Cervical Cancer

What is Cervix?

The cervix is the lower part of the womb also known as uterine cervix. The cervix connects the body of the uterus to the vagina(birth canal). The part of the cervix closest to the body of the uterus is called the endocervix. The part next to the vagina isthe ectocervix. It is about 2-3 cms in length.

Cervical Cancer

More women in India die from cervical cancer than in any other country.

Around 1.23 lakh new women are diagnosed with cervical cancer in India and 67,500 women die of cervical cancer in India every year (Globocan 2012) [1].

The incidence of cervical cancer is higher in rural areas when compared to cities [2].

Risk Factors 

  • Persistent infection of the cervix with Human Papillomavirus (HPV)
  • Giving birth to many children
  • Having many sexual partners
  • Spouse having multiple sexual partners
  • Having first sexual intercourse at a young age
  • Smoking
  • Due to HIV/AIDS, immunosuppressive drugs, transplant etc.

The presence of these risk factors does not imply that you will definitely acquire cancer. However, if you have one or more of these risk factors, it is advisable to consult your doctor.


  • (I) Primary Prevention: It is designed to prevent the disease from occurring in the first place.

    • Adopt safe sex practices (avoid multiple sexual partners).
    • Use of male condoms as barrier contraceptives to reduce the risk of HPV infection.
    • Timely treatment of reproductive tract infections.
    • There is evidence that circumcision for men may reduce the incidence of infection among sexual partners.
    • HPV vaccination: Prophylactic vaccines for cervical cancer target HPV 16 and 18, the most common oncogenic types of HPV responsible for cervical cancer. HPV vaccination is not effective against all oncogenic HPV types. Currently two vaccines, licensed globally are available in India; a quadrivalent vaccine (against HPV genotypes 6, 11, 16, 18) and a bivalent vaccine (against HPV genotypes 16, 18). The vaccine dose is 0.5 ml given intramuscularly, either in the deltoid muscle or in the antero-lateral thigh. It is available as a sterile suspension for injection in a single-dose vial or a prefilled syringe. The recommended age for initiation of vaccination is 9–14 years. Catch-up vaccination is permitted up to the age of 26 years.
      Females who have not been exposed to the HPV infection are likely to benefit more from the vaccine.

    Indian Academy of Pediatrics (IAP) recommendations on HPV vaccination[4]:

    • Only 2 doses of either of the two HPV vaccines for adolescent/pre-adolescent girls aged 9-14 years
    • For girls 15 years and older, and immune-compromised individuals 3 doses are recommended
    • For two-dose schedule, the minimum interval between doses should be 6 months.
    • For 3 dose schedule, the doses can be administered at 0, 1-2 (depending on brands) and 6 months


    Vaccine does not guarantee complete protection against cervical cancer. Cervical screening tests are still important as:

    • Immunization with the HPV vaccine will take several years to reduce the chances of developing cervical cancer.
    • The vaccine does not protect against all HPV types.
    • Not all cases of cervical cancer are caused by the high-risk HPV16 and HPV18 strains.

    Duration of protection of vaccine:
    The duration of vaccine protection is unclear. Current studies indicated that the vaccine is effective for at least 5 years. Ongoing studies are investigating the long term efficacy of the vaccine.


    Currently, there are no guidelines on HPV vaccination in our country.

    (II) Secondary Prevention: Secondary prevention aims at detecting the disease in its early stages (pre-cancers) through screening and to prevent its progression.

    Screening tests are done in apparently healthy women to diagnose changes in the cervix which are pre-cancerous and could develop into cervical cancer in future. If the abnormal tissue or cells are removed, the disease can be prevented from progressing to cancer [5]. Available screening tests for cervical cancer include Pap smear test, VIA (visual inspection with acetic acid), VILI (visual inspection with Lugol’s iodine) and HPV DNA test.

    Pap smear test

    The Pap (Papanicolaou) test is a method that has been used for over 60 years to detect potentially pre-cancerous and cancerous changes in cells of the cervix.

