Cervical Cancer Prevention and Early

Detection
What is cervical cancer?
Cervicalcancerstartsincellsliningthecervix.Thecervixisthelowerpartoftheuterus(womb).
Itissometimescalledtheuterinecervix.Thebodyoftheuterus(theupperpart)iswhereafetus
grows.Thecervixconnectsthebodyoftheuterustothevagina(birthcanal).Thepartofthe
cervixclosesttothebodyoftheuterusiscalledtheendocervix.Thepartnexttothevaginaisthe
exocervix(orectocervix).The2maintypesofcellscoveringthecervixaresquamouscells(on
theexocervix)andglandularcells(ontheendocervix).Theplacethesecelltypesmeetiscalled
thetransformationzone.Theexactlocationofthetransformationzonechangesasyouageand
withchildbirth.Mostcervicalcancersstartinthecellsinthetransformationzone.

Thesecellsdonotsuddenlychangeintocancer.Instead,thenormalcellsofthecervixgradually
developprecancerouschangesthatturnintocancer.Doctorsuseseveraltermstodescribethese
precancerouschanges,includingcervicalintraepithelialneoplasia(CIN),squamous
intraepitheliallesion(SIL),anddysplasia.ThesechangescanbedetectedbythePaptestand
treatedtopreventcancerfromdeveloping(seethesections,ThePap(Papanicolaou)testand
WorkupofabnormalPaptestresults.).
Cervicalcancersandcervicalprecancersareclassifiedbyhowtheylookunderamicroscope.There
are2maintypesofcervicalcancer:squamouscellcarcinomaandadenocarcinoma.About80%to
90%ofcervicalcancersaresquamouscellcarcinomas.Thesecancersformfromcellsinthe
exocervix,andthecancercellshavefeaturesofsquamouscellsunderthemicroscope.

Mostoftheremainingtypesofcervicalcancersareadenocarcinomas.Adenocarcinomasare
cancersthatdevelopfromglandcells.Cervicaladenocarcinomadevelopsfromthemucus
producingglandcellsoftheendocervix.Cervicaladenocarcinomasseemtohavebecomemore
commoninthelast20to30years.
Lesscommonly,cervicalcancershavefeaturesofbothsquamouscellcarcinomasand
adenocarcinomas.Thesearecalledadenosquamouscarcinomasormixedcarcinomas.

Althoughcervicalcancersstartfromcellswithprecancerouschanges(precancers),onlysome

womenwithprecancersofthecervixwilldevelopcancer.Thechangefromprecancertocancer

usuallytakesseveralyearsbutitcanhappeninlessthanayear.Formostwomen,pre
cancerouscellswillremainunchangedorevengoawaywithoutanytreatment.Still,insome
womenprecancersturnintotrue(invasive)cancers.Treatingallprecancerscanpreventalmost
alltruecancers.PrecancerouschangesarediscussedinthesectionWorkupofabnormalPap
testresultsandtreatmentofprecancersisdiscussedinthesection,Howwomenwith
abnormalPaptestresultsorprecancersaretreated.

What are the risk factors for cervical cancer?

Ariskfactorisanythingthatchangesyourchanceofgettingadiseasesuchascancer.Different
cancershavedifferentriskfactors.Forexample,exposingskintostrongsunlightisariskfactor
forskincancer.Smokingisariskfactorformanycancers.Buthavingariskfactor,oreven
several,doesnotmeanthatyouwillgetthedisease.
Severalriskfactorsincreaseyourchanceofgettingcervicalcancer.Womenwithoutanyofthese
riskfactorsrarelydevelopcervicalcancer.Althoughthesefactorsincreasetheoddsofgetting
cervicalcancer,manywomenwiththeseriskfactorsdonotdevelopthisdisease.
Inthinkingaboutthefollowingriskfactors,ithelpstofocusonthoseyoucanchangeoravoid
(likesmokingorhumanpapillomavirusinfection),ratherthanthosethatyoucannot(suchas
yourageandfamilyhistory).Itsstillimportant,though,toknowaboutriskfactorsthatcannot
bechanged,becauseit'sevenmoreimportantforwomenwhohavethesefactorstogetregular
Papteststodetectcervicalcancerearly.Cervicalcancerriskfactorsinclude:

