Cervial Cancer Prevention 2

Cervial Cancer Prevention 3

Cervial Cancer Prevention 4

Cervial Cancer Prevention 5

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      Detailed Guide: Cervical Cancer

Can Cervical Cancer Be Prevented?

Since the most common form of cervical cancer starts with precancerous changes, there are 2 ways to stop this disease from developing. The first way is to prevent the precancers, and the second is to find and treat precancers before they become cancerous.

Avoiding Risk Factors

You can prevent most precancers of the cervix by avoiding exposure to HPV. Delaying having sexual intercourse if you are young can help you avoid HPV. Limiting your number of sexual partners and avoiding sex with people who have had many other sexual partners lower your risk of exposure to HPV. Remember that HPV does not always cause warts or other symptoms, so a person may have the virus and pass it on without knowing it.

Be aware that condoms ("rubbers") do not completely protect against HPV. This is because HPV can be passed from person to person through skin-to-skin contact with any HPV-infected area of the body, such as skin of the genital or anal area not covered by the condom. Even if there are no visible warts or other symptoms, a person with HPV can still pass on the virus to another person. HPV can be present for years with no symptoms.

Still, condoms may provide some protection against HPV, and they also protect against AIDS and other sexually transmitted illnesses that are passed on through some body fluids. Not smoking is another way to reduce the risk of cervical cancer and precancer.

Finding Precancerous Changes

The second way to prevent cervix cancer is to have testing (including a Pap test) to detect HPV and precancers. Treatment of precancers can stop cervical cancer before it is fully developed. Most invasive cervical cancers are found in women who have not had regular Pap tests.

The American Cancer Society recommends the following guidelines for early detection:

All women should begin cervical cancer testing (screening) about 3 years after they begin having vaginal intercourse, but no later than when they are 21 years old. Testing should be done every year with the regular Pap test or every 2 years using the newer liquid-based Pap test.

Beginning at age 30, women who have had 3 normal Pap test results in a row may get tested every 2 to 3 years with either the conventional (regular) or liquid-based Pap test. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, or a weakened immune system due to organ transplant, chemotherapy, or chronic steroid use should continue to be tested yearly.

Another reasonable option for women over 30 is to get tested every 3 years (but not more frequently) with either the regular Pap test or liquid-based Pap test, plus the HPV DNA test (see below for more information on this test).

Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having cervical cancer testing. Women with a history of cervical cancer, DES exposure before birth, HIV infection, or a weakened immune system should continue to have testing as long as they are in good health.

Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having cervical cancer testing, unless the surgery was done as a treatment for cervical cancer or precancer. Women who have had a hysterectomy without removal of the cervix (simple hysterectomy) should continue to follow the guidelines above.

Some women believe that they do not need exams by a health care professional once they have stopped having children. This is not correct. They should continue to follow American Cancer Society guidelines.

Although the Pap test has been more successful than any other screening test in preventing a cancer, it is not perfect. One of its limitations is that Pap tests are examined by humans, so an accurate analysis of the hundreds of thousands of cells in each sample is not always possible. Engineers, scientists, and doctors are working together to improve this test. Because some abnormalities may be missed (even when samples are examined in the best laboratories), it is not a good idea to have this test less often than American Cancer Society guidelines recommend.

Increasing the Accuracy of Your Pap Tests

There are several things you can do to make your Pap test as accurate as possible:

• Try not to schedule an appointment for a time during your menstrual period.

• Do not douche for 48 hours before the test.

• Do not have sexual intercourse for 48 hours before the test.

• Do not use tampons, birth control foams, jellies, or other vaginal creams or vaginal medications for 48 hours before the test.

Pelvic Exam Versus Pap Test

Many people confuse pelvic exams with Pap tests. The pelvic exam is part of a woman's routine health care. During a pelvic exam, the doctor looks at and feels the reproductive organs, including the uterus and the ovaries and may screen for sexually transmitted illnesses. But the pelvic exam will not find cervical cancer at an early stage and cannot find abnormal cells of the cervix. The Pap test is usually done just before the pelvic exam, when the doctor removes cells from the cervix by gently scraping or brushing with a special instrument. Pelvic exams may help find other types of cancers and reproductive problems, but only Pap tests give information on early cervical cancer or precancers.

How the Pap Test Is Done

Cytology is the branch of science that deals with the structure and function of cells. It also refers to tests to diagnose cancer by looking at cells under the microscope. The Pap test (or Pap smear) is a procedure used to collect cells from the cervix for cervical cytology testing.

