Brief overview
- Symptoms: Usually only in advanced stages of cancer, including bleeding after sexual intercourse or after the menopause, heavy periods, intermenstrual bleeding or spotting, discharge (often foul-smelling or bloody), pain in the lower abdomen
- Progression and prognosis:Development over years; the earlier cervical cancer is detected and treated, the higher the chances of recovery
- Causes and risk factors: Infection with the sexually transmitted human papilloma virus (HPV); other risk factors include smoking, frequently changing sexual partners, many births, poor genital hygiene, long-term use of the “pill”
- Treatment: Surgery, radiotherapy and/or chemotherapy, targeted therapy (antibody therapy)
- Prevention: HPV vaccination, condoms, genital hygiene, no smoking
What is cervical cancer?
Cervical cancer, medically known as cervical carcinoma, refers to malignant tumors in the lower part of the uterus – malignant cell growths of the cervix.
Cervical cancer is one of the three most common cancers in women under the age of 45 and is particularly common in regions with a lower income or social status. In Europe, the rate of new cases has been largely stable since the end of the 1990s and is even falling in some countries due to comprehensive early detection measures.
According to estimates by the European Network of Cancer Registries (ENCR), there were 30,447 new cases in Europe in 2020.
Anatomy
The opening of the cervix towards the vagina is called the external cervix. The opening towards the body of the uterus is called the internal cervix.
The inside of the cervix is lined with a mucous membrane: it consists of a covering tissue (squamous epithelium) and mucous glands embedded in it. If the mucous membrane of the cervix undergoes malignant changes, doctors refer to this as cervical cancer (cervical carcinoma). In most cases, it originates from the squamous epithelium and is then classified as squamous cell carcinoma. More rarely, cervical carcinoma develops from the glandular tissue of the mucous membrane. In this case it is an adenocarcinoma.
Cervical cancer should not be confused with uterine cancer (cancer of the uterine body). The latter is also called “uterine carcinoma”, “endometrial carcinoma” or “corpus carcinoma” in medical terminology.
What are the symptoms of cervical cancer?
Cervical cancer usually causes no symptoms in the early stages. Precancerous stages of cervical cancer also go unnoticed for a long time.
In women after the age of 35, heavy periods, intermenstrual bleeding or spotting are also considered potentially cancerous. Bleeding after the menopause is also a symptom of cervical cancer.
These symptoms are not clear signs of cervical cancer! They may have completely different causes. As a precaution, you should therefore seek medical advice for such symptoms.
Some patients also report pain in the lower abdomen. Unexplained weight loss is also common in women with cervical cancer.
There are also signs of other organs being affected in advanced stages of cancer. Some examples:
- A red coloration of the urine occurs, for example, if the cancer cells have affected the urinary tract and bladder, causing bleeding into the bladder.
- Deep back pain, which often radiates into the pelvis, is a possible sign of cancer in the pelvis and spine.
- Severe abdominal pain with paralysis of bowel function is possible if the abdominal intestines are affected by cancer. If the bowel is affected, bowel movements are often disturbed.
In the final stage, the tumor spreads throughout the entire body. Many vital organs then fail, which ultimately leads to death.
What is the life expectancy for cervical cancer?
In very advanced stages of cervical cancer and in the event of a recurrence, a cure is much more difficult, but still possible. If the cervical cancer has already formed metastases in other organs and is already at the terminal stage, treatment is usually only aimed at alleviating the patient’s symptoms and prolonging her life as far as possible.
Doctors refer to treatment that aims to cure the disease as curative. If the treatment only serves to make the patient’s remaining life as symptom-free as possible, it is considered palliative treatment.
In recent decades, the chances of curing cervical cancer have improved significantly, which has led to a corresponding increase in life expectancy: Today, only half as many women die from cervical cancer each year as 30 years ago.
How does cervical cancer develop?
Although the “low-risk” HPV types are not involved in the development of cervical cancer, they do cause warts on the genitals of men and women.
HPV is transmitted almost exclusively through sexual intercourse. Even condoms are not sufficient protection against the human papilloma virus. Skin contact in the intimate area is sufficient to transmit the virus.
Other risk factors
Another major risk factor for cervical cancer is smoking. Certain toxins from tobacco are deposited specifically in the tissue of the cervix. This makes the tissue more susceptible to viruses such as HPV.
Other risk factors for cervical cancer are:
- Large number of sexual partners: The more sexual partners a woman has in her life, the higher her risk of cervical cancer.