Human papilloma virus infection

Themostimportantriskfactorforcervicalcancerisinfectionbythehumanpapillomavirus
(HPV).HPVisagroupofmorethan150relatedviruses,someofwhichcauseatypeofgrowth
calledpapillomas,whicharemorecommonlyknownaswarts.
HPVcaninfectcellsonthesurfaceoftheskin,andthoseliningthegenitals,anus,mouthand
throat,butnotthebloodorinternalorganssuchastheheartorlungs.
HPVcanbespreadfromonepersontoanotherduringskintoskincontact.OnewayHPV
isspreadisthroughsex,includingvaginal,anal,andevenoralsex.
DifferenttypesofHPVcausewartsondifferentpartsofthebody.Sometypescause
commonwartsonthehandsandfeet.Othertypestendtocausewartsonthelipsortongue.
CertaintypesofHPVmaycausewartstoappearonoraroundthegenitalorgansandinthe
analarea.Thesewartsmaybarelybevisibleortheymaybeseveralinchesacross.Theseare
knownasgenitalwartsorcondylomaacuminatum.HPV6andHPV11arethe2typesofHPV
thatcausemostcasesofgenitalwarts.ThesearecalledlowrisktypesofHPVbecausetheyare
seldomlinkedtocervicalcancer.
OthertypesofHPVarecalledhighrisktypesbecausetheyarestronglylinkedtocancers,including

cancersofthecervix,vulva,andvaginainwomen,penilecancerinmen,andanalandoralcancerin
menandwomen.ThehighrisktypesincludeHPV16,HPV18,HPV31,HPV33,

andHPV45,aswellassomeothers.Theremightbenovisiblesignsofinfectionwithahigh
riskHPVuntilprecancerouschangesorcancerdevelops.
DoctorsbelievethatawomanmustbeinfectedbyHPVbeforeshedevelopscervicalcancer.
Althoughthiscanmeaninfectionwithanyofthehighrisktypes,abouttwothirdsofallcervical
cancersarecausedbyHPV16and18.
InfectionwithHPViscommon,andinmostpeoplethebodyisabletocleartheinfectiononits
own.Sometimes,however,theinfectiondoesnotgoawayandbecomeschronic.Chronic
infection,especiallywhenitiswithhighriskHPVtypes,caneventuallycausecertaincancers,
suchascervicalcancer.
AlthoughHPVcanbespreadduringsexincludingvaginalintercourse,analintercourse,
andoralsexsexdoesn'thavetooccurfortheinfectiontospread.Allthatisneededtopass
HPVfromonepersontoanotherisskintoskincontactwithanareaofthebodyinfectedwith
HPV.InfectionwithHPVseemstobeabletobespreadfromonepartofthebodytoanother
forexample,infectionmaystartinthecervixandthenspreadtothevagina.
CompletelyavoidingputtingtheareasofyourbodythatcanbecomeinfectedwithHPV(likethe
mouth,anus,andgenitals)incontactwiththoseofanotherpersonmaybetheonlywaytotruly
preventtheseareasfrombecominginfectedwithHPV.
ThePaptestlooksforchangesincervicalcellscausedbyHPVinfection.Othertestslookforthe
infectionsthemselvesbyfindinggenes(DNA)fromHPVinthecells.Forsomewomen,the
HPVtestisusedalongwiththePaptestasapartofscreening.TheHPVtestmayalsobeusedto
helpdecidewhattodowhenawomanhasamildlyabnormalPaptestresult.Ifthetestfindsa
highrisktypeofHPV,itcouldmeanshewillneedafullevaluationwithacolposcopy
procedure.AlthoughthereiscurrentlynocureforHPVinfection,therearewaystotreatthe
wartsandabnormalcellgrowththatHPVcauses.
FormoreinformationonpreventingHPVinfection,seetheCancervicalcancerbe
prevented?sectioninthisdocumentoraskforourdocumentscalledHPVVaccinesandHPV
andHPVTesting.
AlthoughscientistsbelievethatitsnecessarytohavehadHPVforcervicalcancertodevelop,
mostwomenwiththisvirusdonotdevelopcancer.Doctorsbelievethatotherfactorsmust
comeintoplayforcancertodevelop.Someoftheseknownfactorsarelistedbelow.

