Treatment Update: Cervical Cancer
Thanks to major advances, healthcare providers can now prevent and treat cervical cancer more effectively.
Cervical cancer occurs in the cells of the cervix—the lower part of the uterus that connects to the vagina. It was once one of the most common cancers in women. In recent decades the incidence has decreased, as improved screening methods have made it easier for healthcare providers to find abnormal cells that can become cancerous.
Most cases of cervical cancer are caused by certain types of the human papillomavirus (HPV). In a small percentage of people exposed to HPV, the viral infection can persist for years and contribute to causing cervical cells to become cancerous.
There are two main types of cervical cancer:
Squamous cell carcinoma, which begins in the thin, flat cells (squamous cells) lining the outer part of the cervix. Approximately 70 percent of cervical cancers are squamous cell carcinomas.
Adenocarcinoma, which begins in the column-shaped glandular cells that line the endocervical canal (the passageway from inside the uterus to the vagina).
Cervical cancer is usually slow-growing and may not show any symptoms. Regular screening tests are very effective at detecting precancerous cells that may develop into cervical cancer.
Pap test. During a Pap test, cells are collected from the cervix and examined in a lab for abnormalities.
HPV DNA test. Cells collected from the cervix are tested to see if they are infected with any of the types of HPV that could lead to cervical cancer.
If cervical cancer is suspected after screening tests, a colposcope (magnifying instrument) is used to check if there are visual indications of the presence of abnormal or precancerous cells.
Typically, a gentle scraping of the lower part of the cervical canal will be performed, in which samples of cervical cells are taken and looked at under a microscope by a pathologist. If a diagnosis of cervical cancer is made, further imaging and visual tests will be conducted to determine if the cancer has spread beyond the cervix.
Treatment options depend on the type of cervical cancer, its stage, whether it is newly-diagnosed or recurrent (returned) and if the woman wants to preserve fertility.
Early-stage (confined to the cervix) cervical cancer is usually treated with surgery. Surgical options include:
Cone biopsy. In this procedure, very small cervical cancers are removed entirely by cutting away a cone-shaped piece of cervical tissue. This leaves the rest of the cervix intact and allows for the possibility of a future pregnancy.
Radical trachelectomy. In this surgical approach, the cervix and some surrounding tissue is removed. The uterus remains intact, allowing for the possibility of a future pregnancy.
Total hysterectomy. In a total hysterectomy, the uterus and cervix are removed.
Radical hysterectomy. For cancer that has spread beyond the cervix, a radical hysterectomy is often performed. This surgery involves removing the cervix, uterus, part of the vagina and nearby lymph nodes.
Depending on your individual circumstances, your doctor might discuss the removal of the ovaries during either a total or radical hysterectomy. This procedure is called an oophorectomy.
Chemotherapy uses anti-cancer drugs that enter the bloodstream and kill cancer cells. It can be used to treat cervical cancer that has spread beyond the pelvis, recurs after treatment with surgery or after surgery in combination with chemoradiotherapy (see next section).
Cisplatin (Platinol, Platinol-AQ) is the chemotherapy most commonly used in combination with radiation for the treatment of locally advanced cervical cancer. This drug is given intravenously (as a drip into a vein). When the tumor has spread beyond the pelvis, paclitaxel (Taxol) is often administered.
Topotecan (Hycamtin and others) is usually given for the treatment of cervical cancer that is not responding to (or has stopped responding to) other types of therapy.
Radiation and Chemoradiotherapy
Radiation is the use of high-powered energy beams to kill cancer cells. For certain stages of cervical cancer, radiation is often given at the same time as the chemotherapy cisplatin, as it can make the radiation more effective. Radiation or chemoradiotherapy can also be given following surgery, and to treat cervical cancer that has spread or recurred after treatment.
There are two types of radiation therapy used to treat cervical cancer:
External beam radiation (EBRT)
EBRT uses a machine to aim high-dose radiation at the cancer. The treatments are given several times a week over several weeks. The number of treatments is limited to avoid harming nearby tissues and organs.
Brachytherapy, also called internal radiation therapy, uses instruments which direct a source of radiation in or near the cancer. In intracavitary brachytherapy (the type most often used to treat cervical cancer), a device filled with radioactive material is placed in the vagina or the uterus. Brachytherapy is given on an outpatient basis over several treatments, usually at least a week apart. When brachytherapy is used as a treatment for cervical cancer, it is usually in addition to EBRT and chemotherapy.
Targeted therapies focus on specific molecules and cell mechanisms thought to be important for cancer cell survival and growth, taking advantage of what researchers have learned in recent years about how cancer cells grow. Targeted therapies are meant to spare healthy tissues and provide treatment against cancer cells that is more focused than chemotherapy. It may be a treatment option for later-stage cervical cancer.
Bevacizumab (Avastin) is a type of targeted therapy that “starves” tumors by blocking the action of VEGF (vascular endothelial growth factor), a protein released by tumors that contributes to blood vessel growth (angiogenesis). Bevacizumab is usually given with chemotherapy, as it makes the chemotherapy more effective.
Our immune system works constantly to keep us healthy. It recognizes and fights against danger, such as infections, viruses and growing cancer cells. In general terms, immunotherapy uses our own immune system as a treatment against cancer. It might be considered when the cervical cancer is advanced and other treatments aren’t working.
