Cervical Cancer

Researchers don’t know exactly what causes cervical cancer. Some viruses can cause the cells to grow out of control and become cancerous, but not every woman who’s infected with these viruses develops cervical cancer.

There are several known risk factors for cervical cancer. Keep in mind that many women with these risk factors never develop cervical cancer, and some women who do have the disease have no risk factors.

Cervical cancer risk factors include:

Human papillomavirus (HPV)

HPV infection is the cause of almost all cases of cervical cancer, as well as many vaginal and vulvar cancers, and is the greatest risk factor for cervical cancer. HPV may cause precancerous changes in the cells of the cervix. If not treated, these cells may become cancerous. For more on HPV, scroll down to the bottom of this section.

Age

Cervical cancer usually affects women ages 20 to 50, and the risk increases with age. It’s found most often in women over the age of 40, but younger women often have precancerous cell changes that require treatment.

Smoking

Women who smoke have about twice the risk of developing cervical cancer as nonsmokers, especially in women with HPV. 

Sexual behavior

Certain types of sexual activity may increase the risk of HPV infection, including having multiple sexual partners and having unprotected sex.

Not having regular Pap tests

The Pap test can detect changes in cervical cells before they become cancerous and can also detect cervical cancer at early, highly treatable stages. Women who do not have Pap tests on a regular basis as recommended by their physician have a higher risk of developing cervical cancer, because precancerous cell changes are not detected early and may become cancer. 

Chlamydia

Infection with the sexually transmitted disease (STD) chlamydia may raise cervical cancer risk. Chlamydia is a bacterial infection that often has no symptoms, and women may not know they’re infected unless their physician tests them.

Exposure to diethylstilbestrol (DES) before birth

The drug diethylstilbestrol (DES) was used between 1940 and 1971 to help prevent miscarriages. Women whose mothers were treated with DES during pregnancy have a high risk of vaginal and cervical cancers.

Weakened immune system

Women who have weakened immune systems due to HIV infection, drugs that suppress the body’s immune system response (such as drugs taken for an autoimmune disease) or other reasons have an increased risk of cervical cancer.

Long-term use of birth control pills

Long-term use of oral contraceptives can increase risk, and risk increases the longer the pill is used. The risk decreases when pills are stopped, and reaches normal levels about 10 years after stopping.

Multiple full-term pregnancies

Women who have carried three or more pregnancies to term have a higher risk of cervical cancer.

First full-term pregnancy before 17

Women who were younger than 17 years old when they had their first full-term pregnancy have almost twice the risk of cervical cancer as women who became pregnant at age 25 or later.

Weight

Excess weight can increase the risk of adenocarcinoma of the cervix.

Diet

Eating a diet low in fruits and vegetables may increase the risk.

Family history

Women whose mother or sister had cervical cancer have two to three times the normal risk for the disease. Researchers don’t know if this is due to an inherited condition, or if family members are more likely to share the same non-genetic risk factors.

If you have risk factors for cervical cancer and are concerned about your health, talk with your doctor. If you have family members who have had vulvar cancer, consider talking with one of our genetic counselors.

More on human papillomavirus (HPV)

HPV is a group of more than 150 related viruses that can infect cells lining the genitals, anus, mouth and throat. The virus is spread from one person to another during skin-to-skin contact, including sex. About two-thirds of all cervical cancers are caused by HPV 16 and 18.

Up to 80% of men and women who have had sex have HPV. In 9 out of 10 cases, the body’s immune system clears the virus on its own, and most women with HPV will not develop cervical cancer. But if the infection becomes chronic, the risk of cervical cancer increases. A vaccine series is available for HPV and is recommended for pre-teens between the ages of 11 and 12. In some cases, the vaccine may be recommended up to age 26.

Cervical cancer screening has proven to detect the disease early. More than 90% of US women diagnosed and treated for stage IA cervical cancer survive five years or more.

Types of preventive screenings for cervical cancer

The two types of preventive screening for cervical cancer are the Pap test and HPV DNA test.

Pap test

The Pap test (also known as a Pap smear) can find abnormal cervical cells. It’s a fast, painless test that involves gently scraping cells from the opening of the cervix. Cells are then examined under a microscope. Not only can the test identify cervical cancer at an early stage, it can detect changes in cells even before they become cancer. The Pap test is usually performed as part of an annual well-woman exam, and is fast and painless.

HPV DNA test

The HPV DNA test determines whether a woman is infected with the HPV virus, which is a major risk factor for cervical cancer. This test can be combined with the Pap test.

