cervical cancer cervical cancer cervical cancer is a cancer arising from the cervix. it is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. early on, typically no symptoms are seen. later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. while bleeding after sex may not be serious, it may also indicate the presence of cervical cancer. cervical cancerlocation of cervical cancer and an example of normal and abnormal cellspronunciationuk: /ˈsɜːrvɪkəl/ sur-vik-əl, /sɜːrˈvaɪkəl/ sur-vy-kəlus: /ˈsɜːrvɪkəl/ sur-vik-əl specialtyoncologysymptomsearly: nonelater: vaginal bleeding, pelvic pain, pain during sexual intercourseusual onsetover 10 to 20 yearstypessquamous cell carcinoma, adenocarcinoma, otherscauseshuman papillomavirus infection (hpv)risk factorssmoking, weak immune system, birth control pills, starting sex at a young age, many sexual partners or a partner with many sexual partnersdiagnostic methodcervical screening followed by a biopsypreventionregular cervical screening, hpv vaccines, sexual intercourse with condoms, sexual abstinencetreatmentsurgery, chemotherapy, radiation therapy, immunotherapyprognosisfive-year survival rate:68% (us)46% (india)frequency604,127 new cases (2020)deaths341,831 (2020) human papillomavirus infection (hpv) causes more than 90% of cases; most who have had hpv infections, however, do not develop cervical cancer. hpv 16 and 18 strains are responsible for nearly 50% of high grade cervical pre-cancers. other risk factors include smoking, a weak immune system, birth control pills, starting sex at a young age, and having many sexual partners, but these are less important. genetic factors also contribute to cervical cancer risk. cervical cancer typically develops from precancerous changes over 10 to 20 years. about 90% of cervical cancer cases are squamous cell carcinomas, 10% are adenocarcinoma, and a small number are other types. diagnosis is typically by cervical screening followed by a biopsy. medical imaging is then done to determine whether or not the cancer has spread. hpv vaccines protect against two to seven high-risk strains of this family of viruses and may prevent up to 90% of cervical cancers. as a risk of cancer still exists, guidelines recommend continuing regular pap tests. other methods of prevention include having few or no sexual partners and the use of condoms. cervical cancer screening using the pap test or acetic acid can identify precancerous changes, which when treated, can prevent the development of cancer. treatment may consist of some combination of surgery, chemotherapy, and radiation therapy. five-year survival rates in the united states are 68%. outcomes, however, depend very much on how early the cancer is detected. worldwide, cervical cancer is both the fourth-most common type of cancer and the fourth-most common cause of death from cancer in women. in 2012, an estimated 528,000 cases of cervical cancer occurred, with 266,000 deaths. this is about 8% of the total cases and total deaths from cancer. about 70% of cervical cancers and 90% of deaths occur in developing countries. in low-income countries, it is one of the most common causes of cancer death. in developed countries, the widespread use of cervical screening programs has dramatically reduced rates of cervical cancer. expected scenarios for the reduction of mortality due to cervical cancer worldwide (and specially in low-income countries) have been reviewed, given assumptions with respect to the achievement of recommended prevention targets using triple-intervention strategies defined by who. in medical research, the most famous immortalized cell line, known as hela, was developed from cervical cancer cells of a woman named henrietta lacks. signs and symptoms the early stages of cervical cancer may be completely free of symptoms. vaginal bleeding, contact bleeding (one most common form being bleeding after sexual intercourse), or (rarely) a vaginal mass may indicate the presence of malignancy. also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. in advanced disease, metastases may be present in the abdomen, lungs, or elsewhere. symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, swollen legs, heavy vaginal bleeding, bone fractures, and (rarely) leakage of urine or feces from the vagina. bleeding after douching or after a pelvic exam is a common symptom of cervical cancer. causes in most cases, cells infected with the hpv heal on their own. in some cases, however, the virus continues to spread and becomes an invasive cancer. cervix in relation to upper part of vagina and posterior portion of uterus, showing difference in covering epithelium of inner structures infection with some types of hpv is the greatest risk factor for cervical cancer, followed by smoking. hiv infection is also a risk factor. not all of the causes of cervical cancer are known, however, and several other contributing factors have been implicated. human papillomavirus hpv types 16 and 18 are the cause of 75% of cervical cancer cases globally, while 31 and 45 are the causes of another 10%. people with a cervix who have multiple sexual partners, or have partners who have multiple sexual partners, regardless of sex are at higher risk of cervical cancer . of the 150-200 types of hpv known, 15 are classified as high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82), three as probable high-risk (26, 53, and 66), and 12 as low-risk (6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and cp6108). genital warts, which are a form of benign tumor of epithelial cells, are also caused by various strains of hpv. however, these serotypes are usually not related to cervical cancer. having multiple strains at the same time is common, including those that can cause cervical cancer along with those that cause warts. infection with hpv is generally believed to be required for cervical cancer to occur. smoking cigarette smoking, both active and passive, increases the risk of cervical cancer. among hpv-infected women, current and former smokers have roughly two to three times the incidence of invasive cancer. passive smoking is also associated with increased risk, but to a lesser extent. smoking has also been linked to the development of cervical cancer. smoking can increase the risk in women a few different ways, which can be by direct and indirect methods of inducing cervical cancer. a direct way of contracting this cancer is a smoker has a