    Pap smear is a simple and painless test. An instrument called a speculum is introduced into the vagina to visualize the cervix. The health care provider will then use a special stick or brush to take a few cells from the surface of and inside the cervix. The cells are placed on a glass slide and sent to a lab for cytologic testing. The Pap test is done in married women above 21 years and should be repeated once in every 3 years. If this test is combined with HPV test (for women above 30 years of age), then the duration of screening can be increased to 5 years.



    Other tests used for screening of cervical cancer Pap Test

    HPV test is a laboratory test used to check the presence of DNA or RNA for certain types of HPV. Cells are collected from the cervix and are checked to find out if an infection is caused by a type of HPV that is linked to cervical cancer [7]. This test may be done using the sample of cells removed during a Pap test. This test is not recommended in women aged below 30 years as HPV infection is very common in this age and may be spontaneously cleared within 2 years.

    Visual inspection of the cervix, using acetic acid (VIA) or Lugol’s iodine (VILI) is also used as a screening test to find precancerous lesions[8]. Such procedures do not need laboratories and transport of specimens, require very little equipment and provide women with immediate test results. A range of medical professionals-doctors, nurses, or professional midwives-can effectively perform the procedure, provided they receive adequate training and supervision.

    Abnormal Pap tests

    Abnormal Pap test results usually do not mean you will always have cancer. Most often there is a small problem with the cervix. If results of the Pap test are unclear or show a small change in the cells of the cervix, your doctor may repeat the Pap test immediately, in 6 months or a year, or run more tests. Some abnormal cells will turn into cancer. Treating abnormal cells that don’t go away on their own can prevent almost all cases of cervical cancer. If you have abnormal results, talk to your doctor about what they mean.  If treatment is needed, it can be done early enough to prevent cancer before it develops. Treatment is often done in an out patient department (OPD). If the test finds more serious changes in the cells of the cervix, the doctor will suggest more tests. Results of these tests will help your doctor decide on the best treatment.

Pap Smear Test

The Pap smear is a simple test to collect a small sample of cells from the cervix which helps to diagnose  precancerous and cancerous conditions of the cervix. It also aids in diagnosing infections and inflammation of the lower reproductive tract.

Who should get the Pap test done?

As per the International recommendations, the age to initiate screening is 21 years.

Women who are 30 years and above should undergo a Pap test once in every 3 years until the age of 65 years. If this test is combined with HPV test, then the duration of screening can be increased to 5 years.

Women who do not routinely require Pap test

  • Women aged below 21 years and above 65 years
  • Women who have undergone hysterectomy for benign condition

When should the Pap test be done?

The Pap test yields optimum results if scheduled between 10 to 20 days from the first day of menstrual period. The woman should not be menstruating at the time of test.

Preparation for Pap smear

Following should be avoided 48 hours before the test:

  • Intercourse
  • Douching of vagina
  • Vaginal medications
  • Vaginal contraceptives like creams/ jellies


An instrument called a speculum is gently introduced into the vagina to visualize the cervix. There may be some discomfort or cramping during the procedure, but it is not usually painful.

  • A small wooden stick or spatula is used to gently scrape the surface of the lower part of the cervix to pick up cells.
  • A special brush, called a cytobrush is used to obtain cells from the inner part of the cervix.
  • The cells are placed on a glass slide, immediately fixed in ethanol and sent to laboratory for further processing and interpretation.

Results of Pap test

A Pap test result may be reported as normal or abnormal.

  • Normal Pap test

If the test report is normal, this means no abnormal or cancerous cells have been found in the smear taken.

  • Abnormal Pap tests

Abnormal Pap test results usually do not mean that the woman has cancer. Most often there is a small problem with the cervix. If results of the Pap test are unclear or show a mild abnormality in the cells of the cervix, your doctor may repeat the Pap test in 6 weeks, in 6 months or a year, or run more tests. Treating abnormal cells that don’t go away on their own can prevent almost all cases of cervical cancer. Treatment of this abnormality is often done in an out-patient department (OPD). If the test findings suggest more severe abnormality in the cells, it is confirmed by further diagnostic procedures:

Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas.

