Cervical cancer can be diagnosed by the doctor on the basis of major symptoms like abnormal vaginal bleeding or pain during sex in the patient but tests are always required to confirm pre-malignant and malignant condition.
If there is a diagnosis of invasive cancer, additional specific tests are required before planning treatment of the patient. Patient is also referred to oncologist for chemotherapy.
Diagnosis and testing
Medical history and physical exam
Personal and family medical history is taken from the patient to rule out any potential risk of cervical cancer. Information regarding risk factors and symptoms of cervical cancer is taken from the patient. A complete physical exam helps the doctor in reaching final diagnosis. Pelvic exam is done by the physician to find any possible signs of cervical cancer.
In pelvic examination, the doctor looks for abnormal changes in her cervix, uterus, vagina, ovaries, and other nearby organs. Initially, doctor observes woman’s vulva outside the body. Instruments like speculum can be used to keep vaginal walls open. Bimanual pelvic exam involves insertion of 2 fingers of one hand inside the patient’s vagina while the other hand presses on the lower part of abdomen to check any unusual changes in uterus and ovaries. It is normally done in an outpatient setting. A Pap test is often done at the same time. Pap test can be ordered if it is not done previously. An abnormal Pap test result requires further tests to rule out risk of cervical cancer.
The following tests may be used to evaluate patient for cervical cancer:
During a Pap test, the doctor takes samples of cervical cells by scraping the mucus lining of cervix and vagina.
There are two types of pap tests:
- The liquid-based cytology test involves transference of a thin layer of cervical cells onto a glass slide. The sample is preserved so that it can be used for further tests if results are unsatisfactory. Blood and mucus should be removed from the sample before this test.
- Computer screening, often called AutoPap or FocalPoint, involves scanning of the sample from cervix. It detects any abnormal changes in cervical mucosa.
Results of pap tests are as follows:
- Normal – Healthy cervix showing no abnormal changes.
- Unsatisfactory – Sample was not satisfactory and test should be repeated.
- Benign changes – It refers to any inflammatory changes caused by infection in the pelvic region. Pelvic exam rules out any such cause.
- ASCUS (“Atypical Squamous Cells of Undetermined Significance”) – It denotes any abnormal changes in the cervix. Further tests are required to rule out cervical cancer.
- LSIL (Low Grade Squamous Intraepithelial Lesion) – It refers to the fact you are infected with HPV infection. Test should be repeated after 12 months in such case. Colposcopy can also be ordered to further evaluate the condition.
- HSIL (High Grade Intraepithelial Lesion) – It denotes abnormal changes in the cervix. Pre-malignant conditions like CIN 2 and CIN 3 are referred as HSIL. They have high probability of transforming into invasive cancer, if not treated.
HPV typing test
An HPV test is done by the method similar to Pap test. The test is done on a sample of cervical cells from mucus lining. The doctor usually tests for HPV after abnormal pap test results. Presence of certain types or strains of HPV, such as HPV16 and HPV18 can help in reaching the diagnosis of cervical cancer. But further tests are required to confirm diagnosis of cervical cancer.
Current HPV testing systems are able to find out the presence of viral markers (HPV-DNA in infected cervical cells) in close to 100% of invasive cervical cancer specimens, 75 to 90% of premalignant lesions (LSIL / CIN1, CIN2/3, HSIL) and in 50% of borderline cytology lesions (ASCUS).
Colposcopy is done to check abnormal changes in the cervix. Doctor may use colposcope to guide a biopsy needle to take the sample from the cervix. The colposcope increase the size of the cells of the cervix and vagina. It can be done in the outpatient setting and has no side effects. It can be done on pregnant women as well. This procedure is not at all painful and can be done within minutes.
During cervical tissue biopsy, small amount of tissue is removed carefully for examination under a microscope. It is the only test that can help us reach definitive diagnosis. Small cervical lesions are removed during the biopsy.
There are several types of biopsies. Doctor’s usually perform this method in their office using a local anesthesia. It may result in bleeding which can be controlled easily. Commonly an instrument is used to remove small pieces of cervical tissue.
For this type of biopsy, doctor examine the cervix with a colposcope to find the abnormal areas in the cervix. Biopsy forceps are then used to remove any abnormal area on the surface of the cervix. The biopsy procedure may result in mild cramping and bleeding.
