How does cancer begin?

Cancer begins with a change in the structure of DNA, which is found in all human cells. DNA provides cells with a basic set of instructions, such as when to grow and when to reproduce.

A change in the DNA's structure (genetic mutation) changes these instructions so that the cells carry on growing and reproducing uncontrollably. This produces a lump of tissue known as a tumour.

How does cancer spread?

Left untreated, cancer can quickly grow and spread to other parts of the body, usually through the lymphatic system.

The lymphatic system is a series of glands (or nodes) located throughout your body. It is similar to the blood circulatory system. Lymph glands produce many specialised cells that are needed by your immune system to fight infection.

Once the cancer reaches the lymphatic system, it can spread to any other part of the body, including your bones, blood and organs.

Risk factors

The exact cause of cervical cancer is unknown. However, evidence suggests that a number of risk factors can increase your likelihood of developing cervical cancer:

• human papilloma virus (HPV),
• cervical intra-epithelial neoplasia (CIN),
• smoking, and
• how many children you have, and at what age.

Human papilloma virus (HPV)

Human papilloma virus (HPV) is the name given to a family of viruses that affect the skin and the moist membranes that line the body, such as those in the cervix, anus, mouth and throat.

There are many different types of HPV, some of which are more high risk than others.

Over 99% of all cases of cervical cancer are linked with HPV. The virus can lay dormant for many years before it can start damaging the cells of the cervix, causing a pre-cancerous condition called CIN (see below). CIN can lead to cervical cancer.

However, most women who are infected with HPV will not develop CIN - HPV infection simply increases the risk.

HPV is spread during sexual intercourse, including anal and oral sex.

Cervical intraepithelial neoplasia (CIN) 

Cancer of the cervix usually takes many years to develop. Before it does, the cells in the cervix often show changes, known as cervical intraepithelial neoplasia (CIN). CIN is a form of pre-cancer and is linked to infection by HPV.

If left untreated, CIN can develop into cervical cancer. However, the majority of women with CIN do not develop the disease.

Women with the condition should be closely monitored or treated by a doctor (see Treating CIN).

Smoking

Chemicals from cigarettes get into the bloodstream and can affect cells throughout the body. Smokers are more likely than non-smokers to develop certain cancers, including cervical cancer.

How many children you have, and at what age

Women who have their first baby before the age of 17 have double the risk of developing cervical cancer compared with women who have their first baby at 25 or older.

Research has also found that women with three or more children have an increased risk when compared with women with no children.

Contraceptive pill

Research suggests that women who use the contraceptive pill for more than 10 years may have a slightly increased risk of developing cervical cancer.

However, it is important to remember that the increase in risk is low, that if you have regular cervical screening the increased risk is cancelled out, and that for most women the benefits of taking the pill outweigh the slightly increased risk.

Early diagnosis of cervical cancer is essential for successful treatment of the condition.

Before diagnosing cervical cancer, your GP will ask you about your symptoms and look at your medical history.

If you have abnormal bleeding, they will usually do an internal examination of your vagina. Abnormal bleeding is:

• bleeding between periods,
• bleeding after or during sex, or
• bleeding after your menopause.

You may be tested for chlamydia, to rule out this sexually transmitted infection.

Referral to a gynaecologist

Your GP may refer you to a gynaecologist (specialist in treating conditions of the female reproductive system) for further tests if you have had an abnormal smear test result or if your symptoms suggest cervical cancer.

You should be referred to a gynaecologist urgently (within two weeks) if:

• your GP sees that you have cervical cancer after examining you,
• you are past the menopause and have had one or more episodes of heavy vaginal bleeding (and are not on HRT),
• you have had unexplained or persistant bleeding after stopping HRT for six weeks or more,
• you frequently bleed after sex for no apparent reason, or
• you frequently bleed between periods for no apparent reason.

Colposcopy

If you have had an abnormal smear test result or your symptoms suggest cervical cancer, your gynaecologist will usually do a colposcopy.

A colposcopy is an internal vaginal examination to look for any abnormalities in your cervix.

