Diagnosis and Prognosis of Cervical Cancer

Review of Medical History

Because cervical cancer is intimately related to several risk factors, your doctor will ask you several personal questions. It is crucial that you give honest answers. It is very important that you be extremely candid with your doctor about your sexual history. Depending on what it involves, your risk for cervical cancer could be greatly increased. Your doctor will need to know if you are experiencing any symptoms, such as abnormal vaginal bleeding, discharge, or pain.

Tell your doctor if you smoke. Tobacco use increases your risk for just about every cancer, including cervical cancer. Your doctor may also ask if you know if your mother took DES while she was pregnant with you.

Physical Exam

Your doctor will do a complete physical exam, focusing on the pelvic exam and Pap test. For a complete description of both, see cervical cancer screening]]> .

If your Pap test shows abnormal changes or unhealthy cell growth in the cervix, your doctor will need to perform further testing to determine if you have cancer, an infection, or some other condition.

Testing

If your health care provider suspects that you have abnormal cell growth from the results of your pelvic exam and Pap tests, diagnostic tests will be ordered to determine the nature of the abnormal cell growth of the cervix. Diagnostic tests include the following:

Cytology

Cytology is the study of cells. The cytology of cancer cells differs significantly from normal cells, and physicians use the unique cellular features seen on biopsy samples to determine the diagnosis and assess the prognosis of a cancer.

The criteria for diagnosing precancerous lesions of the cervix vary somewhat among doctors, but important characteristics include cellular immaturity, cellular disorganization, nuclear abnormalities, and increased mitotic activity. Some of the cellular abnormalities seen in cervical cancer include the following:

• Carcinoma in situ is diagnosed when normal endocervical gland cells are replaced by tall, irregular columnar cells that have stratified nuclei and increased cell division.
• Squamous carcinomas have small to medium-sized nuclei and abundant cytoplasm.
• Adenocarcinomas usually present with a wide variety of cell types, growth patterns, and degrees of differentiation.

The Pap test is used to identify the presence of abnormal cell growth that could develop into—or already is—cancerous. Most laboratories in the United States now use the Bethesda System to report Pap test results. The Bethesda System uses descriptive terms rather than class numbers, which were used to report Pap test results in the past.

The Bethesda System divides cervical cell abnormalities into three major categories:

• ASCUS - atypical squamous cells of undetermined significance. Squamous cells are the thin flat cells that form the surface of the cervix.
• LSIL - low-grade squamous intraepithelial lesion. Low-grade means there are early changes in the size and shape of cells. The word lesion refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells.
• HSIL - high-grade squamous intraepithelial lesion. High-grade means that there are more marked changes in the size and shape of the abnormal (precancerous) cells that look very different from normal cells.

ASCUS and LSIL are considered mild abnormalities. HSIL is more severe and has a higher likelihood of progressing to invasive cancer.

The classes of the Pap System are as follows:

• Class I - normal
• Class II - squamous cell abnormalities, infection, reactive changes
• Class IIR - atypical squamous cells of undetermined significance, HPV presence
• Class III - mild, moderate, severe dysplasia
• Class IV - carcinoma in situ
• Class V - invasive squamous carcinoma

Staging

Staging is the process by which physicians determine the prognosis of a cancer that has already been diagnosed. Staging is essential for making treatment decisions (e.g., surgery vs. chemotherapy). Several features of the cancer are used to arrive at a staging classification, the most common being the size of the original tumor, extent of local invasion, and spread to distant sites (metastasis). Low staging classifications (0 – 1) imply a favorable prognosis, whereas high staging classifications (4 – 5) imply an unfavorable prognosis.

Because of the widespread prevalence of cervical cancer throughout the world, the international cancer community has determined that only certain tests are considered relevant and acceptable in the staging process. These tests include a physical examination (under anesthesia if necessary), an intravenous pyelography (IVP), blood work, and a chest x-ray. CT scans, MRI scans, or any other more modern technology is not considered in the staging of cervical cancer, because these technologies are not necessarily available throughout the world. Additional tests to determine staging in the United States may include the following:

• Urine and blood tests
• Additional physical exam, including another pelvic exam in the operating room under anesthesia
• X-rays of various parts of the body, including lungs, bladder, kidney, lymph nodes
• Barium enema to check intestines and rectum – a rectal injection of barium is given to coat the lining of the colon and rectum. It is done before x-rays are taken in order to create better x-ray images
• CT or CAT scan – a type of x-ray that uses a computer to produce cross-sectional images of the inside of the body
• Ultrasonography – the use of sound waves and the characteristic patterns they make bouncing off of various structures in the body to identify tumors and other conditions
• MRI – a test that uses magnetic waves to produce images of the inside of the body. Using a large magnet, radio waves, and a computer, an MRI produces two-dimensional and three-dimensional pictures

The following staging system is used to classify cancer of the cervix:

Prognosis

Prognosis is a forecast of the probable course and/or outcome of a disease or condition. Prognosis is most often expressed as the percentage of patients who are expected to survive over five or ten years. Cancer prognosis is a notoriously inexact process. This is because the predictions are based on the experience of large groups of patients suffering from cancers at various stages. Using this information to predict the future of an individual patient is always imperfect and often flawed, but it is the only method available. Prognoses provided in this monograph and elsewhere should always be interpreted with this limitation in mind. They may or may not reflect your unique situation.

Five-year survival rates based on how far the cancer has spread are as follows:

• All stages: 70%
• Local (cancer is confined to organ of origin): 92%
• Regional (cancer has extended beyond organ and involves surrounding tissues or organs or regional lymph nodes): 49%
• Distant (cancer has spread to parts of the body remote from primary tumor): 15%

Survival rates according to stage are as follow:

• Stage IA: excellent prognosis
• Stage IB: 87% to 90%
• Stage IIA: 62% to 83%
• Stage IIB: 62% to 68%
• Stage III: 33% to 48%
• Stage IV: 14%

The following table shows trends in 5-year survival rates for cervical cancer by race and year of diagnosis in the US, from 1974 to 1997.