Diagnosing cervical cancer


If your screening test results (see below) suggest that you have a higher risk of developing cervical cancer, or you have symptoms of cancer, you will be referred to a specialist for tests to confirm the diagnosis of precancerous changes or cervical cancer.

Some tests allow your doctor to see the tissue in your cervix and surrounding areas more clearly. Other tests tell the doctor about your general health and whether the cancer has spread. You probably won't need to have all the tests described in this section.

Screening test for cervical cancer

Screening is the process of looking for cancer or precancerous changes in people who don't have any symptoms.

For several decades, the Pap test (also called a Pap smear) has been used as a screening test for cervical cancer. While this has helped decrease cervical cancer significantly, scientific evidence has found that screening women for HPV – the virus that causes cervical cancer – is a more effective way of preventing cervical cancer.

In December 2017, a Cervical Screening Test will replace the Pap test as part of the National Cervical Screening Program. The new Cervical Screening Test will detect cancer-causing HPV types in a sample of cells taken from the cervix.

During both the old Pap test and the new Cervical Screening Test, the doctor gently inserts an instrument called a speculum into the vagina to get a clear view of the cervix. The doctor uses a brush or spatula to remove some cells from the surface of the cervix. This can feel slightly uncomfortable, but it usually takes only a minute or two. The sample is placed into liquid in a small container (a vial) and then sent to a laboratory for further testing.

The results of the screening test are used to predict your level of risk for precancerous cell changes or cervical cancer. If the results show a higher risk, your GP will refer you to a specialist (gynaecologist) to discuss whether you need further tests or treatment and how you will be monitored. Monitoring may include a follow up test (usually for HPV) or more frequent screening tests in the future.

For more information about screening tests, call Cancer Council 13 11 20 or visit cancerscreening.gov.au.

The current screening program recommends two-yearly Pap tests for women aged 18–69 who are or have ever been sexually active. Under the new program, women aged 25–74 will be tested for HPV every five years.

Colposcopy

A colposcopy is a way of looking closely at the cervix to help see where abnormal or changed cells are and what they look like. While you are lying on your back, the doctor will use an instrument called a speculum to open up the vagina so they can look at your cervix through a colposcope.

The colposcope is a magnifying instrument that has a light and looks like a pair of binoculars on a large stand. It doesn't touch you or go inside your body. The doctor may coat your cervix and vagina with a fluid to highlight any abnormal areas. The colposcopy takes 10–15 minutes.

Side effects of a colposcopy

You may feel some mild discomfort during the procedure.

Biopsy

A biopsy is when the doctor removes some tissue from the surface of the cervix and sends it to a laboratory for examination under a microscope. A biopsy may be done during the colposcopy. During a biopsy, you may feel uncomfortable for a short time while the tissue sample is taken.

You will be able to go home once the colposcopy and biopsy are over. The results will be available in about a week.

Side effects of a colposcopy with biopsy

After the procedure, it is common to experience cramping that feels similar to menstrual pain. You can ask for medicine to relieve any pain. You may also have some light bleeding or other vaginal discharge for a few hours.

To allow the cervix to heal and to reduce the risk of infection, your doctor will probably advise you not to have sexual intercourse or use tampons for 2–3 days after a biopsy.

Finding and treating precancerous abnormalities

Large loop excision of the transformation zone (LLETZ)

Also called loop electrosurgical excision procedure (LEEP), this is the most common way of removing cervical tissue for examination and treating precancerous changes of the cervix. The abnormal tissue is removed using a thin wire loop that is heated electrically. Sometimes the doctor can remove all visible abnormal cells.

A LLETZ is usually done under a local anaesthetic in the doctor's office or, sometimes, under a general anaesthetic in hospital. It takes about 10 minutes. Sometimes it is done at the same time as a colposcopy, but this is uncommon. The tissue sample will be sent to a laboratory for examination under a microscope. The results will be available in about a week.

Side effects of a LLETZ or LEEP

After a LLETZ or LEEP, you may have some vaginal bleeding and cramping. This will usually ease in a few days, but you may notice some spotting for 3–4 weeks. If the bleeding lasts longer than 3–4 weeks, becomes heavy or has a bad odour, see your doctor. To allow your cervix to heal and to prevent infection, you should not have sexual intercourse or use tampons for 4–6 weeks after the procedure.

