21st Century Adult Cancer Sourcebook: Cervical Cancer (Uterine Cervix) - Clinical Data for Patients, Families, and Physicians
Edition 1.0 - October 2011
National Cancer Institute
Smashwords Edition
Copyright 2011 Progressive Management
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PART ONE
Chapter 1A: Cervical Cancer (Uterine Cervix) Patient Information
Chapter 2A: Cervical Cancer (Uterine Cervix) Health Professional Information
Chapter 3A: Cervical Cancer (Uterine Cervix) NCI Drugs
Chapter 4A: Cervical Cancer (Uterine Cervix) Background Information
Chapter 5A: Cervical Cancer (Uterine Cervix) Cancer Clinical Trials
PART TWO
Chapter 1B: Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (NCI)
Chapter 2B: Glossary of Clinical Trial Terms
Chapter 3B: Clinical Trials Background Information
Chapter 4B: Cancer Clinical Trials -The Basic Workbook
Chapter 5B: Cancer Clinical Trials - The In-Depth Program
Chapter 6B: Clinical Trials at NIH
Chapter 7B: How To Find A Cancer Treatment Trial: A Ten Step Guide
Chapter 8B: Taking Part in Cancer Treatment Research Studies
Chapter 9B: Cancer Clinical Trials
Chapter 10B: Access to Investigational Drugs
Chapter 12B: Taking Time: Support for People with Cancer
Chapter 13B: Facing Forward - Life After Cancer Treatment
Chapter 14B: Chemotherapy and You
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PART ONE
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Chapter 1A: Cervical Cancer (Uterine Cervix) Patient Information
Last Modified: 08/04/2011
Patient Version
General Information About Cervical Cancer
Key Points for This Section
* Cervical cancer is a disease in which malignant (cancer) cells form in the tissues of the cervix.
* Human papillomavirus (HPV) infection is the major risk factor for development of cervical cancer.
* There are usually no noticeable signs of early cervical cancer but it can be detected early with yearly check-ups.
* Possible signs of cervical cancer include vaginal bleeding and pelvic pain.
* Tests that examine the cervix are used to detect (find) and diagnose cervical cancer.
* Certain factors affect prognosis (chance of recovery) and treatment options.
Cervical cancer is a disease in which malignant (cancer) cells form in the tissues of the cervix.
The cervix is the lower, narrow end of the uterus (the hollow, pear-shaped organ where a fetus grows). The cervix leads from the uterus to the vagina (birth canal).
Anatomy of the female reproductive system. The organs in the female reproductive system include the uterus, ovaries, fallopian tubes, cervix, and vagina. The uterus has a muscular outer layer called the myometrium and an inner lining called the endometrium.
Cervical cancer usually develops slowly over time. Before cancer appears in the cervix, the cells of the cervix go through changes known as dysplasia, in which cells that are not normal begin to appear in the cervical tissue. Later, cancer cells start to grow and spread more deeply into the cervix and to surrounding areas.
Cervical cancer in children is rare.
Human papillomavirus (HPV) infection is the major risk factor for development of cervical cancer.
Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor.
Infection of the cervix with human papillomavirus (HPV) is the most common cause of cervical cancer. Not all women with HPV infection, however, will develop cervical cancer. Women who do not regularly have a Pap smear to detect HPV or abnormal cells in the cervix are at increased risk of cervical cancer.
Other possible risk factors include the following:
* Giving birth to many children.
* Having many sexual partners.
* Having first sexual intercourse at a young age.
* Smoking cigarettes.
* Using oral contraceptives ("the Pill").
* Having a weakened immune system.
There are usually no noticeable signs of early cervical cancer but it can be detected early with yearly check-ups.
Early cervical cancer may not cause noticeable signs or symptoms. Women should have yearly check-ups, including a Pap smear to check for abnormal cells in the cervix. The prognosis (chance of recovery) is better when the cancer is found early.
Possible signs of cervical cancer include vaginal bleeding and pelvic pain.
These and other symptoms may be caused by cervical cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:
* Vaginal bleeding.
* Unusual vaginal discharge.
* Pelvic pain.
* Pain during sexual intercourse.
Tests that examine the cervix are used to detect (find) and diagnose cervical cancer.
The following procedures may be used:
* Pap smear: A procedure to collect cells from the surface of the cervix and vagina. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina. The cells are viewed under a microscope to find out if they are abnormal. This procedure is also called a Pap test.
* Pap smear. A speculum is inserted into the vagina to widen it. Then, a brush is inserted into the vagina to collect cells from the cervix. The cells are checked under a microscope for signs of disease.
* Human papillomavirus (HPV) test: A laboratory test used to check DNA (genetic material) for certain types of HPV infection. Cells are collected from the cervix and checked to find out if an infection is caused by a type of human papillomavirus that is linked to cervical cancer. This test may be done if the results of a Pap smear show certain abnormal cervical cells. This test is also called the HPV DNA test.
* Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas. Tissue samples may be taken using a curette (spoon-shaped instrument) and checked under a microscope for signs of disease.
* Biopsy: If abnormal cells are found in a Pap smear, the doctor may do a biopsy. A sample of tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of cancer. A biopsy that removes only a small amount of tissue is usually done in the doctor’s office. A woman may need to go to a hospital for a cervical cone biopsy (removal of a larger, cone-shaped sample of cervical tissue).
* Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. The doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. A speculum is also inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
* Pelvic exam. A doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and presses on the lower abdomen with the other hand. This is done to feel the size, shape, and position of the uterus and ovaries. The vagina, cervix, fallopian tubes, and rectum are also checked.
* Endocervical curettage: A procedure to collect cells or tissue from the cervical canal using a curette (spoon-shaped instrument). Tissue samples may be taken and checked under a microscope for signs of cancer. This procedure is sometimes done at the same time as a colposcopy.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) depends on the following:
* The patient's age and general health.
* Whether or not the patient has a certain type of human papillomavirus.
* The stage of the cancer (whether it affects part of the cervix, involves the whole cervix, or has spread to the lymph nodes or other places in the body).
* The type of cervical cancer.
* The size of the tumor.
Treatment options depend on the following:
* The stage of the cancer.
* The size of the tumor.
* The patient's desire to have children.
* The patient’s age.
Treatment of cervical cancer during pregnancy depends on the stage of the cancer and the stage of the pregnancy. For cervical cancer found early or for cancer found during the last trimester of pregnancy, treatment may be delayed until after the baby is born.
Glossary Terms
abdomen (AB-doh-men)
* The area of the body that contains the pancreas, stomach, intestines, liver, gallbladder, and other organs.
abnormal (ab-NOR-mul)
* Not normal. An abnormal lesion or growth may be cancer, premalignant (likely to become cancer), or benign (not cancer).
biopsy (BY-op-see)
* The removal of cells or tissues for examination by a pathologist. The pathologist may study the tissue under a microscope or perform other tests on the cells or tissue. There are many different types of biopsy procedures. The most common types include: (1) incisional biopsy, in which only a sample of tissue is removed; (2) excisional biopsy, in which an entire lump or suspicious area is removed; and (3) needle biopsy, in which a sample of tissue or fluid is removed with a needle. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.
cancer (KAN-ser)
* A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is a cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is a cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord. Also called malignancy.
cell (sel)
* The individual unit that makes up the tissues of the body. All living things are made up of one or more cells.
cervical cancer (SER-vih-kul KAN-ser)
* Cancer that forms in tissues of the cervix (the organ connecting the uterus and vagina). It is usually a slow-growing cancer that may not have symptoms but can be found with regular Pap tests (a procedure in which cells are scraped from the cervix and looked at under a microscope). Cervical cancer is almost always caused by human papillomavirus (HPV) infection.
cervix (SER-vix)
* The lower, narrow end of the uterus that forms a canal between the uterus and vagina.
colposcope (KOL-poh-SKOPE)
* A lighted magnifying instrument used to examine the vagina and cervix.
colposcopy (kol-POS-koh-pee)
* Examination of the vagina and cervix using a lighted magnifying instrument called a colposcope.
cone biopsy (kone BY-op-see)
* Surgery to remove a cone-shaped piece of tissue from the cervix and cervical canal. Cone biopsy may be used to diagnose or treat a cervical condition. Also called conization.
curette (kyoo-RET)
* A spoon-shaped instrument with a sharp edge.
DNA
* The molecules inside cells that carry genetic information and pass it from one generation to the next. Also called deoxyribonucleic acid.
dysplasia (dis-PLAY-zhuh)
* Cells that look abnormal under a microscope but are not cancer.
endocervical curettage (en-doh-SER-vih-kul kyoo-reh-TAZH)
* A procedure in which the mucous membrane of the cervical canal is scraped using a spoon-shaped instrument called a curette.
fallopian tube (fuh-LOH-pee-in...)
* A slender tube through which eggs pass from an ovary to the uterus. In the female reproductive tract, there is one ovary and one fallopian tube on each side of the uterus.
fetus (FEE-tus)
* The developing offspring from 7 to 8 weeks after conception until birth.
genetic (jeh-NEH-tik)
* Inherited; having to do with information that is passed from parents to offspring through genes in sperm and egg cells.
human papillomavirus (HYOO-mun PA-pih-LOH-muh-VY-rus)
* A type of virus that can cause abnormal tissue growth (for example, warts) and other changes to cells. Infection for a long time with certain types of human papillomavirus can cause cervical cancer. Human papillomavirus may also play a role in some other types of cancer, such as anal, vaginal, vulvar, penile, oropharyngeal, and squamous cell skin cancers. Also called HPV.
immune system (ih-MYOON SIS-tem)
* The complex group of organs and cells that defends the body against infections and other diseases.
infection (in-FEK-shun)
* Invasion and multiplication of germs in the body. Infections can occur in any part of the body and can spread throughout the body. The germs may be bacteria, viruses, yeast, or fungi. They can cause a fever and other problems, depending on where the infection occurs. When the body’s natural defense system is strong, it can often fight the germs and prevent infection. Some cancer treatments can weaken the natural defense system.
laboratory test (LA-bruh-tor-ee...)
