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What are the stages of cervical cancer?

Cervical cancer is a cancer that develops in the tissues of the cervix. It is common in women and thanks largely to widespread regular Pap smear testing and the advent of the HPV vaccine, we’ve made great strides in prevention and early detection. However, over 70% of Australians diagnosed with cervical cancer have either never been screened or have not done so consistently. Therefore, it is vital to have regular screenings to ensure you’re protected against cervical cancer and why awareness is key to ensuring that women are taking the steps to prevention and early detection. One essential aspect of this awareness is understanding the stages of cervical cancer, as each stage dictates the course of treatment and its potential outcomes. In this article we explore what cervical cancer is, with a close look at each stage and its treatments. 

What is cervical cancer?

Cervical cancer emerges from the tissues of the cervix, which is the gateway between the uterus and the upper region of the vagina. Its growth is typically gradual, taking place over a number of years. The cervix is covered by two kinds of cells, squamous and glandular. Squamous cells are flat and thin, forming the outer layer of the cervix, while the glandular cells reside within the cervical canal. 

Prior to the development of genuine cancer cells, the cervix tissues undergo alterations known as dysplasia or pre-cancers, which can be identified through a pap test. If left untreated, these precancerous changes progress into cancerous cells.  

An estimated 942 females were diagnosed with cervical cancer last year, which accounts for 1.3% of all new female cancer that same year.  

Understanding Cervical Cancer Staging 

The FIGO system (International Federation of Gynaecology and Obstetrics) is the widely adopted staging system of cervical cancer, consisting of four stages – as the stage number increases; it indicates a greater extent of cancer spread. There are four stages numbered 1 to 4. Early-stage cervical cancer is usually described as 1A, 1B and 2A. More progressive stages include stage 2B, 3 and 4A which are often described as locally advanced. The final stage is called the advanced stage and refers to stage 4B.  

To accurately determine the stage, doctors rely on diagnostic tests, image scans, biopsy and physical examinations, meaning that the final stage of testing may not be completed until all necessary tests have been conducted.  

Staging helps to determine how serious the cancer is and the most effective treatment strategy. By assessing the stage of the cancer, doctors can also predict the likelihood of treatment success. Diagnosis may involve one and multiple tests and procedures, these can range from: 

  • A colposcopy which allows the doctor to view a magnified image of the cervix, vagina and vulva. 
  • A biopsy whereby a piece of the cervical tissue is removed and sent to a laboratory to be examined. This can be performed in the following ways: 
    •  Loop Electrosurgical Excision (LEEP) or loop diathermy whereby the colposcopist removes the transformation zone of the cervix with a thin wire loop. 
    • Endocervical curettage (ECC) whereby a small amount of tissue is scraped from inside the cervical opening.  
    • A cone biopsy which is used for early-stage and precancer diagnosis. The procedure removes a cone-shaped piece of tissues from the cervix whilst the patient is under anaesthetic.  
  • Examination of the pelvis whilst under anaesthetic to allow the doctor to assess if the cancerous area has spread outside of the cervix. 
  • An ultrasound to examine the body tissues. 
  • Scans and X-rays such as CT scans which take pictures of the inside of the body where the cancer is located, and chest X-rays to examine if the cancer has spread to other organs such as the lungs.  
  • MRI scans to give a more detailed picture of the whole body from inside. 
  • PET scans which help to identify and locate cancerous cells in the body are sometimes used in combination with CT scans.  
  • Blood tests to analyse general health as part of the treatment plan.  

Stage I (early or localised cancer) 

Stage 1 is the earliest stage where the cancer cells have extended beyond the outer layer of the cervix into deeper tissue. The cancer has not spread to distant sites and remains in the uterus. Cervical cancer stage 1 is divided into two groups: stage 1A and stage 1B.  

Stage 1A 

Tumours within this group are on average no more than 5mm deep and not more than 7mm wide. A microscope or colposcope must be used to view cervical tissue and cells due to its small size. Stage 1A is broken down into smaller groups:  

  • Stage IA1: Cancerous area of less than 3 mm in depth and not more than 7 mm in width. 
  • Stage IA2: Cancerous area of more than 3 mm, but not more than 5 mm in depth and not more than 7mm in width. 

Stage 1B 

Tumours within this group are usually bigger than tumours in stage 1A, spreading deeper than 5mm within the cervix and can sometimes be seen without the use of a microscope.    

Stage 1B is broken down into smaller groups: 

  • Stage IB1:  Cancerous area is 5 mm or more in depth but not more than 2 cm wide. The tumour is less than 4 cm at its widest part.  
  • Stage IB2:  Cancerous area is 5 mm or more in depth and between 2 and 4 cm wide. The tumour is more than 4 cm at its widest part.  
  • Stage IB3:  Cancerous area is 4 cm or more in width.   

