Cervical cancer

The cervix is the short, firm canal between the vagina and the cavity of the womb. A tumour here almost never appears out of nowhere: a virus spends years altering the cells of the lining, and only afterwards do those cells turn malignant. That slowness makes cervical cancer one of the very few common tumours that can be caught long before they exist. It is found most often between the ages of thirty and forty-five, but it is possible at any age and in anyone who has a cervix.

The virus behind almost every case

Practically all cases are linked to human papillomavirus, HPV. This is not a rare infection: most people who are sexually active meet it at some point, and the body usually clears it on its own within a year or two without a single sign. Not every type is dangerous, only the fifteen or so types classed as high risk; two of them, sixteen and eighteen, account for around seventy per cent of cervical cancers.

The virus passes on through any contact of skin and mucous membranes in the genital area, not only through penetrative sex but also through oral and anal sex and shared sex toys. A condom lowers the chance of catching it but does not cover all the skin, so it is not full protection.

Trouble begins when the infection does not go away and stays for years. Changes build up in the cells of the cervix, mild at first and then severe; the word for them is dysplasia. Ten to twenty years usually separate infection from cancer, and for almost all of that stretch the changes either return to normal by themselves or are removed by a minor procedure. That reserve of time is exactly what screening uses.

Signs that should not be sat on

Pre-cancerous changes do not hurt and cannot be felt at all, which is the worst thing about them. Cancer itself usually announces itself through bleeding that falls outside the usual rhythm:

• bleeding after sex, between periods or after an examination;
• periods that have become heavier or longer than they have been for years;
• any bleeding after the menopause;
• discharge that has changed: watery, heavy, pinkish or foul-smelling;
• pain during sex;
• a dragging pain low in the abdomen, in the lower back or between the hip bones.

All of this also happens with fibroids, polyps, endometriosis or ordinary inflammation, so most of the time it is not cancer. But one cannot be told from another by eye, and an early tumour has far better odds of being cured outright. If you have lived with similar sensations for years because of another condition, watch for change: a symptom that becomes different, stronger, or turns up outside its usual pattern is a reason to be seen.

Seek help urgently, without waiting for a routine appointment, if bleeding is heavy enough to soak a pad within an hour; if there is any bleeding after the menopause; if urine or bowel contents leak from the vagina; if one leg becomes swollen and painful; if blood appears in urine or stool. Bleeding in pregnancy also means being seen the same day, whatever the stage.

What actually shifts the odds

The main factor is nothing exotic: it is going without checks. Most advanced tumours are found in people who had not had a smear for many years. Next comes smoking, which roughly doubles the risk because it weakens local defences and delivers carcinogens straight into the mucus of the cervix. Then come states in which immunity is suppressed: HIV, medication after a transplant, long-term immunosuppressive treatment. In those people the virus stays around far more often.

The odds are nudged up a little by many births, by a first birth at a very young age, and by earlier cancer of the vagina or vulva. Combined hormonal contraception used for more than five years also shifts the risk slightly upward, but after stopping it returns to normal, and for most women the balance of those pills stays in their favour. A separate and rare story is diethylstilbestrol, a hormone drug prescribed in pregnancy until the mid-seventies: the daughters of those pregnancies develop a particular form of tumour and need follow-up under rules of its own.

If the womb was removed together with the cervix, cervical cancer is no longer possible. But when the operation was done for severe dysplasia, follow-up continues anyway: the vaginal vault is checked.

Vaccine and screening: what really works

These are two different tools. The vaccine stops the changes from starting; screening catches the ones that have already started. Together they cover the subject almost completely, which is why neither replaces the other.

Screening means a smear for cytology, an HPV test, or the two combined. Checks usually begin between twenty-one and twenty-five and continue to about sixty-five; how often depends on the test, since cytology is repeated more frequently and the virus test less so. Ages and intervals differ from country to country, so it is worth confirming the exact schedule with your own doctor. The procedure itself takes a few minutes and may be uncomfortable, but it should not be painful. A virus found, or altered cells found, is not cancer and most often not even pre-cancer: it is a reason to look at the cervix more closely.

The HPV vaccine works best before sexual activity begins, which is why it is given to teenagers of nine to fourteen, boys included, since they carry the virus and develop other tumours linked to it. Having it later is possible, though the benefit is more modest. Vaccinated people still need screening: the vaccine does not cover every cancer-causing type.

One more caveat that is rarely spelled out. Cytology sees tumours growing deep inside the canal, the adenocarcinomas, less well. So a clear smear from a year ago does not cancel a visit to the doctor once bleeding has appeared.

How the diagnosis is pinned down

The first step is an examination with a speculum and a colposcopy: the cervix is viewed through a magnifying device that stays outside the body and painted with solutions that make suspicious areas change colour. A piece of tissue is taken from the same place for analysis. Sometimes, instead of a biopsy, the altered area is removed straight away as a cone, so that the procedure both settles the diagnosis and clears the pre-cancer.

Once a tumour is confirmed, its size and spread are worked out: MRI of the pelvis, computed or positron emission tomography, sometimes an examination under anaesthetic, and blood tests. Not everyone needs all of them. Results often take weeks, and a long wait does not in itself mean bad news. The choice of treatment depends on what these tests show, so accuracy here beats speed.

How it is treated

Cervical cancer is treatable, and at early stages often curable outright. The method is chosen by the size and type of the tumour, its position, whether it has spread, and the person's general condition.

• Early stage. Sometimes it is enough to remove a cone-shaped piece of the cervix. For a slightly larger tumour there is an operation that takes the cervix but leaves the body of the womb, after which pregnancy is still possible. The more usual option is removal of the womb with the cervix and the pelvic lymph nodes.
• The tumour has spread beyond the cervix. The main treatment is radiotherapy from outside together with brachytherapy, where the source is placed right against the cervix, alongside chemotherapy. This is not a fallback for people who cannot be operated on, but a treatment in its own right, given with the aim of cure.
• Advanced or returning disease. Chemotherapy is used, along with drugs that cut off the tumour's blood supply and with immunotherapy. The aim is to hold growth back and extend life.

Children and hormones are a conversation for before treatment starts, not after: the chances of preserving fertility narrow sharply once it is under way. In young women the ovaries are sometimes moved out of the radiation field to delay the menopause. It is worth asking in advance what to expect afterwards as well: early menopause, dryness and narrowing of the vagina, a swollen leg from the removed lymph nodes. All of it can be treated and discussed, and there is no reason to keep quiet about it. When the disease cannot be cured, treatment carries on regardless, because it holds the tumour back and eases symptoms, and a supportive care team joins in alongside it.

Online consultation

In a remote appointment the doctor goes through what exactly has changed: what the bleeding is like, how it relates to your cycle and to sex, when you were last screened and what the results showed then. They will explain which test is needed and how urgently, help you read cytology, HPV or colposcopy reports you already have, and point you to the specialist to book in person. If treatment is already running, it is a good moment to go over side effects and work out which of them you should not be putting up with.

This material is for information only and does not replace medical advice.