A National Cancer Institute-designated Comprehensive Cancer Center

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Cervical Cancer

Cervical Cancer
City of Hope is at the forefront of some of the nation’s most promising cervical cancer treatment and research programs.
Our comprehensive and aggressive approach to cervical cancer involves:

  • screening to facilitate early detection
  • vaccine and/or surgical prevention
  • surgical treatments including minimally-invasive robotic surgery
  • advanced medical therapies including intense-modulated-light radiotherapy, and investigational chemotherapy drugs
  • supportive care

Our Gynecologic Oncology Program delivers these services using the latest technology, providing the most effective, strategic and targeted care.
About Cervical Cancer
  • Cervical cancer is one of the more common cancers of the female reproductive system. Most cervical cancers are linked to infection by HPV (human papillomavirus).
  • Cervical cancer is defined as a disease in which cells of the cervix, the lower part of the uterus adjoining the vagina, become malignant, forming a tumor or tumors. It is usually a slow-growing cancer that may not have symptoms but can be found with regular Pap tests (a procedure in which cells are scraped from the cervix and viewed under a microscope).
  • Approximately 80 percent of cervical cancers are classified as squamous cell carcinomas, which arise from cells in the exocervix (the part closest to the vagina), while about 15 percent are adenocarcinomas, which arise from a different type of cell in the endocervix (the part further away from the vagina). In rare circumstances, cervical cancers may exhibit involvement of both cell types; these are known as adenosquamous carcinomas.
Risk Factors
Studies suggest the following may be risk factors for developing cervical cancer:

  • Human papillomaviruse (HPV) infection is the main risk factor for cervical cancer.
  • HPV is a group of viruses that can infect the cervix.
  • HPV infections are very common and can be passed from person to person through sexual contact. Most adults have been infected with HPV at sometime in their lives.
  • Some types of HPV can cause changes to cells in the cervix. These changes can lead to genital warts, cancer and other problems. Doctors may check for HPV even if there are no warts or other symptoms.
  • If a woman has an HPV infection, her doctor can discuss ways to avoid infecting other people. The Pap test can detect cell changes in the cervix caused by HPV.
  • Treatment of these cell changes can prevent cervical cancer. There are several treatment methods, including freezing or burning the infected tissue. Sometimes medicine also helps.
  • Lack of regular Pap tests: Cervical cancer is more common among women who do not have regular Pap tests. The Pap test helps doctors find precancerous cells. Treating precancerous cervical changes often prevents cancer.
  • Weakened immune system: Women with HIV (the virus that causes AIDS) infection or who take drugs that suppress the immune system have a higher-than-average risk of developing cervical cancer. For these women, doctors suggest regular screening for cervical cancer.
  • Age: Cancer of the cervix occurs most often in women over the age of 40.
  • Sexual history: Women who have had many sexual partners have a higher-than-average risk of developing cervical cancer. Also, a woman who has had sexual intercourse with a man who has had many sexual partners may be at higher risk of developing cervical cancer. In both cases, the risk of developing cervical cancer is higher because these women have a higher-than-average risk of HPV infection.
  • Other sexually transmitted diseases (STDs): Infection with other STDs such as chlamydia, syphilis or gonorrhea makes infection with HPV more likely.
  • Smoking cigarettes: Women with an HPV infection who smoke cigarettes have a higher risk of cervical cancer than women with HPV infection who do not smoke.
  • Using birth control pills over a long period: Using birth control pills over a long period (five or more years) may increase the risk of cervical cancer among women with HPV infection.
  • Having many children: Studies suggest that giving birth to many children may increase the risk of cervical cancer among women with HPV infection.
  • Diethylstilbestrol (DES) may increase the risk of a rare form of cervical cancer and certain other cancers of the reproductive system in daughters exposed to this drug before birth. DES was given to some pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.)

Preventing Cervical Cancer

In addition to avoiding the established risk factors wherever possible, prophylaxis of cervical cancer with a new vaccine provides powerful protection. The vaccine, commercially marketed as Gardasil, protects females against the four types of HPV that cause most cervical cancers and genital warts.
  • The HPV vaccine is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 who have not yet been vaccinated or completed the vaccine series.
  • Prophylactic (preventive) hysterectomy may be indicated for extremely high-risk patients.

