous cell carcinoma and adenocarcinoma. About 80% to 90% of cervical cancers are squamous cell carcinomas. These cancers form from cells in the exocervix, and the cancer cells have features of squamous cells under the microscope.

Most of the remaining types of cervical cancers are adenocarcinomas. Adenocarcinomas are cancers that develop from gland cells. Cervical adenocarcinoma develops from the mucus-producing gland cells of the endocervix. Cervical adenocarcinomas seem to have become more common in the last 20 to 30 years.

Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.

Although cervical cancers start from cells with pre-cancerous changes (pre-cancers), only some women with pre-cancers of the cervix will develop cancer. The change from pre-cancer to cancer usually takes several years − but it can happen in less than a year. For most women, pre-cancerous cells will remain unchanged or even go away without any treatment. Still, in some women pre-cancers turn into true (invasive) cancers. Treating all pre-cancers can prevent almost all true cancers.

Signs and symptoms of cervical cancer

Women with early cervical cancers and pre-cancers usually have no symptoms. Symptoms often do not begin until a pre-cancer becomes a true invasive cancer and grows into nearby tissue. When this happens, the most common symptoms are:

  • Abnormal vaginal bleeding, such as bleeding after sex (vaginal intercourse), bleeding after menopause, bleeding and spotting between periods, and having longer or heavier (menstrual) periods than usual. Bleeding after douching, or after a pelvic exam is a common symptom of cervical cancer but not pre-cancer.
  • An unusual discharge from the vagina − the discharge may contain some blood and may occur between your periods or after menopause.
  • Pain during sex (vaginal intercourse).

These signs and symptoms can also be caused by conditions other than cervical cancer. For example, an infection can cause pain or bleeding. Still, if you have any of these problems, you should see your health care professional right away − even if you have been getting regular Pap tests. If it is an infection, it will need to be treated. If it’s cancer, ignoring symptoms might allow it to progress to a more advanced stage and lower your chance for effective treatment.

Even better, don’t wait for symptoms to appear. Be screened regularly.

How is cervical cancer staged?

The process of finding out how far the cancer has spread is called staging. Information from exams and diagnostic tests is used to determine the size of the tumor, how deeply the tumor has invaded tissues in and around the cervix, and the spread to lymph nodes or distant organs (metastasis). This is an important process because the stage of the cancer is the key factor in selecting the right treatment plan.

The stage of a cancer does not change over time, even if the cancer progresses. A cancer that comes back or spreads is still referred to by the stage it was given when it was first found and diagnosed, only information about the current extent of the cancer is added. A person keeps the same diagnosis stage, but more information is added to the diagnosis to explain the current disease status

A staging system is a way for members of the cancer care team to summarize the extent of a cancer’s spread. The 2 systems used for staging most types of cervical cancer, the FIGO (International Federation of Gynecology and Obstetrics) system and the AJCC (American Joint Committee on Cancer) TNM staging system, are very similar. Gynecologists and gynecologic oncologists use the FIGO system, but the AJCC system is included here to be complete. The AJCC system classifies cervical cancer on the basis of 3 factors: the extent of the tumor (T), whether the cancer has spread to lymph nodes (N) and whether it has spread to distant sites (M). The FIGO system uses the same information. The system described below is the most recent AJCC system, which went into effect January 2010. Any differences between the AJCC system and the FIGO system are explained in the text.

This system classifies the disease in stages 0 through IV. Staging is based on clinical rather than surgical findings. This means that the extent of disease is evaluated by the doctor’s physical examination and a few other tests that are done in some cases, such as cystoscopy and proctoscopy − it is not based on the findings during surgery or on imaging tests.

When surgery is done, it might show that the cancer has spread more than the doctors first thought. This new information could change the treatment plan, but it does not change the patient’s stage.

Tumor extent (T)

Tis: The cancer cells are only found on the surface of the cervix (in the layer of cells lining the cervix), without growing into deeper tissues. (Tis is not included in the FIGO system)

T1: The cancer cells have grown from the surface layer of the cervix into deeper tissues of the cervix. The cancer may also be growing into the body of the uterus, but it has not grown outside the uterus.

T1a: There is a very small amount of cancer, and it can be seen only under a microscope.

  • T1a1: The area of cancer is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide.
  • T1a2: The area of cancer invasion is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide.

T1b: This stage includes stage I cancers that can be seen without a microscope. This stage also includes cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm.

  • T1b1: The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches).
  • T1b2: The cancer can be seen and is larger than 4 cm.

T2: In this stage, the cancer has grown beyond the cervix and uterus, but hasn’t spread to the walls of the pelvis or the lower part of the vagina. The cancer may have grown into the upper part of the vagina.

T2a: The cancer has not spread into the tissues next to the cervix (called the parametria).

  • T2a1: The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches).
  • T2a2: The cancer can be seen and is larger than 4 cm.

T2b: The cancer has spread into the tissues next to the cervix (the parametria)

T3: The cancer has spread to the lower part of the vagina or the walls of the pelvis. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder).

  • T3a: The cancer has spread to the lower third of the vagina but not to the walls of the pelvis.
  • T3b: The cancer has grown into the walls of the pelvis and/or is blocking one or both ureters (this is called hydronephrosis).

T4: The cancer has spread to the bladder or rectum or it is growing out of the pelvis

Lymph node spread (N)

NX: The nearby lymph nodes cannot be assessed

N0: No spread to nearby lymph nodes

N1: The cancer has spread to nearby lymph nodes

Distant spread (M)

M0: The cancer has not spread to distant lymph nodes, organs, or tissues

M1: The cancer has spread to distant organs (such as the lungs or liver), to lymph nodes in the chest or neck, and/or to the peritoneum (the tissue coating the inside of the abdomen).

