Diagnosis and Prognosis of Cervical Cancer
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The diagnosis of cervical cancer usually begins in the doctor's office, during a routine pelvic exam and Pap test. Cervical cancer rarely produces symptoms in its early stages, so having a regularly scheduled pelvic exam is important.
The diagnosis and prognosis of cervical cancer includes the following:
- ]]>Review of medical history]]>
- ]]>Physical exam]]>
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.
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.
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:
A colposcopy is the use of a colposcope, an instrument that shines a light on the cervix and magnifies the view, to closely examine your genitals, vagina, and cervix. The doctor places the speculum into your vagina and opens it slightly to see the cervix. A vinegar solution is swabbed onto the cervix and vagina. This solution makes abnormal tissue turn white so the doctor can identify the areas that need to be evaluated. If abnormal cells are found during a colposcopy, the doctor may do a biopsy.
A biopsy is the removal of a sample of cervical tissue to tested for cancer cells. There are several procedures used to obtain biopsies, including the following:
- Cone biopsy – (also known as cold cone biopsy or cold knife cone biopsy) – the use of a laser or a surgical scalpel to remove tissue.
- Loop electrosurgical excision procedure (LEEP) – the use of an electric wire loop to slice off a thin, round piece of tissue.
- Endocervical curettage – the use of a small, spoon-shaped instrument called a curette to scrape tissue from inside the cervical opening.
If the area of abnormal cell growth is small, these biopsy procedures may be able to remove all of the affected area. The tissue removed during biopsy is sent to a laboratory to be analyzed.
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 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:
Stage 0: Carcinoma in situ.
The abnormal cells are found only in the first layer of cells lining the uterus.
The cancer is strictly confined to the cervix. This stage has six levels, depending upon the size of the cancer:
- IA - Invasive cancer is identified only microscopically
- IA1 - Measured invasion of the stroma (the lining of the cervix) is no greater than 3 millimeters (mm) in depth and no wider than 7 mm in diameter
- IA2 - Measured invasion of stroma is greater than 3 mm but no greater than 5 mm and no wider than 7 mm in diameter
- IB - Clinical lesions are confined to the cervix or preclinical lesions are greater than in IA
- IB1 - Clinical lesions are no greater than 4 centimeters (cm) in size
- IB2 - Clinical lesions are greater than 4 cm in size
Cancer has spread to nearby areas but is still inside the pelvic area. This stage has two levels.
- IIA - Cancer has spread beyond the cervix to the upper part of the vagina, but does not involve the lower third of the vagina.
- IIB - Cancer has spread to the tissue next to the cervix. This tissue is called parametrial tissue.
Cancer has spread throughout the pelvic area. The tumor involves the lower third of the vagina or the pelvic wall, and may be blocking the ureters, which are the tubes that carry urine from the kidney to the bladder. This stage has two levels.
- IIIA - Cancer has spread to the lower third of the vagina, but not to the pelvic sidewall.
- IIIB - Cancer extends to the pelvic wall and/or is blocking the urine flow to the bladder.
Cancer has spread to other parts of the body. This is the most advanced stage of cervical cancer. This stage has two levels, depending on which organs the cancer has invaded:
- IVA - Cancer has spread to adjacent organs, such as the bladder or rectum.
- IVB - Cancer has spread to distant organs beyond the pelvic area, such as the lungs, liver, or bone.
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.
|Adapted from Cancer Facts & Figures by the American Cancer Society|
American Academy of Family Physicians
The National Women’s Health Information Center
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Last reviewed February 2003 by ]]>Jondavid Pollock, MD, PhD]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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