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 (punch biopsy) is usually done in the OPD.

Visual Inspection using Acetic acid (VIA)
Naked-eye visual inspection of the uterine cervix, after application of 5% acetic acid (VIA) provides simple tests for the early detection of cervical precancerous lesions and early invasive cancer. The results of VIA are immediately available and do not require any laboratory support.
Acetic acid caused intracellular dehydration and coagulation of protein within abnormal cervical cells. So the abnormal cells will turn white after application of acetic acid.
Instruments and materials required:
• Examining table
• Light source
• Bivalve speculum (Cusco)
• Instrument tray or container
• Bottles with normal saline
• 5% acetic acid (freshly prepared)
• Cotton-tipped -swab sticks
• Disposible gloves
• 0.5% chlorine solution for decontaminating
• Forms and registers for recording the findings

Preparation of 5% acetic acid:Acetic acid is to be freshly prepared everyday
Ingredients Quantity
1. Glacial acetic acid 5 ml
2. Distilled water 95 ml

Preparation: Carefully add 5 ml of glacial acetic acid into 95 ml of distilled water and mix thoroughly.
Storage: Unused acetic acid should be discarded at the end of the day.

Note: It is important to remember to dilute the glacial acetic acid, since the undilutedstrength causes a severe chemical burn if applied to the epithelium.

Procedure of VIA examination:

• Explain the screening in detail to the woman. The woman should be reassured that the procedure is painless, and every effort should be made to ensure that she is fully relaxed and remains at ease during testing.
• Written informed consent should be obtained before screening.
• The woman is invited to lie down in a modified lithotomy position on a couch with leg rests or knee crutches or stirrups.
• Gently introduce the speculum and open the blades of the speculum to view the cervix in the presence of good light source.
• Identify the external os, columnar epithelium (red in colour), squamous epithelium (pink) and the squamocolumnar junction.
• Proceed to identify the transformation zone, the upper limit of which is formed by the squamocolumnar junction. (Cervical neoplasias occur in the transformation zone nearest to the squamocolumnar junction).
• Gently, but firmly, apply 5% acetic acid using a cotton swab soaked in acetic acid. The secretions should be gently wiped off. The swabs after use should be disposed of in the waste bucket.
• The curdy-white discharge associated with candidiasis is particularly sticky, and if particular care is not taken to remove it properly, it may mimic an acetowhite lesion, thus leading to a false-positive result.
• After removing the swab, carefully look at the cervix to see whether any white lesions appear, particularly in the transformation zone close to the squamocolumnar junction, or dense, non-removable acetowhite areas in the columnar epithelium.
• The results one minute after application of acetic acid should be reported. Note how rapidly the acetowhite lesion appears and then disappears.

Carefully observe:
• The intensity of the white colour of the acetowhite lesion: if it is shinywhite, cloudy-white, pale-white or dull-white.
• The borders and demarcations of the white lesion: distinctly clear and sharp or indistinct diffuse margins; raised or flat margins; regular or irregular margins.
• Whether the lesions are uniformly white in colour, or the colour intensity varies across the lesion, or if there are areas of erosion within the lesion.
• Location of the lesion: is it in, near or far away from the transformation zone? Is it abutting (touching) the squamocolumnar junction? Does it extend into the endocervical canal? Does it occupy the entire, or part of, the transformation zone? Does it involve the entire cervix (which usually indicates early preclinical invasive cancer)?
• Size (extent or dimensions) and number of the lesions.

VIA negative (-)
VIA screening is reported as negative inthe case of any of the followingobservations:
• No acetowhite lesions are observed on the cervix.
• Polyps protrude from the cervix with bluish-white acetowhite areas.
• Nabothian cysts appear as button-like areas, as whitish acne or pimples
• Dot-like areas are present in the endocervix, which are due to grapelike columnar epithelium staining with acetic acid.
• There are shiny, pinkish-white, cloudywhite, bluish-white, faint patchy or doubtful lesions with ill-defined, indefinite margins, blending with the rest of the cervix
• Angular, irregular, digitating acetowhite lesions, resembling geographical regions, distant (detached) from the squamocolumnar junction (satellite lesions).
• Faint line-like or ill-defined acetowhitening is seen at the squamocolumnar junction.
• Streak-like acetowhitening is visible in the columnar epithelium.
• There are ill-defined, patchy, pale, discontinuous, scattered acetowhite areas.