Smoking
Womenwhosmokeareabouttwiceaslikelyasnonsmokerstogetcervicalcancer.Smoking
exposesthebodytomanycancercausingchemicalsthataffectorgansotherthanthelungs.
Theseharmfulsubstancesareabsorbedthroughthelungsandcarriedinthebloodstream
throughoutthebody.Tobaccobyproductshavebeenfoundinthecervicalmucusofwomen
whosmoke.ResearchersbelievethatthesesubstancesdamagetheDNAofcervixcells,andmay
contributetothedevelopmentofcervicalcancer.Smokingalsomakestheimmunesystemless
effectiveinfightingHPVinfections.

Immunosuppression
Humanimmunodeficiencyvirus(HIV),thevirusthatcausesAIDS,damagestheimmunesystem
andputswomenathigherriskforHPVinfection.Thismight,inpart,explaintheincreasedrisk
ofcervicalcancerinwomenwithAIDS.Also,thattheimmunesystemmaybeimportantin
destroyingcancercellsandslowingtheirgrowthandspread.Inwomenwithanimpaired
immunesystemfromHIV,acervicalprecancermightdevelopintoaninvasivecancerfaster
thanitnormallywould.Anothergroupofwomenatriskofcervicalcancerarethosetakingdrugs
tosuppresstheirimmuneresponse,suchasthosebeingtreatedforanautoimmunedisease(in
whichtheimmunesystemseesthebodysowntissuesasforeignandattacksthem,asitwoulda
germ)orthosewhohavehadanorgantransplant.

Chlamydia infection
Chlamydiaisarelativelycommonkindofbacteriathatcaninfectthereproductivesystem.Its
spreadbysexualcontact.Chlamydiainfectioncancausepelvicinflammation,leadingtoinfertility.
Somestudieshaveseenahigherriskofcervicalcancerinwomenwhosebloodtestresultsshow
signsofpastorcurrentchlamydiainfection(comparedwithwomenwithnormaltestresults).
Womenwhoareinfectedwithchlamydiaoftenhavenosymptoms.Infact,theymaynotknowthat
theyareinfectedatallunlesstheyaretestedforchlamydiaduringapelvicexam.

A diet low in fruits and vegetables

Womenwhosedietsdontincludeenoughfruitsandvegetablesmaybeatincreasedrisk
forcervicalcancer.

Being overweight
Overweightwomenaremorelikelytodevelopadenocarcinomaofthecervix.

Long-term use of oral contraceptives (birth control pills)

Thereisevidencethattakingoralcontraceptives(OCs)foralongtimeincreasestheriskof
cancerofthecervix.Researchsuggeststhattheriskofcervicalcancergoesupthelongera
womantakesOCs,buttheriskgoesbackdownagainaftertheOCsarestopped.Inonestudy,
theriskofcervicalcancerwasdoubledinwomenwhotookbirthcontrolpillslongerthan5
years,buttheriskreturnedtonormal10yearsaftertheywerestopped.
TheAmericanCancerSocietybelievesthatawomanandherdoctorshoulddiscusswhether
thebenefitsofusingOCsoutweighthisveryslightpotentialrisk.Awomanwithmultiple
sexualpartnersshouldusecondomstolowerherriskofsexuallytransmittedinfectionsno
matterwhatotherformofcontraceptionsheuses.