When to get screened

For women 30 and older, screening with both an HPV test and a Pap test at the same time is more likely to find abnormal cervical cell changes than either test performed alone, according to the National Cancer Institute. Be sure to discuss the best approach for your individual care with your doctor.

How often you should get screened depends on three factors:

• Your age
• Whether you have had a hysterectomy
• Whether you have an increased risk for cervical cancer

Recommended screenings by age group

The following screening recommendations apply to most women. If you’ve had a hysterectomy or have an increased risk of cervical cancer, your recommendations may differ (see below).

• Age 21 to 29: Pap test every three years.
• Age 30 to 64: Pap test and HPV test every five years, or Pap test every three years.
• Age 65 or older: If you’ve had no unusual Pap or HPV test results in the past 10 years, you may not need additional exams. If you have been diagnosed with precancers, you should continue to be screened for at least 20 years after your initial diagnosis.

Screening for women who have had a hysterectomy

For women who have had a hysterectomy, but have not had cervical cancer or severe cervical dysplasia, screening recommendations depend on whether the cervix was removed during the hysterectomy.

• If your hysterectomy included removal of the cervix, ask your doctor whether you should continue screening.
• If your cervix was not removed, you should have a Pap test and HPV test every five years.

Screening for women at increased risk

Women at increased risk may need to start screening at an earlier age, get additional tests or be tested more often. You’re at increased risk for cervical cancer if you have any of the following:

• History of severe cervical dysplasia, which is a precancerous condition
• Persistent HPV infection after age 30
• An immune system that doesn’t function properly, such as after an organ transplant or if you take medication to suppress your immune system
• History of human immunodeficiency virus (HIV)
• Diethylstilbestrol (DES) exposure before birth

If you may be at increased risk, talk with your doctor about your screening recommendations.

Preventive factors

Cervical cancer cannot be completely prevented, you can take some steps to help with cervical cancer prevention:

• Have Pap tests and HPV tests as recommended
• Ask your doctor about an HPV vaccine
• Use condoms during sex to protect against STDs
• Maintain a healthy weight
• Avoid tobacco
• Eat a diet high in fruits and vegetables
• Discuss oral contraceptive use with your doctor

If you have an abnormal screening exam or potential symptoms, your doctor may recommend additional tests to confirm or rule out a cervical cancer diagnosis. Scripps cancer specialists diagnose and stage cervical cancer using advanced imaging and diagnostic techniques. Staging helps determine the best course of treatment.

Cervical cancer diagnostic tests may include:

Colposcopy

During a colposcopy, the physician uses an instrument called a colposcope to examine the magnified surface of the cervix. The colposcope remains outside of the body.

Hysteroscopy

Hysteroscopy is the insertion of a small telescope into the cervix for a physician to view the uterus. 

Cervical biopsy

During a biopsy, the doctor removes a tissue sample from the cervix to be examined under a microscope. There are several types of cervical biopsies, performed through the vagina:

• Endocervical curettage (ECC) is when a tissue sample is scraped from an area just past the opening of the cervix using a curette (small, spoon-shaped instrument) or a thin, soft brush.
• LEEP (loop electro-surgical excision procedure) is when a small wire heated with low-voltage, high-frequency radio waves is used to remove cells from the cervix.
• Cone biopsy is when a cone-shaped sample of tissue is removed and examined for abnormal cells in the tissue beneath the surface.

Cystoscopy or proctoscopy

Cystoscopy or proctoscopy is the insertion of slender tubes with lights and/or lenses that allow doctors to see if cervical cancer has spread to nearby organs.

Computed tomography (CT) scan

A CT scan is an imaging test that captures images of the body from different angles. The images are combined to create detailed cross-sectional views of organs, bones and blood vessels.

Magnetic resonance imaging (MRI)

MRI relies on a powerful magnet, radio waves and advanced digital technology to provide detailed images of organs, bone and soft tissue.

Positron emission tomography (PET) scan

A PET scan involves a type of radioactive sugar that existing cancer cells will quickly absorb so they can be identified under a special camera. It’s combined with a CT scan to give physicians the ability to view a picture of potentially cancerous areas through the PET while also seeing more detailed images from a CT scan.

Lymph node dissection

Using minimally invasive surgical techniques, lymph nodes are removed to determine if cancer has spread.

Cervical cancer stages indicate how far cancer may have spread beyond the cervix and into other areas of the body. Staging cervical cancer helps doctors plan the best course of treatment.

Stage 0

Abnormal cells are in the inner lining of the cervix and may become cancer. Stage 0 also is called carcinoma in situ.

