High Risk and Underscreened
- Older women (age 60 and above) are at increased
risk for cervical cancer as they are less willing or able to seek medical care
for screening for this disease and participate in treatment.
- Minorities including African Americans, Native
Americans, and Hispanics
(but not Asian Americans) have a higher risk than Caucasians. Much of the
difference can be explained by socioeconomic factors and associated risk
- Decreased mortality secondary to cytological
screening for cervical abnormalities has been demonstrated in multiple,
broad-based population studies. Unscreened or underscreened high-risk groups
should be identified and targeted for screening programs.
- Educational efforts,
transportation, efforts to establish a regular health care provider, and
screening convenient to the work place have been shown to have a positive impact
on women participating in screening.
- In communities where English is a second
language, healthcare providers fluent in the native language can effectively
facilitate these efforts.
- Frequently, the high-risk individual is seen at a
medical facility for unrelated health issues and is not provided with cytologic
screening. Provision of a modality by which hospitals and emergency services
could identify and screen these women could potentially further reduce mortality.
Incidence and Mortality
- An estimated 12,200 new cervical cancers and
4,100 cervical cancer deaths will occur in the United States in 2003.
An additional 1,250,000 women will be diagnosed yearly with changes referred to
as squamous intraepithelial lesions (SIL) or cervical intraepithelial neoplasia
(CIN). These changes form a continuum divided into low-grade or high-grade SIL
or CIN 1, 2, and 3 that reflects increasingly abnormal changes of the affected
epithelium. These lesions can persist, regress, or progress to an invasive
High-grade SIL (CIN 2-3) is more likely to persist or progress and
less often regresses spontaneously, while low-grade SIL (CIN 1) often regresses
The average time for progression of CIN 3 to invasive cancer
has been estimated to be 10 to 15 years, based on the mean age of diagnosis of
these 2 conditions. There is a small subset of rapidly progressive cervical
cancers which are diagnosed within 3 years of a confirmed negative Pap test.
These tumors occur in younger women with higher socioeconomic status as compared
to a control cervical cancer group. One third of these cancers are
adenocarcinomas of endocervical origin which may not be adequately screened by
conventional Pap test methods.
The Pap test is a screening tool that identifies
women likely to have premalignant disease and at high risk for cervical cancer.
The widely used Bethesda System of reporting Pap tests was developed in 1988.
The cytologic terms, low-grade and high-grade squamous intraepithelial lesions (LSIL
and HSIL), correlate with the histopathologic diagnoses of CIN 1, and CIN 2-3,
respectively. Strengths of this system are that it requires an evaluation of the
adequacy of the specimen and encourages a descriptive diagnosis of
abnormalities. Abnormalities that do not fulfill the criteria for SIL are termed
atypical squamous cells of undetermined significance (ASCUS). Persistent
atypical smears should be evaluated colposcopically. An estimated 5% to 10% of
patients with this cytologic finding will subsequently be shown to have HSIL or
rarely, invasive cancer.
Reliability of the smear depends on the technique
employed to obtain the cytologic specimen and the adequacy of its review by the
cytologist. Pap test failure rate in diagnosing invasive cancer can be as high
as 50%emphasizing the need to biopsy any visible lesions of the cervix, even if
associated with a normal Pap test. Careful inspection of the cervix and lower
genital tract for areas of nodularity and friability should be part of each
The accessibility of the cervix to examination
provides a unique opportunity to evaluate the disease status and response to
intervention. Commonly employed methods of treatment for premalignant lesions
include laser vaporization or excision, cryosurgery, cold knife conization, loop
electrosurgical excision, or simple hysterectomy. Strategies to combine
diagnosis and treatment such as loop electrosurgical excision procedure (LEEP)
may be appropriate, particularly in women for whom follow-up is not effective.