Intrauterine device use

Astudyfoundthatwomenwhohadeverusedanintrauterinedevice(IUD)hadalowerriskof
cervicalcancer.TheeffectonriskwasseeneveninwomenwhohadanIUDforlessthanayear,
andtheprotectiveeffectremainedaftertheIUDswereremoved.
UsinganIUDmightalsolowertheriskofendometrial(uterine)cancer.However,IUDsdo
havesomerisks.AwomaninterestedinusinganIUDshouldfirstdiscussthepotentialrisksand
benefitswithherdoctor.Also,awomanwithmultiplesexualpartnersshouldusecondomsto
lowerherriskofsexuallytransmittedillnessesnomatterwhatotherformofcontraceptionshe
uses.

Having multiple full-term pregnancies

Womenwhohavehad3ormorefulltermpregnancieshaveanincreasedriskofdeveloping
cervicalcancer.Noonereallyknowswhythisistrue.Onetheoryisthatthesewomenhadto
havehadunprotectedintercoursetogetpregnant,sotheymayhavehadmoreexposureto
HPV.Also,studieshavepointedtohormonalchangesduringpregnancyaspossiblymaking
womenmoresusceptibletoHPVinfectionorcancergrowth.Anotherthoughtisthatpregnant
womenmighthaveweakerimmunesystems,allowingforHPVinfectionandcancergrowth.

Being younger than 17 at your first full-term pregnancy

Womenwhowereyoungerthan17yearswhentheyhadtheirfirstfulltermpregnancyare
almost2timesmorelikelytogetcervicalcancerlaterinlifethanwomenwhowaitedtoget
pregnantuntiltheywere25yearsorolder.

Poverty
Povertyisalsoariskfactorforcervicalcancer.Manywomenwithlowincomesdonothave
readyaccesstoadequatehealthcareservices,includingPaptests.Thismeanstheymightnotget
screenedortreatedforcervicalcancersandprecancers.

Diethylstilbestrol (DES)
DESisahormonaldrugthatwasgiventosomewomentopreventmiscarriagebetween1940and
1971.WomenwhosemotherstookDESwhenpregnantwiththemareoftencalledDES
daughters.Thesewomendevelopclearcelladenocarcinomaofthevaginaorcervixmoreoften
thanwouldnormallybeexpected.Thistypeofcancerisextremelyrareinwomenwhoarenot
DESdaughters.Thereisabout1caseofthistypeofcancerinevery1,000womenwhosemother
tookDESduringtheirpregnancy.Thismeansthatabout99.9%ofDESdaughtersdonotdevelop
thesecancers.

DESrelatedclearcelladenocarcinomaismorecommoninthevaginathanthecervix.The
riskappearstobegreatestinwomenwhosemotherstookthedrugduringtheirfirst16weeks
ofpregnancy.TheaverageageofwomenwhentheyarediagnosedwithDESrelatedclearcell

adenocarcinomais19years.SincetheuseofDESduringpregnancywasstoppedbytheFDAin
1971,eventheyoungestDESdaughtersareolderthan35pasttheageofhighestrisk.Still,
theresnoagecutoffwhenthesewomenaresafefromDESrelatedcancer.Doctorsdonotknow
exactlyhowlongwomenwillremainatrisk.
DESdaughtersmayalsobeatincreasedriskofdevelopingsquamouscellcancersandpre
cancersofthecervixlinkedtoHPV.
AlthoughDESdaughtershaveanincreasedriskofdevelopingclearcellcarcinomas,women
donthavetobeexposedtoDESforclearcellcarcinomatodevelop.Itisextremelyrare,
butwomenwerediagnosedwiththediseasebeforeDESwasinvented.
YoucanlearnmoreaboutDESinourseparatedocumentcalledDESExposure:Questions
andAnswers.Itcanbereadonourwebsite,orcalltohaveafreecopysenttoyou.