The health care professional first places a speculum, a metal or plastic instrument that keeps the vagina open so that the cervix can be seen clearly, inside the vagina. Next, a sample of cells and mucus is lightly scraped from the ectocervix (part next to the vagina) using a small spatula. A small brush or a cotton-tipped swab is used to take a sample from the endocervix (part closest to the body of the uterus). There are 2 main options for preparing the cell samples for testing in the laboratory, where specially trained technologists (cytotechnologists) and doctors (pathologists) look at the samples under a microscope.

The sample can be smeared directly onto a glass microscope slide, which is then sent to the laboratory. For about 50 years, all cervical cytology samples were handled this way. This method works quite well and is relatively inexpensive. However, cells smeared onto the slide are sometimes piled up on each other, so cells at the bottom of the pile cannot be clearly seen. Also, infections of the cervix or vagina may cause inflammatory (pus) cells, increased mucus, yeast cells, or bacteria that hide the cervical cells. Another problem with direct smears is that the cells may become distorted by drying out. Cells can be difficult to examine accurately if they are not treated with alcohol to preserve them immediately after they are spread on the slide.

A newer method called liquid-based cytology, or liquid-based Pap test, can remove some of the mucus, bacteria, yeast, and pus cells in a sample and can spread the cervical cells more evenly on the slide. Instead of being directly placed on a slide, the sample is placed into a special preservative solution. This new method, also known by brand names ThinPrep or AutoCyte, also prevents cells from drying out and becoming distorted. Recent studies show that liquid-based testing can slightly improve detection of cancers, greatly improve detection of precancers (SILs -- described below), and reduce the number of tests that need to be repeated. This method is more expensive than a usual Pap smear.

Another approach to improving the Pap test is the use of computerized instruments that can spot abnormal cells in Pap tests. The AutoPap instrument has been approved by the US Food and Drug Administration (FDA) for retesting Pap test samples that were interpreted as normal by technologists. It is also approved by the FDA for initial testing of Pap tests, instead of testing by a technologist. However, a technologist would still examine all smears identified as abnormal by the AutoPap.

These computerized instruments can find abnormal cells that are sometimes missed by technologists. Most of the abnormal cells found in this way are in rather early stages, such as atypical squamous cells (ASCs), but high-grade abnormalities missed by human testing are sometimes found by the computerized instrument. Scientists do not yet know whether the instrument can find enough high-grade abnormalities missed by human testing to have a significant impact on preventing invasive cervical cancers. Automated testing also increases the cost of the cervical cytology testing.

For now, the most important way to improve early detection of cervical cancer is to make certain that all women are tested according to American Cancer Society guidelines. Unfortunately, many of the women most at risk for cervical cancer are not being tested often enough or at all.

How Pap Test Results Are Reported

The most widely used system for describing Pap test results is The Bethesda System (TBS). This system has been revised twice since it was developed in 1988 – first in 1991 and, most recently, in 2001. The information that follows is based on the 2001 version. The general categories are:

• negative for intraepithelial lesion or malignancy

• epithelial cell abnormalities

• other malignant neoplasms

Negative for intraepithelial lesion or malignancy: This first category means that no signs of cancer or precancerous changes or other significant abnormalities were found. Some specimens in this category appear entirely normal. Other findings may be unrelated to cervical cancer, such as evidence of reproductive system infections (yeast, herpes, or Trichomonas, for example). Some cases may also show reactive cellular changes, which is a response of cervical cells to infection or other irritation.

Epithelial cell abnormalities: The second TBS category, epithelial cell abnormalities, means that the cells of the lining layer of the cervix show changes that might be cancer or a precancerous condition. This category is divided into several groups for squamous cells and glandular cells.
The epithelial cell abnormalities for squamous cells are called:

• Atypical squamous cells (ASCs); these are further divided into ASC-US and ASC-H

• Low-grade squamous intraepithelial lesions (SILs)

• High-grade SILs

• Squamous cell carcinoma

Atypical squamous cells: This term is used when it is not possible to tell (from how the cells look under a microscope) whether the abnormal cells are caused by an infection, another cause of irritation, or by a precancer. The Pap test is usually repeated after several months, or other tests, such as colposcopy (explained below) and biopsy may be recommended, depending on the patient's history and the results of previous Pap tests and whether a high grade SIL is suspected (ASC-H). Most doctors recommend having an HPV test in this situation. If this shows no HPV, then only usual follow-up is needed. If it does show HPV, colposcopy is recommended.

