cervical cancer

Issue

Vol. 2 No. 1 (2025)

Date Log

Submitted
May 23, 2024
Accepted
June 29, 2024
Published
February 10, 2025

Cervical Cancer - Causes, Risk Factors, Symptoms, Diagnosis and Treatment

https://doi.org/10.69512/ajphi.v2i1.42
Gauri Adhikari, MD
Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal
Prabha Bhandari, MD
Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

Corresponding Author(s) : Gauri Adhikari, MD

gauryadhikary@gmail.com

The American Journal of Patient Health Info, Vol. 2 No. 1 (2025)

Abstract


  1. Prevalence and Causes: Cervical cancer ranks fourth among women's cancers, mainly attributed to Human Papilloma Virus (HPV).

  2. Silent Progression: Often symptomless, symptoms may indicate advanced stages, underscoring the importance of early detection.

  3. Slow Progression, Early Detection: Slow progression improves prognosis and higher survival rates with early detection.

  4. Screening Tool: The Pap test emerges as a simple yet effective screening tool for cervical cancer.

  5. Preventive Vaccination: HPV vaccination stands as a preventive measure, significantly reducing the risk of cervical cancer.

Keywords

Cervical Cancer Human Papilloma Virus Pap Smear Hysterectomy Vaccination
Adhikari, MD, G., & Bhandari, MD, P. (2025). Cervical Cancer - Causes, Risk Factors, Symptoms, Diagnosis and Treatment. The American Journal of Patient Health Info, 2(1). https://doi.org/10.69512/ajphi.v2i1.42
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References
  1. Singh D, Vignat J, Lorenzoni V, Eslahi M, Ginsburg O, Lauby-Secretan B, et al. Global Estimates of Incidence and Mortality of Cervical Cancer in 2020: a Baseline Analysis of the WHO Global Cervical Cancer Elimination Initiative. The Lancet Global Health [Internet]. 2022 Dec;11(2). Available from: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00501-0/fulltext
  2. CDC. Cervical Cancer Statistics [Internet]. Cervical Cancer. 2024. Available from: https://www.cdc.gov/cervical-cancer/statistics/index.html
  3. Zhang S, Xu H, Zhang L, Qiao Y. Cervical cancer: Epidemiology, Risk Factors and Screening. Chinese Journal of Cancer Research. 2020 Dec 31;32(6):720–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797226/
  4. Okunade KS. Human papillomavirus and cervical cancer. J Obstet Gynaecol. 2020 Jul;40(5):602-608. Available from: https://pubmed.ncbi.nlm.nih.gov/31500479/
  5. Kashyap N, Krishnan N, Kaur S, Ghai S. Risk Factors of Cervical Cancer: A Case-Control Study. Asia-Pacific Journal of Oncology Nursing. 2019;6(3):308.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518992/
  6. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. Available from: https://pubmed.ncbi.nlm.nih.gov/34292926/
  7. Wamakima BW, McKinney S, Bookman L, Gompers A, Hacker MR, Farid H. Postmenopausal Vaginal and Cervical Cancer Risk Related to In Utero Diethylstilbestrol Exposure. Journal of lower genital tract disease.2023 Jan 1;27(1):35-39. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10311286/
  8. Prasad D, Sinha A, Mishra U, Sadia Parween, Ravi Bhushan Raman, Goel N. Colposcopic evaluation of cervix in symptomatic women and its correlation with Pap smear. A prospective study at a tertiary care centre. Journal of family medicine and primary care. 2021 Jan 1;10(8):2923–3. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483131/
  9. Nassiri S, Soheila Aminimoghaddam, Marjan Ranjbar Sadaghian, Mahboobeh Nikandish, Niousha Jamshidnezhad, Elham Saffarieh. Evaluation of the diagnostic accuracy of the cervical biopsy under colposcopic vision. European Journal of Translational Myology. 2022 Oct 12;82(233863783). Available from: https://pubmed.ncbi.nlm.nih.gov/36226527/
  10. 10.Cooper DB, Menefee GW. Conization Of Cervix. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441845/
  11. Mayo clinic. Cervical cancer - Diagnosis and treatment - Mayo Clinic [Internet]. Mayoclinic.org. 2023. Available from: https://www.mayoclinic.org/diseases-conditions/cervical-cancer/diagnosis-treatment/drc-20352506
  12. Kaur P, Mehrotra R, Rengaswamy S, Kaur T, Hariprasad R, Mehendale S, et al. Human papillomavirus vaccine for cancer cervix prevention: Rationale & recommendations for implementation in India. Indian Journal of Medical Research. 2017;146(2):153. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761024/
  13. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Available from: https://pubmed.ncbi.nlm.nih.gov/34292926/
  14. Spayne J, Hesketh T. Estimate of global human papillomavirus vaccination coverage: analysis of country-level indicators. BMJ Open. 2021 Sep;11(9):e052016. Available from: https://bmjopen.bmj.com/content/11/9/e052016
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Gauri Adhikaria, Prabha Bhandarib

a Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal

b Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

Background

Cervical cancer is marked by abnormal cell growth in the cervix, the lower part of the uterus connecting to the vagina. It is the fourth most prevalent cancer in women. Every year in the United States, around 11,500 women are diagnosed with cervical cancer, and about 4,000 women die from it. [1,2] Often linked to Human papillomavirus (HPV), this cancer may progress silently without symptoms, especially in its early stages. Early detection is pivotal for improved prognosis and heightened survival rates. Screening tools like the Pap test play a crucial role. Understanding the significance of cervical cancer, its causes, and the preventive potential of HPV vaccination is essential in fostering awareness and promoting women's health.

Causes of Cervical Cancer

The primary cause of cervical cancer is infection with high-risk strains of the HPV. HPV is a common group of viruses transmitted through sexual contact. While most HPV infections are temporary, and the body's immune system successfully clears them, persistent infections with certain high-risk strains can lead to cervical cancer. Without treatment, HPV infections can turn into cancerous cells over 15–20 years. However, for women with weakened immune systems, such as those with untreated HIV, this process may speed up in 5–10 years. [3]

Risk Factors of Cervical Cancer

There are several factors attributed to the increased risk of cervical cancer. It is important to note that while these factors can elevate the risk, their presence does not mean that you are going to get cervical cancer.

Figure 1.

  • High-risk HPV Infection: Infection with high-risk strains of the HPV (strains 16 and 18) is the leading risk factor for cervical cancer. At least 70% of cervical cancer cases result from high-risk HPV types. [4] If you are infected with the low-risk types, you might only get genital warts. [5] The risk of HPV transmission is reduced by using condoms correctly and regularly, but it doesn't provide total protection. The reason for this is that HPV infection can occur in parts of the body that condoms do not cover, like the vulva, scrotum, and perineum. [6]
  • Sexual Activity: Those women who become sexually active at a young age, who have multiple sexual partners, or who have one partner who is considered a high risk are at increased risk of having cervical cancer. [3]
  • Smoking: It has been found that women who smoke are about twice as likely to get cervical cancer than those who do not smoke. Smoking is believed to cause damage to the DNA of cervical cells. This damage can lead to the progression of cervical cancer. Additionally, smoking weakens the immune system, making it harder to fight against HPV infections. [4]
  • Multiple Pregnancy: Three or more full-term pregnancy is considered to have an increased risk of developing cervical cancer. It is thought to be due to increased exposure to HPV, and also hormonal changes make women more susceptible to HPV infection. [4]
  • Miscellaneous: Women with weakened immune systems, infection with other sexually transmitted diseases, low socio-economic status, long-term use of contraceptive pills, and exposure to diethylstilbesterol use in utero have also been linked to the increased risk of cervical cancer. [3,7].

Symptoms of Cervical Cancer

Women with cervical cancer usually have no symptoms. It can cause symptoms once it has progressed and grows into nearby tissue. The most common symptoms are:

Figure 2.

