Screening for cervical cancer is the testing of women for precancerous developments even in the absence of any symptoms. The intended outcome of cervical cancer screening is different from that of screening for other types of cancer: the primary goal of cervical cancer screening is not to find cancer, but to find precancerous lesions. The reason for this is that detection and treatment of precancerous cervical lesions (dysplasia) can actually prevent cervical cancer from ever occurring. Additionally, if cervical cancer is detected while in its earliest in situ stage, the likelihood of survival is almost 100 percent with timely and appropriate treatment and follow-up.

Screening techniques that also include HPV testing may increase the ability to detect abnormal cell changes early, and may also let a woman know whether or not she carries one of the more dangerous viruses, which would increase the need to be extra vigilant about screening.

All women who are 18 or older, or who are sexually active, should receive yearly pelvic examinations and Pap smears. The Pap smears should be done annually for at least three consecutive negative Pap smears in a row. While some physicians perform Pap smears less regularly after three consecutive negative results, the safer course is to continue to perform yearly Pap smears, especially if there are any risk factors present. In addition, if a woman has previously been treated for cervical or endometrial cancer, more frequent Pap smears are recommended; typically, every 3-6 months in the first 3 years after completion of treatment with surgery or radiation therapy.

The Pap Smear

Pap smears are tests performed during the pelvic examination by inserting a speculim into the vagina so that the Cervix can be visualized and a sample of cells can be removed from the outer portion of the cervix using a wooden or plastic spatula. A small brush is then used to take a second sample from the inner part of the cervix. These samples are immediately preserved on glass slides and are then microscopically analyzed for the presence of cancerous or precancerous changes. For women who have undergone a hysterectomy with removal of the cervix, the vaginal cuff is visually inspected and the sample is taken from the vaginal cuff.

If cancerous or precancerous changes are detected, a cancer diagnosis work-up is required to determine the nature of the cancer and whether it has spread.

If a woman has an abnormal Pap smear, it is appropriate to do a workup to determine whether only precancerous changes are present in the cervix, or whether cancer cells are already present. If cancer cells are already present, it must also be determined how much cancer is present and how far the cancerous cells have spread. If the cancer has spread beyond the cervix, it is said to have metastasized.

The size and spread of the cancer is classified as the stage of the cancer. Knowing the stage of the cancer is important because it is the primary factor in the selection of treatment and in the prognosis for the woman. One or more of the following tests may be necessary to identify the stage of the cancer:

• Colposcopy is a procedure that involves the insertion of a viewing scope (the colposcope) into the vagina in order to magnify the region for inspection. Prior to inserting the colposcope, a Schiller test, a rinse of an iodine solution applied with a cotton swab, is administered to turn abnormal cells yellow or white. Small clusters of these abnormal cells can then be removed for biopsy with an Endocervical Curettage.

• Endocervical Curettage (ECC) is often performed during the colposcopy. ECC involves the scraping of cells from the inner portion of the cervix. Since it may not be possible to properly view the inner cervix with the colposcope, performing an ECC may be necessary in order to detect certain forms of cervical cancer, such as adenocarcinoma, which grows in the upper portion of the cervix. Together, colposcope and ECC will identify most cervical cancers.

• Loop electrocautery excision procedure (LEEP) In this procedure, abnormal or suspicious cervical tissue is removed with a sharp wire loop and the site is cauterized to eliminate remaining abnormal tissue. The area of the cervix containing abnormal cells is known as the transformation zone.

• Conization, or a cone biopsy. This procedure uses a scalpel or laser to remove a cone-shaped section of the cervix for biopsy. Conization helps assess how much tissue is diseased. Because it requires removal of part of the cervix, it is generally recommended when other diagnostic tests have revealed cancerous abnormalities, invasive cervical cancer is suspected, and a comprehensive diagnosis is necessary.

• Pelvic Ultrasound is an imaging technique that uses sound waves to produce an image that can be used to measure the size and position of the cancer.

• CT Scan (or CAT Scan), which stands for computerized axial tomography, uses computerized X-ray pictures to evaluate internal organs of the body. The CT scan is most often used prior to administering radiation therapy (discussed further under cancer treatment) in order to help calculate how much radiation and where exactly in the body the radiation should be delivered by determining the size and position of the cancer.

• MRI, which stands for magnetic resonance imaging is a non-invasive procedure that produces a two-dimensional view of organs and structures. The MRI images can be used to identify abnormal nodules in bones and in the lymph nodes, a sign that the cancer may be spreading.

• Endoscopy is a procedure that uses a thin flexible tube (called an endoscope) that has a lens or camera at the end and records images of what is seen through the camera on a computer screen, allowing visualization of internal organs, such as the uterus. Biopsy samples are often taken through the endoscope during the procedure.

• Laboratory Tests, such as a blood test and a urine test, can be used to check the cells of the blood to determine the level of functioning of the kidneys and liver. X-rays can be used to check the status of the organs, such as the lungs.

The cancer's stage is documented by using a standard system which assigns letters and numbers to indicate the size and spread of the cancer:

• Stage 0 or carcinoma in situ

  Carcinoma in situ is very early cancer. When discussing stage 0 and carcinoma in situ of the cervix or vagina, the condition is more properly understood as a pre-cancerous problem that has not yet behaved like a cancer. The abnormal cells are found only in the first layer of cells of the primary site and do not invade the deeper tissues.

• Stage I

  Cancer involves the primary site, but has not spread to nearby tissues.

  • stage IA:

    a very small amount of cancer -- visible under a microscope -- is found deeper in the tissues.

  • stage IB:

    a larger amount of cancer is found in the tissues.

• Stage II

  Cancer has spread into surrounding structures such as the upper part of the vagina or nearby lymph nodes but is still inside the primary site.

  • stage IIA:

    cancer has spread beyond the primary site but is limited compared to IIB.

  • stage IIB:

    cancer has spread to other tissue around the primary site.

• Stage III

  Cancer has spread to surrounding structures such as the lower part of the vagina, nearby lymph nodes, the outer layer of the womb, or nearby structures within the pelvic area.

• Stage IV

  Cancer has spread beyond the pelvic area, to such areas as the bladder, bowel, lungs, liver, or bone.

  • stage IVA:

    cancer has spread to organs close to the pelvic area.

  • stage IVB:

    cancer has spread to distant organs, such as the lungs.

• Recurrent

  Recurrent disease means that the cancer has come back (recurred) after it has been treated.

The malignancy (or aggressiveness) of the cervical cancer is documented by assigning a grade to the cancer. The grade assigned to the cancer is based upon the appearance of the cancer cells and how they are arranged together. The grade is generally determined by a microscopic examination of cancerous cells obtained from the cervix by a biopsy.

The cancer's grade is assigned using a standard grading system which assigns cancer cells a score from 1 to 3:

• low-grade cancer. This is the least-aggressive type of cancer. Cells from low-grade cervical cancer have an appearance most like normal cells, and tend to be slow-growing. Such cancer cells are called well-differentiated.

• intermediate-grade cancer. By the time the cancer has become intermediate-grade, it has turned more aggressive than a low-grade cancer. Intermediate-grade cancer cells have an appearance that is less like normal cells and is often faster growing than low-grade cancer cells. Such cells are called moderately-differentiated.

• high-grade level. This is the most aggressive type of cancer. Cells from high-grade cervical cancer are the least like normal cells. They are rapid-growing and highly aggressive, often spreading into the lymph nodes and bone. Such cells are called poorly-differentiated.

The higher the grade of the cancer, the more difficult it is to successfully treat the cancer.

Once the diagnostic workup is completed, a proper treatment plan can be developed.