Cervical Cancer

What is cervical cancer?
The cervix is a small passage between a woman’s womb and vagina. Cervical cancer is cancer that starts in the cells of the cervix.

Cervical cancer is one of the most common cancers in women, with around 570,000 women being diagnosed worldwide in 2018. [1] It mainly affects women between the ages of 30 and 45 who are sexually active. [2]

What are the risk factors for cervical cancer?
Almost all cervical cancers are caused by a virus called human papillomavirus (HPV), which is passed from person to person through skin to skin contact in the genital area. Therefore, people who are sexually active are more likely to catch the virus. HPV is a very common virus but there are some strains of the virus (called ‘high-risk’) that are more harmful than others (called ‘low-risk’). Most HPV infections will not result in cervical cancer as the body’s immune system usually fights and clears the virus. However, persistent infections of high-risk HPV can cause changes in the cells of the cervix, which given time may develop into cancer. Regular testing allows the HPV virus to be detected and treated before it develops into cervical cancer. There are two tests that can detect HPV:

• Cervical screenings (also known as smear tests or PAP tests) – cells from the cervix are checked for abnormalities caused by the HPV virus [3]
• HPV testing – cells from the cervix are tested for the HPV virus. [4]

There is also an HPV vaccine that aims to stop people from catching the HPV virus. The HPV vaccine can be given to women and men of any age but is most commonly recommended for teenage girls and young women. This is because it works best before a person comes into contact with HPV, which is usually through sexual contact. [5]

Although the vaccine protects against most types of cancer-causing HPV, it is not 100% effective so people who have had the vaccine should still attend cervical screening. [6]

Although almost all cervical cancers are caused by HPV, there are some factors that are known to increase the chance of a person developing this disease, called ‘risk factors’. Having a risk factor does not mean that you will definitely get the disease. Some risk factors for cervical cancer are: [7]

• Not attending regular cervical screening and/or HPV testing
• Being sexually active from a younger age
• Having children at a younger age
• Giving birth to many children
• Having a higher number of sexual partners
• Smoking
• Having a weakened immune system
• Your mother being treated with a drug called diethylstilbestrol (DES) while she was pregnant with you (this drug was only given to women between 1938 and 1971).

How can the risk of getting cervical cancer be reduced?
There are certain things that you can do to reduce the chance of you getting cervical cancer:

• Get the HPV vaccine
• Attend cervical screenings
• Practice safe sex
• Do not smoke.

What are the symptoms of cervical cancer?
Women with unusual cervical cells do not always have symptoms, which is why attending regular cervical screenings and/or HPV testing is so important. Some symptoms that might occur include: [8]

• Unusual bleeding – such as bleeding between periods or bleeding during or after sex
• Bleeding after going through the menopause
• Unusual vaginal discharge
• Pain or discomfort during sex
• Lower back pain.

Some other symptoms that might occur in more advanced cervical cancer are: [1, 8]

• Needing to go to the toilet more often
• Blood in the urine
• Bleeding from the rectum (back passage)
• Diarrhoea
• Not being able to control the bladder
• One swollen leg.

How is cervical cancer diagnosed?
If your doctor thinks you might have cervical cancer, they will send you for some tests. These may include: [9]  

• Colposcopy – a doctor or nurse will look at your cervix in detail using a type of magnifying glass and will take tissue samples (biopsies) from any areas that look abnormal
• Cone biopsy – a small operation to remove a cone-shaped piece of tissue from your cervix to test for cancerous cells.

Once your diagnosis is confirmed, further tests will be performed to help doctors to understand the type, stage and grade of your cervical cancer (more information on these can be found below). These tests may include a pelvic examination (a doctor will examine all of the organs in your pelvis while you are under anaesthetic), scans (MRI or CT), blood tests or x-rays. [10]

What are the types of cervical cancer?
There are 2 main types of cervical cancer: [11]  

• Squamous cell – around 80 out of 100 people with cervical cancer have the squamous cell type. It starts in the surface cells at the end of the cervix (connected to the vagina).
• Adenocarcinoma – around 15 to 20 out of 100 people with cervical cancer have the adenocarcinoma type. It starts in the cells deeper inside the cervix, in the passage between the womb and the vagina.