Endocervical curettage (endocervical scraping)
Transformation zone cannot be visualized with the colposcope so doctor takes a sample of an endocervix by inserting a curette into the endocervical canal. Sample is sent to the pathologist for further examination. After this procedure, patient may experience some pain and bleeding. This procedure is called endocervical curettage (ECC). Curette used in this procedure is a spoon-shaped instrument that removes small amount of tissue from inside the cervical opening.
Cone biopsy is done by removing a cone-shaped piece of tissue from the cervix. The base of the cone is normally formed by the exocervix and the point or apex of the cone is from the endocervical canal. This method is used to remove tissue from transformation zone of cervix. This procedure is also called conization.
It is the best method for the treatment of any pre-cancerous conditions and some early stage malignancies. One of the disadvantages of this procedure is that it makes women prone to premature birth.
Most common methods for cone biopsies are the loop electrosurgical excision procedure (LEEP) and the cold knife cone biopsy.
- Loop electrosurgical procedure (LEEP, LLETZ,): In this procedure, the tissue is scraped off with a thin wire loop heated by electricity. A LEEP is very effective in removing precancer or an early-stage cancer. It is also called large loop excision of the transformation zone (LLETZ,).
- Cold knife cone biopsy: A surgical scalpel or a laser is used to remove the cervical tissue. It is more advanced and safe procedure than LLETZ,.
How biopsy results are reported
Biopsy can detect any cancerous or pre-cancerous changes in a biopsy are called cervical intraepithelial neoplasia (CIN). CIN is graded on a scale of 1 to 3 based on extent of abnormal changes.
- In CIN1, mild dysplastic changes can be seen
- CIN2, moderate dysplastic changes can be seen
- In CIN3, severe dysplastic changes can be seen throughout the epithelium. It is also called carcinoma in situ.
- If the biopsy shows presence of cervical cancer, doctor may suggest additional tests to look for metastasis.
Your doctor may also recommend that you get a screening more frequently based on your circumstances.
Certain tests are done if doctor suspect cervical cancer on biopsy:
An x-ray is done to rule out spread of malignant cells to chest, abdominal region or pelvic region.
Computed tomography (CT or CAT) scan.
A CT scan can help the doctor in staging the invasive cervical cancer. A CT scan can be used to measure the size of tumor. Lymph node involvement can also be seen in CT scan. Contrast medium is given before the scan to increase the quality and detail of an image.
Magnetic resonance imaging (MRI).
An MRI uses magnetic fields to produce images of the body. Size of the tumor can be measured with an MRI. Involvement of organs other than cervix can be seen in an MRI.
Positron emission tomography (PET)
A PET scan is usually combined with a CT scan to produce pictures of organs and tissues inside the body. Malignant cells tend to use energy actively so they absorb more of the radioactive substance. Detailed images of high quality are produced.
Any ominous bladder or rectal symptom accompanied with cervical cancer require these procedures
A cystoscopy is a method that helps the doctor to view the inside of the bladder. A cystoscopy helps in finding out whether cancer has metastasized to the bladder.
Sigmoidoscopy (also called a proctoscopy).
A sigmoidoscopy helps the doctor in viewing colon and rectum with a sigmoidoscope. A sigmoidoscopy is used to look for rectal spread of cancer.
Screening of cervical cancer
Three screening tests are important for prevention of cervical cancer. Death due to cervical cancer has decreased dramatically over the 40 years as proper screening has increased the survival rate to more than 90 percent for patients of early stage cervical cancer. Increased screening decreased the incidence of invasive cervical cancer by 50 percent between 1975 and 2014.
The first is liquid-based cytology (LBC) test that involves scraping of the cervix with a small brush to collect mucosal cells. The head of this brush is then removed and preserved in liquid. It is then sent to pathologist for look out for any abnormalities. There is general agreement that high quality cytology is a highly specific screening test, with estimates of the order of 95–99%.
Second is the Pap test (or Pap smear) which looks for precancerous conditions that can transform into cervical cancer if they are not treated as early as possible.
Third is the HPV test that looks for DNA of the virus (human papillomavirus) that can cause these cell changes in the cervix of human. HPV 16 and HPV 18 are most common causes of invasive cervical cancer.