Examples of VIA negative

The VIA test outcome is reported as positive in any of the following situations:
• There are distinct, well-defined,dense (opaque, dull- or oyster-white)acetowhite areas with regular orirregular margins, close to orabutting the squamocolumnarjunction in the transformation zoneor close to the external os if the squamocolumnar junction is not visible.
• Strikingly dense acetowhite areas areseen in the columnar epithelium
• The entire cervix becomes denselywhite after the application of acetic acid.
• Condyloma and leukoplakia occurclose to the squamocolumnarjunction, turning intensely white afterapplication of acetic acid.

VIA positive, invasive cancer

The test outcome is scored as invasive cancer when:
• There is a clinically visible ulceroproliferativegrowth on the cervix thatturns densely white after applicationof acetic acid and bleeds on touch


If any of the screening tests (Pap test, VIA, HPV test) are found to be positive, further testing may be necessary to determine whether the changes are cancerous. A colposcopy may be performed and/or a small sample of tissue (biopsy) will be obtained from the cervix

  • Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas.
  • Biopsy: If abnormal cells are found in a Pap test, 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 out patient department (OPD). A woman may need to go to a hospital for a cervical cone biopsy (removal of a larger, cone-shaped sample of cervical tissue).

The process to find out the extent of disease is called staging.

  • Stage 0 or Carcinoma in situ:  abnormal cells are found in the innermost lining of the cervix which may not be seen to naked eye.
  • Stage I: In this stage, cancer is limited to cervix only.
  • Stage II:  Cancer has spread beyond the cervix but not to the tissues that line the part of the body between the pelvic wall or to the lower third of the vagina.
  • 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 IV: Cancer has spread to the bladder, rectum, or other parts of the body. 

Three types of treatment are used to treat cervical cancer viz. surgery, radiotherapy and chemotherapy. These therapies may be given alone or in combination with one another. Treatment depends on the stage of the cancer, the type of tumor cells and a woman’s medical condition.

Treatment of pre-cancerous lesions may include the following: Removal or destruction of the part of the cervix affected by disease.

  •  Cryosurgery: application of freezing probe to destroy abnormal or diseased tissue in the cervix for about 5 minutes.

  • Loop electrosurgical excision procedure (LEEP): procedure to remove abnormal and or cancerous cells in the cervix using a thin, low-voltage electrified wire loop that acts as a knife.

  • Laser surgery: Using a laser beam to burn of abnormal cells in the cervix.
  • Conization: Excision of a cone-shaped sample of tissue from the mucous membrane of the cervix by using cold knife or scalpel. This procedure is carried out under general anesthesia in a hospital operating room.

  • Hysterectomy: for women whose tumor cannot be completely removed by conization and who no longer want to have children.

Stage I Cervical Cancer

Treatment of stage I cervical cancer may include surgery, chemotherapy and/or radiation therapy depending on the sub-stage, age and desire of the patient and preference of the treating physician.

  • Total hysterectomy with or without bilateral salpingo-oophorectomy
  • Modified radical hysterectomy and removal of lymph nodes.
  • Internal 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.
  • A combination of internal radiation therapy and external radiation therapy


Stage II Cervical Cancer

 Treatment of stage II cervical cancer may include the following:

  • Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
  • 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.

Stage III Cervical Cancer

Treatment of stage III cervical cancer may include internal and external radiation therapy combined with chemotherapy

Stage IV Cervical Cancer

  • Radiation therapy to relieve symptoms caused by the cancer and improves quality of life (radiation therapy as palliative therapy).
  • Chemotherapy and targeted therapy (monoclonal antibodies). Chemotherapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life.

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