What are the stages of cervical cancer?
The stage of your cervical cancer describes where the cancer is and how far it has spread into nearby tissues and/or around the body. [11]  

• Stage 1 – the cancer is only in the cervix and has not spread.
• Stage 2 – the cancer is in the cervix and has spread into the pelvic area around the cervix and/or the top of the vagina.
• Stage 3 – the cancer has spread throughout the pelvis into the lower part of the vagina or to the tubes that connect the bladder and kidneys.
• Stage 4 – the cancer has spread outside of the pelvis to nearby organs like the bladder or rectum (back passage), or other more distant organs such as the lungs.

What are the grades of cervical cancer?
The grade of your cervical cancer describes how fast it is likely to grow and spread around the body. [11]

• Grade 1 – the cancer cells look similar to normal cells and are less likely to spread and come back after treatment.
• Grade 2 – the cancer cells look different to normal cells and are more likely to spread and come back after treatment.
• Grade 3 – the cancer cells look very different to normal cells and are the most likely to spread and come back after treatment.

What treatment options are available for cervical cancer?
The most common treatments for cervical cancer are surgery (to remove as much of the cancer as possible), radiotherapy and chemotherapy (to kill cancer cells). Treatment will vary based on the type, stage and grade of your cervical cancer, and will depend on what is approved in your country. [12] If your cancer is only in the cervix, you are likely to be treated with radiotherapy and/or surgery. If your cancer has spread into the pelvis or other organs, you are likely to be treated with radiotherapy and/or chemotherapy. [13, 14] 

Surgery
If you have surgery, the surgeons will try to remove as much of the cancer as possible from affected areas. Your doctor may recommend a procedure called a hysterectomy, which can involve removing some or part of the reproductive organs, including the cervix, womb, fallopian tubes and ovaries, to give you the best possible outcome and reduce the likelihood that your cancer will come back after treatment. If you have very early stage cervical cancer, you may be able to have minimal surgery that would still allow you to become pregnant. [14]

Radiotherapy
If you are given radiotherapy, you may be given external radiotherapy (given from outside the body) and/or internal radiotherapy (given from inside the body). [15]

• External radiotherapy – This treatment is given by aiming x-rays at the cancer from outside your body. You will have to go to your local hospital for treatment 5 days a week for a few weeks, but each treatment usually only lasts a few minutes. The exact timing of your visits will be decided by your doctor.
• Internal radiotherapy – This treatment is given by placing an internal radiation device at the end into the top of the vagina, next to the cervix, before releasing radiation directly towards the tumour. The device will be placed while you are under anaesthetic (you will either be asleep or numb from the waist down). You may have several treatments over 1–2 days (the device may be left inside you) or you may have several treatments a few days apart (device will be removed at the end of each treatment). The exact timing of your visits will be decided by your doctor.

Chemotherapy
Chemotherapies are drugs that aim to stop cancer cells from growing. You may be given chemotherapy for later stage cervical cancer. Sometimes chemotherapy is given with radiotherapy to help the radiotherapy work better. This is called chemoradiotherapy. Chemotherapy may be given as a mixture of drugs as this sometimes works better than one type of chemotherapy on its own. Chemotherapy is given as an infusion into your vein over a few hours. You will need to go to your hospital or clinic regularly to be given chemotherapy treatment, and the exact timing of your visits will be decided by your doctor. [16]

Depending on the type and stage of your cervical cancer, and at what point in your treatment you are, you may also be given one of the following treatments, depending on what is approved in your country:

• Targeted therapy - These therapies are able to target specific changes in the cancer cell’s DNA that are causing them to grow out of control [17]   
• Immunotherapy - These therapies work by boosting the body’s immune system so that it can work better at recognising and destroying cancer cells. [18]

There are new treatments being developed for cervical cancer. Clinical trials investigate these new drugs and compare them with the current therapies already available. If you would like to know more about clinical trials, or are interested in taking part in a clinical trial, speak to your doctor or visit the clinical trials page on the Roche ForPatients platform (https://forpatients.roche.com/en/faq/what-is-a-clinical-trial.html).

What is the outlook for a person with cervical cancer?
The outlook for cervical cancer depends on the type, stage and grade of the cancer when it is diagnosed. [19, 20] Please talk to your doctor about the outlook for your cervical cancer.