After a LLETZ or LEEP procedure you can still become pregnant, however the procedure may slightly increase your risk of having the baby prematurely. Talk to your doctor before the procedure if you are concerned.

Cone biopsy

This procedure is similar to a LLETZ, and is used when there are abnormal glandular cells in the cervix or when early-stage cancer is suspected. In some cases, it is also used to treat very small, early-stage cancers.

A surgical knife (scalpel) is used to remove a cone-shaped piece of tissue from the cervix. The cone biopsy is usually done under a general anaesthetic and involves a day or overnight stay in hospital. Results are usually available in a week.

Side effects of a cone biopsy

You may have some light bleeding or cramping for a few days after the cone biopsy. Avoid doing any heavy lifting for a few weeks, as the bleeding could become heavier or start again. If the bleeding lasts longer than 3–4 weeks, becomes heavy or has a bad odour, see your doctor. Some women notice a dark brown discharge for a few weeks, but this will ease.

To allow your cervix time to heal and to prevent infection, you should not have sexual intercourse or use tampons for 4–6 weeks after the procedure.

A cone biopsy may weaken the cervix. If you would like to become pregnant in the future, talk to your doctor before the procedure. It is usually still possible to become pregnant, but you may be at a higher risk of having a miscarriage or having the baby prematurely. Some women who become pregnant after a cone biopsy have stitches inserted into the cervix to strengthen it. These stitches are usually removed before the baby is born.

Cone biopsy

Laser surgery

This procedure uses a laser beam in place of a knife to burn away the abnormal cells or remove pieces of tissue for further study.

A laser beam is a strong, hot beam of light. The laser beam is directed through the vagina and the procedure is done under local anaesthetic. Laser surgery takes about 10–15 minutes, and you can go home as soon as the treatment is over.

Laser surgery is just as effective as LLETZ and may be a better option if the precancerous cells extend into the wall of the vagina or if the lesion on the cervix is very large.

Side effects of laser surgery

These are similar to those of LLETZ. Most women are able to return to normal activity within 2–3 days after laser surgery.

Further tests

If any of the tests described above show that you have cervical cancer, you may need to have further tests to help the doctor work out whether the cancer has spread to other parts of your body. This is called staging. You may have one or more of the tests described below.

Blood test and chest x-ray

You may have a blood test to check your general health and how well your kidneys and liver are working. You may also have an x-ray of your chest so the doctor can examine your lungs for signs of cancer.

Imaging scans

CT scan

A CT (computerised tomography) scan uses x-rays to take pictures of the inside of your body and then compiles them into a detailed, three-dimensional picture. The scan can show whether the cancer has spread to lymph nodes in the abdomen or pelvis or to other organs in the body.

Before the scan, you may be given a drink or an injection of a dye (called contrast) into one of your veins. The contrast may make you feel hot all over for a few minutes. You may also be asked to insert a tampon into your vagina. The dye and the tampon make the pictures clearer and easier to read.

For the scan, you will need to lie still on a table that moves in and out of the CT scanner, which is large and round like a doughnut. The scan is painless and takes 5–10 minutes.

The dye used in a CT scan usually contains iodine. If you have had an allergic reaction to iodine or dyes, let the person performing the scan know in advance. You should also tell them if you're diabetic, have kidney disease or are pregnant.

MRI scan

An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to build up detailed crosssectional pictures of the inside of your body. Let your medical team know if you have a pacemaker or any other metal implant as some may interfere with an MRI.

During the scan, you will lie on a treatment table that slides into a large metal cylinder that is open at both ends. The noisy, narrow machine can make some people feel anxious or claustrophobic. If you think you may become distressed, mention it beforehand to your medical team. You may be given medication to help you relax, and you will usually be offered headphones or earplugs. MRI scans usually take 30–90 minutes.

PET scan

Before a PET (positron emission tomography) scan, you will be injected with a glucose (sugar) solution containing some radioactive material. You will be asked to lie still for 30–60 minutes while the solution spreads throughout your body.

Cancer cells show up brighter on the scan because they absorb more of the glucose solution than normal cells do. It may take a few hours to prepare for a PET scan, but the scan itself usually takes about 30 minutes.

Examination under anaesthetic

Another way for the doctor to check whether the cancer has spread is to examine your cervix, vagina, uterus, bladder and rectum. This is done in hospital under general anaesthetic. If the doctor sees any abnormal areas of tissue during the procedure, they will take a biopsy and send the sample to a laboratory for examination.