Symptoms of Cervical Cancer

Precancerous changes and early cancers of the cervix generally do not cause pain or other symptoms. It is important not to wait to feel pain before seeing a doctor. When the disease progresses, women may notice one or more of these symptoms:
  • Abnormal vaginal bleeding
  • Bleeding that occurs between regular menstrual periods
  • Bleeding after sexual intercourse, douching or a pelvic exam
  • Menstrual periods that last longer and are heavier than usual
  • Bleeding after menopause
  • Increased vaginal discharge
  • Pelvic pain
  • Pain during sexual intercourse

How We Screen for and Diagnose Cervical Cancer

It is very important to be examined for cervical changes before there are symptoms. Screening can help the doctor find abnormal cells before cancer develops. Finding and treating these abnormal cells can prevent most cervical cancer. Also, screening can help find cancer early, when treatment is more likely to be effective.

Today, screening has a powerful new component: the ability to test for the presence of HPV. This augments the Pap smear and other methods in early detection and disease prevention.

For the past several decades, the number of women diagnosed each year with cervical cancer has been decreasing. Doctors believe this is mainly because of the success of screening.

Pap smear
Doctors recommend that women help reduce their risk of cervical cancer by having regular Pap tests. A Pap test (sometimes called Pap smear or cervical smear) is a simple test used to look at cervical cells. For most women, the test is not painful. A Pap test is done in a doctor's office or clinic during a pelvic exam. The doctor or nurse scrapes a small sample of cells from the cervix. A lab checks the cells on the slides under a microscope for abnormalities.

Pap tests can find cervical cancer or abnormal cells that can lead to cervical cancer.

Doctors generally recommend that women:
  • begin having Pap tests three years after they begin having sexual intercourse, or when they reach age 21 (whichever comes first).
  • should have a Pap test at least once every three years.
  • aged 65 to 70 who have had at least three normal Pap tests and no abnormal Pap tests in the past 10 years may decide, after speaking with their doctor, to stop cervical cancer screening.
  • who have had a hysterectomy to remove the uterus and cervix, also called a total hysterectomy, do not need to have cervical cancer screening. However, if the surgery was treatment for precancerous cells or cancer, the woman should continue with screening.
Women should talk with their doctor about when they should begin having Pap tests, how frequently and when they can stop having them. This is especially important for women at higher-than-average risk of cervical cancer.

Some activities can hide abnormal cells and affect Pap test results. Doctors suggest the following tips:
  • Do not douche for 48 hours before the test
  • Do not have sexual intercourse for 48 hours before the test
  • Do not use vaginal medicines (except as directed by a doctor) or birth control foams, creams or jellies for 48 hours before the testDoctors also suggest that a woman schedule her Pap test for a time that is 10 to 20 days after the first day of her menstrual period.
Most often, abnormal cells found by a Pap test are not cancerous. However, some abnormal conditions may develop into cancer over time:
  • Low-grade squamous intraepithelial lesion (LSIL):
    LSILs are mild cell changes on the surface of the cervix. Such changes often are caused by HPV infections. LSILs are common, especially in young women, yet are are not cancer. Even without treatment, most LSILs stay the same or go away. However, some turn into high-grade lesions, which may lead to cancer.
  • High-grade squamous intraepithelial lesion (HSIL):
    HSILs are not cancer, but without treatment they may lead to cancer. The precancerous cells are only on the surface of the cervix. They look very different from normal cells.
HPV Test
The HPV test is usually performed at the same time as a Pap smear, and analyzes the DNA of cervical cells for the presence of HPV. It is usually performed in women 30 or older.
A positive HPV test result only indicates the presence of the virus; it does not mean the woman has cervical cancer. A positive HPV test result signals a doctor to examine the Pap smear for any precancerous changes. A colposcopy and/or biopsy may then be ordered to detect abnormal cervical cells.
Diagnosing Cervical Cancer
If a woman has a symptom or Pap test results that suggest precancerous cells or cancer of the cervix, and/or her HPV test is positive, her doctor will suggest other procedures to make a diagnosis.

These may include:
  • Colposcopy: The doctor uses a colposcope, which combines a bright light with a magnifying lens to make tissue easier to see, to examine the cervix. It is not inserted into the vagina. A colposcopy is usually done in the doctor's office or clinic.
  • Biopsy: The doctor removes tissue to look for precancerous cells or cancer cells. Most women have their biopsy in the doctor's office with local anesthesia. A pathologist checks the tissue with a microscope.
  • Punch biopsy: The doctor uses a sharp, hollow device to pinch off small samples of cervical tissue.
  • Loop electrosurgical excision procedure: The doctor uses an electric wire loop to extract a thin, round piece of tissue.
  • Endocervical curettage: The doctor uses a curette (a small, spoon-shaped instrument) to scrape a small sample of tissue from the cervical canal. Some doctors may use a thin, soft brush instead of a curette.
  • Conization (Cone biopsy): The doctor removes a cone-shaped sample of tissue. A conization, or cone biopsy, lets the pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. The doctor may do this test in the hospital under general anesthesia. Conization also may be used to remove a precancerous area.
  • Removing tissue from the cervix may cause some bleeding or other discharge. The area usually heals quickly. Women may also feel some pain similar to menstrual cramps. Medicine can relieve this discomfort.

