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January is Cervical Cancer Awareness Month, a time to spread vital information and deepen understanding of the fourth most common cancer among women globally. Thanks to the human papillomavirus (HPV) vaccine, increased education, and enhanced screening, cervical cancer is highly preventable and treatable when caught in its early stages.

We spoke with Jaclyn Wall, M.D., a gynecologic oncologist at VCU Massey Comprehensive Cancer Center, to learn more about the updated guidelines for cervical cancer screening, common symptoms, treatment options and how to lower the risk of cervical cancer.

What are the different types of cervical cancer?

There are two main types of cervical cancer, squamous cell carcinoma and adenocarcinoma. These are cancers that are most commonly derived from cervical dysplasia, or precancer that's caused by HPV.

There are also a couple of very rare types of cervical cancer. These are called adenoma malignum, which is similar to gastric types of cancer, or a small cell or neuroendocrine tumor. These kinds are not caused by HPV infections.

How common is cervical cancer?

Worldwide, cervical cancer is one of the most common gynecologic cancers. In the United States, there are about 13,000 new cases of cervical cancer and 4,000 deaths every year.

What are the most common symptoms of cervical cancer?

The kind of symptoms depend on the stage of the cancer and when and how it is diagnosed. A pap smear can detect a completely asymptomatic cancer that is microscopic, or not yet visible or with any symptoms. Symptoms change as cervical cancer begins to grow and spread. Bleeding is the most common symptom. Cervical tumors are very sensitive and bleed easily.

A common presentation of cervical cancer is a patient who has pain and bleeding following sex, because that's traumatic to the tumor. Tumors that are larger in size or have spread into the upper part of the vagina or toward the sides of the pelvis can cause pain with bowel movements, back pain and abdominal pain. If they grow to the point where they're obstructing the ureters, which connect each kidney to the bladder, that can cause flank pain and urinary pain and symptoms. Symptoms of metastatic cervical cancer depend on the distribution of disease.

What are the current screening guidelines for cervical cancer?

Screening for cervical cancer should start at age 21 and continue until age 65 in patients who have no history of cervical cancer or high-grade cervical dysplasia. The screening algorithm traditionally has been from age 21 to 29, you have a pap smear every three years. If it's anything that's abnormal, HPV testing may be added onto it, or you would have a follow-up test called a colposcopy.

Traditionally, between ages 30 and 65, there are several options. The most common is what's called co-testing, which is a pap smear with HPV testing, done once every five years in patients who have normal results.

Recently, the American Cancer Society has recommended primary HPV testing every five years starting at age 25 for average risk patients. That is more indicative of your risk for cervical high-grade dysplasia or cervical cancer, as opposed to the cytology, which is what a pap smear is detecting. Cytology is looking at the cells themselves under the microscope. The collection process is identical, so you wouldn't be able to tell the difference if you were having a pap smear or HPV testing, because the brush used to collect the sample is the same.

Another new opportunity is doing self-collection for HPV testing, as an alternative to having that collected in the clinic. This helps to improve access to screening in low-resource areas where people don't have consistent access to a primary care provider or OB-GYN to do their cervical cancer screening. For patients who have a history of trauma, a pelvic exam can be very triggering and difficult. With this new opportunity, they're able to collect the tests themselves and still have a very accurate result. This test should be completed every three years. Any abnormal results require an in-person follow-up visit and examination to evaluate potential areas of abnormality.

If someone does opt for a self-collected specimen, is it important to still see an OB-GYN?

Yes. Cervical cancer screening is a very important part of your wellness exam, but it's not the only thing that you're seeing your OB-GYN or primary care doctor for, especially for patients who maybe have issues with irregular bleeding, heavy cycles, or women who are either perimenopausal or menopausal and going through those changes. It's still important to have an avenue to address other important facets of gynecologic health. For patients with concerns and difficulty with this sensitive exam, we encourage you to work closely with your health care team to make a plan that is comfortable for you and your unique needs.

Why is the HPV vaccine essential to prevent cervical cancer?

The HPV vaccine has very well-established efficacy and safety profiles. It currently covers nine different strains of HPV that cause cervical cancer, cervical precancer and genital warts.

The age range for recommendation of when to give it is in adolescents, usually around 11 or 12, because it's most effective if it's given before the initiation of any sexual activity, because HPV is spread through sexual contact. It can be given as young as age nine if parents want to vaccinate their children early. There is some evidence that one dose of the vaccine may be sufficient, but currently, two doses of the HPV vaccine are recommended for those starting the series before age 15. For teens and young adults who start the series at ages 15 through 26 years, and for immunocompromised individuals, three doses of the HPV vaccine are recommended, according to the CDC.

If someone didn’t receive the HPV vaccine as a child, they can get it up until age 45 in the United States.

How is cervical cancer treated?

Treatment depends on the stage of diagnosis. Patients with a small cancer confined to the cervix may be a candidate for surgery. For patients who have a locally advanced disease, meaning a large cervical tumor or involvement of certain pelvic organs or structures, the standard of care treatment is radiation to the pelvis rather than surgery.

Patients receive five weeks of daily radiation, which is externally delivered to the pelvis, followed by several internal treatments, which are a higher dose, delivered right to the cervix. A small dose of chemotherapy is given at the same time to make the radiation work better. The techniques of radiation now, compared to how they were years ago, are much better because they are tailored specifically to individual patients, which helps minimize the toxicity.

Patients who have metastatic disease, for example to the lungs, are treated with systemic chemotherapy.

What are the side effects of cervical cancer treatment?

The side effects depend on the treatment used. While treatments have improved greatly, both acute and long-term side effects are still very significant, especially for those receiving radiation. This can cause diarrhea or gastrointestinal issues, burns to the skin, bleeding and pain.

Long-term, radiation can cause vaginal shortening and narrowing. If patients are not having regular intercourse, we recommend the use of a vaginal dilator to help keep the vagina functional. This is also important for follow-up after treatment to ensure there is no return of cancer in the vagina.

The ovaries are in the radiated field, which results in loss of ovarian hormone function and menopause. We place patients in this situation on hormone replacement therapy to treat the symptoms of menopause, as well as vaginal estrogen.

Overall, these cancer treatments are really impactful on quality of life. I think that providers are better now at discussing potential side effects upfront with patients and connecting them with resources so that these things are addressed. It is important for patients to have these side effects managed well so they can enjoy their lives and minimize suffering.

What are misconceptions about cervical cancer?

Cervical cancer is mostly caused by HPV, which is sexually transmitted. That can lead to patients feeling vulnerable and afraid of disclosing their diagnosis to people. It's not a personal failure and should not cause stigma.I don't want patients to feel that way. I think we can do more to educate the public that this is a public health issue.

We need to be better about vaccinating, doing screening effectively and educating the public about why these things are so important.

Is there anything else that’s important for people to know?

This is a cancer that is almost completely preventable now with vaccination.

For those who were unable to be vaccinated, if you're having regular screening, cervical cancer is very detectable in early stages, and very treatable and curable.

Sometimes a pelvic exam is very difficult for patients, and that can be a barrier to screening. So, I think being able to adopt these new screening modalities and using them effectively to help patients get screening when they wouldn't otherwise, is going to help us continue to lower the number of new cases of cervical cancer. I hope patients feel empowered to tell their providers their concerns so we can work together to ensure the best outcomes.

To learn more about cervical cancer, tune in to this conversation with Dr. Wall on the Healthy with VCU Health podcast.

For more information on available cervical cancer treatment options, visit the Massey website.

 Written by: Tatiana Del Valle