* A medical procedure that involves testing a sample of blood, urine, or other substance from the body. Tests can help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time.
lymph node (limf node)
* A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called lymph gland.
microscope (MY-kroh-SKOPE)
* An instrument that is used to look at cells and other small objects that cannot be seen with the eye alone.
oral contraceptive pill (OR-ul KON-truh-SEP-tiv)
* A pill used to prevent pregnancy. It contains hormones that block the release of eggs from the ovaries. Most oral contraceptives include estrogen and progestin. Also called birth control pill.
organ (OR-gun)
* A part of the body that performs a specific function. For example, the heart is an organ.
ovary (OH-vuh-ree)
* One of a pair of female reproductive glands in which the ova, or eggs, are formed. The ovaries are located in the pelvis, one on each side of the uterus.
Pap smear (pap smeer)
* A procedure in which cells are scraped from the cervix for examination under a microscope. It is used to detect cancer and changes that may lead to cancer. A Pap smear can also show conditions, such as infection or inflammation, that are not cancer. Also called Pap test and Papanicolaou test.
pathologist (puh-THAH-loh-jist)
* A doctor who identifies diseases by studying cells and tissues under a microscope.
pelvic (PEL-vik)
* Having to do with the pelvis (the lower part of the abdomen located between the hip bones).
pelvic examination (PEL-vik eg-ZA-mih-NAY-shun)
* A physical examination in which the health care professional will feel for lumps or changes in the shape of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. The health care professional will also use a speculum to open the vagina to look at the cervix and take samples for a Pap test. Also called internal examination.
prognosis (prog-NO-sis)
* The likely outcome or course of a disease; the chance of recovery or recurrence.
rectum (REK-tum)
* The last several inches of the large intestine closest to the anus.
risk factor (... FAK-ter)
* Something that increases the chance of developing a disease. Some examples of risk factors for cancer are age, a family history of certain cancers, use of tobacco products, being exposed to radiation or certain chemicals, infection with certain viruses or bacteria, and certain genetic changes.
speculum (SPEK-yoo-lum)
* An instrument used to widen an opening of the body to make it easier to look inside.
stage
* The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.
symptom (SIMP-tum)
* An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.
tissue (TIH-shoo)
* A group or layer of cells that work together to perform a specific function.
tumor (TOO-mer)
* An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancer), or malignant (cancer). Also called neoplasm.
uterus (YOO-teh-rus)
* The small, hollow, pear-shaped organ in a woman's pelvis. This is the organ in which a fetus develops. Also called womb.
vagina (vuh-JY-nuh)
* The muscular canal that goes from the uterus to the outside of the body. During birth, the baby passes through the vagina. Also called birth canal.
vaginal (VA-jih-nul)
* Having to do with the vagina (the birth canal).
Table of Links
1 http://www.cancer.gov/cancertopics/pdq/treatment/unusual-cancers-childhood/Pati
Stages of Cervical Cancer
Key Points for This Section
* After cervical cancer has been diagnosed, tests are done to find out if cancer cells have spread within the cervix or to other parts of the body.
* There are three ways that cancer spreads in the body.
* The following stages are used for cervical cancer:
* Carcinoma in Situ (Stage 0)
* Stage I
* Stage II
* Stage III
* Stage IV
After cervical cancer has been diagnosed, tests are done to find out if cancer cells have spread within the cervix or to other parts of the body.
The process used to find out if cancer has spread within the cervix or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
* Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
* CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
* Lymphangiogram: A procedure used to x-ray the lymph system. A dye is injected into the lymph vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels, and x-rays are taken to see if there are any blockages. This test helps find out whether cancer has spread to the lymph nodes.
* Pretreatment surgical staging: Surgery (an operation) is done to find out if the cancer has spread within the cervix or to other parts of the body. In some cases, the cervical cancer can be removed at the same time. Pretreatment surgical staging is usually done only as part of a clinical trial.
* Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
* MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
* Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid, using a thin needle.
The results of these tests are viewed together with the results of the original tumor biopsy to determine the cervical cancer stage.
There are three ways that cancer spreads in the body.
The three ways that cancer spreads in the body are:
* Through tissue. Cancer invades the surrounding normal tissue.
* Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
* Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
The following stages are used for cervical cancer:
Carcinoma in Situ (Stage 0)
In carcinoma in situ (stage 0), abnormal cells are found in the innermost lining of the cervix. These abnormal cells may become cancer and spread into nearby normal tissue.
