Cervical cancer occurs when abnormal cells develop and spread in the cervix, the lower part of the uterus. A unique fact about cervical cancer is that most cases are triggered by a type of virus.                                                                                                                                    Cervical cancer is the fourth most common cancer in women globally with around 660 000 new cases and around 350 000 deaths in 2022. In the same year, about 94% of the 350 000 deaths caused by cervical cancer occurred in low- and middle-income countries. The highest rates of cervical cancer incidence and mortality are in sub-Saharan Africa (SSA), Central America and South-East Asia. Regional differences in the cervical cancer burden are related to inequalities in access to vaccination, screening and treatment services, risk factors including HIV prevalence, social and economic determinants such as sex, gender biases and poverty.

Cervical cancer is caused by persistent infection with the human papillomavirus (HPV).  Women living with HIV are 6 times more likely to develop cervical cancer compared to women without HIV and an estimated 5% of all cervical cancer cases are attributable to HIV. Cervical cancer disproportionately affects younger women, and as a result, 20% of children who lose their mother to cancer do so due to cervical cancer.

Prophylactic vaccination against HPV and screening and treatment of pre-cancer lesions are effective strategies to prevent cervical cancer and are very cost-effective.

 Cervical cancer can be cured if diagnosed at an early stage and treated promptly.

Causes.

The human papillomavirus (HPV) is a large group of viruses. About 40 types can infect the genital areas, and some have high risk for cervical cancer. Genital HPV infections usually clear up on their own. If one becomes chronic, it can cause changes in the cells of the cervix. And it's these changes that may lead to cancer. Worldwide, over 90% of cervical cancers are caused by an HPV infection. HPV infections usually have no symptoms and go away on their own. Some types of the HPV virus may cause genital warts, but these are not the same strains linked to cervical cancer. It's important to note that genital warts will not turn into cancer, even if they are not treated. The dangerous types of HPV can stay in the body for years without causing any symptoms.

Human papillomavirus (HPV) is a common sexually transmitted infection which can affect the skin, genital area and throat. Almost all sexually active people will be infected at some point in their lives. In most cases the immune system clears HPV from the body. Persistent infection with high-risk HPV can cause abnormal cells to develop, which go on to become cancer. This causes 95% of cervical cancers. Typically, it takes 15–20 years for abnormal cells to become cancer, but in women with weakened immune systems, such as untreated HIV, this process can be faster and take 5–10 years. Risk factors for cancer progression include the grade of oncogenicity of the HPV type, immune status, the presence of other sexually transmitted infections, number of births, young age at first pregnancy, hormonal contraceptive use, and smoking.                                             

Symptoms.

When cervical cells first become abnormal, there are rarely any warning signs. As the cancer progresses, symptoms may include: Unusual vaginal discharge, vaginal bleeding between periods, bleeding after menopause and bleeding or pain during sex. 

HPV is so common that most people who have ever had sex - both women and men - will get the virus at some point in life. Because HPV can linger quietly, it's possible to carry the infection even if it has been years since you had sex.  HPV is also linked to cancers of the vulva, vagina, penis, and to anal and oral cancers in both sexes. The risk is also higher in infected women who: smoke, have many children, use birth control pills for a long time, are HIV positive or have a weakened immune system, have multiple sexual partner.

Cervical screening and treatment of precancers.

Women should be screened for cervical cancer every 5–10 years starting at age 30. Women living with HIV should be screened every 3 years starting at age 25. The global strategy encourages a minimum of two lifetime screens with a high-performance HPV test by age 35 and again by age 45 years. Precancers rarely cause symptoms, which is why regular cervical cancer screening is important, even if you have been vaccinated against HPV.

Self-collection of a sample for HPV testing, which may be a preferred choice for women, has been shown to be as reliable as samples collected by healthcare providers.

After a positive HPV test (or other screening method) a healthcare provider can look for changes on the cervix (such as precancers) which may develop into cervical cancer if left untreated. Treatment of precancers is a simple procedure and prevents cervical cancer. Treatment may be offered in the same visit (the see and treat approach) or after a second test (the see, triage and treat approach), which is especially recommended for women living with HIV.

Treatments of precancers are quick and generally painless causing infrequent complications. Treatment steps include colposcopy or visual inspection of the cervix to locate and assess the lesion followed by: thermal ablation, which involves using a heated probe to burn off cells; cryotherapy, which involves using a cold probe to freeze off the cells; LEETZ (large loop excision of the transformation zone), which involves removing your abnormal tissues with an electrically heated loop; and/or a cone biopsy, which involves using a knife to remove a cone-shaped wedge of tissue.

Early detection, diagnosis and treatment of cervical cancer.

Cervical cancer can be cured if diagnosed and treated at an early stage of disease. Recognizing symptoms and seeking medical advice to address any concerns is a critical step. Women should see a healthcare professional if they notice: unusual bleeding between periods, after menopause, or after sexual intercourse, increased or foul-smelling vaginal discharge, symptoms like persistent pain in the back, legs, or pelvis, weight loss, fatigue and loss of appetite, vaginal discomfort and swelling in the legs. The Pap test is one of the great success stories in early detection. A swab of the cervix can reveal abnormal cells, often before cancer appears. At age 21, women should start having a Pap test every three years. From age 30 to 65, women who get both a Pap test and an HPV test can go up to five years between testing. But women at higher risk may need testing more often, so it's best to check with your doctor who will help you know what the best testing schedule is for you.