Squamous intraepithelial lesions (SILs): These abnormalities are subdivided into low-grade SIL and high-grade SIL. All patients should have colposcopy. High-grade SILs are less likely than low-grade SILs to go away without treatment and are more likely to eventually develop into cancer if they are not treated. However, treatment can cure all SILs and prevent true cancer from developing. A Pap test cannot determine for certain whether a woman has a high- or low-grade SIL. It merely flags the result as fitting into one of these abnormal categories. The need for treatment is based on further testing and examination (see below). The HPV test is less helpful because most of these women will test positive for HPV.

Squamous cell carcinoma: This cytology result shows that the woman is likely to have an invasive squamous cell cancer. Further testing will be done to be sure of the diagnosis before doctors recommend treatments such as radiation therapy, chemotherapy, or radical surgery.

The Bethesda System also describes epithelial cell abnormalities for glandular cells. Cancers of the glandular cells are reported as adenocarcinomas. In some cases, the pathologist examining the cells can suggest whether the adenocarcinoma started in the endocervix, in the endometrium (the upper part of the uterus), or elsewhere in the body. When the glandular cells have features that do not permit a clear decision as to whether they are cancerous, the term used is atypical glandular cells. The patient usually undergoes further testing if her cervical cytology result shows atypical glandular cells.

Other types of cancer: These can be uncommon forms of cancer such as malignant melanoma, sarcomas, and lymphoma. Compared with squamous cell carcinoma and adenocarcinoma, these cancers affect the cervix very rarely.

The HPV DNA Test

As mentioned earlier, the most important risk factor for developing cervical cancer is having had the human papillomavirus (HPV). Doctors can now test for the types of HPV that are most likely to cause cervical cancer ("high-risk" types) by looking for pieces of their DNA in cervical cells. The test is done in a similar way to the Pap test in terms of how the sample is collected, and in some cases can even be done on the same sample.

The HPV DNA test can be used in 2 situations:

The FDA recently approved it for use as a screening test in combination with the Pap test in women over 30 years old (see American Cancer Society screening guidelines above). It is not recommended as a screening test in women under 30 because the test is not as useful in this population. Women in their 20s who are sexually active are much more likely to have an HPV infection (most of which will go away on their own), so the results of the test are not as significant and may be more confusing. For more information, see the American Cancer Society document, "What Every Woman Should Know About Cervical Cancer and the Human Papilloma Virus."

The HPV DNA test is also used in women with slightly abnormal Pap test results to find out if more testing or treatment might be needed (see next section).

Other Tests for Women With Abnormal Cervical Cytology Results

Because the Pap test is a screening test rather than a diagnostic test, if you have an abnormal result, you will need to have other tests (colposcopy and biopsy, and sometimes an endocervical scraping) to find out whether a precancerous change or cancer is present. Nearly all doctors recommend one or more of these tests for women with a Pap result of SIL or atypical glandular cells.
Doctors are less certain about what to do when the result is atypical squamous cells. Some recommend colposcopy and biopsy if ASC-H and less commonly for ASC-US, and others recommend a repeat Pap test after several months for ASC-US. In making decisions about follow-up, some doctors take into account your previous Pap test results, whether you have any cervical cancer risk factors, whether you have remembered to have Pap tests done in the past, and whether the test result is ASC-H or ASC-US.

Recently, some doctors have started using an intermediate step, testing for HPV. If a high-risk type of HPV is found in women with atypical squamous cells, doctors are more inclined to do a colposcopy for all ages. Generally, if you have SIL or ASC-H, a colposcopy will be done. If the biopsy shows SIL, or cervical intra-epithelial neoplasia, steps will be taken to prevent an actual cancer from developing.
Colposcopy: If certain symptoms suggest cancer or if the Pap test shows abnormal cells, you will need to have an additional test called a colposcopy. In this procedure you will lie on the exam table as you do with a pelvic exam. A speculum is placed in the vagina to expose the cervix. The doctor will use the colposcope to examine the cervix. The colposcope is an instrument with magnifying lenses very much like binoculars. With the colposcope, doctors can see the surface of the cervix closely and clearly.

The exam is not painful, has no side effects, and can be done safely even if you are pregnant. If abnormal areas are seen on the cervix, a biopsy (removal of a small tissue sample usually after numbing the cervix) is done. The sample is sent to a pathologist to look at under a microscope. A biopsy is the only way to tell for certain whether an abnormal area is a precancer, a true cancer, or neither.