  • Abnormal Vaginal Bleeding: You can have bleeding after sex, between periods, or bleeding after menopause. The bleeding during periods can also be heavier and longer than usual.
  • Painful Sex: You might experience pain or discomfort after having sex. This can sometimes be the only sign until the late stage.
  • Vaginal Discharge: You can have unusual vaginal discharge. The discharge can be watery or blood-mixed and foul smelling.
  • Advanced Symptoms: When the disease has progressed to nearby structures, you might also experience difficulty urinating, swollen legs, pelvic pain, significant weight loss, abdominal pain, or back pain.

Diagnosis of Cervical Cancer

The diagnosis of cervical cancer typically involves a series of steps aimed at detecting abnormalities in the cervix. Here's an overview of the diagnostic process for cervical cancer:

Figure 3.

1. Routine Screening Tests

These tests can be done as a part of routine screening and diagnosis in suspected cases.

  • Pap Smear: A Pap smear, also known as a Pap test, is a routine screening procedure in which a healthcare provider collects cells from the cervix and examines them under a microscope to identify abnormalities.
  • HPV Test: An HPV test may be performed in addition to or in combination with a Pap smear to check for the presence of high-risk strains of HPV.

2. Colposcopy

If the results of a Pap smear or HPV test are abnormal, your doctor may recommend a colposcopy. A colposcope (a magnifying instrument) is used to examine the cervix closely during this procedure. A biopsy may be taken for further analysis if suspicious areas are identified. [8]

3. Biopsy

A biopsy involves the removal of a small tissue sample from the cervix. This sample is then sent to a laboratory for examination by a pathologist to determine if cancerous cells are present. The sample may be taken with a punch biopsy. This procedure uses a sharp tool to punch out a piece of cervical tissue. Alternatively, a spoon-shaped instrument can be used to scrape off the tissue from the cervix, called endocervical curettage. Suppose the results of these tests are suspicious of cancer. In that case, an electrical wire loop can be used to take tissue samples in a procedure called a loop electrosurgical excision procedure (LEEP). Another procedure is called conization, where a cone-shaped tissue sample can be collected from the deeper layers of the cervix for confirmation. [9]

4. Imaging Studies

In some cases, imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scans can be performed to assess the extent of cancer spread, especially if cervical cancer is confirmed.

5. Staging

Once cervical cancer is diagnosed, it is staged to determine the extent of its spread. Staging also helps guide treatment decisions. The stages range from 0 (early, confined to the cervix) to IV (advanced, involving nearby or distant organs).

Treatment of Cervical Cancer

The treatment options for cervical cancer depend on various factors, including the stage of cancer, the individual's overall health, and personal preferences. Here are the primary treatment options for cervical cancer:

Figure 4.

1. Surgery

You might need surgery to diagnose or treat the condition. The type of surgery will depend on the stage of cancer, fertility, and your overall health.

  • Conization: This procedure can be used for both diagnosis of cervical cancer and also to treat cancer that has not spread to the basement membrane of the cervix. A cone-shaped piece of sample tissue is removed from the cervix during the procedure. The tissue removed includes the zone where cancers are most likely to start. This method is better for smaller cancers as it can remove the cancerous tissue completely and also help preserve fertility as the uterus is kept intact. [10]
  • Hysterectomy: It is the removal of the uterus and possibly nearby tissues, such as the ovaries and fallopian tubes. The extent of the surgery depends on the stage of the cancer. The hysterectomy procedure is used to treat cervical cancers that have not progressed beyond the cervix. It can be an abdominal hysterectomy or vaginal hysterectomy and can be either laparoscopic, open, or robotic-assisted.