Pelvic examination

The doctor will put a speculum into your vagina to check for cancer.

Uterus

The cervix will be dilated (stretched) and some of the cells in the lining of the uterus (endometrium) will be removed and sent to a laboratory for examination under a microscope. This is called a dilation and curettage (D&C).

Bladder

A thin tube with a lens and a light called a cystoscope will be inserted into your urethra (the tube that carries urine from the bladder to the outside of the body) to examine your bladder.

Rectum

The doctor will use a gloved finger to feel for any abnormal growths inside your rectum. To examine your rectum more closely, the doctor may insert an instrument called a sigmoidoscope, which is a flexible tube with a camera attached.

You will most likely be able to go home from hospital on the same day as the examination under anaesthetic. You may have some light bleeding and cramping for a few days afterwards. Your doctor will talk to you about side effects you may experience.

Staging cervical cancer

The tests described above help the doctors decide how far the cancer has spread. This is called staging.

Knowing the stage of the cancer helps your health care team recommend the best treatment for you.

In Australia, cervical cancer is usually staged using the International Federation of Gynecology and Obstetrics (FIGO) staging system. It is often used for other cancers of the female reproductive organs. FIGO divides cervical cancer into four stages. Each stage is further divided into several sub-stages.

Cervical cancer stages
Stage I The cancer is found only in the tissue of the cervix.
Stage II Cancer has spread outside the cervix to the upper two-thirds of the vagina or other tissue next to the cervix (parametrium).
Stage III Cancer has spread to the tissue on the side of the pelvis (pelvic sidewall) and/or the lower third of the vagina.
Stage IV The cancer has spread to the bladder or rectum, or beyond the pelvis to the lungs, liver or bones.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the disease.

In general, the earlier cervical cancer is diagnosed and treated, the better the outcome. Most early-stage cervical cancers have a good prognosis with high survival rates. If cancer is found after it has spread to other parts of the body (referred to as an advanced stage), the prognosis is worse and there is a higher chance of recurrence.

To work out your prognosis, your doctor will consider:

  • your test results
  • the type of cervical cancer you have
  • the rate and depth of tumour growth
  • other factors such as your age, fitness and medical history.

Key points

  • Cervical cell changes may be detected by a screening test. Low-grade changes usually go away on their own; highgrade changes will require treatment.
  • During a colposcopy, the doctor examines the cervix and vagina using a magnifying instrument called a colposcope.
  • A biopsy is when a sample of tissue is removed from the cervix to be examined under a microscope.
  • An examination of cervical tissue will show whether the cell changes are cancerous.
  • Precancerous changes can be checked and treated in several ways including large loop excision of the transformation zone (LLETZ)/ loop electrosurgical excision procedure (LEEP); cone biopsy or laser surgery.
  • Further tests or scans, including CT, MRI and PET scans, may be required to check whether the cancer has spread to other parts of the body.
  • Staging describes how far the cancer has spread in the body. Knowing the stage of the cancer allows the doctor to recommend the best treatment for you.
  • Prognosis is the expected outcome of a disease. If cervical cancer is diagnosed, early, it can usually be treated successfully.
  • You will see many health professionals, including gynaecological oncologist, radiation oncologist and medical oncologist as necessary, who work together as a multidisciplinary team.

Expert content reviewers:

Prof Ian Hammond, Gynaecological Oncologist (retired), WA and Chair, Cancer Council Australia Cervical Cancer Screening Guidelines Working Party, National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Cancer Council Australia, Sydney, 2016; Jennifer Duggan, Clinical Nurse Consultant Gynaecological Oncology, Royal Hospital for Women, NSW; Dr Rhonda Farrell, Gynaecological Oncologist, Royal Hospital for Women, Prince of Wales Private Hospital, St George Hospital, and Conjoint Lecturer, School of Women's & Children's Health, University of NSW; Melinda Grant, Consumer; Karen Hall, 13 11 20 Consultant, Cancer Council SA; Dr Pearly Khaw, Consultant Radiation Oncologist, Peter MacCallum Cancer Centre, VIC; Megan Smith, Program Manager – Cervix/HPV and Breast Group, Cancer Research Division, Cancer Council NSW.

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