What is Cervical Cancer?

Each year, more than 3,200 women are diagnosed with cervical cancer in the UK and this type of cancer can affect anyone with a cervix at any age, but the incidence is highest in women between the ages of 30 and 34. It is very rare under 25 years of age, but it can occur.

On 22nd March 2009, reality television star Jade Goody died from cervical cancer aged 27 years. Her seven-month battle with cervical cancer attracted intense media coverage across the world. It has been widely claimed that Jade Goody’s illness led to greater awareness of the disease and increased the uptake of cervical cancer screening, particularly in the UK. University Hospital Lewisham, in south-east London, reported that it carried out 21% more tests in the months after Jade Goody was diagnosed with cervical cancer compared with the same period the previous year.

However, the vast media coverage of her battle with the disease mainly focused on human interest aspects of her illness and tended not to include factual or educational information that could inform women, or help them to recognise early symptoms of the disease.

What is cervical cancer?

Cervical cancer is the 14th most common cancer in females in the UK. It is cancer of the cervix which connects the womb and vagina and is sometimes called the neck of the womb. Cervical cancer can develop on the outer surface of the cervix and inside the cervix in the cervical canal. Most cervical cancers develop where these parts of the cervix meet, an area called the transformation zone.

Cervical cancer develops very slowly from abnormal cell changes in the cervix. These changes generally do not cause any symptoms, but they can be picked up through cervical screening tests.

What are the types of cervical cancer?

There are two main types of cervical cancer; the most common is squamous cell carcinoma. About 7 to 8 in 10 (70% to 80%) of cervical cancers are of this type. Squamous cells are thin, flat, skin-like cells that line the surface of the cervix. The cancer often develops where the outer surface of the cervix joins with the cervical canal.

The other type of cervical cancer is adenocarcinoma. This develops from a different type of cell found in the cervical canal, the endocervix. Adenocarcinoma is less common than squamous cell cancer. About 2 out of 10 (20%) cervical cancers are adenocarcinomas.

Adenocarcinoma of the cervix starts in the gland cells inside the cervical canal. These cells produce mucus, a sticky fluid. It keeps the cervix, womb, ovaries and fallopian tubes healthy by protecting them from bacteria and infection. There are gland cells scattered along the lining of the narrow passage that runs from the cervix up into the womb. This passage is called the cervical canal. The adeno part of adenocarcinoma refers to glands, and carcinoma refers to cancer in the cells that line tissues. This type of cancer can be more difficult to find through cervical screening because it develops inside the cervical canal.

Rarer types of cervical cancer include:

• Adenosquamous carcinoma – about 5 to 6 out of 100 (5% to 6%) cervical cancers are adenosquamous carcinomas. Adenosquamous carcinoma includes cancer cells from squamous cell cervical cancer and adenocarcinoma, some squamous cells and some gland cells.
• Clear cell carcinoma – is tested for in a similar way to other cervical cancers. Clear cell cervical cancer is more common in women and people with a cervix whose mothers had a drug called diethylstilbestrol (DES) when pregnant.
• Neuroendocrine carcinoma or small cell carcinoma of the cervix – small cell cervical cancer is rare, about 1 in 100 (1%) cervical cancers are this type. Small cell cervical cancer develops in cells which form part of the neuroendocrine system, which is made up of nerves and glands which release hormones. It is also called small cell neuroendocrine carcinoma. Neuro refers to the nerves, and endocrine refers to hormones and the glands that release them. It is called a small cell cancer because the cancer cells look small under a microscope.

Other types of cancer can occur in the cervix, including sarcomas and lymphomas. These are less common than the cervical cancer types we have already talked about on this page. Sarcomas and lymphomas are treated in a different way to other types of cervical cancer.

• Lymphoma – a lymphoma is a cancer that starts in the cells of the lymphatic system, which is part of your immune system. The lymphatic system is made up of cells called lymphocytes which help fight infection. These cells are present in the lymph glands (or nodes) which exist throughout your body, including near your cervix. Lymphoma can develop when these cells start to grow in an uncontrolled way. There are different types of lymphoma which need different types of treatment.
• Sarcoma – sarcomas are uncommon cancers which affect the bones or soft tissues. They can affect any part of the body, including the cervix. You might hear sarcoma of the cervix being called cervical carcinosarcoma. Treatments can include surgery followed by radiotherapy and chemotherapy. As they are rare tumours, they need to be discussed by specialist healthcare professionals.