If the biopsy shows that you have cancer, your doctor will do a thorough pelvic exam and may remove additional tissue to learn the extent (stage) of your disease. The stage tells whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body.

These are the stages of cervical cancer:
  • Stage 0: The cancer is found only in the top layer of cells in the tissue that lines the cervix. Stage 0 is also called carcinoma in situ.
  • Stage I: The cancer has invaded the cervix beneath the top layer of cells. It is found only in the cervix.
  • Stage II: The cancer extends beyond the cervix into nearby tissues. It extends to the upper part of the vagina. The cancer does not invade the lower third of the vagina or the pelvic wall (the lining of the part of the body between the hips).
  • Stage III: The cancer extends to the lower part of the vagina. It also may have spread to the pelvic wall and nearby lymph nodes.
  • Stage IV: The cancer has spread to the bladder, rectum or other parts of the body. Recurrent cancer:The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body.

To learn the extent of disease and suggest a course of treatment, the doctor may order some of the following tests:
  • Chest X-rays: X-rays often can show whether cancer has spread to the lungs.
  • Computed tomography (CT) scan: An X-ray machine linked to a computer takes a series of detailed pictures of your organs. You may receive contrast material by injection in your arm or hand, by mouth or by enema. (Some people are allergic to contrast materials that contain iodine. Tell your doctor or nurse if you have allergies.) The contrast material makes abnormal areas easier to see. A tumor in the liver, lungs or elsewhere in the body can show up on the CT scan.
  • Magentic resonance imagine (MRI): A powerful magnet linked to a computer is used to make detailed pictures of your pelvis and abdomen. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether cancer has spread. Sometimes contrast material makes abnormal areas show up more clearly on the picture.
  • Ultrasound: An ultrasound device is held against the abdomen or inserted into the vagina. The device sends out sound waves that people cannot hear. The waves bounce off the cervix and nearby tissues, and a computer uses the echoes to create a picture. Tumors may produce echoes that are different from the echoes made by healthy tissues. The picture can show whether cancer has spread.

Cervical Cancer Treatment Approaches

City of Hope uses a multidisciplinary approach to combat cervical cancer. Our surgeons, medical and radiation oncologists and researchers collaborate closely throughout treatment to ensure cervical cancer patients receive the best care possible.

Surgery remains the preferred method for treatment of cervical cancer. Because most cervical cancers are found early, surgical removal offers an excellent chance at curing the patient.

Many patients with cervical cancer, even in early stages, will choose to have a total hysterectomy (removal of the cervix and uterus). However, for very early (Stage 0) cervical cancer, a hysterectomy may not be needed. Other ways to remove the cancerous tissue include conization, cryosurgery, laser surgery, or a loop electrosurgical excision procedure.
Some women need a radical hysterectomy. A radical hysterectomy is surgery to remove the uterus, cervix and part of the vagina. With either type of hysterectomy, a physician may also perform a bilateral salpingo-oophorectomy which entails removal of the fallopian tubes and ovaries. The surgeon may also remove the lymph nodes near the tumor to see if they contain cancer. If cancer cells have reached the lymph nodes, it means the disease may have spread to other parts of the body.

The predominant technique utilized is the abdominal hysterectomy. As the name implies, the incision and access to the uterus is via an abdominal incision. This allows for a better view and easier dissection of the necessary areas. As an alternative, hysterectomy can also be performed via a vaginal incision, and a laparoscopic approach is also possible. Laparoscopic surgeries allow for smaller incisions, less bleeding and less postoperative pain.

City of Hope is one of a few institutions to operate four da Vinci S HD Surgical Systems – the most advanced robotic technology available. Our team possesses a thorough knowledge of robotics, due in part to our large volume of patients and expertise across a variety of procedures.

The robotic surgical approach means smaller incisions, reducing trauma to the patient and resulting in quicker healing. This means that women may feel better and return to their normal lives sooner. Robotic systems use highly advanced imaging navigation, high-definition monitors and fine optics so surgeons can operate with more precision than ever before.

In radiation therapy, high-energy rays are used to kill cancer cells. Like surgery, radiation therapy is a local therapy. It affects cancer cells only in the treated area.

Women may have radiation therapy alone, with chemotherapy, or with chemotherapy and surgery. The doctor may suggest radiation therapy instead of surgery for the small number of women who cannot have surgery for medical reasons. Most women with cancer that extends beyond the cervix have radiation therapy and chemotherapy. For cancer that has spread to distant organs, radiation therapy alone may be used.

