Cervical cancer

Why cervical cancer develops

Almost all cases are caused by persistent infection with high-risk types of human papillomavirus (HPV), mainly types 16 and 18. The infection is common and clears on its own in most people, but when the virus persists for years, dysplasia (CIN) develops in the cervical cells and can progress to cancer. Smoking, weakened immunity and lack of regular screening raise the risk.

Effective prevention is therefore HPV vaccination and screening: a Pap test and an HPV test. High-grade dysplasia is treated by conization — removal of a small cone of the cervix, after which pregnancy is usually possible, although the risk of preterm birth rises somewhat.

Histologically, squamous cell carcinoma and adenocarcinoma are the most common types; others are rarer. Adenocarcinoma grows in the cervical canal, so a Pap test detects it less reliably — another reason to combine the Pap test with HPV testing.

Are there symptoms

Precancerous changes and early cancer usually cause no symptoms and are most often found through screening. Later, bleeding after intercourse, between periods or after menopause and heavy, foul-smelling discharge appear. Pain in the lower back or pelvis, leg swelling and urinary problems indicate spread of the tumor.

Bleeding after intercourse is a reason for a gynecologic examination and colposcopy, even if the last Pap test was normal.

Examinations needed

• Colposcopy with biopsy — confirms the diagnosis; in microinvasive cancer the diagnosis and stage are established by conization.
• Pelvic MRI — the main test for assessing spread: tumor size, extension to the parametrium, vagina, bladder and rectum, state of the lymph nodes.
• PET-CT — for locally advanced tumors or suspected lymph node involvement; for early tumors — CT of the chest and abdomen.
• Pelvic examination by an experienced gynecologic oncologist, under anesthesia if needed.
• Cystoscopy or proctoscopy — only if invasion of the bladder or rectum is suspected.

When surgery is possible

Surgery is the main treatment for early tumors without lymph node involvement. For microinvasive cancer, conization with clear margins or a simple hysterectomy is usually sufficient; the extent depends on vascular invasion, and lymph nodes are assessed if needed. For tumors up to 4 cm confined to the cervix, radical hysterectomy with pelvic lymph node assessment is performed; for small low-risk tumors the extent can be reduced.

For women planning pregnancy with tumors up to 2 cm, fertility-sparing surgery is possible — conization or trachelectomy (removal of the cervix while preserving the body of the uterus) once it is confirmed that the lymph nodes are not involved.

If surgery is not possible now

For tumors of 4 cm or more, with parametrial extension or lymph node involvement, the standard is chemoradiotherapy: external beam radiation with chemotherapy and brachytherapy. If involved lymph nodes are found during surgery, radical hysterectomy is usually abandoned and the patient is referred for chemoradiotherapy.

With distant metastases treatment is systemic, with immunotherapy for some patients. For a central pelvic recurrence after radiation, some patients may undergo pelvic exenteration — removal of the pelvic organs together with the tumor.

How the operation is performed

Radical hysterectomy is removal of the uterus with the cervix, the parametria (tissues around the cervix), the upper third of the vagina and the pelvic lymph nodes; the sentinel lymph nodes are often identified and examined first. In young patients with squamous cell carcinoma, the ovaries are usually preserved. The nerves that control the bladder are spared during surgery to reduce urinary problems.

Unlike many other tumors, the standard approach for radical hysterectomy is open: large trials showed a higher risk of recurrence after laparoscopic surgery. A minimally invasive approach may be discussed only for tumors under 2 cm removed by conization with clear margins, after discussing the risks.

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. After radical hysterectomy the bladder may temporarily empty less well — a catheter is left in for a few days and residual urine is checked. Leg swelling may occur after lymph node removal, so lymphedema prevention is important.

If pathology shows risk factors — involved lymph nodes, parametrium or margins — chemoradiotherapy is usually given after surgery.

Follow-up

For the first 2 years, a check-up every 3–6 months, then less often up to 5 years; tests are ordered according to symptoms and stage. After fertility-sparing surgery, follow-up is more intensive: cytology, HPV testing and MRI on the doctor’s schedule.

What to bring to the consultation

• the biopsy or conization pathology report with tumor size, depth of invasion and margin status;
• tissue blocks and slides — for review by another laboratory;
• pelvic MRI, PET-CT or CT discs with reports;
• cytology and HPV test results, the colposcopy report;
• records of previous treatment, if any.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.