What causes cervical cancer?

Since the 1970s it has been known that human papillomavirus (HPV) is the major cause of cervical cancer. HPV is the name of a very common group of viruses; there are more than 100 different types of HPV, and around 40 that affect the genital area. They do not cause any problems in most people, but some types can cause genital warts or cancer. HPV does not usually cause any symptoms and most people who have it do not realise and do not have any problems, and 90% of these HPV infections resolve spontaneously within 2 years.

HPV infection is very common and it is estimated that 20% of sexually active girls will contract the virus by the age of 18 years, and up to 80% of all sexually active women are likely to be affected with at least one virus type in their lifetime. However, a small proportion of women who encounter persistent infection from high-risk genotypes, that is HPV 16 and 18, and a few other strains that may, over time, cause abnormal tissue growth as well as other changes, can go on to develop cervical cancer, if not treated. Between them, HVP types 16 and 18 are the cause of most cervical cancers in the UK – more than 80%. Types 31, 33, 45, 52 and 58 cause an additional 15% of cervical cancers.

There’s no blood test for HPV, and testing is part of cervical screening. During cervical screening, a small sample of cells is taken from the cervix and tested for HPV.

You can get HPV from:

• Any skin-to-skin contact of the genital area.
• Vaginal, anal or oral sex.
• Sharing sex toys.

What are the risk factors for cervical cancer?

With HPV being one of the main causes of cervical cancer, contracting HPV is one of the main risk factors. The National Institute for Health and Care Excellence (NICE) cite risk factors for acquiring HPV infection that include:

• Age – cervical cancer is more common in younger women and people with cervixes, with more than half of those diagnosed being below the age of 45.
• Early age of first sexual intercourse – infection with at least one type of HPV occurs soon after the start of sexual activity, with nearly 40% of women infected within 2 years.
• Multiple sexual partners or a high-risk sexual partner.
• History of sexually transmitted infection (STI). People who may have another sexually transmitted disease, for example chlamydia, may be at increased risk of cervical cancer.
• Lack of use of barrier methods of contraception, such as condoms.
• History of HPV-related vaginal or vulvar dysplasia.
• Conditions causing immunocompromise or immunosuppression, such as solid organ transplant or HIV infection.

Early sexual experience and a high number of sexual partners increase the risk and severity of HPV infection and may be seen as indirect causes of cervical cancer. However, you do not have to have sexual contact with a lot of people to get HPV. You can get HPV the first time you have sex.

NICE also cite factors which increase the risk of HPV progression to cervical cancer as:

• Co-infection with other STIs.
• High parity, that is more than five full-term births, and young age at first birth, that is less than 17 years of age.
• Family history of cervical cancer and/or HPV in a first-degree relative.
• Conditions causing immunocompromise or immunosuppression, such as solid organ transplant or HIV infection – these increase the risk of persistent HPV infection, precancerous lesions, and invasive cervical cancer.
• Use of the combined oral contraceptive pill for longer than 5 years – this may be related to the effect of sex steroids on oncogene expression.

There is some evidence that there are certain lifestyle risk factors such as being overweight or obese might increase the risk of cervical cancer. Overweight is a Body Mass Index (BMI) between 25 and 29.9, whilst obese is a BMI of 30 and over. Body Mass Index (BMI) is calculated by dividing weight in kilograms by height in centimetres squared and multiplying by a conversion factor of 703.

Research shows that there are several reasons for the link between body weight and cancer. For example, we know that fat cells release hormones such as oestrogen. Excess oestrogen can increase the risk of some cancers, like breast and womb cancer, and promote their growth. Storing too much fat can cause insulin resistance, where insulin becomes less effective at controlling blood sugar levels, which encourages the body to produce growth hormones. High levels of these hormones can promote the growth of cancer cells.