Stage I
Millimeters (mm). A sharp pencil point is about 1 mm, a new crayon point is about 2 mm, and a new pencil eraser is about 5 mm.
In stage I, cancer is found in the cervix only. Stage I is divided into stages IA and IB, based on the amount of cancer that is found.
* Stage IA: A very small amount of cancer that can only be seen with a microscope is found in the tissues of the cervix. Stage IA is divided into stages IA1 and IA2, based on the size of the tumor.
* In stage IA1, the cancer is not more than 3 millimeters deep and not more than 7 millimeters wide.
* In stage IA2, the cancer is more than 3 but not more than 5 millimeters deep, and not more than 7 millimeters wide.
* Stage IB: In stage IB, cancer can only be seen with a microscope and is more than 5 millimeters deep or more than 7 millimeters wide, or can be seen without a microscope. Cancer that can be seen without a microscope is divided into stages IB1 and IB2, based on the size of the tumor.
* In stage IB1, the cancer can be seen without a microscope and is 4 centimeters or smaller.
* In stage IB2, the cancer can be seen without a microscope and is larger than 4 centimeters.
Stage II
In stage II, cancer has spread beyond the cervix but not to the pelvic wall (the tissues that line the part of the body between the hips) or to the lower third of the vagina. Stage II is divided into stages IIA and IIB, based on how far the cancer has spread.
* Stage IIA: Cancer has spread beyond the cervix to the upper two thirds of the vagina but not to tissues around the uterus. Stage IIA is divided into stages IIA1 and IIA2, based on the size of the tumor.
* In stage IIA1, the tumor can be seen without a microscope and is 4 centimeters or smaller.
* In stage IIA2, the tumor can be seen without a microscope and is larger than 4 centimeters.
* Stage IIB: Cancer has spread beyond the cervix to the upper two thirds of the vagina and to the tissues around the uterus.
Stage III
In stage III, cancer has spread to the lower third of the vagina, and/or to the pelvic wall, and/or has caused kidney problems. Stage III is divided into stages IIIA and IIIB, based on how far the cancer has spread.
* Stage IIIA: Cancer has spread to the lower third of the vagina but not to the pelvic wall.
* Stage IIIB:
* Cancer has spread to the pelvic wall and/or the tumor has become large enough to block the ureters (the tubes that connect the kidneys to the bladder). This blockage can cause the kidneys to enlarge or stop working. Cancer may also have spread to lymph nodes in the pelvis; or
* Cancer has spread to lymph nodes in the pelvis and may be in the uterus, the pelvic wall and/or lower third of the vagina, and/or has caused the kidneys to stop working.
Stage IV
In stage IV, cancer has spread to the bladder, rectum, or other parts of the body. Stage IV is divided into stages IVA and IVB, based on where the cancer is found.
* Stage IVA: Cancer has spread to the bladder or rectal wall, and/or beyond the pelvis. Cancer may also have spread to lymph nodes in the pelvis.
* Stage IVB: Cancer has spread beyond the pelvis and pelvic lymph nodes to other places in the body, such as the abdomen, liver, intestinal tract, lungs, bones, or distant lymph nodes.
Recurrent Cervical Cancer
Recurrent cervical cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the cervix or in other parts of the body.
Treatment Option Overview
Key Points for This Section
* There are different types of treatment for patients with cervical cancer.
* Three types of standard treatment are used:
* Surgery
* Radiation therapy
* Chemotherapy
* New types of treatment are being tested in clinical trials.
* Patients may want to think about taking part in a clinical trial.
* Patients can enter clinical trials before, during, or after starting their cancer treatment.
* Follow-up tests may be needed.
There are different types of treatment for patients with cervical cancer.
Different types of treatment are available for patients with cervical cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Three types of standard treatment are used:
Surgery
Surgery (removing the cancer in an operation) is sometimes used to treat cervical cancer. The following surgical procedures may be used:
* Conization: A procedure to remove a cone-shaped piece of tissue from the cervix and cervical canal. A pathologist views the tissue under a microscope to look for cancer cells. Conization may be used to diagnose or treat a cervical condition. This procedure is also called a cone biopsy.
* Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
* Hysterectomy. The uterus is surgically removed with or without other organs or tissues. In a total hysterectomy, the uterus and cervix are removed. In a total hysterectomy with salpingo-oophorectomy, (a) the uterus plus one (unilateral) ovary and fallopian tube are removed; or (b) the uterus plus both (bilateral) ovaries and fallopian tubes are removed. In a radical hysterectomy, the uterus, cervix, both ovaries, both fallopian tubes, and nearby tissue are removed. These procedures are done using a low transverse incision or a vertical incision.