Having a family history of cervical cancer

Cervicalcancermayruninsomefamilies.Ifawomansmotherorsisterhadcervicalcancer,
herchancesofdevelopingthediseaseare2to3timeshigherthanifnooneinthefamilyhadit.
Someresearcherssuspectsomeinstancesofthisfamilialtendencyarecausedbyaninherited
conditionthatmakessomewomenlessabletofightoffHPVinfectionthanothers.Inother
instances,womenfromthesamefamilyasapatientalreadydiagnosedcouldbemorelikelyto
haveoneormoreoftheothernongeneticriskfactorspreviouslydescribedinthissection.

Signs and symptoms of cervical cancer

Womenwithearlycervicalcancersandprecancersusuallyhavenosymptoms.Symptoms
oftendonotbeginuntilaprecancerbecomesatrueinvasivecancerandgrowsintonearby
tissue.Whenthishappens,themostcommonsymptomsare:

Abnormalvaginalbleeding,suchasbleedingaftersex(vaginalintercourse),bleeding
aftermenopause,bleedingandspottingbetweenperiods,andhavinglongerorheavier
(menstrual)periodsthanusual.Bleedingafterdouching,orafterapelvicexamisa
commonsymptomofcervicalcancerbutnotprecancer.

Anunusualdischargefromthevaginathedischargemaycontainsomebloodand
mayoccurbetweenyourperiodsoraftermenopause.

Painduringsex(vaginalintercourse).

Thesesignsandsymptomscanalsobecausedbyconditionsotherthancervicalcancer.For
example,aninfectioncancausepainorbleeding.Still,ifyouhaveanyoftheseproblems,you
shouldseeyourhealthcareprofessionalrightawayevenifyouhavebeengettingregularPap
tests.Ifitisaninfection,itwillneedtobetreated.Ifitscancer,ignoringsymptomsmightallow
ittoprogresstoamoreadvancedstageandloweryourchanceforeffectivetreatment.

Evenbetter,don'twaitforsymptomstoappear.Bescreenedregularly.

Can cervical cancer be prevented?

Sincethemostcommonformofcervicalcancerstartswithprecancerouschanges,thereare2
waystostopthisdiseasefromdeveloping.Onewayistofindandtreatprecancersbeforethey
becometruecancers,andtheotheristopreventtheprecancersinthefirstplace.

Finding cervical pre-cancers

Awellprovenwaytopreventcervixcanceristohavetesting(screening)tofindprecancers
beforetheycanturnintoinvasivecancer.ThePaptest(sometimescalledthePapsmear)andthe
HPV(humanpapillomavirus)testareusedforthis.Ifaprecancerisfound,itcanbetreated,
stoppingcervicalcancerbeforeitreallystarts.SincenoHPVvaccineprovidescomplete
protectionagainstalloftheHPVtypesthatcancausecancerofthecervix,itcannotpreventall
casesofcervicalcancer.Thisiswhyitisveryimportantthatwomencontinuetohavecervical
cancerscreeningevenaftertheyvebeenvaccinated.Mostinvasivecervicalcancersarefoundin
womenwhohavenothadregularscreening.
Seethesection,TheAmericanCancerSocietyguidelinesforthepreventionandearly
detectionofcervicalcancerformoredetails.

Things to do to prevent pre-cancers and cancers

Avoidcontactwiththehumanpapillomavirus(HPV)
SinceHPVisthemaincauseofcervicalcancerandprecancer,avoidingexposuretoHPVcould
helpyoupreventthisdisease.HPVispassedfromonepersontoanotherduringskintoskin
contactwithaninfectedareaofthebody.AlthoughHPVcanbespreadduringsexincluding
vaginal,anal,andoralsexsexdoesn'thavetooccurfortheinfectiontospread.Allthatis
neededisskintoskincontactwithanareaofthebodyinfectedwithHPV.Thismeansthatthe
viruscanbespreadthroughgenitaltogenitalcontact(withoutintercourse).Itisevenpossible
foragenitalinfectiontospreadthroughhandtogenitalcontact.
Also,HPVinfectionseemstobeabletobespreadfromonepartofthebodytoanother.This
meansthataninfectionmaystartinthecervixandthenspreadtothevaginaandvulva.
ItcanbeveryhardnottobeexposedtoHPV.ItmaybepossibletopreventgenitalHPV
infectionbynotallowingotherstohavecontactwithyouranalorgenitalarea,buteventhen
theremightbeotherwaystobecomeinfectedthatarentyetclear.Forexample,arecentstudy
foundHPVonthesurfaceofsextoys,sosharingsextoysmightspreadHPV.
HPVinfectioninwomen:HPVinfectionsoccurmainlyinyoungerwomenandareless
commoninwomenolderthan30.Thereasonforthisisnotclear.Certaintypesofsexual
behaviorincreaseawoman'sriskofgettingHPVinfection,suchashavingsexatanearlyage
andhavingmanysexpartners.