An instrument called a colposcope is used, which is a small microscope with a light on the end of it.

Your doctor may remove a small sample of the tissue (a biopsy) so this can be checked under a microscope for cancerous cells.

Cone biopsy

If your gynaecologist cannot see properly with the colposcope, you may need a cone biopsy.

This is a minor operation carried out in hospital under local (or sometimes general) anaesthetic.

A small, cone-shaped section of your cervix is removed so this can be checked under a microscope for cancerous cells.

It is normal to have bleeding from your vagina for up to four weeks after this minor operation, and you may also have period-like pains.

Further testing

If the results of the biopsy suggest that you have cancer, and there is a risk that the cancer may have spread, you will probably require further testing to assess how widespread the cancer is.

These tests may include:

• A pelvic examination under general anaesthetic. Your womb, vagina, rectum and bladder are checked for cancer.
• Blood tests.
• CT scan: This is a computerised X-ray that can take detailed pictures of the inside of the body. It is useful for showing up cancer tumours, and checking whether cancer cells have spread.
• MRI scan: This is a scan that uses radio waves and magnets to produce detailed pictures of the inside of the body. It is used to check whether cancer has spread.
• Chest X-ray: This will show up any cancer that has spread to your lungs.

Cancer of the cervix is a relatively rare type of cancer. In the UK, around 2,800 women are diagnosed with it each year.

The symptoms of cervical cancer are not always obvious. It may not cause any symptoms at all until it has reached an advanced stage.

If cervical cancer causes symptoms, the most common is abnormal vaginal bleeding, e.g. between periods or after sexual intercourse (see Symptoms).

The cervix

The cervix is the lower part (or neck) of the womb. It is made of muscle tissue and is the entrance to the womb from the vagina.

Types of cervical cancer

There are two main types of cervical cancer:

• Squamous cell carcinoma is the most common type of cervical cancer. It develops from the squamous cells, which are the flat cells in the outer layer of the cervix at the top of the vagina.
• Adenocarcinoma develops from the cells that line the glands in the cervix. Adenocarcinoma can be more difficult to detect using cervical screening tests.

Who is affected?

Cervical cancer is often diagnosed in younger women. It is the second most common cancer in women aged under 35, after breast cancer.

What is the cause?

More than 99% of cases of cervical cancers are thought to be caused by the human papilloma virus (HPV). See Causes for more information.

In September 2008, the NHS launched a vaccination programme for HPV. The vaccine provides protection against the two types of HPV that cause cervical cancer (see Prevention).

Outlook

Early-stage cancer that is confined to the cervix can usually be successfully treated through surgery and/or radiotherapy (see Treatment). However, if the cancer has spread to the surrounding areas, such as the vagina, bladder or lymph nodes, the outlook is less positive.

Cervical cancer can be prevented if it is detected in the early stages via cervical screening.

Practising safe sex

There is a strong link between certain types of human papilloma virus (HPV) and the development of abnormalities that may turn into cervical cancer.

As HPV is spread through unprotected sex, using a condom is the best way to avoid it.

Before beginning a sexual relationship with a new partner, it is a good idea for you both to be tested for sexually transmitted infections at a sexual health (GUM) clinic. All tests are free and confidential.

Cervical screening

Regular cervical smear tests are the best way to identify abnormal changes in cells of the cervix early on.

Women aged 25-49 are invited for screening every three years, and women aged 50-64 are invited every five years. Make sure your GP surgery has your current contact details so that you carry on getting screening invitations.

It is still important to attend screening tests even if you have been vaccinated for HPV (see below), as the vaccine does not guarantee protection against cervical cancer.

If you have been treated for abnormal cervical cell changes, you will be invited for screening more frequently for some years following treatment. How regularly you need to go depends on how severe the cell change is.

HPV vaccination

There is now a vaccine that provides protection against the two strains of HPV that are thought to be responsible for most cases of cervical cancer.

Girls should be offered the HPV vaccine as part of their routine childhood immunisation programme. The vaccine should be given to girls who are 12 to 13 years of age, with three doses given over six months.

For more information, go to Health A-Z: HPV vaccination.