Body fat also stimulates an inflammatory response. Inflammation can promote the growth of cancer by encouraging cancer cells to divide. This inflammatory response may underpin the wide variety of different cancers that have been linked to obesity.

Smoking increases the risk of developing precancerous lesions and squamous cell carcinoma. It is estimated that 2% of deaths from cervical cancer worldwide are attributable to smoking tobacco. The effect of smoking tobacco is independent to that of viral infection.

What are the signs and symptoms of cervical cancer?

Cervical cancer can affect women generally between the ages of 25 and 64 years; however, although cervical cancer is very rare if you are under 25, it is important for younger women to be aware of cervical cancer symptoms too. If you have any symptoms, don’t ignore them, as it is important to see your doctor as soon as possible.

Early-stage cervical cancer generally produces no signs or symptoms. Signs and symptoms of more-advanced cervical cancer can include:

• Vaginal bleeding after intercourse, between periods or after menopause.
• Watery, bloody vaginal discharge that may be heavy and have a foul odour.
• Blood in your urine or leaking urine.
• Other changes to your bladder or bowel habits.
• Pelvic pain or pain during intercourse.
• Unexplained pain in your lower back or between your hip bones (pelvis).
• Pain in your side or between your ribs and hips.
• Swollen ankles, legs and feet (oedema).
• Loss of appetite.
• Weight loss.
• Extreme tiredness (fatigue).

There are many other conditions that can cause these symptoms such as fibroids or endometriosis, and most of them are much more common than cervical cancer, so it is fairly unlikely to be cervical cancer, but it is still very important to get any unusual pain, bleeding or discharge checked out. You should contact your GP to arrange an appointment if you experience any of these symptoms.

How is cervical cancer diagnosed?

If you have any of the symptoms listed above, your GP will examine you and may refer you to the hospital for a specialist assessment and tests. If your GP thinks you may have cancer, they will refer you urgently to the hospital.

To diagnose cervical cancer, you usually have the following tests:

• Colposcopy – this test uses a microscope called a colposcope to look closely at the cervix. It shows any abnormal areas of the cervix and how abnormal these are.
• Biopsy – samples of cells called biopsies are taken from the cervix. You may have these taken during the colposcopy, or during another test such as a large loop excision of the transformation zone (LLETZ), or a needle excision of the transformation zone (NETZ) or a cone biopsy. Sometimes a LLETZ or cone biopsy removes all the cancer cells from the cervix – for very early-stage cervical cancer, this may be the only treatment needed.

After the test, the samples are checked at a laboratory for cancer cells. It is normal to have some bleeding or discharge after a biopsy. It may take up to 2 or 3 weeks for the biopsy results to come back to your doctor. If the colposcopy or tissue collected during treatment for abnormal cells shows you have cervical cancer, your doctor will need to check whether the cancer has spread beyond the cervix and will also check your general health.

These tests help your doctors plan your treatment, and might include:

• Blood tests – these can check your general health and the number of blood cells in your blood (blood count). They can also check how well your kidneys and liver are working.
• Chest x-ray – this uses x-rays to take a picture of your chest. It may be done to check your general health and to look at your lungs and heart.
• MRI scan – this uses magnetism to build up a detailed picture of the inside of your body.
• CT scan – this makes a three-dimensional (3D) picture of the inside of the body using x-rays taken by the CT scanner.
• PET scan – this uses low-dose radiation to check the activity of cells in different parts of the body. It is sometimes given together with a CT scan (PET-CT scan).
• Examination under anaesthetic (EUA) – this is an examination of the vagina and cervix that is done under a general anaesthetic; however, this is not used very often.

Cervical cancer may also be diagnosed during cervical screening for HPV. This is not common but can sometimes happen.

Can cervical cancer be detected early?

In the UK, women between the ages of 25 and 64 years are invited for regular cervical screening under the NHS cervical screening programme. Women will usually be offered a smear test every 3 years or every 5 years if aged over 50 years. Trans men or non-binary people who have a cervix, should have screening too.

Cervical screening is a way of detecting and preventing cervical cancer; that is, cancer of the cervix. It uses tests to find abnormal changes in the cells of the cervix. The first part of cervical screening is to have a smear test. According to figures, only 1 in 3 women take up their cervical screening offer and surveys show that the most common (42%) reason is embarrassment. However, it is estimated that 70% of cervical cancer deaths could be prevented if detected early enough through screening.