* Radical hysterectomy: Surgery to remove the uterus, cervix, part of the vagina, and a wide area of ligaments and tissues around these organs. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed.
* Modified radical hysterectomy: Surgery to remove the uterus, cervix, upper part of the vagina, and ligaments and tissues that closely surround these organs. Nearby lymph nodes may also be removed. In this type of surgery, not as many tissues and/or organs are removed as in a radical hysterectomy.
* Bilateral salpingo-oophorectomy: Surgery to remove both ovaries and both fallopian tubes.
* Pelvic exenteration: Surgery to remove the lower colon, rectum, and bladder. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to make an artificial vagina after this operation.
* Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
* Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
* Loop electrosurgical excision procedure (LEEP): A treatment that uses electrical current passed through a thin wire loop as a knife to remove abnormal tissue or cancer.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
New types of treatment are being tested in clinical trials.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
Glossary Terms
abdomen (AB-doh-men)
* The area of the body that contains the pancreas, stomach, intestines, liver, gallbladder, and other organs.
abdominal (ab-DAH-mih-nul)
* Having to do with the abdomen, which is the part of the body between the chest and the hips that contains the pancreas, stomach, intestines, liver, gallbladder, and other organs.
abnormal (ab-NOR-mul)
* Not normal. An abnormal lesion or growth may be cancer, premalignant (likely to become cancer), or benign (not cancer).
bilateral salpingo-oophorectomy (by-LA-teh-rul sal-PIN-goh-oh-oh-foh-REK-toh-mee)
* Surgery to remove both ovaries and both fallopian tubes.
bladder (BLA-der)
* The organ that stores urine.
carcinoma in situ (KAR-sih-NOH-muh in SY-too)
* A group of abnormal cells that remain in the place where they first formed. They have not spread. These abnormal cells may become cancer and spread into nearby normal tissue. Also called stage 0 disease.
catheter (KA-theh-ter)
* A flexible tube used to deliver fluids into or withdraw fluids from the body.
cavity (KA-vih-tee)
* A hollow area or hole. It may describe a body cavity (such as the space within the abdomen) or a hole in a tooth caused by decay.
cell (sel)
* The individual unit that makes up the tissues of the body. All living things are made up of one or more cells.
cerebrospinal fluid (seh-REE-broh-SPY-nul FLOO-id)
* The fluid that flows in and around the hollow spaces of the brain and spinal cord, and between two of the meninges (the thin layers of tissue that cover and protect the brain and spinal cord). Cerebrospinal fluid is made by tissue called the choroid plexus in the ventricles (hollow spaces) in the brain. Also called CSF.
cervical cancer (SER-vih-kul KAN-ser)
* Cancer that forms in tissues of the cervix (the organ connecting the uterus and vagina). It is usually a slow-growing cancer that may not have symptoms but can be found with regular Pap tests (a procedure in which cells are scraped from the cervix and looked at under a microscope). Cervical cancer is almost always caused by human papillomavirus (HPV) infection.
cervix (SER-vix)
* The lower, narrow end of the uterus that forms a canal between the uterus and vagina.
chemotherapy (KEE-moh-THAYR-uh-pee)
* Treatment with drugs that kill cancer cells.
clinical trial (KLIH-nih-kul TRY-ul)
* A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Also called clinical study.
colon (KOH-lun)
* The longest part of the large intestine, which is a tube-like organ connected to the small intestine at one end and the anus at the other. The colon removes water and some nutrients and electrolytes from partially digested food. The remaining material, solid waste called stool, moves through the colon to the rectum and leaves the body through the anus.
conization (koh-nih-ZAY-shun)
* Surgery to remove a cone-shaped piece of tissue from the cervix and cervical canal. Conization may be used to diagnose or treat a cervical condition. Also called cone biopsy.
cryosurgery (KRY-oh-SER-juh-ree)
* A procedure in which tissue is frozen to destroy abnormal cells. Liquid nitrogen or liquid carbon dioxide is used to freeze the tissue. Also called cryoablation and cryosurgical ablation.
diagnosis (DY-ug-NOH-sis)
* The process of identifying a disease, such as cancer, from its signs and symptoms.
drug (drug)
* Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.
external radiation therapy (...RAY-dee-AY-shun THAYR-uh-pee)
* A type of radiation therapy that uses a machine to aim high-energy rays at the cancer from outside of the body. Also called external-beam radiation therapy.
fallopian tube (fuh-LOH-pee-in...)