- Early onset of sexual activity: Girls who have sexual intercourse before the age of 14 have an increased risk of HPV infection – and therefore also of developing cervical cancer (or its precursors).
- Low socio-economic status: People with a low income are more likely to be infected with HPV than members of higher social classes.
- Many pregnancies and births: Every pregnancy that lasts at least five to six months or every birth increases the risk of HPV infection and therefore cervical cancer. This is either due to tissue changes during pregnancy or to the fact that women with a low socio-economic status in particular become pregnant several times.
- Other sexually transmitted diseases: In women infected with HPV, an additional sexually transmitted disease (such as genital herpes or chlamydia) sometimes contributes to the development of cervical cancer.
- Weakened immune system: A weakened immune system is caused, for example, by illness (such as AIDS) or by medication that suppresses the immune system (administered after transplants, for example). A weakened immune system is correspondingly less effective in combating an HPV infection.
According to current knowledge, genetic factors play only a minor role in the development of cervical cancer.
How is cervical cancer detected?
The most important examination is the regular check-up at the gynecologist (early detection of cancer). This also applies to women who have been vaccinated against the most important HP viruses: Vaccination does not replace screening, it only supplements the screening program.
In Germany, every woman over the age of 20 is entitled to an annual preventive/early detection examination by a gynecologist – also known as primary screening. All health insurance companies cover the costs. You can obtain more information from your gynecologist.
The routine examination for the early detection of cervical cancer is carried out in exactly the same way as the examination carried out in the event of a specific suspicion of cervical cancer (due to symptoms such as irregular bleeding):
Medical history interview
First, the doctor asks the woman about her medical history (anamnesis). For example, he asks how regular and heavy the menstrual bleeding is and whether there is occasional intermenstrual bleeding or spotting. He will also ask about any complaints and previous illnesses as well as the use of contraceptives.
Gynecological examination & PAP test
He also takes a cell sample from the surface of the mucous membrane on the cervix and in the cervical canal using a small brush or a cotton bud and examines it more closely under the microscope. This allows the doctor to see if there are any altered cell forms among the mucosal cells. Doctors refer to this examination as a cervical smear or cervical smear (PAP test).
Conization
If the suspicious tissue change is only small, the gynaecologist usually performs a so-called conization: This involves cutting a cone out of the tissue, consisting of the pathologically altered cells and a border of healthy cells around it. The latter is intended to ensure that no altered cells remain. In the laboratory, medical staff examine the removed tissue for cancer cells.
HPV test
A test for human papilloma viruses (HPV test) is also useful when investigating the possibility of cervical cancer. The gynecologist examines a smear from the cervix for the presence of HP viruses (more precisely: for their genetic material).
The HPV test is not usually useful for younger women because HPV is often found in them, but the infection usually clears up on its own.
Regardless of a woman’s age, an HPV test is indicated if the PAP smear gives an unclear result. The costs of the test are then covered by health insurance.
Further examinations
Sometimes the doctor will order a computer tomography (CT) scan and/or magnetic resonance imaging (MRI). This can be used to detect metastases in the pelvis, abdomen or chest. An X-ray examination of the chest (chest X-ray) is suitable for detecting metastases in the chest cavity.
If there is a suspicion that the cervical cancer has spread to the bladder or rectum, a cystoscopy or rectoscopy is necessary. This allows any cancer to be detected.
Sometimes surgical staging is immediately followed by treatment. This enables the doctor to decide during the examination to remove the cancerous tumor (usually together with the entire uterus). However, this only happens if the patient has given her consent in advance.
Staging
Depending on how far the cervical cancer has spread at the time of diagnosis, doctors differentiate between different stages of cancer. This is important for treatment planning. The stage also makes it easier to assess the course and prognosis of the cancer.
What is the treatment for cervical cancer?
In principle, there are three treatment options for cervical carcinoma. They are used individually or in combination:
- surgery
- Radiation (radiotherapy)
- Drug treatment (chemotherapy and targeted therapies)
Some women only have a preliminary stage of cervical cancer (dysplasia). If these cell changes are only slight, doctors usually wait and see because they often disappear on their own. The doctor then checks this during regular check-ups.
Surgery for cervical cancer
Several techniques are available for cervical cancer surgery. There are also various access routes to remove the diseased tissue, for example via the vagina, an abdominal incision or laparoscopy.
Conization
Doctors therefore advise you to wait some time after a conization as a precaution before having a child. You can obtain more detailed information on this from your doctor.