Stage I

Stage I cervical cancer is in the cervix only. Stage I is divided into several substages based on how far the cancer has spread.

• Stage IA is when a small amount of cancer is in the tissues of the cervix and is visible only with a microscope.
• Stage IA1 is when cancer is not more than 3 mm deep and not more than 7 mm wide.
• Stage IA2 is when the cancer is more than 3 but not more than 5 mm deep and not more than 7 mm wide.
• Stage IB is when cancer is more than 5 mm deep or more than 7 mm wide, or it can be seen without a microscope.
• Stage IB1 is when cancer can be seen without a microscope and is not larger than 4 cm.
• Stage IB2 is when cancer can be seen without a microscope and is larger than 4 cm.

Stage II

Stage II cervical cancer has spread beyond the cervix, but not to the tissues that line the pelvic wall. Stage II is divided into two substages.

• Stage IIA is when cancer has spread beyond the cervix to the upper two thirds of the vagina, but not to tissues around the uterus.
• Stage IIB is when cancer has spread beyond the cervix to the upper two thirds of the vagina and to tissues around the uterus.

Stage III

Stage III cervical cancer is divided into two substages.

• Stage IIIA is when cancer has spread to the lower third of the vagina but not to the pelvic wall.
• Stage IIIB is when cancer has spread to the pelvic wall and/or the tumor has become large enough to block the ureters that connect the kidneys to the bladder, which can cause the kidneys to become enlarged or stop working. Cancer cells may also have spread to nearby lymph nodes.

Stage IV

Stage IV cervical cancer has spread to other organs or body parts. It’s divided into two substages.

• Stage IVA is when cancer has spread to the bladder or rectal wall and may have spread to lymph nodes in the pelvis.
• Stage IVB is when cancer has spread beyond the pelvis and pelvic lymph nodes to other places in the body, such as the abdomen, liver, intestinal tract or lungs.

A cervical cancer diagnosis can be upsetting. You may feel frightened, overwhelmed, anxious or sad — all of which are normal reactions. The more you learn about your diagnosis and next steps, the sooner you can make informed decisions about your treatment.

Questions and considerations

Here are some questions you may want to ask your doctor or health insurance provider regarding your cervical cancer diagnosis:

• Should I get a second opinion?
• How do I find a specialist?
• What is my cancer treatment plan?
• Will I have to miss work/school?
• What are the side effects of cervical cancer treatment?
• How successful is my treatment likely to be?
• What costs will be covered by insurance?
• Which costs will I be responsible for?

Your Scripps team is here to help you find the answers you need to take an active role in your care. In addition, there are a number of community resources that provide education, information and helpful resources — often at no cost.

Learn more about the many cancer patient resources available to you and your loved ones via Scripps.

Your Scripps cancer care team will customize your treatment plan based on several factors, including:

• The cancer stage
• Whether cancer has spread
• Whether you plan to become pregnant
• Your age and overall health

If you’re diagnosed with cervical cancer during pregnancy, your treatment also will depend on how far along you are. If you’re in your third trimester, or if your cancer is found at an early stage, your team may recommend delaying treatment until after your baby is born.

Cervical cancer surgery

Scripps physicians may use several surgical procedures to remove precancerous cells, or early-stage cervical cancers that have not spread. These include:

• Cryosurgery (cryotherapy) is when an instrument is inserted through the vagina to allow the surgeon to freeze and destroy abnormal tissue.
• Laser surgery is when the surgeon uses a laser beam to destroy abnormal cells.
• LEEP (loop electro-surgical excision procedure) is when a small wire heated with low-voltage, high-frequency radio waves is used to remove cells from the cervix.
• Cone biopsy, also called conization, can be performed for early-stage cervical cancers.

For cervical cancer that has spread beyond the cervix, more extensive surgery may be needed. Surgical options may include:

• Trachelectomy is when surgeons remove the cervix, upper part of the vagina and nearby lymph nodes. The uterus is not removed, which allows a woman to still become pregnant.
• Hysterectomy is the removal of the uterus and possibly the cervix. Whenever possible, Scripps surgeons perform hysterectomy using single-site robotic surgery, which requires just one small incision. If this isn’t appropriate, our surgeons can perform the hysterectomy through an abdominal incision, through the vagina or through minimally invasive procedures, such as laparoscopic surgery or robotic-assisted surgery.
• Lymph node dissection is when surgeons remove lymph nodes from the pelvic region and the area next to the heart’s aorta to see if the cancer has spread. This can be performed through a minimally invasive laparoscopic surgery.
• Pelvic exenteration is the most extensive surgical approach and is typically used for recurrent cervical cancer. It involves removal of the uterus, cervix, bladder, vagina, rectum and possibly part of the colon, based on how far the cancer has spread.