Cervical biopsies: Several types of biopsies are used to diagnose cervical precancers and cancers. For precancers and early cancers, some types of biopsies can completely remove the abnormal tissue and may be the only treatment needed. In some situations, additional treatment of precancers or cancers is needed.

Colposcopic biopsy: For this type of biopsy, a doctor or other health care professional first examines the cervix with a colposcope to find the abnormal areas. Using a biopsy forceps, he or she will remove a small (about 1/8-inch) section of the abnormal area on the surface of the cervix. The biopsy procedure may cause mild cramping or brief pain, and you may have light bleeding afterward. A local anesthetic may be used to numb the cervix.

Endocervical curettage (endocervical scraping): This procedure is usually done at the same time as the colposcopic biopsy. A narrow instrument (the curette) is inserted into the endocervical canal (the passage between the outer part of the cervix and the inner part of the uterus). Some of the tissue lining the endocervical canal is removed by scraping with the curette. This tissue sample is sent to the laboratory for examination.

Because the colposcope allows a view only of the outer part of the cervix and not into the endocervix, health care professionals use an endocervical speculum or endocervical scraping to find out if this area is affected by precancer or cancer. A local anesthetic may be used to numb the cervix. Patients may have a temporary sensation, similar to a severe menstrual cramp, and they may have light bleeding after the procedure.

Cone biopsy: In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the ectocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal.

The transformation zone (the border between the ectocervix and endocervix) is contained within the cone. This is the area of the cervix where precancers and cancers are most likely to develop. The cone biopsy is also a treatment and can be used to completely remove many precancers and very early cancers.

There are 2 methods commonly used for cone biopsies: the loop electrosurgical excision procedure (LEEP; also called large loop excision of the transformation zone [LLETZ]) and the cold knife cone biopsy.

• LEEP (LLETZ): The tissue is removed with a thin wire loop that is heated by electrical current and acts as a scalpel. For this procedure, a local anesthetic is used, and it can be done in your doctor's office. It takes only about 10 minutes. You may have mild cramping during and after the procedure, and mild to moderate bleeding may persist for several weeks.

• Cold knife cone biopsy: A surgical scalpel or a laser as a scalpel is used rather than a heated wire to remove tissue. It requires general anesthesia (you are asleep during the operation) and is done in a hospital, but no overnight stay is needed. After the procedure, cramping and some bleeding may persist for a few weeks.

How biopsy results are reported: The terms for reporting biopsy results are slightly different from The Bethesda System for reporting Pap test results. Instead of The Bethesda System term "squamous intraepithelial lesion (SIL)," biopsy reports use 2 other terms, "cervical intraepithelial neoplasia (CIN)" and, rarely, "dysplasia," to refer to precancerous changes. The terms for reporting cancers ("squamous cell carcinoma" and "adenocarcinoma") are the same.

How Patients With Abnormal Pap Test Results Are Treated to Prevent Cervical Cancers From
Developing

If an area of SIL is seen during the colposcopy and usually confirmed by biopsy, your doctor will be able to remove the abnormal area by using such biopsy techniques as the LEEP (LLETZ procedure) or a cold knife cone biopsy or by destroying the abnormal cells with cryosurgery or laser surgery.

During cryosurgery, the doctor uses a metal probe cooled with liquid nitrogen to kill the abnormal cells by freezing them.

In laser surgery, the doctor uses a focused beam of high-energy light to vaporize (burn off) the abnormal tissue. This is done through the vagina, with local anesthesia.

Both of these outpatient treatments can be done in a doctor's office or clinic. After treatment, you may have a watery brown discharge for a few weeks.

These treatments are almost always effective in destroying precancers and preventing them from developing into true cancers. You will need follow-up exams to make sure that the abnormality does not come back. If it does, treatments can be repeated.

Vaccines: Vaccines have been developed that can immunize people against HPV. So far, vaccines that protect against HPV 16 and 18 have been shown to be effective in preventing the infection and reducing the chances of an abnormal pap test. Clinical trials of vaccines against other HPV types are in progress. It is hoped that in the future, a vaccine that protects against the major cancer-causing HPV types will be available for all young women. For now, this is still in the developmental stage and is used to prevent HPV infection – before an abnormal Pap smear develops – and not to treat an existing infection.

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