Trachelectomy
Sometimes not all of the cancerous tissue can be removed by conization – a more extensive operation is then necessary. If the patient still wishes to have a child, a so-called trachelectomy is a possible treatment method: the surgeon removes part of the cervix (up to two thirds) as well as the inner retaining ligaments of the uterus. However, the inner cervix and the body of the uterus remain intact (the surgeon connects the inner cervix to the vagina).
Hysterectomy
If a woman with cervical cancer no longer wishes to have children, the doctor often removes the entire uterus. The operation is also necessary if the tumor has already grown deeper into the tissue. After this operation, the woman is no longer able to become pregnant.
The bladder and rectum should also be removed if the cervical cancer has already spread to these organs.
Radiotherapy for cervical cancer
If extensive surgery is not possible (e.g. if the patient is in poor general health) or the woman refuses it, cervical cancer can alternatively be treated with radiotherapy or a combination of radiotherapy and chemotherapy (radiochemotherapy). Sometimes radiotherapy is also used after surgery to kill any remaining cancer cells. Doctors then refer to this as adjuvant radiotherapy.
Radiotherapy for cervical cancer sometimes causes acute side effects. These include, for example, painful irritation of the mucous membranes in the vagina, bladder or bowel as well as diarrhea and infections. Such symptoms usually disappear within a few weeks after radiation.
In addition, there are sometimes late effects months or years after treatment, some of which are permanent, such as impaired bladder function, loss of bowel control, inflammation of the mucous membranes with bleeding or a constricted, dry vagina.
Chemotherapy for cervical cancer
The rapidly dividing cancer cells react particularly sensitively to these drugs. However, cytostatic drugs also impair the proliferation of rapidly growing healthy cells, such as hair root cells, mucous membrane cells and blood-forming cells. This explains the possible side effects of chemotherapy such as hair loss, nausea and vomiting as well as changes in the blood count with increased susceptibility to infections.
Targeted therapy for cervical cancer
Sometimes doctors treat cervical cancer with an artificially produced antibody (bevacizumab) that specifically targets the tumor: as soon as the cancerous tumor has reached a certain size, it needs its own newly formed blood vessels to ensure the supply of oxygen and nutrients. The antibody bevacizumab inhibits a certain growth factor and thus the formation of new blood vessels. This prevents the tumor from growing further.
Doctors administer bevacizumab as an infusion. However, targeted therapy is only an option in certain cases, namely when the cervical cancer:
- cannot be suppressed with other therapies or
- returns after an initially successful therapy (relapse, also known as recurrence).
Complementary treatments
Malignant tumors such as cervical cancer sometimes cause severe pain. Those affected then receive individually tailored pain therapy.
Many patients develop anemia – either due to the cancer itself or the treatment (such as chemotherapy). Under certain circumstances, the women affected may receive blood transfusions.
Radiotherapy for cervical cancer can sometimes lead to a dry, constricted vagina: lubricants can help prevent unpleasant dryness during sexual intercourse. A constriction can be prevented by regularly stretching the vagina with aids for a few minutes.
The diagnosis and treatment of cervical cancer (or other cancers) can be very stressful for some women. Patients are therefore entitled to psycho-oncological support. Psycho-oncologists are specially trained doctors, psychologists or social pedagogues who provide cancer patients and their relatives with emotional support in dealing with the disease.
Rehabilitation after cervical cancer (or any other cancer) aims to enable patients to return to their social and professional lives. Various therapists and counselors (doctors, psychologists, physiotherapists, etc.) help the women affected to cope with the possible consequences of the illness or treatment and to get physically fit again. Patients can obtain all important information about rehab from their attending doctor and the social services at the clinic.
- In the first three years after treatment, follow-up examinations are indicated every three months.
- In the fourth and fifth year after completion of treatment, a follow-up examination is recommended every six months.
- From the sixth year onwards, the follow-up examination takes place once a year.
The follow-up examination usually consists of the following parts:
- Discussion and consultation
- Physical examination of the reproductive organs with palpation of the lymph nodes
- PAP test
In addition, doctors carry out an HPV test, an ultrasound examination of the vagina and kidneys and a magnifying glass examination (colposcopy) at certain intervals.
Can cervical cancer be prevented?
Experts recommend that boys also get vaccinated against HPV. If they are not infected, there is no risk of infection for their sexual partners – this protects them from cervical cancer. The vaccination also offers boys themselves protection against genital warts and cell changes that may lead to cancer (such as penile cancer).
Vaccination
You can read everything you need to know about the process, effects and side effects of the vaccination in the article HPV vaccination.
Adequate genital hygiene and refraining from smoking also help to prevent cervical cancer.