WomenwhohavehadmanysexpartnersaremorelikelytogetinfectedwithHPV,butawoman
whohashadonlyonesexpartnercanstillgetinfected.Thisismorelikelyifshehasapartner
whohashadmanysexpartnersorifherpartnerisanuncircumcisedmale.
WaitingtohavesexuntilyouareoldercanhelpyouavoidHPV.Italsohelpstolimityour
numberofsexpartnersandtoavoidhavingsexwithsomeonewhohashadmanyothersex
partners.Althoughthevirusmostoftenspreadsbetweenamanandawoman,HPVinfectionand
cervicalcanceralsoareseeninwomenwhohaveonlyhadsexwithotherwomen.Remember
thatsomeonecanhaveHPVforyearsandstillhavenosymptomsitdoesnotalwayscause
wartsorotherproblems.Someonecanhavethevirusandpassitonwithoutknowingit.
Still,sinceallthatsneededtopassHPVfromonepersontoanotherisskintoskincontactwith
anareaofthebodyinfectedwithHPV,evenneverhavingsexdoesntguaranteethatyouwont
evergetinfected.ItmightbepossibletopreventanalandgenitalHPVinfectionbynever
allowinganotherpersontohavecontactwiththoseareasofyourbody.
HPVinfectioninmen:Formen,themainfactorsinfluencingtheriskofgenitalHPV
infectionarecircumcisionandthenumberofsexpartners.
Menwhoarecircumcised(havehadtheforeskinofthepenisremoved)havealowerchanceof
becomingandstayinginfectedwithHPV.Menwhohavenotbeencircumcisedaremorelikely
tobeinfectedwithHPVandpassitontotheirpartners.Thereasonsforthisareunclear.Itmay
bethataftercircumcisiontheskinontheglans(ofthepenis)goesthroughchangesthatmakeit
moreresistanttoHPVinfection.Anothertheoryisthatthesurfaceoftheforeskin(whichis
removedbycircumcision)ismoreeasilyinfectedbyHPV.Still,circumcisiondoesnot
completelyprotectagainstHPVinfectionmenwhoarecircumcisedcanstillgetHPVand
passitontotheirpartners.
TheriskofbeinginfectedwithHPVisalsostronglylinkedtohavingmanysexualpartners
(overaman'slifetime).

Usecondoms
Condoms(rubbers)providesomeprotectionagainstHPVbuttheydontcompletelyprevent
infection.MenwhousecondomsarelesslikelytobeinfectedwithHPVandtopassitontotheir
femalepartners.Onestudyfoundthatwhencondomsareusedcorrectlyeverytimesexoccurs
theycanlowertheHPVinfectionratebyabout70%.Onereasonthatcondomscannotprotect
completelyisbecausetheydontcovereverypossibleHPVinfectedareaofthebody,suchas
skinofthegenitaloranalarea.Still,condomsprovidesomeprotectionagainstHPV,andthey
alsoprotectagainstHIVandsomeothersexuallytransmittedinfections.Condoms(whenused
bythemalepartner)alsoseemtohelptheHPVinfectionandcervicalprecancersgoaway
faster.
Femalecondomsfitinsidethevaginaandcanhelpprotectagainstpregnancy.Theyalsocan
protectagainstsexuallytransmittedinfections,includingHPVandHIV,althoughforthisthey
arentaseffectiveasmalecondoms.