* A slender tube through which eggs pass from an ovary to the uterus. In the female reproductive tract, there is one ovary and one fallopian tube on each side of the uterus.
follow-up (FAH-loh-up)
* Monitoring a person's health over time after treatment. This includes keeping track of the health of people who participate in a clinical study or clinical trial for a period of time, both during the study and after the study ends.
incision (in-SIH-zhun)
* A cut made in the body to perform surgery.
injection (in-JEK-shun)
* Use of a syringe and needle to push fluids or drugs into the body; often called a "shot."
internal radiation therapy (in-TER-nul RAY-dee-AY-shun THAYR-uh-pee)
* A type of radiation therapy in which radioactive material sealed in needles, seeds, wires, or catheters is placed directly into or near a tumor. Also called brachytherapy, implant radiation therapy, and radiation brachytherapy.
laparoscope (LA-puh-ruh-SKOPE)
* A thin, tube-like instrument used to look at tissues and organs inside the abdomen. A laparoscope has a light and a lens for viewing and may have a tool to remove tissue.
laser (LAY-zer)
* A device that forms light into intense, narrow beams that may be used to cut or destroy tissue, such as cancer tissue. It may also be used to reduce lymphedema (swelling caused by a buildup of lymph fluid in tissue) after breast cancer surgery. Lasers are used in microsurgery, photodynamic therapy, and many other procedures to diagnose and treat disease.
laser surgery (LAY-zer SER-juh-ree)
* A surgical procedure that uses the cutting power of a laser beam to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
lesion (LEE-zhun)
* An area of abnormal tissue. A lesion may be benign (not cancer) or malignant (cancer).
loop electrosurgical excision procedure (loop ee-LEK-troh-SER-jih-kul ek-SIH-zhun proh-SEE-jer)
* A technique that uses electric current passed through a thin wire loop to remove abnormal tissue. Also called LEEP and loop excision.
lymph node (limf node)
* A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called lymph gland.
microscope (MY-kroh-SKOPE)
* An instrument that is used to look at cells and other small objects that cannot be seen with the eye alone.
NCI
* NCI, part of the National Institutes of Health of the United States Department of Health and Human Services, is the Federal Government's principal agency for cancer research. It conducts, coordinates, and funds cancer research, training, health information dissemination, and other programs with respect to the cause, diagnosis, prevention, and treatment of cancer. Access the NCI Web site at http://www.cancer.gov. Also called National Cancer Institute.
organ (OR-gun)
* A part of the body that performs a specific function. For example, the heart is an organ.
ovary (OH-vuh-ree)
* One of a pair of female reproductive glands in which the ova, or eggs, are formed. The ovaries are located in the pelvis, one on each side of the uterus.
pathologist (puh-THAH-loh-jist)
* A doctor who identifies diseases by studying cells and tissues under a microscope.
pelvic exenteration (PEL-vik ek-SEN-teh-RAY-shun)
* Surgery to remove the lower colon, rectum, and bladder, and create stomata (openings) through which urine and stool are passed out of the body. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed.
plastic surgery (PLAS-tik SER-juh-ree)
* An operation that restores or improves the appearance of body structures.
radiation (RAY-dee-AY-shun)
* Energy released in the form of particle or electromagnetic waves. Common sources of radiation include radon gas, cosmic rays from outer space, medical x-rays, and energy given off by a radioisotope (unstable form of a chemical element that releases radiation as it breaks down and becomes more stable).
radiation therapy (RAY-dee-AY-shun THAYR-uh-pee)
* The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called irradiation and radiotherapy.
radical hysterectomy (RA-dih-kul HIS-teh-REK-toh-mee)
* Surgery to remove the uterus, cervix, and part of the vagina. The ovaries, fallopian tubes, and nearby lymph nodes may also be removed.
radioactive (RAY-dee-oh-AK-tiv)
* Giving off radiation.
radioactive seed (RAY-dee-oh-AK-tiv...)
* A small, radioactive pellet that is placed in or near a tumor. Cancer cells are killed by the energy given off as the radioactive material breaks down and becomes more stable.
rectum (REK-tum)
* The last several inches of the large intestine closest to the anus.
recur
* To come back or to return.
regional chemotherapy (REE-juh-nul KEE-moh-THAYR-uh-pee)
* Treatment with anticancer drugs directed to a specific area of the body.
side effect (side eh-FEKT)
* A problem that occurs when treatment affects healthy tissues or organs. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.
stage
* The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.
standard therapy (... THAYR-uh-pee)
* Treatment that experts agree is appropriate, accepted, and widely used. Also called best practice, standard medical care, and standard of care.
stoma (STOH-muh)
* A surgically created opening from an area inside the body to the outside.
stool (stool)
* The material in a bowel movement. Stool is made up of undigested food, bacteria, mucus, and cells from the lining of the intestines. Also called feces.
surgery (SER-juh-ree)
* A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.
systemic chemotherapy (sis-TEH-mik KEE-moh-THAYR-uh-pee)
* Treatment with anticancer drugs that travel through the blood to cells all over the body.
tissue (TIH-shoo)
* A group or layer of cells that work together to perform a specific function.
total hysterectomy (TOH-tul HIS-teh-REK-toh-mee)
* Surgery to remove the entire uterus, including the cervix. Also called complete hysterectomy.