Quit smoking

You can decrease your chance of getting cervical cancer by not smoking. Smokers are less able to get rid of the HPV infection from the body, which can develop into cancer.

The symptoms of cervical cancer are not always obvious and it may not cause any symptoms at all until it has reached an advanced stage.

This is why it is extremely important for you to have regular cervical smear tests.

Bleeding

If cervical cancer does cause symptoms, the most common is abnormal vaginal bleeding, such as between periods, or after sexual intercourse.

In post-menopausal women (those who have stopped having periods), there may be new bleeding.

Other symptoms

Other symptoms of cervical cancer may include smelly vaginal discharge and discomfort when having sex.

When to seek medical advice

There are many other conditions that can cause vaginal bleeding, smelly discharge and discomfort during sex. However, you should visit your GP or practice nurse if you experience any of these symptoms (see Diagnosis).

Cancer treatment team

Many primary care trusts (PCTs) have multi-disciplinary teams that treat cervical cancer. See box, below left.

If you have cervical cancer, you may see several or all of these professionals as part of your treatment.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

Staging

Health professionals use a staging system to describe how far cervical cancer has spread.

• Stage 0. This is very early cancer (sometimes called carcinoma in situ) found only in the surface layer of the cervix. It may be treated with a cone biopsy (see box, bottom left).
• Stage 1. The cancer is only in the neck of the womb. It is generally treated with surgery or radiotherapy. 
• Stage 2. The cancer has begun to spread outside the neck of the womb and into the surrounding areas, such as the vagina. It is usually treated with surgery or radiotherapy, or both. 
• Stage 3. The cancer has spread into the pelvic area. It is usually treated with radiotherapy and chemotherapy (called chemoradiation).
• Stage 4 (advanced cancer). The cancer has spread to other organs, such as your bladder, rectum or even your lungs. It is treated with surgery and chemoradiation. 

Your doctor will be able to advise you on the best treatment plan for you, depending on factors such as your age, general health, the type and size of tumour, and whether it has spread beyond the cervix.

If you are pregnant and have been diagnosed with cervical cancer, go to the Cancer Research UK's factsheet on Cervical cancer and pregnancy.

Surgery

Surgery usually means having a hysterectomy, which is the removal of your womb and cervix.

However, if you have early-stage cancer, it may be possible to leave enough of your cervix behind so that you may be able to become pregnant afterwards. This is called a trachelectomy.

If your cancer is advanced, you may need to have other organs removed, such as your vagina and lymph nodes, as well as your womb and cervix.

If surgery does not remove all the cancer cells, or if cancer cells were found in your nearby lymph nodes, your doctor may recommend a course of radiotherapy to follow.

For detailed information, go to the Cancer Research UK's factsheet on cervical cancer surgery

Radiotherapy

Radiotherapy may be used after surgery if there is a risk that some cancer cells may be left behind, or to reduce the risk of cancerous cells returning.

If cervical cancer has spread beyond the cervix and cannot be treated using surgery, radiotherapy is usually used instead and may be given in combination with chemotherapy (see below). It can also help patients whose cancer cannot be cured by relieving symptoms and prolonging a good quality of life.

Radiotherapy uses radiation to kill cancer cells.

• If it is given internally, a small radioactive metal object is placed inside your vagina and left for a few hours or days. See the Cancer Research UK factsheet on internal radiotherapy for more information.
• If it is given externally, it is given from outside the body using a machine that directs high energy X-rays at the cancer. You have a few minutes of radiotherapy daily, five days a week for several weeks.

While it kills cancerous cells, radiotherapy can also affect healthy tissue and has a number of side effects, including:

• sore, red skin (like sunburn),
• pain while passing urine,
• diarrhoea,
• tiredness, and
• nausea.

If you have external radiotherapy to the pelvis, you may experience an early menopause (if you have not had the menopause already). This means you will no longer be able to have children.

Chemoradiation

Chemotherapy taken alongside radiotherapy, called chemoradiation, improves overall survival rates by lowering the risk of the cancer coming back.

Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. It is usually given by injection (called intravenous chemotherapy).