Doctors use two types of radiation therapy to treat cervical cancer:
  • External radiation: In external radiation therapy, a large machine outside the body is used to aim radiation at the tumor area. The woman is usually an outpatient in a hospital or clinic and receives external radiation five days a week for several weeks. This schedule helps protect healthy cells and tissue by spreading out the total dose of radiation. No radioactive materials are put into the body for external radiation therapy.
  • Intensity-Modulated Radiotherapy (IMRT) has evolved as a technique that can treat certain areas such as the tumor or areas at risk of recurrence while sparing adjacent normal tissues from high-dose irradiation. IMRT is an advanced form of radiotherapy that produces high-dose volume of radiation, which may have an irregular shape that better conforms to the clinical target volume. By having a better conformation of the target volume, normal pelvic tissues (e.g., small bowel, bladder, rectum) are relatively spared. The potential advantage of IMRT in these treatments, in the post-operative setting, is the ability to shape a dose distribution that delivers a lower dose to abdominal cavity contents (e.g., small and large bowel), which in turn will make it possible to reduce side effects from treatment.
  • Internal radiation: In internal radiation therapy, tiny tubes containing a radioactive substance are inserted through the vagina and left in place for a few days. The woman stays in the hospital during this treatment. To protect others from radiation exposure, the patient may not be able to have visitors or may have visitors only for a short period of time while the implant is in place. Once the implant is removed, the woman has no radioactivity in her body.
Some patients need both external and internal radiation therapies.

In advanced cervical cancer, chemotherapy may be indicated. Combinations of the following have been used clinically:
  • ifosfamide
  • 5-FU
  • irinotecan
  • paclitaxel
  • docetaxel
  • gemcitabine
In 2006, the Food and Drug Administration approved the combination of topotecan (Hycamtin) and cisplatin for late-stage cervical cancer.

Cervical Cancer Research/Clinical Trials

City of Hope is at the forefront of some of the nation’s most promising cervical cancer research and treatment programs. We conduct vital research and clinical trials to improve treatment and quality of life for women living with the disease, and early detection and prevention of uterine cancer for all women. City of Hope's commitment to this crucial biomedical field will not only serve City of Hope patients, but the scientific knowledge generated here is made available to cancer centers across the country. This ensures that the most advanced therapies help women afflicted with cervical cancer everywhere, every day.

Current research in cervical cancer treatment includes the use of intensity-modulated radiotherapy post-surgery, alone or in combination with chemotherapy, as well as investigational agents added to conventional chemotherapy.

To learn more about our clinical trials program and specifically about trials for cervical cancer, click here.



Cervical Cancer Resources

Our cervical cancer patients have access to the Sheri & Les Biller Patient and Family Resource Center , which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs such as music therapy, meditation and many others.  

Additional Resources
National Cervical Cancer Coalition
The National Cervical Cancer Coalition (NCCC) is a growing coalition of people battling cervical cancer and human papillomavirus related issues. The NCCC places a very special and personal focus on providing outreach support to women and family members going through the personal battle against cancer and HPV disease.

Women’s Cancer Network
The Women’s Cancer Network is an interactive Web site developed by the Gynecologic Cancer Foundation, which is dedicated to informing women around the world about gynecologic cancer. Its goal is to assist women who have developed cancer, as well as their families, to understand more about the disease, learn about treatment options and gain access to new or experimental therapies.
American Cancer Society
866-228-4327 for TYY
The American Cancer Society has many national and local programs, as well as a 24-hour support line, to help cancer survivors with problems such as travel, lodging and emotional issues.
National Comprehensive Cancer Network (NCCN)
888-909-NCCN (6226)
The National Comprehensive Cancer Network, an alliance of 21 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.
National Cancer Institute (NCI)
The National Cancer Institute, established under the National Cancer Act of 1937, is the federal government's principal agency for cancer research and training.

Cervical Cancer Team

Support This Program

We deliver exquisite care at the leading edge of cancer treatment. It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts - and those of our supporters today -- have built the foundation for the care we provide and the research we conduct. It enables City of Hope to strive for new breakthroughs and better therapies - helping more people enjoy longer, better lives.

For more information on supporting this specific program, please contact:

Janet Morgan

Senior Director
Phone: 213-241-7250
Email: jmorgan@coh.org

Refer a Patient
Physicians can choose a number of options to refer a patient:

  • Call 800-826-HOPE (4673) to speak with a patient referral specialist.
  • Fax the patient face sheet to 626-301-8432
  • Complete an online callback request form
As an leader in cancer research, our goal is to bring the latest scientific findings into medical practice as quickly as possible.
For the 11th year, U.S.News & World Report has named City of Hope one of the top cancer hospitals in the country.
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