tumor (TOO-mer)
* An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancer), or malignant (cancer). Also called neoplasm.
urine (YOOR-in)
* Fluid containing water and waste products. Urine is made by the kidneys, stored in the bladder, and leaves the body through the urethra.
uterus (YOO-teh-rus)
* The small, hollow, pear-shaped organ in a woman's pelvis. This is the organ in which a fetus develops. Also called womb.
vagina (vuh-JY-nuh)
* The muscular canal that goes from the uterus to the outside of the body. During birth, the baby passes through the vagina. Also called birth canal.
vaginal (VA-jih-nul)
* Having to do with the vagina (the birth canal).
vein (vayn)
* A blood vessel that carries blood to the heart from tissues and organs in the body.
x-ray (EX-ray)
* A type of high-energy radiation. In low doses, x-rays are used to diagnose diseases by making pictures of the inside of the body. In high doses, x-rays are used to treat cancer.
Table of Links
1 http://www.cancer.gov/cancertopics/druginfo/cervicalcancer
2 http://cancer.gov/clinicaltrials
* * * * * * * * * * * *
Treatment Options by Stage
Carcinoma in Situ (Stage 0)
Stage IA Cervical Cancer
Stage IB Cervical Cancer
Stage IIA Cervical Cancer
Stage IIB Cervical Cancer
Stage III Cervical Cancer
Stage IVA Cervical Cancer
Stage IVB Cervical Cancer
A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.
Carcinoma in Situ (Stage 0)
Treatment of carcinoma in situ (stage 0) may include the following:
* Loop electrosurgical excision procedure (LEEP).
* Laser surgery.
* Conization.
* Cryosurgery.
* Total hysterectomy for women who cannot or no longer want to have children.
* Internal radiation therapy for women who cannot have surgery.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage 0 cervical cancer 1. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Stage IA Cervical Cancer
Treatment of stage IA cervical cancer may include the following:
* Total hysterectomy with or without bilateral salpingo-oophorectomy.
* Conization.
* Modified radical hysterectomy and removal of lymph nodes.
* Internal radiation therapy.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IA cervical cancer 3. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Stage IB Cervical Cancer
Treatment of stage IB cervical cancer may include the following:
* A combination of internal radiation therapy and external radiation therapy.
* Radical hysterectomy and removal of lymph nodes.
* Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
* Radiation therapy plus chemotherapy.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IB cervical cancer 4. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Stage IIA Cervical Cancer
Treatment of stage IIA cervical cancer may include the following:
* A combination of internal radiation therapy and external radiation therapy plus chemotherapy.
* Radical hysterectomy and removal of lymph nodes.
* Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IIA cervical cancer 5. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Stage IIB Cervical Cancer
Treatment of stage IIB cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IIB cervical cancer 6. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Stage III Cervical Cancer
Treatment of stage III cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III cervical cancer 7. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Stage IVA Cervical Cancer
Treatment of stage IVA cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IVA cervical cancer 8. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Stage IVB Cervical Cancer
Treatment of stage IVB cervical cancer may include the following:
* Radiation therapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life.
* Chemotherapy.
* Clinical trials of new anticancer drugs or drug combinations.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IVB cervical cancer 9. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site 2.
Treatment Options for Recurrent Cervical Cancer
Treatment of recurrent cervical cancer may include the following:
* Pelvic exenteration followed by radiation therapy combined with chemotherapy.
* Chemotherapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life.
* Clinical trials of new anticancer drugs or drug combinations.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
* * * * * * * * * * * *
Chapter 2A: Cervical Cancer (Uterine Cervix) Health Professional Information
General Information About Cervical Cancer
Incidence and Mortality
Estimated new cases and deaths from cervical (uterine cervix) cancer in the United States in 2011:[1]
• New cases: 12,710.
• Deaths: 4,290. Prognostic Factors
The prognosis for patients with cervical cancer is markedly affected by the extent of disease at the time of diagnosis. A vast majority (>90%) of these cases can and should be detected early through the use of the Pap test and human papillomavirus (HPV) testing; however,[2] the current death rate is far higher than it should be, which reflects that, even today, the Pap test and HPV testing are not done on approximately 33% of eligible women. Clinical stage, however, as a prognostic factor must be supplemented by several gross and microscopic pathologic findings in surgically treated patients. These include: volume and grade of tumor, histologic type, lymphatic spread, and vascular invasion.
In a large surgicopathologic staging study of patients with clinical stage IB disease reported by the Gynecologic Oncology Group (GOG) (GOG-49), the factors that predicted most prominently for lymph node metastases and a decrease in disease-free survival were capillary-lymphatic space involvement by tumor, increasing tumor size, and increasing depth of stromal invasion, with the latter being most important and reproducible.[3,4] In a study of 1,028 patients treated with radical surgery, survival rates correlated more consistently with tumor volume (as determined by precise volumetry of the tumor) than clinical or histologic stage.[5]
A multivariate analysis of prognostic variables in 626 patients with locally advanced disease (primarily stages II, III, and IV) studied by the GOG identified several variables that were significant for progression-free interval and survival:[6]
• Periaortic and pelvic lymph node status.