Like radiotherapy, the powerful medicines used in chemotherapy can also damage healthy tissue and cause a range of side effects. Side effects include:

• nausea,
• vomiting,
• hair loss, and
• fatigue.

Chemotherapy can also weaken your immune system, making you more vulnerable to infection. However, the side effects should stop once treatment has finished.

Clinical trials

As cervical cancer is relatively rare, you may be asked to take part in a clinical trial. Clinical trials are an important way for health professionals to learn more about the best way to treat specific conditions.

Most clinical trials involve comparing a new treatment with an existing treatment to determine whether the new treatment is more or less effective.

If you do receive a new treatment, there is no guarantee that it will be more effective than an existing one.

Your care team can tell you if there are clinical trials in your area, and explain the advantages and disadvantages of taking part.

For more information on clinical trials, see Clinical trials and medical research

Dr Andy Nordin, consultant gynaecologist and gynaecological oncologist, answers your questions.

What is my chance of being cured?

Most women in the UK with cervical cancer are diagnosed with early-stage disease, when the chance of it being cured is extremely high. 

Many women are cured even if the disease has started to invade other areas in the pelvis.

But if the disease is very advanced when it is diagnosed, there is sometimes no prospect of it being cured. In this situation, the best we can do is manage the symptoms and control the cancer’s progression.

Will I be able to have children?

Cervical cancer often affects young women, who may not have had children when they're diagnosed.

For very early-stage cervical cancer, there are a number of treatments that can preserve fertility. Even when the cancer is larger, there's a new operation called a trachelectomy that removes the cervix and the tissues alongside it, but preserves the womb and the ovaries.

Treatments for advanced-stage cervical cancer generally don't allow a woman to get pregnant in the future.

Discuss with your gynaecologist whether there's any prospect of remaining fertile and treating the cancer safely and effectively.

Will I be able to have sex again?

Most women who have surgical treatment for cervical cancer will have the possibility of a normal sex life afterwards.

Many women who have radiotherapy as part of their treatment will also be able to have a normal sex life, although they are more likely to have some problems, as a possible side effect of radiotherapy is narrowing of the vagina. If you are treated with radiotherapy, your clinical nurse specialist can advise you about using vaginal dilators to maintain the function of your vagina following treatment.

How long will it be before I know the cancer has gone?

Traditionally, we use five years' survival as the indicator that the cancer has been cured. However, recurrence of cervical cancer is uncommon after three years, so if the cancer doesn't come back within three years after treatment, it’s unlikely you’ll have problems after that.

If you have been diagnosed with cancer, your treatment and medical care will probably be the first thing on your mind. But there are other aspects of your life to think about and it is important to know exactly what kind of assistance is available and where you can get it.

If you are finding it hard to cope with day-to-day life, talk about your needs with your doctor or nurse, who will refer you to a social worker. Your social worker will assess exactly the kind of help you need (see below). 

Social care options

Care attendants

Care attendants can help with housework, dressing and washing, or even just keep you company and give your carer a break. Look into this as soon as you can, as many care attendants have waiting lists.

Crossroads is an organisation in England and Wales that helps carers by visiting homes and taking over the responsibilities of care for a while. Visit the Crossroads website at www.crossroads.org.uk (links to external site), or phone 0845 450 0350.

Meals on wheels

Contact your local council about its meals on wheels service. It will usually be able to offer financial assistance to help pay for this. Go to Directgov for details of your eligibility.

Benefits

You may be eligible for income support, disability living allowance or attendance allowance. Get in touch with the Benefit Enquiry Line for more details on 0800 882200 (textphone 0800 243355) or online at www.dwp.gov.uk (links to external site).

Home adaptations

Occupational therapists provide a detailed assessment of your needs at home, making life easier by arranging equipment and making adaptations to your home.

The aim is to create a comfortable and practical place to live during your treatment. This could mean anything from putting a shower downstairs to adding handrails around the house.

There are more than five million people in England who look after an ill or disabled partner, child, relative or friend. Caring for someone can be a varied and demanding job. This is because of the broad range of medical, personal and emotional needs that a person can have.

