The Farber Center: For Radiation Oncology

The cervix is the lower part of the uterus that opens into the vagina. Cervical cancer occurs when abnormal cells grow out of control.
It is usually found at a very early stage through a Pap test and can often be cured when it’s found early.
Nearly half of women diagnosed with cervical cancer have never had a Pap test.
Pregnant women have the same risk of developing cervical cancer as nonpregnant women.
The incidence of cervical cancer has decreased in developed countries around the world because of an increase in the use of Pap smears for screening and appropriate follow-up treatment. In developing countries, Pap smears are not as readily available.
Cervical cancer most often affects women between the ages of 35 to 39 and 60 to 64.

Abnormal cervical cell changes rarely cause symptoms. But if those cell changes grow into cervical cancer you may have any of the following:

• Bleeding from the vagina that is not normal, or a change in your menstrual cycle that you can't explain.
• Bleeding when something comes in contact with your cervix, such as during sex or when you put in a diaphragm.
• Pain during sex.
• Vaginal discharge that is tinged with blood.

Risk Factors:

• HPV: Most cervical cancer is caused by a virus called human papillomavirus, or HPV. There are several types of HPV and not all of them cause cervical cancer. You can get HPV by having sex with someone who has it. You can have HPV for years and not know it which is why Pap smears are important. Pap smears can find changes in cervical cells before they turn into cancer. If you treat these cell changes, you may prevent cervical cancer.
• High-risk sexual behaviors: such as having unprotected sex with multiple partners.
• Having an impaired immune system such as HIV: Women with HIV have higher rates of HPV infection, are more likely to develop cervical cell changes from HPV, and are more likely to quickly develop cervical cancer from those cell changes.
• Using birth control pills for more than 5 years: This may be related to infection with HPV.
• Prenatal exposure: to diethylstilbestrol (DES) though this is rare.
• Smoking: or a history of smoking, and possibly exposure to secondhand smoke.

As part of your regular pelvic exam, you should have a Pap smear which is when the doctor scrapes a small sample of cells from the surface of the cervix to look for abnormalities.

To confirm a diagnosis of cervical cancer, a biopsy is needed.

Once the diagnosis is confirmed, tests to determine the extent (stage) of cervical cancer may include:

• A cone biopsy or loop electrosurgical excision procedure (LEEP). These tests are sometimes recommended to determine the spread of cancer in cervical tissue.
• A cystoscopy, to look at the urinary tract and a proctoscopy, to look at the GI tract to see if the cancer involves those areas.
• Blood work
• Imaging such as a CT scan and MRI scan of the abdomen and pelvis and a total body PET scan.

Tumor extent (T)
Tis: The cancer cells are only found on the surface of the cervix (in the layer of cells lining the cervix), without growing into deeper tissues.

T1: The cancer cells have grown from the surface layer of the cervix into deeper tissues of the cervix. The cancer may also be growing into the body of the uterus, but it has not grown outside of the uterus.

• T1a: There is a very small amount of cancer, and it can be seen only under a microscope.
  T1a1: The area of cancer is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide.
  T1a2: The area of cancer invasion is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide.
  
  
• T1b: This stage includes stage I cancers that can be seen without a microscope. This stage also includes cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm.
T1b1: The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches).
T1b2: The cancer can be seen and is larger than 4 cm.

T2: In this stage, the cancer has grown beyond the cervix and uterus, but hasn't spread to the walls of the pelvis or the lower part of the vagina. The cancer may have grown into the upper part of the vagina.

• T2a: The cancer has not spread into the tissues next to the cervix (called the parametria).
T2a1: The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches).
T2a2: The cancer can be seen and is larger than 4 cm.


• T2b: The cancer has spread into the tissues next to the cervix (the parametria)

T3: The cancer has spread to the lower part of the vagina or the walls of the pelvis. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder).

• T3a: The cancer has spread to the lower third of the vagina but not to the walls of the pelvis.
• T3b: The cancer has grown into the walls of the pelvis and/or is blocking one or both ureters (this is called hydronephrosis).

T4: The cancer has spread to the bladder or rectum or it is growing out of the pelvis.

Lymph node spread (N)

NX: The nearby lymph nodes cannot be assessed
N0: No spread to nearby lymph nodes
N1: The cancer has spread to nearby lymph nodes

Distant spread (M)

M0: The cancer has not spread to distant lymph nodes, organs, or tissues.
M1: The cancer has spread to distant organs (such as the lungs or liver), to lymph nodes in the chest or neck, and/or to the peritoneum (the tissue coating the inside of the abdomen).