2. Radiation Therapy

Radiation uses high-energy X-rays to kill cancer cells. For cervical cancer that has spread outside of the cervix, radiation therapy is frequently used in conjunction with chemotherapy as the primary treatment. In cases when there is a higher chance of the cancer returning, radiation therapy can be used following the surgery. It can be:

  • External Beam Radiation: X-rays are aimed from outside the body in this procedure. Precise beams of radiation are directed at the cervix. This procedure is usually combined with chemotherapy for more efficacy.
  • Brachytherapy: Brachytherapy is also known as internal radiation therapy. In this treatment, radioactive sources are placed directly inside or very close to the tumor to deliver targeted radiation.

3. Chemotherapy

Chemotherapy uses anti-cancer drugs administered orally or intravenously to kill cancer cells or stop their growth. Chemotherapy may be used alone or in combination with radiation therapy. It can also be used before the surgery to decrease the tumor size.

4. Targeted Therapy

Targeted drugs block specific molecules involved in cancer cell growth and spread. These drugs can be directed toward cancer cells' blood vessels or tissue factor proteins. This type of therapy is often used in combination with chemotherapy and is an option for advanced cervical cancer.

5. Immunotherapy

These drugs help boost a person’s immune system. They include various kinds of drugs like pembrolizumab. They target immune system cells to help them recognize and kill cancer cells. Immunotherapy can be an option for advanced cancer when other treatment options are not working.

Palliative Care

Palliative therapy plays a vital role in supporting individuals with life-threatening illnesses like cervical cancer. Its primary focus is alleviating pain and managing other symptoms to improve comfort and quality of life. Delivered by a multidisciplinary team of healthcare professionals, including doctors, nurses, and specialists, palliative care aims to enhance the well-being of both patients and their families. These experts work closely with you, your loved ones, and your medical team, providing additional care and support throughout your cancer treatment journey. Palliative care can also be provided with aggressive cancer therapies, including radiation therapy, chemotherapy, or surgery. [11]

After Cervical Cancer Treatment

Some women can be completely cured of cervical cancer, especially if it is caught in the early stages. However, for others, it may remain a lifelong condition. If your treatment successfully removes the tumor and you are declared cancer-free, your doctor will still need to monitor you regularly. Follow-up care is very important after treatment to check for any signs of cancer coming back.

HPV Vaccines to Prevent Cervical Cancer

HPV vaccines are proven to be highly effective in reducing the risk of cervical cancer and other HPV-related diseases. As of 2023, there are six globally available HPV vaccines protecting high-risk HPV types 16 and 18. The vaccine is recommended for girls aged 9-14 years before they become sexually active. Some countries vaccinate boys to reduce HPV prevalence and prevent penile cancers in men. [12] For children initiating vaccination at 11-12 years, a 2-dose schedule spaced 6 to 12 months apart is recommended. For those who start at age 15 or older, a 3-dose schedule is advised over six months. Catch-up vaccination is recommended for individuals up to age 26 who were not previously vaccinated. HPV vaccination is not generally recommended for people over 26 years old. [13]

Global coverage of HPV vaccination remains suboptimal, with significant disparities between high-income countries and low- and middle-income countries. As of 2020, global HPV immunization coverage was estimated at 15%. [14].

Screening for Cervical Cancer

It is recommended that women aged 21 to 29 be screened for cervical cancer every three years with cervical cytology alone. For women aged 30 to 65, it is recommended to get screened every three years with cervical cytology alone, every five years with high-risk HPV testing (hrHPV) alone, or every five years with hrHPV in combination with cytology (known as contesting).

Figure 5.

  • Cervical Cytology: Cervical cytology testing is commonly known as a Pap smear or Pap test. During this testing, your doctor collects cells from your cervix with a brush or spatula, which are then examined under a microscope. If any abnormalities are found, further diagnostic tests are performed.
  • High-Risk HPV Testing: The test involves taking cells from your cervix to check for infections with specific HPV types linked to cervical cancer. This test can be done simultaneously with the Pap smear or afterward, especially if the Pap test results show abnormalities.

