Cervical cancer is the term used to describe tumors that can grow at the lower end of the womb. These tumors usually develop from abnormal cell changes at the entrance to the womb from the vagina (the opening of the cervix). Abnormal cell changes can be detected through screening and then removed. A vaccine against viruses that cause cancer (HPV vaccine) can reduce the risk of cervical cancer.
The cervix (neck of the womb) is a strong, muscular tube-like structure. The very bottom end of the cervix sticks out into the vagina a little, at the opening of the cervix. The inside of the cervix is lined with a mucous membrane. Glands in the mucous membrane produce a thick liquid (cervical mucus) that acts as a barrier, preventing germs from entering the womb from the vagina.
Cervix and opening of the cervix
It usually takes years, if not decades, for abnormal cells to develop into cervical cancer. These abnormal cells are often harmless and don’t cause any, or only few, symptoms. If they develop into cancer, it can cause the following symptoms:
- abnormal bleeding – for instance after sex, between periods or after the menopause
- abnormal vaginal discharge that might have an unpleasant odor
- tiredness and weight loss
- pain in the abdomen and pelvis
- pain when urinating (“peeing”)
By the time cervical cancer starts causing symptoms, it is often already at quite an advanced stage.
Cervical cancer is nearly always caused by a long-term infection with particular viruses known as human papillomaviruses (HPV). There are many different types of HPV. They infect skin cells and mucous membrane cells, and are spread through sex or direct contact in the genital area. Infection through body fluids like sperm, blood or saliva is considered to be unlikely. Most women have an HPV infection at some point in their lives, many between the ages of 20 and 30. Men can also become infected and pass the infection on.
HPV infections usually don’t cause any symptoms. They may lead to temporary abnormal cell changes (dysplasia) in the mucous membranes lining the cervix. These often go away again on their own. But sometimes particular types of HPV stay in the lining of the cervix for several years or decades. If this happens, the cells may gradually become precancerous and eventually develop into cervical cancer.
Most cervical cancer tumors develop from abnormal cells at the opening of the cervix. The medical name for this kind of cancer is “squamous cell carcinoma.” Cervical cancer can also develop from gland cells, but that is less common. Those tumors are called adenocarcinomas.
Certain groups of women are more likely than others to get cervical cancer. For instance, women who smoke are at higher risk. This might be because their immune systems are less effective at fighting the viruses. Other things that weaken the immune system – such as diseases like AIDS, and medication that is taken after an organ transplant – can increase this risk too.
Because HPV is a sexually transmitted infection, things that generally increase the risk of sexually transmitted diseases are also considered to be risk factors for cervical cancer. So, for example, the more sexual partners someone has, the higher their risk of cervical cancer.
About 4,600 women develop cervical cancer in Germany each year, and about 1,600 of them die of it. A woman’s risk of cervical cancer mainly depends on whether she goes for screening, whether she has had an HPV vaccine, and how old she is.
The following table shows estimates of how many women of different ages will develop cervical cancer if they don’t go for screening and don’t have an HPV vaccine.
|Woman's age||Out of 1,000 women, the following number are expected
to get cervical cancer within the next ten years:
|20 years old||Fewer than 1|
|30 years old||1|
|40 years old||5|
|50 years old||9|
|60 years old||8|
|70 years old||6|
There may be reason to believe that a woman has precancerous cell changes or cervical cancer if she has certain symptoms, abnormal smear test (Pap test) results, or abnormal findings during a gynecological examination. In this kind of physical examination, the doctor feels the area around the womb with their hands, both from the outside (belly) and from the inside (vagina). They also insert a special instrument (speculum) into the vagina, to look at the tissue at the opening of the cervix. If the tissue has changed a lot, it can be examined more closely using a kind of magnifying glass called a colposcope. A sample of tissue can be taken too (biopsy). This is then tested in a lab.
If the lab results confirm that the cervical tissue has abnormal cells or cancer cells in it, what happens next will depend on how much the cells have changed. Smaller areas of abnormal cells and smaller tumors can be removed using surgery called conization. This involves removing a cone-shaped piece of tissue.
Other examinations such as ultrasound, x-ray, magnetic resonance imaging (MRI) or computed tomography (CT) scans may be needed if the cancer has spread to deeper layers of tissue. Keyhole surgery is often performed too, to remove lymph nodes in the abdomen (lower belly). The results of these examinations can be used to determine how advanced the cancer is.
Screening allows abnormal (precancerous) tissue to be discovered and removed before it can develop into cervical cancer. The screening test involves doing a “smear test” (or “Pap test”) to get a sample of cells which are then examined. Statutory health insurers in Germany cover the costs of this test in women aged 20 and above. Since these regular screening tests were introduced in the 1970s, there has been quite a big drop in the number of women who develop cervical cancer.
Women between the ages of 20 and 34 can have a free smear test done once a year. The test involves taking a sample of cells from the cervix and examining them in a laboratory. From the age of 35, women are offered a combined test that includes a smear test and a test for certain human papillomaviruses (an HPV test) every three years. The sample of cells is then checked to both look for changes in the cells as well as for HPV viruses.
Further tests may be needed, depending on the results of the screening.
Cervical cancer nearly always develops as a rare consequence of a long-term infection with particular types of HPV. So, at least theoretically, there are three ways to help prevent it:
- Avoiding sexual contact or using condoms
- HPV vaccine in girls
- Screening and removing abnormal tissue
If you would like to protect yourself from infection, you would either have to avoid sexual contact altogether or be sure that your partner has also never had sexual contact with other people.
Condoms can offer effective protection from many sexually transmitted diseases, so it definitely makes sense to use them if you have different sexual partners. But condoms don’t offer 100% protection from HPV because they don’t cover all of the possibly infected areas of skin in the genital area.
A vaccine is available for girls and women who haven’t yet been infected with HPV.
The most appropriate type of treatment will mainly depend on the size of the tumor and whether the cancer has spread. If the tumor is discovered at a very early stage, a small surgical procedure (conization) might be enough. If the tumor has already spread to the surrounding tissue, doctors usually recommend having surgery to remove the entire womb (a hysterectomy). The lymph nodes are removed in a wide area around the womb too. Radiotherapy might also be considered. Radiotherapy is still an option even if the tumor can no longer be removed through surgery. In some patients it can be combined with chemotherapy.
When people are ill or need medical advice, they usually go to see their family doctor first. Read about how to find the right doctor, how to prepare for the appointment and what to remember.
Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG), Arbeitsgemeinschaft Gynäkologische Onkologie (AGO). S3-Leitlinie Diagnostik, Therapie und Nachsorge der Patientin mit Zervixkarzinom. AWMF-Registernr.: 032-033OL. September 2014. (Leitlinienprogramm Onkologie).
Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Invitation and decision aid for cervical cancer screening; Final report; Commission P15-02. September 29, 2017. (IQWiG reports; Volume 548).
Krebsinformationsdienst (KID), Deutsches Krebsforschungszentrum (DKFZ). Gebärmutterhalskrebs: Das Zervixkarzinom. March 26, 2015.
Robert Koch-Institut (RKI). Bericht zum Krebsgeschehen in Deutschland 2016. Berlin: Ruksaldruck; 2016.
World Health Organization (WHO). Comprehensive cervical cancer control: a guide to essential practice. Second edition. Genf: WHO Press; 2014.
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