A cervical smear test checks for abnormal cell changes in the cervix. Finding these changes can prevent cervical cancer from developing. Test results are generally available within 2–4 weeks after the test.

What are the stages of cervical cancer?

The stage of cervical cancer refers to its size and whether it has spread beyond the area of the body where it first started. Knowing the extent of the cancer helps the doctors decide on the most appropriate treatment for you. Cervical cancer is divided into four main stages. Each stage then has further sub-divisions. Your doctors may also use the following names to describe the stage of the cancer:

Early-stage cervical cancer. Cervical cancer stage 1 means that the cancer cells are only within the cervix. Stage 1 can be further divided into:

• Stage 1A – The cancer can only be seen with a microscope or colposcope.
• Stage 1A1 – The cancer is less than 3mm deep.
• Stage 1A2 – The cancer is between 3mm and 5mm deep.
• Stage 1B – The cancer is 5mm or more, deep, but still confined to the cervix.
• Stage 1B1 – The cancer is no larger than 2cm wide.
• Stage 1B2 – The cancer is between 2cm and 4cm wide.
• Stage 1B3 – The cancer is 4cm or more, wide.

Locally advanced cervical cancer. Cervical cancer stage 2, means that the cancer has spread into the upper part of the vagina or the tissues next to the cervix.

Stage 2 can be further divided into:

• Stage 2A – The cancer has spread into the upper part of the vagina.
• Stage 2A1 – The cancer is no larger than 4cm.
• Stage 2A2 – The cancer is larger than 4cm.
• Stage 2B – The cancer has spread into the tissues next to the cervix.

Advanced-stage or metastatic cervical cancer. Cervical cancer stage 3. This means that the cancer has spread to the lower part of the vagina, or to the tissues at the sides of the pelvic area (called the pelvic wall), or to nearby lymph nodes.

Stage 3 can be divided into the following:

• Stage 3A – The cancer has spread into the lower part of the vagina.
• Stage 3B – The cancer has spread to the pelvic wall, or is pressing on the tubes that carry urine from the kidneys to the bladder (ureters). If the tumour is pressing on a ureter, urine may build up in the kidney.
• Stage 3C – The cancer has spread to nearby lymph nodes.
• Stage 3C1 – The cancer has spread to lymph nodes in the pelvis.
• Stage 3C2 – The cancer has spread to lymph nodes above the pelvis, called the para-aortic lymph nodes.

Cervical cancer stage 4. This means that the cancer has spread to the bladder or bowel or beyond the pelvic area.

Stage 4 can be further divided into:

• Stage 4A – The cancer has spread to nearby organs, such as the bladder and bowel.
• Stage 4B – The cancer has spread to organs further from the cervix, such as the lungs, liver or bone.

If the cancer comes back after initial treatment, this is known as recurrent cancer.

How is cervical cancer treated?

Cervical cancer can be treated and cured, if detected in its early stages. If you have been diagnosed with cervical cancer then a team of specialists will meet to discuss the best possible treatment for you; they are called a multidisciplinary team (MDT).

The treatment you have will depend on:

• The stage of the cancer.
• The size of the cancer.
• Your general health.
• Whether you have been through the menopause.
• Whether you want to get pregnant in the future.

Although your doctor will be an expert in the most effective treatments, you will know most about your own situation and preferences so you and your specialist doctor will decide together on the right treatment plan for you.

Treatments for cervical cancer may include more than one of these treatments:

• Surgery – this aims to remove all the cancer.
• Radiotherapy – this uses high-energy rays to destroy cancer cells. This may be used on its own or in combination with chemotherapy (chemoradiation).
• Chemotherapy – this uses anti-cancer (cytotoxic) drugs to destroy cancer cells.
• Targeted therapies – these are drugs that target something in or around the cancer cell that is helping it grow and survive.
• Immunotherapies – these are treatments that use the immune system to find and attack cancer cells. The immune system protects the body against illness and infection.

