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
1Medical 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.