Detection and Diagnosis
How is cervical cancer diagnosed?
Precancerous cervical cell changes and early cancers of the cervix generally do not cause symptoms. Cervical cell changes are often detected through screening.
The Papanicolaou test (also called Pap smear or Pap test) is a screening test used to detect pre-cancerous and cancerous cells in the cervix. The test was invented by and named after the prominent Greek doctor Georgios Papanikolaou.
When conducting a Pap test, a healthcare provider uses a speculum to open the vaginal canal to allow for the collection of cells from the outer opening of the cervix of the uterus. The cells are examined under a microscope to look for abnormalities. The test aims to detect potentially pre-cancerous changes (called cervical intraepithelial neoplasia (CIN) or cervical dysplasia), which are usually caused by HPV. The test remains an effective, widely used method for early detection of pre-cancer and cervical cancer.
When conducting a Pap test, the provider may also perform a pelvic examination, where the provider will check the uterus, ovaries, and other organs to make sure there are no problems. When a cancer diagnosis is made, the doctor examines the pelvic area to see if the cancer has spread to nearby organs, such as the uterus, vagina, bladder, and rectum.
If the Pap test results show these cell changes, this is usually called cervical dysplasia. Other common terms the healthcare provider may use include abnormal cell changes, precancerous cells changes, CIN (cervical intraepithelial neoplasia), or SIL (squamous intraepithelial lesions). All of these terms mean similar things - it simply means that abnormalities were found.
What if Pap test results are abnormal?
If a Pap test shows abnormal cells, additional test may be performed. These tests include:
Colposcopy: A colposcopy is an examination of the vagina and cervix using a lighted magnifying instrument called a colposcope.
Cervical biopsy: In a biopsy, the healthcare provider removes a small amount of tissue for examination under a microscope to look for precancerous cells or cancer cells. Most women have the biopsy in the doctor's office, and no anesthesia is needed. To do the biopsy, the doctor will insert a speculum to hold the vagina open and take a very small sample. After the sample is taken, it will be sent to a laboratory where another doctor checks the tissue using a microscope. You may experience some bleeding and discharge after the exam and discomfort similar to menstrual cramps. Ibuprofen can be taken to relieve these symptoms.
Colposcopic biopsy: While viewing your cervix with a colposcope, the healthcare provider removes a tiny portion of abnormal tissue from the surface of the cervix with a special tweezers. The cells are then examined under a microscope.
Endocervical curettage: A procedure in which the mucous membrane of the cervical canal is scraped using a spoon-shaped instrument called a curette. This can be done in your healthcare provider's office and does not require anesthesia. There may be some cramping and bleeding after the procedure.
Cone biopsy: A cone-shaped sample of tissue is removed from the cervix to see if abnormal cells are in the tissue beneath the surface of the cervix. This specimen is much bigger than the biopsy done in the office without anesthesia. A sample of tissue can be removed for a cone biopsy using a LEEP cone procedure, which can be done under local anesthesia, or a knife cone procedure, done in an operating room under local or general anesthesia. You may have some vaginal bleeding for about a week and some spotting for about three weeks after the procedure.
LEEP (Loop Electro-Surgical Excision Procedure): The LEEP is performed using a small heated wire to remove tissue and precancerous cells from the cervix. This procedure can be done in your provider's office and requires local anesthesia. There may be some cramping during and after the procedure. You may have moderate to heavy vaginal discharge that lasts for up to three weeks.
Stages of cancer
Once cancer has been diagnosed, additional tests may be performed to determine whether or not the cancer has spread to other parts of the body. This is called staging. Learning the stage of the cancer helps plan treatment options.
Tests that may be performed to determine whether cancer has spread include:
- Cystoscopy or proctoscopy to check to see if cancer has spread to the urethra or bladder
- Computed tomography scan (CT), which combines multiple X-rays to provide three-dimensional clarity and show various types of tissue, including blood vessels.
- Magnetic resonance imaging (MRI), using magnets and radio waves provide three-dimensional body images. It may also be used to determine if a tumor is benign or malignant.
- Positron emission tomography scan (PET), called a PET scan. A PET scan is an imaging test that can help reveal how your tissues and organs are functioning. A small amount of radioactive material is necessary to show this activity.
The International Federation of Gynecology and Obstetrics (FIGO) believes that any staging system should be universally feasible and applicable, as well as provide a worldwide standardized classification that allows various medical centers to compare results. The major categories of the FIGO classification are as follows:
- Stage 0: Carcinoma in situ. Abnormal cells in the innermost lining of the cervix.
- Stage I: Invasive carcinoma that is strictly confined to the cervix.
- Stage II: Locoregional spread of the cancer beyond the uterus but not to the pelvic sidewall or the lower third of the vagina.
- Stage III: Cancerous spread to the pelvic sidewall or the lower third of the vagina, and/or hydronephrosis or a nonfunctioning kidney that is incident to invasion of the ureter.
- Stage IV: Cancerous spread beyond the true pelvis or into the mucosa of the bladder or rectum.
The FIGO stages are further categorized as follows:
- Stage Ia cervical carcinoma: Preclinical invasive carcinoma that can be diagnosed only by means of microscopy
- Stage Ib cervical carcinoma: A clinically visible lesion that is confined to the cervix uteri
- Stage Ib1: Primary tumor not greater than 4.0 cm in diameter.
- Stage Ib2: Primary tumor greater than 4.0 cm in diameter.
- Stage IIa cervical carcinoma: Spread into the upper two thirds of the vagina without parametrial invasion
- Stage IIb cervical carcinoma: Extension into the parametrium but not into the pelvic sidewall
- Stage IIIa cervical carcinoma: Extension into lower one third of the vagina, without spread to the pelvic sidewall
- Stage IIIb cervical carcinoma: Extension into the pelvic sidewall and/or invasion of the ureter, with the latter resulting in a nonfunctioning kidney or hydronephrosis
- Stage IVa cervical carcinoma: Extension of the tumor into the mucosa of the bladder or rectum
- Stage IVb cervical carcinoma: Spread of the tumor beyond the true pelvis and/or by metastasis into distant organs