Cervical cancer


Diagnosing cervical cancer

Sunday 16 August, 2020

You may have tests for cervical cancer because you have symptoms or because your cervical screening test results (see below) suggest that you have a higher risk of developing 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

Cervical screening is the process of looking for cancer or pre-cancerous changes in people who don’t have any symptoms. The cervical screening test detects cancer-causing types of human papillomavirus (HPV) in a sample of cells taken from the cervix.

The National Cervical Screening Program recommends, if you have a cervix and are between 25 and 74 years old, that you have a cervical screening test two years after your last Pap test, and then once every five years. Whether you identify as straight, lesbian, gay, bisexual, transgender or intersex, if you have a cervix you should have regular cervical screening tests.

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 and sent to a laboratory to check for HPV.

If HPV is found, a specialist doctor called a pathologist will do an additional test on the sample to check for cell abnormalities. This is called liquid-based cytology (LBC).

The results of the cervical screening test are used to predict your level of risk for significant cervical changes. What happens next depends on the level of risk that is shown by the results:

  • a higher risk – your general practitioner (GP) will refer you to a specialist (gynaecologist) for colposcopy (see below)
  • an intermediate risk – you will be monitored by having a follow-up test (usually for HPV) in 12 months and more frequent screening tests in the future
  • a low risk – you will be due for your next cervical screening test in five years.

A small number of people are diagnosed with cervical cancer because of an abnormal cervical screening test. For more information about screening tests, call Cancer Council 13 11 20 or visit cervicalscreening.org.au.

Colposcopy and biopsy

A colposcopy lets your doctor look closely at the cervix to help see where abnormal or changed cells are and what they look like. The colposcope is a magnifying instrument that has a light and looks like a pair of binoculars on a large stand. It is placed near your vulva but does not enter your body.

A colposcopy usually takes 10 to 15 minutes. You will be advised not to have sex or put anything in your vagina (for example, tampons) for 24 hours before the procedure.

You will lie on your back in an examination chair with your knees up and apart. The doctor will use a speculum to spread the walls of your vagina apart, and then apply a vinegar-like liquid or iodine to your cervix and vagina. This makes it easier to see abnormal cells through the colposcope. You may feel a mild stinging or burning sensation, and you may have a brown discharge from the vagina afterwards.

If the doctor sees any suspicious-looking areas, they will usually take a tissue sample (biopsy) from the surface of the cervix for examination. 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 done. The doctor will send the tissue sample to a laboratory; a pathologist will examine the cells under a microscope to see if they are cancerous. The results are usually available in about a week.

Side effects

After the procedure it is common to experience cramping that feels similar to menstrual pain. Pain is usually short-lived and you can take mild pain medicines such as paracetamol or non-steroidal anti-inflammatory drugs. 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 two to three days after a biopsy.

Treating pre-cancerous abnormalities

If any of the tests show pre-cancerous cell changes, you may have one of the following treatments to prevent you developing cervical cancer.

Large loop excision of the transformation zone (LLETZ)

Also called loop electrosurgical excision procedure (LEEP), a large loop excision of the transformation zone (LLETZ) is the most common way of removing cervical tissue to treat pre-cancerous changes of the cervix. The abnormal tissue is removed using a thin wire loop that is heated electrically. The doctor aims to remove all the abnormal cells from the surface of the cervix.

A LLETZ or LEEP is done under local anaesthetic in your doctor’s office or under general anaesthetic in hospital. It takes about 10 to 20 minutes. The tissue sample is sent to a laboratory for examination under a microscope. Results are usually available within a week.

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

Side effects

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 three to four weeks. If the bleeding lasts longer than three to four weeks, becomes heavy or smells bad, see your doctor.

After a LLETZ or LEEP you can still become pregnant, but you may have a slightly higher 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. It is used when the abnormal cells are found in the cervical canal, when early stage cancer is suspected, or for older women needing a larger excision. In some cases, it is also used to treat very small, early stage cancers, particularly for young women who would like to have children in the future.

The cone biopsy is usually done as day surgery in hospital under general anaesthetic. A surgical knife (scalpel) is used to remove a cone-shaped piece of tissue from the cervix. The tissue is examined to make sure that all the abnormal cells have been removed. Results are usually available within a week.

Side effects

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 three to four weeks, becomes heavy or has a bad smell, 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 four to six weeks after the procedure.

A cone biopsy may weaken the cervix. You can still become pregnant after a cone biopsy, but you may be at a higher risk of having a miscarriage or having the baby prematurely. If you would like to become pregnant in the future, talk to your doctor before the procedure. 

Laser surgery

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

A laser beam is a strong, hot beam of light. The laser beam is pointed at the cervix through the vagina. The procedure is done under local anaesthetic. Laser surgery takes about 10 to 15 minutes. You can go home as soon as the treatment is over.