If you're caring for a family member, you may not consider yourself a carer because you're just doing what needs to be done. You might feel that you have no other options. This can be stressful and you may feel resentful towards the person you're caring for, which can also leave you feeling guilty. You may have been forced to leave your job, give up hobbies and stop socialising, which can be very isolating.

It's important to remember that you're not alone and that there is support available. By law you're entitled to a free health and social care assessment, which you can access through your local authority. The assessment will look at the possibility of you getting practical and financial help.You can find out about assessments on Carers Direct.

Being a carer means that you may be entitled to certain financial benefits, especially if you have to give up work. Find out more about carers' benefits on Carers Direct. Carers can also get help with breaks from caring from local authorities or organisations such as Crossroads Care. You can find out about getting time off on Carers Direct.

Regular smear tests saved Tina's life and her fertlilty. She talks about her experience of cervical cancer and her treatment.

Cervical cancer doesn’t always mean you won’t be able to have a baby. Gynaecologist Dr Andy Nordin says, “For very early stage cervical cancer, where the cancer is very small and confined to the cervix, there are a number of different approaches that can preserve fertility.

“A simple treatment to the cervix called a cone biopsy may be all that is required to remove the cancer, with or without an operation to remove lymph nodes in the pelvis (depending on the size of the cancer).

“Even when the cancer is a little bit larger, generally up to 2cm in diameter, there is a relatively new operation called a trachelectomy that removes the cervix and the tissues adjacent to it, but preserves the womb and the ovaries, enabling a pregnancy to be achieved. 

“However, treatments for advanced stage cervical cancer generally do not enable a woman to preserve the possibility of carrying a pregnancy in the future, although for some women it is possible to effectively treat the cancer and enable the function of the ovaries to be preserved.”

For more information

Cancer Research UK

Cancerbackup (both link to external sites).

Prevention and early diagnosis can save lives

What you need to know about cervical cancer 

• Cervical cancer is cancer of the cervix.  The cervix connects a woman’s womb and her vagina.  It is also known as the neck of the womb
• Cervical cancer can affect women of all ages but is most common in women between 30 – 45 years of age.  It is very rare in women under 25
• Cervical screening –  previously known as a smear test - can prevent cervical cancer and saves thousands of lives each year
• In the future, most cervical cancers will be prevented by HPV vaccination. But for the next few decades, cervical screening will still be vitally important
• The earlier cervical cancer is diagnosed, the better the outcome will be, so it is important to know the signs and symptoms

What causes cervical cancer?

Nearly all cervical cancers are caused by a common sexually transmitted infection called human papilloma virus (HPV).  Most women have HPV at some time, which usually clears up on its own.  If the infection doesn’t clear up there is a risk of abnormal cells developing which could become cervical cancer over time.

What are the signs and symptoms of cervical cancer?

The following are the most common symptoms of cervical cancer.

• Any unusual bleeding from the vagina, particularly after sex or after the menopause when your periods have stopped
• Persistent vaginal discharge that is blood stained or smells unpleasant

If you have any of these symptoms, tell your doctor, even if you have been for screening. The chances are that they are not due to cancer, but it is important to have them checked.

What can I do to reduce my risk of developing cervical cancer?

• Go for cervical screening when you are invited
• Have the HPV vaccine if you are offered it
• If you smoke, try to stop
• Use a condom to reduce your risk of HPV and other sexually transmitted infections.

Even if you have had a normal screening result or have been vaccinated against HPV, it’s important to let your doctor know if you develop any of the symptoms of cervical cancer so they can be checked out.  Like all screening tests, cervical screening isn’t 100% perfect, and the HPV vaccine does not stop all types of HPV that may cause cervical cancer.

Be informed and make a plan

• Work out what you will do if you have abnormal bleeding – arrange to see a doctor
• As soon as your invitation to cervical screening arrives work out when you can go and make the appointment
• If you are 18 or under, consider having the HPV vaccination if you have not already done so.

The above information was produced by the Department of Health with grateful thanks to the cervical cancer key messages forum.