Treatment

Treatment typically involves surgery to remove the tumour. Usually, the surgery required to remove the tumour involves removing the cervix and womb (hysterectomy) which means the patient can no longer become pregnant. In some cases, if the cancer is in very early stages some of the cervix can be left behind so the patient might still be able to become pregnant afterwards. After a hysterectomy you may have small wounds if you had keyhole surgery, or you could have incisions either on your bikini line or vertically on your abdomen. The badges will be removed the day following your surgery and the wounds will be cleaned. There may be stitches or clips which will be removed between seven – ten days after by a nurse. Possible side effects following the surgery include vaginal bleeding or pinkish or brown discharge which can last up to 6 weeks. Sanitary towels or panty liners are recommended for any vaginal discharge or bleeding, and tampons should be avoided until you no longer have pain.  

Other methods such as a large loop excision of the transformation zone (LLETZ) or cone biopsy might be used to remove the cancerous area if the patient has stage 1A1.   

Other treatment options may be required such as a combination of radiotherapy and chemotherapy if the patient has stage 1B. Typically, a course of daily radiotherapy is mixed with chemotherapy once a week or once every two or three weeks.  

Stage II (locally advanced cancer) 


In Stage 2, the cancer cells extend beyond the uterus and cervix to the vagina area or tissue near the cervix but remain within the pelvic area. The cancer has not spread to distant sites or the wall of the pelvis or lower part of the vagina. Cervical cancer stage II is divided into two groups: 

  • Stage 2A: Cancerous area has spread outside of the cervix and the uterus. It has not spread to the lower vagina or tissue next to the cervix (called the parametria).  
  • Stage 2A1: Cancerous area is no more than 4 cm wide. 
  • Stage 2A2:  Cancerous area is 4 cm or more in width.  
  • Stage 2B: Cancerous area has spread outside of the cervix and the uterus. It has not spread to the lower vagina or walls of the pelvis but has grown into the tissue next to the cervix (called the parametria).  

Treatment

A combination of chemotherapy and radiotherapy are used to treat Stage 2A and Stage 2B cervical cancer. Chemoradiotherapy typically involves daily external radiotherapy across five days for approximately five weeks combined with chemotherapy one a week or every two – three weeks depending on the chemotherapy drugs. A boost of internal radiotherapy is administered at the end of the five-week course. 

Chemoradiotherapy can cause a range of side effects, depending on the area treated by radiation and the type of the chemotherapy drug given. Nausea is a common side effect of chemotherapy, for which anti-sickness tablets are usually prescribed before and after treatment. Chemotherapy can cause nose bleeds, bleeding gums when brushing and an increased risk of infection due to reduced white blood cell count in the body.  

Radiotherapy, on the other hand, can cause inflammation in the bowel lining, leading to an increase in wind, cramping pain, diarrhoea, and the urge to go to the toilet. Soreness in the bladder and cystitis can occur as the treatment temporarily inflames the lining of the bladder. Drinking plenty of water can help to ease these side effects, especially diarrhoea. Feeling lethargic, weak and tired are most common and will gradually get worse during treatment along with the other side effects. It is important to speak to your doctor if you experience any side effects.  

In some cases, surgery is also required for stage 2A1 which typically involves a hysterectomy (removing the womb and cervix) and removal of the surrounding lymph nodes. Unfortunately, this treatment results in infertility. See stage 1 for more detail.   

Stage III (locally advanced cancer) 


In Stage 3, the cancer cells have spread into the lower part of the vagina; however, it has not grown outside the walls of the pelvis. This growth causes hydronephrosis and may have spread to the regional lymph nodes but not to other areas of the body. 

Treatment

Treatment for stage 3 cervical cancer is a combination of chemotherapy and radiotherapy called Chemoradiotherapy. The treatment planned is the same as stage 2, daily external radiotherapy across five days for approximately five weeks combined with chemotherapy once a week or every two – three weeks depending on the chemotherapy drugs. A boost of internal radiotherapy is administered at the end of the 5-week course. The side effects of the treatment can be found above in stage 2. Cervical cancer stage III is divided into three groups: 

  • Stage 3A: The cancerous area has spread to the lower third of the vagina, but not into the pelvic wall.  
  • Stage 3B: The cancerous area has grown into the walls of the pelvis and/or affects the kidney by blocking the ureter.  
  • Stage 3C: The cancerous area can be any size and has spread to regional pelvic lymph nodes or para-aortic lymph nodes. This can be detected using imaging tests, pathology or biopsy. 
  • Stage IIIC1: The cancer has spread to lymph nodes in the pelvis. 
  • Stage IIIC2: The cancer has spread to para-aortic lymph nodes, located in the abdomen near the base of the spine and near the aorta. 