Laser surgery works just as well as LLETZ and may be a better option if the pre-cancerous cells extend from the cervix into the vagina or if the lesion (group of cells) on the cervix is very large.

Side effects

These are similar to those of LLETZ. Most people are able to return to normal activity two to three days after laser surgery, but will need to avoid sexual intercourse for four to six weeks.

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

You may have a blood test to check your general health, and how well your kidneys and liver are working.

Imaging scans

You may have one or more of the following imaging scans to find out if the cancer has spread to lymph nodes in the pelvis or abdomen or to other organs in the body.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast during previous scans. You should also let them know if you have diabetes or kidney disease or are pregnant.

CT (computerised tomography) 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. 

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 shaped like a doughnut. The scan is painless and takes five to ten minutes.

MRI (magnetic resonance imaging) scan

An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to build up detailed cross-sectional 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 affect how an MRI works.

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 to your medical team before the scan. You may be given medication to help you relax, and you will usually be offered headphones or earplugs. MRI scans usually take 30 to90 minutes.

PET (positron emission tomography) 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 to 60 minutes while the solution spreads throughout your body.

Cancer cells show up more brightly 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.

PET–CT scan

A PET scan combined with a CT scan is a specialised test available at many major metropolitan hospitals. It produces a three-dimensional colour image. The CT helps pinpoint the location of any abnormalities revealed by the PET scan.

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.

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.

Pelvic examination

The doctor will put a speculum into your vagina and spread the walls of the vagina apart so they can check your cervix and vagina for cancer.

Uterus

The cervix will be dilated (gently opened) 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 an  attached camera.

For more information about the most common tests used to diagnose cancer – from blood tests and biopsies to CT, MRI and PET scans – listen to our “Tests and Cancer” podcast episode at cancercouncil.com.au/podcasts.

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 healthcare 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 Where the cancer is Name
I Cancer is found only in the tissue of the cervix. Early or localised cancer
II Cancer has spread outside the cervix to the upper two-thirds of the vagina or other tissue next to the cervix. Locally advanced cancer
III Cancer has spread to the lower third of the vagina or the tissue on the side of the pelvis (pelvic wall) or to both of these areas. The cancer may also have spread to lymph nodes in the pelvis or abdomen, or caused a kidney to stop working. Locally advanced cancer
IV Cancer has spread to the bladder or rectum (stage IVA) or beyond the pelvis to the lungs, liver or bones (stage IVB). Metastatic or advanced cancer

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 anyone to predict the exact course of the disease. Instead your doctor can give you an idea about the general prognosis for people with the same type and stage of cancer.

To work out your prognosis, your doctor will consider these points:

  • 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 overall health.

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 the cancer coming back after treatment (recurrence).

Key points

Cervical screening test

A cervical screening test checks for  human papillomavirus (HPV), the virus that causes almost all cervical cancers. If
HPV is detected, a pathologist will look for cell changes. HPV usually goes away on its own, but if your cervical screening test shows you are at higher risk of pre-cancerous cell changes, you will usually have further tests.

Pre-cancerous cell changes

Pre-cancerous cell 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.

Follow-up tests

  • If you are at higher risk of significant cervical abnormalities, the first test is a colposcopy to look for cell changes in the cervix and vagina.

  • Your doctor may take a tissue sample (biopsy) from the cervix to see whether any cell changes are pre-cancerous or cancerous.

  • You may have further tests or imaging scans to find out whether the cancer has spread to other parts of the body.

Staging and prognosis

  • The stage shows how far the cancer has spread through the body.

– Early cervical cancer is stage I.

– Locally advanced cervical cancer is stage II or III.

– Advanced (metastatic) cervical cancer is stage IV.

  • If cervical cancer is diagnosed early, it can usually be treated successfully.

Expert content reviewers:

Associate Professor Penny Blomfield, Gynaecological Oncologist, Hobart Women’s Specialists, and Chair, Australian Society of Gynaecological Oncologists, Tas; Karina Campbell, Consumer; Carmen Heathcote, 13 11 20 Consultant, Cancer Council Queensland; Dr Pearly Khaw, Consultant Radiation Oncologist, Peter MacCallum Cancer Centre, Vic; Associate Professor Jim Nicklin, Director, Gynaecological Oncology, Royal Brisbane and Women’s Hospital, and Associate Professor Gynaecologic Oncology, University of Queensland; Professor Martin K .Oehler, Director, Gynaecological Oncology, Royal Adelaide Hospital, SA; Dr Megan Smith, Program Manager – Cervix, Cancer Council NSW; Pauline Tanner, Cancer Nurse Coordinator – Gynaecology, WA Cancer & Palliative Care Network, WA; Tamara Wraith, Senior Clinician, Physiotherapy Department, Royal Women’s Hospital, Vic

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