In October 2021, the U.S. Food and Drug Administration (FDA) approved the immunotherapy pembrolizumab (Keytruda), with or without bevacizumab, for the treatment of recurrent or metastatic (advanced) cervical cancer with tumors that express a molecular “brake” known as PD-L1. The brake prevents the body’s immune system from attacking tumors. Pembrolizumab, which is designed to reverse the effect of the brake, is given intravenously.
In September 2021, the FDA approved tisotumab vedotin-tftv (Tivdak) for the treatment of recurrent or metastatic cervical cancer in people whose disease has progressed during or after chemotherapy. Tisotumab vedotin-tftv is an antibody-drug conjugate (ADC), a type of anticancer treatment that combines a targeted therapy with a chemotherapy drug.
If you experience any of these treatment side effects, talk to your doctor or nurse immediately:
• Fever or chills;
• Heavy bleeding or unusual vaginal discharge;
• Severe pain;
• Redness or discharge from incisions;
• Problems urinating or having a bowel movement;
• Shortness of breath or chest pain.
You should also work with your health care team to manage the following possible life changes due to cancer treatment:
Premature Menopause and Sexual Side Effects
For premenopausal women under age 50 who have a hysterectomy that includes removal of the ovaries, the procedure may cause premature menopause. Estrogen therapy may be prescribed if the woman is young or experiences menopausal symptoms such as hot flashes.
Some women may also experience vaginal dryness after hysterectomy, which can affect their sexual well-being. Many effective prescription and over-the-counter treatments are available to correct vaginal dryness. Most of them are estrogen-based products in cream, gel or other forms. Discuss with your doctor the best option for you.
Before using complementary or alternative treatments such as vitamins or products containing plant-based estrogens, talk to your doctor about the product’s safety and effectiveness.
Avoid using certain products that may irritate the vagina, including douches (especially ones containing vinegar or yogurt), scented lotions, antibacterial or fragrant soaps, bubble baths and bath oils.
Changes in Fertility
Cancer treatments can affect your ability to conceive a child. It’s important to talk to your doctor before treatment to discuss your options for preserving your fertility, even if you aren’t sure you want to have children in the future. The surgical procedure called trachelectomy, discussed on page in the chapter on treatments, can benefit some women with early cervical cancer who wish to become pregnant.
Maintaining Good Nutrition
Eating well is important before, during and after cancer treatment. You need the right amount of calories to maintain a healthy weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.
Sometimes, especially during or soon after treatment, you may not feel like eating. Perhaps foods don’t taste the same as they used to. Ask your doctor about speaking with a registered dietitian who can suggest ways to help you meet your nutritional needs.
HPV is the main cause of cervical cancer and abnormal cervical cells. Up to 80 percent of people have been exposed to HPV at some point in their lives.
Although HPV can be spread during vaginal, anal and oral sex, such contact does not have to occur for the infection to spread. All that is needed is skin-to-skin contact with an area of the body infected with HPV.
Women who have had more than one sex partner are more likely to get infected with HPV, but a woman who has had only one sex partner can still get infected. Even women who are not sexually active can become infected with HPV through skin-toskin contact with an infected person.
Condoms provide some protection against HPV, but they do not completely prevent infection. Still, men who regularly use condoms are less likely to be infected with HPV and pass it on to their partners.
Vaccines are available that can protect against certain HPV infections. Some can also protect against infections with other HPV subtypes, including those that cause anal and genital warts. These vaccines only work to prevent HPV infection— they will not treat an infection already present. That is why, to be most effective, the HPV vaccine should be given before a person becomes exposed to HPV.
These vaccines help prevent precancers and cancers of the cervix. The HPV vaccination is recommended for preteen girls and boys 11 or 12 years old.
Q: What are the risk factors for cervical cancer?
A: Factors that increase the risk of cervical cancer include persistent HPV infection, smoking and an immune system that may be weakened by another health condition or by infection with HIV (the human immunodeficiency virus). A common bacteria called chlamydia, which can infect the reproductive system through sexual contact, may also increase the risk of cervical cancer.
You can reduce your risk of developing cervical cancer by having screening tests. Receiving the vaccine that protects against HPV infection before being exposed to the virus also reduces the risk.
Q: I am in a same-sex relationship. Do I need cervical cancer screening?
A: Because HPV is so common, women in the LGBTQ+ communities are at the same risk as heterosexual women, and screening for cervical cancer is recommended.
Q: I am going to be treated with radiation and want to preserve my fertility. What are my options?
A: Before treatment begins, discuss options with your healthcare provider that might be right for you. Ask about newer options for preserving fertility, such as oocyte cryopreservation, also known as egg freezing. In this process, the unfertilized eggs are removed, frozen and stored for later use.
Q: I had a hysterectomy as treatment for my cervical cancer and am now experiencing hot flashes. Do you have any tips for me?
A: There are several medications that potentially help decrease hot flashes. Talk to your healthcare provider to determine the best options for you.
The following tips may also help:
- Identify the triggers for your hot flashes. For many, hot flashes can be triggered by stress, a hot shower, caffeine or spicy foods.
- Change your lifestyle habits to cope with your specific triggers. That may mean regular exercise, using relaxation techniques and changing your diet.
- Dress in layers so that you can remove clothing if needed.
- Keep ice water handy to help you cool off.
- Avoid synthetic materials, especially at nighttime. Wear pajamas and use sheets made of cotton.
- Take a cool shower before going to bed.