Once you have completed treatment, it is important to have regular follow-up appointments with your oncologist. These may occur every two-four months for the first year, and less frequent in the future. Check ins involve physical examinations, blood tests, HPV tests or imaging tests. You should inform your Oncologist if you experience stomach or back pain, issues with urination or develop a cough or fever.  

Regular check-ups are key to making sure recurrent cervical cancer or secondary cancer is detected early. In some cases, cervical cancer can come back due to the original cancers not responding to treatment or cancer has spread to a different part of the body.  

Stage IV (metastatic or advanced cancer) 


During stage 4, the cancer has spread into the bladder or rectum or has spread to distant organs like the lungs or bones. A combination of pelvic exenteration surgery along with chemotherapy, radiation and targeted therapy are used to treat stage 4 cervical cancer. There are three types of exenteration operation: 

  • Anterior (front) exenteration which is the removal of cervix, womb, ovaries and all or part of the vagina, lymph nodes and bladder. 
  • Posterior (back) exenteration which is the removal of cervix, womb, ovaries and all or part of the vagina, lymph nodes and back passage (rectum) and part of the large bowel (colon). 
  • Total exenteration is the removal of all parts of the vagina, cervix, womb and ovaries along with the removal of the bladder, rectum, colon and lymph nodes.  

Treatment  

In some cases, targeted therapy drugs such as Bevacizumab (Avastin) are used with a combination of chemotherapy. This treatment is administered through a cannula usually every two – three weeks. The side effects of Avastin can be high blood pressure, high temperature, feeling nausea, feeling of numbness or tingling, and increased risk of infection or bruising.  

Stage IV is divided into two groups. 

  • Stage 4A: The cancerous area has grown into the bladder, rectum or is growing outside of the pelvis.  
  • Stage 4B: The cancerous area has spread to distant organs outside of the pelvis, such as distant lymph nodes, lungs or bones. 

It is important to let your oncologist and health team know if you are experiencing any side effects, should that be physically or emotionally, so they can support your care needs and manage any symptoms. Receiving a cancer diagnosis can cause a variety of different emotions and levels of stress such as anxiety, anger, fear or sadness. Palliative care is offered to support patients and can include financial advice, travel assistance to the hospital, time off work, and emotional support. With palliative care you will have access to: 

  • Doctors, oncology nurses, physician assistants and nurse practitioners. 
  • A psychologist or psychiatrist for mental health support for both you and your family. 
  • A social worker to help with daily tasks and adjusting a cancer diagnosis. 
  • A dietitian or nutritionist to help with any side effects from treatment.  
  • An occupational therapist to help perform daily activities.  
  • A religious person if spiritual support is requested.  

Palliative care aims to give patients their independence and the best quality of life possible by managing and reducing any side effects and supporting patients and their families. 

Recovery from cervical cancer can take time and you may still have side effects in the months following. The severity and duration vary from patient to patient but there are ways to reduce the discomfort.  

Radiation therapy and surgery can cause pain in the abdomen from trapped wind, inflammations or swelling, constipation and diarrhoea. This can be managed by drinking plenty of water, chamomile or peppermint tea and avoiding alcohol.  

You may find your bladder control has changed following surgery and radiation. By practising pelvic floor muscles exercises, you can strengthen your muscles and improve urinary incontinence. Continence pads can also help with any leakage.  

Some patients will experience early menopause if the ovaries are removed via surgery or damaged during radiation or chemotherapy. Menopause is when a female no longer produces oestrogen or progesterone hormones and stops having periods. The vagina can become very dry during menopause and become narrow causing pain during intercourse. Speak with your doctor for advice on ways to improve sexual activity and libido as well as how to improve your bones strength and recommended nutrition and exercise plans. 

Radiation therapy and surgery in the pelvic region can have side effects on the surrounding lymph nodes preventing the draining properly. This is known as Lymphoedema and results in swelling surrounding the genital area and legs which, if mild, can be managed with the use of compressions on the legs and regular exercise. Most cancer patients experience fatigue and a lack of energy following chemotherapy and radiation that can last months or even years post treatment. It may take some time for your body to recover and to readjust back to daily life.  

Getting regular screening tests for prevention and early detection of cervical cancer

Determining cervical cancer stages assists healthcare professionals in identifying the extent of the cancerous area, which helps them make informed decisions regarding the patient’s treatment plan. Once the cancer stage is established, treatment options can be decided based on what has the best possible outcome. Depending on the stage of cervical cancer determined, the patient can be given information regarding time frame, survival, possible side effects, and methods of managing them. The treatment options may include surgery to remove the cancerous area or chemotherapy and radiation to slow cell production.  

By having regular screenings, you are taking proactive steps towards safeguarding yourself from cervical cancer. Regular screening for cervical cancer is crucial in preventing the disease. If you identify as a woman or person with a cervix, aged between 25 – 74, and engage in sexual activity, it is highly recommended that you undergo cervical screening every five years. 

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