Questions To Ask Your Doctor

  1. What is the most likely cause of cervical cancer in my case?
  2. What are the potential complications or side effects associated with the recommended treatments?
  3. What is the long-term outlook for someone with HPV infection or cervical cancer?
  4. What may influence the prognosis of my cervical cancer?
  5. Are there any lifestyle changes I can bring after treatment of cervical cancer to prevent recurrence?

Conflict of Interest

GA serves as a paid research assistant, and PB works as a nonpaid research assistant at eHealthyInfo. There are no other conflicts of interest to declare.

Peer Reviewed By

Swati Kumari, MD, Bronxcare NY

References

  1. Singh D, Vignat J, Lorenzoni V, Eslahi M, Ginsburg O, Lauby-Secretan B, et al. Global Estimates of Incidence and Mortality of Cervical Cancer in 2020: a Baseline Analysis of the WHO Global Cervical Cancer Elimination Initiative. The Lancet Global Health [Internet]. 2022 Dec;11(2). Available from: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00501-0/fulltext
  2. CDC. Cervical Cancer Statistics [Internet]. Cervical Cancer. 2024. Available from: https://www.cdc.gov/cervical-cancer/statistics/index.html
  3. Zhang S, Xu H, Zhang L, Qiao Y. Cervical cancer: Epidemiology, Risk Factors and Screening. Chinese Journal of Cancer Research. 2020 Dec 31;32(6):720–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797226/
  4. Okunade KS. Human papillomavirus and cervical cancer. J Obstet Gynaecol. 2020 Jul;40(5):602-608. Available from: https://pubmed.ncbi.nlm.nih.gov/31500479/
  5. Kashyap N, Krishnan N, Kaur S, Ghai S. Risk Factors of Cervical Cancer: A Case-Control Study. Asia-Pacific Journal of Oncology Nursing. 2019;6(3):308.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518992/
  6. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. Available from: https://pubmed.ncbi.nlm.nih.gov/34292926/
  7. Wamakima BW, McKinney S, Bookman L, Gompers A, Hacker MR, Farid H. Postmenopausal Vaginal and Cervical Cancer Risk Related to In Utero Diethylstilbestrol Exposure. Journal of lower genital tract disease.2023 Jan 1;27(1):35-39. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10311286/
  8. Prasad D, Sinha A, Mishra U, Sadia Parween, Ravi Bhushan Raman, Goel N. Colposcopic evaluation of cervix in symptomatic women and its correlation with Pap smear. A prospective study at a tertiary care centre. Journal of family medicine and primary care. 2021 Jan 1;10(8):2923–3. Available from: https://pubmed.ncbi.nlm.nih.gov/34660425/
  9. Nassiri S, Soheila Aminimoghaddam, Marjan Ranjbar Sadaghian, Mahboobeh Nikandish, Niousha Jamshidnezhad, Elham Saffarieh. Evaluation of the diagnostic accuracy of the cervical biopsy under colposcopic vision. European Journal of Translational Myology. 2022 Oct 12;82(233863783). Available from: https://pubmed.ncbi.nlm.nih.gov/36226527/
  10. Cooper DB, Menefee GW. Conization Of Cervix. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441845/
  11. Mayo clinic. Cervical cancer - Diagnosis and treatment - Mayo Clinic [Internet]. Mayoclinic.org. 2023. Available from: https://www.mayoclinic.org/diseases-conditions/cervical-cancer/diagnosis-treatment/drc-20352506
  12. Kaur P, Mehrotra R, Rengaswamy S, Kaur T, Hariprasad R, Mehendale S, et al. Human papillomavirus vaccine for cancer cervix prevention: Rationale & recommendations for implementation in India. Indian Journal of Medical Research. 2017;146(2):153. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761024/
  13. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Available from: https://pubmed.ncbi.nlm.nih.gov/34292926/
  14. Spayne J, Hesketh T. Estimate of global human papillomavirus vaccination coverage: analysis of country-level indicators. BMJ Open. 2021 Sep;11(9):e052016. Available from: https://bmjopen.bmj.com/content/11/9/e052016

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