Nivolumab (Opdivo®) and ipilimumab (YERVOY®) are immunotherapy drugs that are starting to be used in cervical cancer treatment. At the moment, they can only be used as part of a clinical trial.

Most cancers of the cervix are diagnosed at an early stage. Surgery is the main treatment. Radiotherapy or chemoradiation (radiotherapy given with chemotherapy) is sometimes used instead of surgery, if you are not fit for a big operation or general anaesthetic. They are also used after surgery, to reduce the risk of the cancer coming back.

Chemoradiation is the main treatment for locally advanced cancer. Chemotherapy, and sometimes a targeted therapy called bevacizumab, may be used if the cancer has spread to distant parts of your body such as the liver or lungs. It may help to shrink and control the cancer and relieve symptoms. This is called palliative treatment. If treatment is not provided, cervical cancer can be fatal.

After your treatment has finished, you will have regular check-ups with your cancer doctor – this is called follow-up care. How often you see the doctor for follow-up care depends on different things, including:

• The type and stage of the cancer.
• The treatment you have had.
• Your needs and wishes.
• The arrangements at the hospital you go to.

Treatments for cervical cancer may affect your fertility and cause an early menopause. An early menopause means having the menopause before the age of 45. If you want to get pregnant in the future, it is important to talk to your doctors about this. You may be able to have treatment that can protect your fertility. If this is not possible, your doctor can refer you to a fertility specialist. You can talk with the specialist about options such as having egg or embryo storage before treatment.

Can cervical cancer be prevented?

HPV vaccines can prevent HPV infection, the main cause of cervical cancer. In England, there are two human papillomavirus (HPV) vaccination programmes. One is for children who are 12 to 13 years of age, and the 1st dose is offered when they are in Year 8 at school; the 2nd dose is offered 6 to 24 months after the 1st dose. There is an estimated relative reduction in cervical cancer of 87% for vaccinated 12- to 13-year-olds compared with a reference unvaccinated cohort.

The other one is for gay, bisexual and other men up to 45 years of age who have sex with men (MSM). Trans women, that is people who were assigned male at birth, are eligible for the HPV vaccine if their risk of getting HPV is similar to the risk of MSM who are eligible for the HPV vaccine.

The HPV vaccine should not be given to people who:

• Have had a severe allergic reaction (anaphylaxis) to a previous dose of the HPV vaccine or any of its ingredients.
• Are known to be pregnant.

Gardasil has been the HPV vaccine used in the NHS vaccination programme since 2012. Gardasil 9 protects against 9 types of HPV – 6, 11, 16, 18, 31, 33, 45, 52 and 58 – the main causes of cervical cancer. As with other vaccines, there are some side effects. More than 1 in 100 people, but less than 1 in 10, who have the Gardasil or Gardasil 9 HPV vaccine experience:

• Bruising or itching at the site of the injection.
• A high temperature or feeling hot and shivery.
• Feeling sick (nausea).
• Pain in the arms, hands, fingers, legs, feet or toes.
• Feeling dizzy or faint after vaccination.

Final thoughts

Being diagnosed with cervical cancer and having treatment can be life-changing, so it is normal to experience a range of difficult thoughts and feelings. There is no right or wrong way to think and feel, but it is important to recognise what you are going through and to seek help if you feel you need it.

There are many organisations that provide helplines, support and advice for anyone affected by cervical cancer:

• The Eve Appeal telephone 020 7605 0100 or freephone 0808 802 0019 via email nurse@eveappeal.org.uk.
• Jo’s Cervical Cancer Trust is the UK’s leading cervical cancer charity. For information and support, call the freephone helpline on 0808 802 8000. For general enquiries, email info@jostrust.org.uk.
• Macmillan Cancer Support – confidential support to people living with cancer and their loved ones. Freephone 0808 808 00 00. Chat online.
• UK Cervical Cancer info@ukcervicalcancer.org.uk – from 31 October to 30 November UK Cervical Cancer is having its first Awareness Month with a campaign entitled ‘Scream for Screen’.
• GO Girls is a UK charity supporting women diagnosed with a gynaecological cancer.
• Marie Curie – care and support for anyone affected by a terminal illness. Helpline 0800 090 2309.