Skipping tests raises your risk for invasive cervical cancer.  You'll still need Pap tests after getting the HPV vaccine because it doesn't prevent all cervical cancers. If test results show a minor abnormality, you may need a repeat Pap test. Your doctor may schedule a colposcopy - an exam with a lighted magnifying device - to get a better look at any changes in the cervical tissue and also take a sample to be examined under a microscope.

If abnormal cells are precancerous, they can then be removed or destroyed. Treatments are highly successful in preventing precancerous cells from developing into cancer. In some cases, doctors may offer the option of the HPV DNA test in addition to a Pap test. This test checks for the presence of high-risk forms of HPV. It may be used in combination with a Pap test to screen for cervical cancer in women over 30. It may also be recommended for a woman of any age after an abnormal Pap test result.

Clinical evaluations and tests to confirm a diagnosis are important and will generally be followed by referral for treatment services, which can include surgery, radiotherapy and chemotherapy as well as palliative care to provide supportive care and pain management.

Management pathways for invasive cancer care are important tools to ensure that a patient is referred promptly and supported as they navigate the steps to diagnosis and treatment decisions. Features of quality care include: a multidisciplinary team ensuring diagnosis and staging (histological testing, pathology, imaging) takes place prior to treatment decisions; treatment decisions in line with national guidelines; and interventions are supported by holistic psychological, spiritual, physical and palliative care.
As low- and middle-income countries scale-up cervical screening, more cases of invasive cervical cancer will be detected, especially in previously unscreened populations. Therefore, referral and cancer management strategies need to be implemented and expanded alongside prevention services.                            

 Cervical biopsy. This involves the removal of cervical tissue for examination in a lab. A pathologist will check the tissue sample for abnormal changes, precancerous cells, and cancer cells. A cone biopsy allows the pathologist to check for abnormal cells beneath the surface of the cervix, but this test may require anesthesia. 

Stages of Cervical Cancer.

Cervical cancer is divided into four stages.

In stage I, the cancer is beyond the lining of the cervix, but it’s still only in your uterus.

Stage II means it’s spread beyond your cervix and uterus. At this stage, it can also spread to nearby tissues.

A stage III tumor reaches the lower part of your vagina and may make it hard to pee.

Stage IV, the most advanced, means the cancer has spread to other parts of the body, like nearby organs.

Treatment.                                                                      

Surgery. If the cancer has not progressed past Stage II, surgery is usually recommended to remove any tissue that might contain cancer. Surgical treatment options vary from cervical conization to simple hysterectomy to radical hysterectomy. A radical hysterectomy includes, the removal of the cervix and uterus as well as some of the surrounding tissue. The surgeon may also remove the fallopian tubes, ovaries, and lymph nodes near the tumor.

Radiation. External radiation therapy uses high-energy X-rays to kill cancer cells in a targeted area. It can also help destroy any remaining cancer cells after surgery. Internal radiation, or brachytherapy, uses radioactive material that is inserted into the tumor. Women with cervical cancer are often treated with a combination of radiation and chemotherapy. Side effects can include low blood cell counts, feeling tired, upset stomach, nausea, vomiting, and loose stools.

Chemotherapy. Chemotherapy uses drugs to reach cancer wherever it is in the body. When cervical cancer has spread to distant organs, chemotherapy may be the main treatment option. Depending on the specific drugs and dosages, side effects may include fatigue, bruising easily, hair loss, nausea, vomiting, and loss of appetite.

Other treatment options include targeted therapy and immunotherapy.

 

Coping with Cancer Treatments. Cancer treatments may make you tired or uninterested in food. But it's important to take in enough calories to maintain a healthy weight. Check with a dietitian for tips on eating well during cancer treatment. Staying active is also important. Gentle exercise can increase your energy while reducing nausea and stress. Check with your doctor to find out which activities are appropriate for you.

Cervical Cancer and Fertility. Treatment for cervical cancer often involves removing the uterus and may also involve removing the ovaries, ruling out a future pregnancy. However, if the cancer is caught very early, you still may be able to have children after surgical treatment. A procedure called a radical trachelectomy can remove the cervix and part of the vagina while leaving the majority of the uterus intact.

Survival Rates for Cervical Cancer. The odds of surviving cervical cancer are tied to how early it's found. About 66% of women overall will survive for at least five years after diagnosis. But statistics don't predict how well any one individual will respond to treatment.                                                

Prevention.

Boosting public awareness, access to information and services are key to prevention and control across the life course.

Being vaccinated at age 9–14 years is a highly effective way to prevent HPV infection, cervical cancer and other HPV-related cancers.

Screening from the age of 30 (25 years in women living with HIV) can detect cervical disease, which when treated, also prevents cervical cancer.

At any age with symptoms or concerns, early detection followed by prompt quality treatment can cure cervical cancer.

HPV vaccination and other prevention steps

As of 2023, there are 6 HPV vaccines available globally. All protect against the high-risk HPV types 16 and 18, which cause most cervical cancers and have been shown to be safe and effective in preventing HPV infection and cervical cancer.

As a priority, HPV vaccines should be given to all girls aged 9–14 years, before they become sexually active. The vaccine may be given as 1 or 2 doses. People with reduced immune systems should ideally receive 2 or 3 doses. Some countries have also chosen to vaccinate boys to further reduce the prevalence of HPV in the community and to prevent cancers in men caused by HPV.

Other important ways to prevent HPV infection include: Being a non-smoker or stopping smoking, voluntary male circumcision.  

 The CDC recommends vaccination for everyone through age 26 if they didn't have the vaccine when younger.  Some adults from ages 27 to 45 could get the shots, but they should discuss it with their health care provider.