With pelvic exenteration, the following organs may be involved:

• If the bladder is removed, the surgeon may use a piece of intestine to form a new bladder, and urine may be drained through a catheter (tube) into a small plastic bag worn outside of the body.
• If the rectum and part of the colon are removed, you may have an opening on the abdomen that allows solid waste (stool) to pass into a small bag worn on the outside of the body, called a colostomy. In some cases, the surgeon may be able to reconnect the colon, so no colostomy is needed.
• If the vagina is removed, the surgeon may be able to make a new one from other tissue.

Radiation therapy

Radiation therapy may be used to treat cervical cancers that have spread beyond the cervix, or to shrink large tumors before surgery. Scripps radiation oncologists use advanced radiation therapy techniques that precisely target tumors while minimizing radiation exposure to nearby healthy tissues and organs.

• High-dose brachytherapy is internal radiation therapy in which radioactive material is inserted through the vagina and placed near the tumor for a few minutes at a time. Radioactive implants may be given alone or with a shortened course of external beam radiation therapy.
• Intensity-modulated radiation therapy (IMRT) is an advanced form of radiation therapy that allows the radiation oncologist to specify the dose of radiation for the tumor while restricting the dose to surrounding healthy tissues.

Chemotherapy

Chemotherapy may be given as a primary treatment for metastatic cervical cancer (cancer that has spread) or for cervical cancer that returns. It also may be used combination with radiation therapy.

Some cervical cancer treatment plans may involve clinical trials. Talk with your physician about whether a clinical trial is right for you. 

For a list of clinical trial that are currently enrolling patients, see our current list of clinical trials.

Your Scripps cancer team will develop a customized treatment plan outlining the treatments and therapies we recommend for your care. Before you begin treatment, you and your physician will review your plan together and discuss any questions or concerns you may have.

Your cervical cancer treatment plan generally includes:

• Family and medical history
• A summary of your cancer diagnosis and staging information
• Diagnostic testing completed (e.g., imaging, biopsy, lab tests)
• Plans for surgery, radiation, chemotherapy and/or other treatments
• Potential side effects of treatments
• Contact information for your cancer care team members

Along with helping you understand your course of treatment and encouraging discussion between you and your physician, your plan helps your team coordinate your care. You also can share your treatment plan with other providers who may be involved in your medical care.

Your cervical cancer care team includes health and medical professionals from a wide range of specialties. Scripps will customize your team to ensure you have the expertise and support you need. 

Your team may include:

• Gynecologists
• Gynecologic surgeons
• Surgeons and surgical oncologists
• Radiation oncologists
• Medical oncologists
• Registered nurses
• Nurse navigators
• Dietitians
• Oncology social workers

Visit your cancer care team for more on Scripps Cancer Center's multidisciplinary approach to treatment.

We are here for you — not only as your oncologists, but as a robust multidisciplinary team of experts who understands that your cancer journey is about much more than your medical treatment. Specifically, Scripps Cancer Center offers a variety of patient support services to ensure your physical, psychological and emotional well-being as well as resources for dealing with the logistical and financial aspects of cancer care. Our services and resources include:

• Oncology nurses and nurse navigators with extensive clinical expertise in cancer care to help guide you and your caregivers to make informed decisions and ensure your optimal care.
• Palliative care to provide an extra layer of supportive care to manage pain and relieve symptoms, offer emotional and spiritual support, and improve your quality of life. 
• Oncology social workers specially trained to provide counseling, connect you with community and medical resources, assist with transportation and housing and coordinate care after discharge.
• Our registered dietitian nutritionists offer individualized nutrition support for patients whose efforts to optimize their nutrition may be affected by cancer symptoms or treatment side effects.
• Referrals and professional care from experts in psychology, psychiatry and emotional health, including individual and family counseling to help with the emotional challenges of cancer.
• Physical rehabilitation and occupational therapy services, including wound care, voice therapy and swallowing therapy, lymphedema therapy, balance and vestibular rehabilitation, yoga and more.
• Scripps Center for Integrative Medicine for patients interested in mind-body healing through acupuncture, biofeedback, herbal nutrition, massage therapy, integrative cancer care and more.
• Nondenominational spiritual care offered by our chaplains to help coordinate spiritual care with your own clergy, rabbi or spiritual advisor.
• Visiting patient services if you reside beyond San Diego and want help arranging appointments or learning more about short-term lodging.

For the full spectrum of offerings, please visit our cancer patient support services section.