higher chance of cervical intraepithelial neoplasia (cin3) occurring, which has the potential of forming cervical cancer. when cin3 lesions lead to cancer, most of them have the assistance of the hpv virus, but that is not always the case, which is why it can be considered a direct link to cervical cancer. heavy smoking and long-term smoking seem to have more of a risk of getting the cin3 lesions than lighter smoking or not smoking at all. although smoking has been linked to cervical cancer, it aids in the development of hpv, which is the leading cause of this type of cancer. also, not only does it aid in the development of hpv, but also if the woman is already hpv-positive, she is at an even greater likelihood of contracting cervical cancer. oral contraceptives long-term use of oral contraceptives is associated with increased risk of cervical cancer in women who have had hpv. women who have used oral contraceptives for 5 to 9 years have about three times the incidence of invasive cancer, and those who used them for 10 years or longer have about four times the risk. multiple pregnancies having many pregnancies is associated with an increased risk of cervical cancer. among hpv-infected women, those who have had seven or more full-term pregnancies have around four times the risk of cancer compared with women with no pregnancies, and two to three times the risk of women who have had one or two full-term pregnancies. diagnosis cervical cancer seen on a t2-weighted sagittal mr image of the pelvis biopsy the pap test can be used as a screening test, but produces a false negative in up to 50% of cases of cervical cancer. other concerns is the cost of doing pap tests, which make them unaffordable in many areas of the world. confirmation of the diagnosis of cervical cancer or precancer requires a biopsy of the cervix. this is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix, with visual contrast provided by staining the normal tissues a mahogany brown with lugol's iodine. medical devices used for biopsy of the cervix include punch forceps. colposcopic impression, the estimate of disease severity based on the visual inspection, forms part of the diagnosis. further diagnostic and treatment procedures are loop electrical excision procedure and cervical conization, in which the inner lining of the cervix is removed to be examined pathologically. these are carried out if the biopsy confirms severe cervical intraepithelial neoplasia. this large squamous carcinoma (bottom of picture) has obliterated the cervix and invaded the lower uterine segment. the uterus also has a round leiomyoma up higher. often before the biopsy, the doctor asks for medical imaging to rule out other causes of woman's symptoms. imaging modalities such as ultrasound, ct scan, and mri have been used to look for alternating disease, spread of the tumor, and effect on adjacent structures. typically, they appear as heterogeneous mass on the cervix. interventions such as playing music during the procedure and viewing the procedure on a monitor can reduce the anxiety associated with the examination. precancerous lesions histopathologic image (h&e stain) of carcinoma in situ (also called cin3), stage 0: the normal architecture of stratified squamous epithelium is replaced by irregular cells that extend throughout its full thickness. normal columnar epithelium is also seen. cervical intraepithelial neoplasia, the potential precursor to cervical cancer, is often diagnosed on examination of cervical biopsies by a pathologist. for premalignant dysplastic changes, cervical intraepithelial neoplasia grading is used. the naming and histologic classification of cervical carcinoma precursor lesions has changed many times over the 20th century. the world health organization classification system was descriptive of the lesions, naming them mild, moderate, or severe dysplasia or carcinoma in situ (cis). the term cervical intraepithelial neoplasia (cin) was developed to place emphasis on the spectrum of abnormality in these lesions, and to help standardize treatment. it classifies mild dysplasia as cin1, moderate dysplasia as cin2, and severe dysplasia and cis as cin3. more recently, cin2 and cin3 have been combined into cin2/3. these results are what a pathologist might report from a biopsy. these should not be confused with the bethesda system terms for pap test (cytopathology) results. among the bethesda results: low-grade squamous intraepithelial lesion (lsil) and high-grade squamous intraepithelial lesion (hsil). an lsil pap may correspond to cin1, and hsil may correspond to cin2 and cin3, but they are results of different tests, and the pap test results need not match the histologic findings. cancer subtypes histologic subtypes of invasive cervical carcinoma include: squamous cell carcinoma (about 80–85%) adenocarcinoma (about 15% of cervical cancers in the uk) adenosquamous carcinoma small cell carcinoma neuroendocrine tumour glassy cell carcinoma villoglandular adenocarcinoma invasive squamous cell carcinoma of the cervix is characterized by infiltration as irregular anastomosing nests or single cells. this case is poorly differentiated. h&e stain. the location of cervical cancer can be described in terms of quadrants, or corresponding to a clock face when the subject is in supine position. though squamous cell carcinoma is the cervical cancer with the most incidence, the incidence of adenocarcinoma of the cervix has been increasing in recent decades. endocervical adenocarcinoma represents 20–25% of the histological types of cervical carcinoma. gastric-type mucinous adenocarcinoma of the cervix is a rare type of cancer with aggressive behavior. this type of malignancy is not related to high-risk human papillomavirus (hpv). noncarcinoma malignancies which can rarely occur in the cervix include melanoma and lymphoma. the international federation of gynecology and obstetrics (figo) stage does not incorporate lymph node involvement in contrast to the tnm staging for most other cancers. for cases treated surgically, information obtained from the pathologist can be used in assigning a separate pathologic stage, but is not to replace the original clinical stage. staging main article: cervical cancer staging cervical cancer is staged by the figo system, which is based on clinical examination rather than surgical findings. prior to the 2018 revisions to figo staging, the system allowed only