Alternative approach in low income countries:
In developing countries, few technical and financial constraints are the reason for introduction of alternative approach for effective screening. Visual inspection with 3–5% acetic acid (VIA) appears to accomplish the basic standard of a satisfactory screening test. VIA involves non-magnified visualization of uterine cervix soaked with 3–5% acetic acid. Research has revealed that VIA and cervical cytology has similar sensitivity to detect CIN, although VIA has lower specificity.
When to Get Screened
Different screening criteria has been set for women of different age groups.
If You Are 21 to 29 Years Old
Doctor advise Pap tests at the age of 21. If Pap test result is normal, person is advised to repeat the test every 3 years. Younger women are more prone to low-grade squamous intraepithelial lesions (LSIL) which can easily be treated.
If You Are 30 to 65 Years Old
The average age of diagnosis of cervical cancer is 50. Cases most frequently occur between ages 35 to 44 (SEER). Following tests can be advised in certain situations:
- A Pap test only. If test results are normal, repeat every 3 years.
- An HPV test only. This is called primary HPV testing. If test result is normal, repeat every 5 years.
- An HPV test along with the Pap test. This is called co-testing. If both of test results are normal, repeat them after 5 years.
If You Are Older Than 65
If you are 65 years old and your test results are normal, you may be advised not to be screened anymore. Certain conditions when further screening is not required are:
- Normal screening test results for several years.
- Person has his cervix removed as part of a total hysterectomy for benign conditions, like fibroids.
Test results normally come in 3 weeks. If your test shows any abnormality, doctor plan appropriate plan of treatment. Proper follow up of the patient is very important for proper diagnosis and effective treatment of the disease.
Normal test result alleviates person’s chance of developing cervical cancer in the next few years. But it is always advised to visit the doctor for regular checkup. Women who have been vaccinated against HPV should also be screened regularly. Cervical screening is no longer advised yearly as additional screening can cause more harm than benefit. A false positive result can lead to stress and cause long-term risks to the patient.
Prognosis of cervical cancer
Prognosis of cervical cancer depends on stage of the cancer at the time of diagnosis. Most patients are diagnosed at stage 1 or 2. It is one of very few tumors that are mostly diagnosed at an early stage. Most of these early stage cancers have great prognosis and survival rate. Proper vaccination and screening of the women have alleviated the incidence of cervical cancer in developed countries.
Five-year survival rate for all women suffering from cervical cancer is 66 percent. Five-year survival rate for Caucasians and Africans is 69 percent and 56 percent respectively. Five-year survival rate for the people diagnosed with early stage cancer is 92 percent. But, if the cancer has spread to nearby structures, five-year survival rate drops down to 57 percent. It drops down further to 17 percent for people diagnosed with cancer that has metastasized to lung, liver and bones.
Cervical Cancer Statistics
Survival statistics for each stage of cervical cancer are:
Around 95 out of 100 women (around 95%) survive their cancer for 5 years or more after the time of diagnosis.
More than 50 out of 100 women (more than 50%) survive their cancer for 5 years or more after the time of diagnosis.
Almost 40 out of 100 women (almost 40%) survive their cancer for 5 years or more after the time of diagnosis.
Around 5 out of 100 women (around 5%) will survive their cancer for 5 years or more after being diagnosed.
Survival for all stages of cervical cancer
If statistics of all stages of cervical cancer are considered then,
- More than 80 out of every 100 (more than 80%) survive their cancer for 1 year or more after they are diagnosed
- More than 65 out of every 100 (more than 65%) survive their cancer for 5 years or more after diagnosis
- More than 60 women out of every 100 (more than 60%) survive their cancer for 10 years or more after diagnosis
Cervical cancer comprises approximately 12% of all cancers in women. It can be diagnosed at an early stage if patient does not ignore early symptoms of the disease. Pap smear is a powerful screening tool that can detect precancerous lesions. HPV test and colposcopy are done to further evaluate the condition. Biopsy is the only test that can provide definitive diagnosis. Major methods of biopsy are cone biopsy and endocervical curettage. MRI, CT scan and PET scan are used to stage the cervical cancer. Different screening criteria are set for different age groups. Doctor advise Pap tests at the age of 21. If Pap test result is normal, person is advised to repeat the test every 3 years. HPV test is asked to repeat after 5 years. Prognosis of cervical cancer depends on stage of the cancer at the time of diagnosis. Early stage cancers have great prognosis and survival rate.