• Tumor size.
• Patient age.
• Performance status.
• Bilateral disease.
• Clinical stage.
The study confirmed the overriding importance of positive periaortic nodes and suggested further evaluation of these nodes in locally advanced cervical cancer. The status of the pelvic nodes was important only if the periaortic nodes were negative. This was also true for tumor size.
In a large series of cervical cancer patients treated by radiation therapy, the incidence of distant metastases (most frequently to lung, abdominal cavity, liver, and gastrointestinal tract) was shown to increase as the stage of disease increased, from 3% in stage IA to 75% in stage IVA.[7] A multivariate analysis of factors influencing the incidence of distant metastases showed stage, endometrial extension of tumor, and pelvic tumor control to be significant indicators of distant dissemination.[7]
GOG studies have indicated that prognostic factors vary whether clinical or surgical staging are utilized, and with treatment. Delay in radiation delivery completion is associated with poorer progression-free survival when clinical staging is used. It is unclear whether stage, tumor grade, race, and age hold up as prognostic factors in studies utilizing chemoradiation.[8]
Invasive Carcinomas of the Uterine Cervix
Whether adenocarcinoma of the cervix carries a significantly worse prognosis than squamous cell carcinoma of the cervix remains controversial.[9] Reports conflict about the effect of adenosquamous cell type on outcome.[10,ll] One report showed that approximately 25% of apparent squamous tumors have demonstrable mucin production and behave more aggressively than their pure squamous counterparts, suggesting that any adenomatous differentiation may confer a negative prognosis.[12] The decreased survival is mainly the result of more advanced stage and nodal involvement rather than cell type as an independent variable. Women with human immunodeficiency virus have more aggressive and advanced disease and a poorer prognosis.[13] A study of patients with known invasive squamous carcinoma of the cervix found that overexpression of the C-myc oncogene was associated with a poorer prognosis.[14] The number of cells in S phase may also have prognostic significance in early cervical carcinoma.[15] HPV type 18 DNA has been found to be an independent adverse molecular prognostic factor. Two studies have shown a worse outcome when identified in cervical cancers of patients undergoing radical hysterectomy and pelvic lymphadenectomy.[16,17]
Human Papillomavirus Infection and Cervical Cancer
Molecular techniques for the identification of HPV DNA are highly sensitive and specific. More than 6 million women in the United States are estimated to have HPV infection, and proper interpretation of these data is important. Epidemiologic studies convincingly demonstrate that the major risk factor for development of preinvasive or invasive carcinoma of the cervix is HPV infection, which far outweighs other known risk factors such as high parity, increasing number of sexual partners, young age at first intercourse, low socioeconomic status, and positive smoking history.[18,19] Some patients with HPV infection appear to be at minimal increased risk for development of cervical preinvasive and invasive malignancies, while others appear to be at significant risk and are candidates for intensive screening programs and/or early intervention.
HPV DNA tests are unlikely to separate patients with low-grade squamous intraepithelial lesions into those who do and those who do not need further evaluation. A study of 642 women found that 83% had one or more tumorigenic HPV types when cervical cytologic specimens were assayed by a sensitive (hybrid capture) technique.[20] The authors of the study and of an accompanying editorial concluded that using HPV DNA testing in this setting does not add sufficient information to justify its cost.[20] HPV DNA testing has proven useful in triaging patients with atypical squamous cells of undetermined significance to colposcopy and has been integrated into current screening guidelines.[20-22] Patients with an abnormal cytology of a high-risk type (Bethesda classification) should be thoroughly evaluated with colposcopy and biopsy.
Other studies show patients with low-risk cytology and high-risk HPV infection with types 16, 18, and 31 are more likely to have cervical intraepithelial neoplasia (CIN) or microinvasive histopathology on biopsy. [19,23-25] One method has also shown that integration of HPV types 16 and 18 into the genome, leading to transcription of viral and cellular messages, may predict patients who are at greater risk for high-grade dysplasia and invasive cancer.[26] Studies suggest that acute infection with HPV types 16 and 18 conferred an 11- to 16.9-fold risk of rapid development of high-grade CIN, [19,27] but there are conflicting data requiring further evaluation before any recommendations may be made. Patients with low-risk cytology and low-risk HPV types have not been followed long enough to ascertain their risk. At present, studies are ongoing to determine how HPV typing can be used to help stratify women into follow-up and treatment groups. HPV typing may prove useful, particularly in patients with low-grade cytology or cytology of unclear abnormality. At present, how therapy and follow-up should be altered with low- versus high-risk HPV type has not been established.