Stage grouping and FIGO stages

Information about the tumor, lymph nodes, and any cancer spread is then combined to assign the stage of disease. This process is called stage grouping. The stages are described using the number 0 and Roman numerals from I to IV. Some stages are divided into sub-stages indicated by letters and numbers. FIGO stages are the same as AJCC stages, except that FIGO staging doesn’t include the lymph nodes until stage III. In addition, stage 0 doesn’t exist in the FIGO system.

Stage 0 (Tis, N0, M0): The cancer cells are only in the cells on the surface of the cervix (the layer of cells lining the cervix), without growing into (invading) deeper tissues of the cervix. This stage is also called carcinoma in situ (CIS) which is part of cervical intraepithelial neoplasia grade 3 (CIN3). Stage 0 is not included in the FIGO system.

Stage I (T1, N0, M0): In this stage the cancer has grown into (invaded) the cervix, but it is not growing outside the uterus. The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).

Stage IA (T1a, N0, M0): This is the earliest form of stage I. There is a very small amount of cancer, and it can be seen only under a microscope.

The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).

  • Stage IA1 (T1a1, N0, M0): The cancer is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide. The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).
  • Stage IA2 (T1a2, N0, M0): The cancer is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide. The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).
  • IB (T1b, N0, M0): This includes stage I cancers that can be seen without a microscope as well as cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm. These cancers have not spread to nearby lymph nodes (N0) or distant sites (M0).
  • IB1 (T1b1, N0, M0): The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches). It has not spread to nearby lymph nodes (N0) or distant sites (M0).
  • IB2 (T1b2, N0, M0): The cancer can be seen and is larger than 4 cm. It has not spread to nearby lymph nodes (N0) or distant sites (M0).

Stage II (T2, N0, M0): In this stage, the cancer has grown beyond the cervix and uterus, but hasn’t spread to the walls of the pelvis or the lower part of the vagina.

Stage IIA (T2a, N0, M0): The cancer has not spread into the tissues next to the cervix (called the parametria). The cancer may have grown into the upper part of the vagina. It has not spread to nearby lymph nodes (N0) or distant sites (M0).

  • IIA1 (T2a1, N0, M0): The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches). It has not spread to nearby lymph nodes (N0) or distant sites (M0).
  • IIA2 (T2a2, N0, M0): The cancer can be seen and is larger than 4 cm.
  • IIB (T2b, N0, M0): The cancer has spread into the tissues next to the cervix (the parametria).

Stage III (T3, N0, M0): The cancer has spread to the lower part of the vagina or the walls of the pelvis. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). It has not spread to nearby lymph nodes (N0) or distant sites (M0).

  • IIIA (T3a, N0, M0): The cancer has spread to the lower third of the vagina but not to the walls of the pelvis. It has not spread to nearby lymph nodes (N0) or distant sites (M0).
  • IIIB (T3b, N0, M0; OR T1-T3, N1, M0): either:
  • cancer has grown into the walls of the pelvis and/or has blocked one or both ureters (a condition called hydronephrosis),

OR

  • cancer has spread to lymph nodes in the pelvis (N1) but not to distant sites (M0). The tumor can be any size and may have spread to the lower part of the vagina or walls of the pelvis (T1 to T3).

Stage IV: This is the most advanced stage of cervical cancer. The cancer has spread to nearby organs or other parts of the body.

  • IVA (T4, N0, M0): The cancer has spread to the bladder or rectum, which are organs close to the cervix (T4). It has not spread to nearby lymph nodes (N0) or distant sites (M0).
  • IVB (any T, any N, M1): The cancer has spread to distant organs beyond the pelvic area, such as the lungs or liver.

Survival rates for cervical cancer, by stage

Survival rates are often used by doctors as a standard way of discussing a person’s prognosis (outlook). Some patients with cancer may want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many people live much longer than 5 years (and many are cured). Also, these are observed survival rates and include deaths from any cause. People with cancer may die from things other than cancer, and these rates don’t take that into account.

In order to get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Improvements in treatment since then may result in a more favorable outlook for people now being diagnosed with cervical cancer.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person’s case. Many other factors can affect a person’s outlook, such as their general health and how well the cancer responds to treatment. Your doctor can tell you how the numbers below may apply to you, as he or she is familiar with the aspects of your particular situation.

The rates below are based on the stage of the cancer at the time of diagnosis. Your doctor can give you information about what kind of survival you may be able to expect if your cancer has come back or progressed.

The rates below were published in 2010 in the 7th edition of the AJCC staging manual. They are based on data collected by the National Cancer Data Base from people diagnosed between 2000 and 2002. These are the most recent statistics available for survival by the current staging system.

Stage 5-Year
Observed
Survival Rate
0 93%
IA 93%
IB 80%
IIA 63%
IIB 58%
IIIA 35%
IIIB 32%
IVA 16%
IVB 15%

The important messages to take away with you from this blog are. Cervical Cancer is treatable with early detection. Treatment options will be customized to the patients needs. If treatment fails, or if treatment is not an option, supportive care is available from Front Range Hospice.

If you would like more information about Front Range Hospice please call 303-957-3101 or 970-776-8080 or email us at info@frhospice.com

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About Front Range Hospice- Legendary Care

Front Range Hospice is a center for excellence in providing end-of-life care and we continue to strive to keep our company achieving distinction. Visit us at www.frhospice.com.
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