Stage Grouping
Stage 0 (Tis, N0, M0)
The cancer cells are only in the cells on the surface of the cervix (the layer of cells lining the cervix), without growing into (invading) deeper tissues of the cervix. This stage is also called carcinoma in situ (CIS) or cervical intraepithelial neoplasia (CIN) grade III (CIN III).

Stage I (T1, N0, M0)
In this stage the cancer has grown into (invaded) the cervix, but it is not growing outside the uterus. The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).

• Stage IA (T1a, N0, M0): This is the earliest form of stage I. There is a very small amount of cancer, and it can be seen only under a microscope. The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).
• Stage IA1 (T1a1, N0, M0): The cancer is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide. The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).
• Stage IA2 (T1a2, N0, M0): The cancer is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide. The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).
• Stage IB (T1b, N0, M0): This stage includes stage I cancers that can be seen without a microscope as well as cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm. These cancers have not spread to nearby lymph nodes (N0) or distant sites (M0).
Stage IB1 (T1b1, N0, M0): The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches). It has not spread to nearby lymph nodes (N0) or distant sites (M0).
Stage IB2 (T1b2, N0, M0): The cancer can be seen and is larger than 4 cm. It has not spread to nearby lymph nodes (N0) or distant sites (M0).

Stage II (T2, N0, M0)
In this stage, the cancer has grown beyond the cervix and uterus, but hasn't spread to the walls of the pelvis or the lower part of the vagina.

• Stage IIA (T2a, N0, M0): The cancer has not spread into the tissues next to the cervix (called the parametria). The cancer may have grown into the upper part of the vagina. It has not spread to nearby lymph nodes (N0) or distant sites (M0).
Stage IIA1 (T2a1, N0, M0): The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches). It has not spread to nearby lymph nodes (N0) or distant sites (M0).
Stage IIA2 (T2a2, N0, M0): The cancer can be seen and is larger than 4 cm. It has not spread to nearby lymph nodes (N0) or distant sites (M0).


• Stage IIB (T2b, N0, M0): The cancer has spread into the tissues next to the cervix (the parametria). It has not spread to nearby lymph nodes (N0) or distant sites (M0).

Stage III (T3, N0, M0)
The cancer has spread to the lower part of the vagina or the walls of the pelvis. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). It has not spread to nearby lymph nodes (N0) or distant sites (M0).

• Stage IIIA (T3a, N0, M0): The cancer has spread to the lower third of the vagina but not to the walls of the pelvis. It has not spread to nearby lymph nodes (N0) or distant sites (M0).
• Stage IIIB (T3b, N0, M0; OR T1-3, N1, M0): either:
The cancer has grown into the walls of the pelvis and/or has blocked one or both ureters (a condition called hydronephrosis), but has not spread to lymph nodes or distant sites.
OR
The cancer has spread to lymph nodes in the pelvis (N1) but not to distant sites (M0). The tumor can be any size and may have spread to the lower part of the vagina or walls of the pelvis (T1-T3).

Stage IV
This is the most advanced stage of cervical cancer. The cancer has spread to nearby organs or other parts of the body.

• Stage IVA (T4, N0, M0): The cancer has spread to the bladder or rectum, which are organs close to the cervix (T4). It has not spread to nearby lymph nodes (N0) or distant sites (M0).
• Stage IVB (any T, any N, M1): The cancer has spread to distant organs beyond the pelvic area, such as the lungs or liver.

SURGERY
is used to remove cervical cancer if it is caught in the early stages. Surgeries can be a relatively small procedure such as a cone biopsy or loop electrosurgical excision procedure (LEEP), which removes a wedge of cervical tissue that contains the cancer. Surgeries can also be more extensive such as a hysterectomy.

RADIATION THERAPY
is the use of high-dose X-rays to destroy cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or it may come from the placement a radiation source inside the body (internal radiation therapy, or brachytherapy). The two forms of brachytherapy used to treat cervical cancer include low-dose-rate (LDR) brachytherapy and high-dose-rate (HDR) brachytherapy.

CHEMOTHERAPY
is the use of medicine to destroy cancer cells. It is called a systemic treatment because it enters the bloodstream, travel through the body, and can destroy cancer cells that may have escaped the cervix and traveled. Chemotherapy is often used in combination with radiation (with or without surgery) for cervical cancer.

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.