Despite the efficacy of excisional treatment of intraepithelial
lesions in reducing the risk of developing invasive cervical cancer, the risk of
cancer remains elevated above that of the general population and warrants
careful follow-up for at least 8 to 10 years. The slow progression of
preinvasive disease into invasive cancer and the easy access to visual and
cytologic investigation makes squamous intraepithelial lesions an ideal disease
for chemoprevention clinical trials.
General Information About
- Cervical cancer is a disease in which malignant (cancer) cells form in the
tissues of the cervix
- The cervix is the lower, narrow end of the uterus (the hollow, pear-shaped
organ where a fetus grows). The cervix leads from the uterus to the vagina
- Cervical cancer usually develops slowly over time. Before cancer appears in
the cervix, the cells of the cervix go through changes known as dysplasia, in
which cells that are not normal begin to appear in the cervical tissue. Later,
cancer cells start to grow and spread more deeply into the cervix and to
- Human papillomavirus (HPV) infection is the major risk factor for development
of cervical cancer.
- Infection of the cervix with human papillomavirus (HPV) is the most common
cause of cervical cancer. Not all women with HPV infection, however, will
develop cervical cancer. Women who do not regularly have a Pap smear to detect
HPV or abnormal cells in the cervix are at increased risk of cervical cancer.
Other possible risk factors include the following:
- Giving birth to many children.
- Having many sexual partners.
- Having first sexual intercourse at a young age.
- Smoking cigarettes.
- A diet lacking in vitamins A and C.
- Oral contraceptive use (“the Pill“).
- Weakened immune system.
- There are usually no noticeable signs of early cervical cancer but it can be
detected early with yearly check-ups.
- Early cervical cancer may not cause noticeable signs or symptoms. Women
should have yearly check-ups, including a Pap smear to check for abnormal cells
in the cervix. The prognosis (chance of recovery) is better when the cancer is
- Possible signs of cervical cancer include vaginal bleeding and pelvic pain.
These and other symptoms may be caused by cervical cancer or by other
conditions. A doctor should be consulted if any of the following problems occur:
- Vaginal bleeding.
- Unusual vaginal discharge.
- Pelvic pain.
- Pain during sexual intercourse.
Tests that examine the cervix are used to detect (find) and diagnose cervical
The following procedures may be used:
- Pap smear: A piece of cotton, a brush, or a small wooden stick is used to
collect cells from the cervix and vagina. The cells are viewed under a
microscope. Abnormal (precancerous) cells in the tissues of the cervix can
usually be found by a Pap smear.
- Colposcopy: The tissues of the vagina and cervix are examined using a
lighted magnifying instrument called a colposcope.
- Biopsy: If abnormal cells are found in a Pap smear, the doctor may do a
biopsy. A sample of tissue is cut from the cervix and viewed under a
microscope. A biopsy that removes only a small amount of tissue is usually
done in the doctor’s office. A woman may need to go to a hospital for a
cervical cone biopsy (removal of a larger, cone-shaped sample of cervical
- Pelvic exam: A procedure to check the uterus, vagina, ovaries, fallopian
tubes, bladder, and rectum to find any abnormality in their shape or size.
- Endocervical curettage: A curette (a spoon-shaped instrument) is used to
collect cells from the cervical canal. The cells are viewed under a
microscope. This procedure is sometimes done at the same time as the
Certain factors affect treatment options and prognosis (chance of recovery).
The treatment options and prognosis (chance of recovery) depend on the stage
of the cancer (whether it affects part of the cervix, involves the whole cervix,
or has spread to the lymph nodes or other places in the body), the type of
cervical cancer, the size of the tumor, and the patient’s desire to have
children. Lymph nodes are small, bean-shaped structures found throughout the
body. They filter substances in a fluid called lymph and help fight infection
Treatment of cervical cancer during pregnancy depends on the stage of the
cancer and the stage of the pregnancy. For cervical cancer found early or for
cancer found during the last trimester of pregnancy, treatment may be delayed
until after the baby is born.
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