Dontsmoke
Notsmokingisanotherimportantwaytoreducetheriskofcervicalprecancerandcancer.

Getvaccinated
VaccinesareavailablethatcanprotectagainstcertainHPVinfections.Allofthesevaccines
protectagainstinfectionwithHPVsubtypes16and18.Somecanalsoprotectagainstinfections
withotherHPVsubtypes,includingsometypesthatcauseanalandgenitalwarts.
ThesevaccinesonlyworktopreventHPVinfectiontheywillnottreataninfectionthat
isalreadythere.Thatiswhy,tobemosteffective,theHPVvaccinesshouldbegiven
beforeapersonbecomesexposedtoHPV(suchasthroughsexualactivity).
Thesevaccineshelppreventprecancersandcancersofthecervix.SomeHPVvaccinesarealso
approvedtohelppreventothertypesofcancersandanalandgenitalwarts.
Thevaccinesrequireaseriesof3injectionsovera6monthperiod.Sideeffectsareusuallymild.
Themostcommononeisshorttermredness,swelling,andsorenessattheinjectionsite.Rarely,
ayoungwomanwillfaintshortlyafterthevaccineinjection.
TheFederalAdvisoryCommitteeonImmunizationPractices(ACIP)recommendsthatfemales
aged11to12routinelybevaccinatedforHPVwiththefullseriesof3shots.Femalesasyoung
asage9mayalsoreceivetheHPVvaccineatthediscretionoftheirdoctors.ACIPalso
recommendedwomenages13to26whohavenotyetbeenvaccinatedgetcatchup
vaccinations.
TheAmericanCancerSocietyalsorecommendsthattheHPVvaccineberoutinelygiventogirls
ages11to12andasearlyasage9atthediscretionofdoctors.TheSocietyalsoagreesthat
catchupvaccinationsshouldbegiventofemalesuptoage18.Theindependentpanelmaking
theSocietyrecommendationsfoundthattherewasnotyetenoughproofthatcatchup
vaccinationsforallwomenaged19to26yearswouldbebeneficial.Asaresult,theAmerican
CancerSocietyrecommendsthatwomenaged19to26talkwiththeirhealthcareproviderabout
theirriskofpreviousHPVexposureandpotentialbenefitfromvaccinationbeforedecidingtoget
thevaccine.Atthistime,theAmericanCancerSocietysguidelinesdonotaddresstheuseofthe
vaccineinolderwomenormales.
Itsimportanttorealizethatnovaccineprovidescompleteprotectionagainstallcancer
causingtypesofHPV,soroutinecervicalcancerscreeningisstillnecessary.
FormoreinformationonthevaccineandHPV,pleaseseeourdocument,HPVVaccines.

The American Cancer Society guidelines for the

prevention and early detection of cervical cancer

TheAmericanCancerSocietyrecommendsthatwomenfollowtheseguidelinestohelpfind
cervicalcancerearly.Followingtheseguidelinescanalsofindprecancers,whichcanbetreated
tokeepcervicalcancerfromforming.

Allwomenshouldbegincervicalcancertesting(screening)atage21.Womenaged21to29,
shouldhaveaPaptestevery3years.HPVtestingshouldnotbeusedforscreeninginthis
agegroup(itmaybeusedasapartoffollowupforanabnormalPaptest).

Beginningatage30,thepreferredwaytoscreeniswithaPaptestcombinedwithan
HPVtestevery5years.Thisiscalledcotestingandshouldcontinueuntilage65.

Anotherreasonableoptionforwomen30to65istogettestedevery3yearswithjustthe
Paptest.

Womenwhoareathighriskofcervicalcancerbecauseofasuppressedimmunesystem
(forexamplefromHIVinfection,organtransplant,orlongtermsteroiduse)orbecause
theywereexposedtoDESinuteromayneedtobescreenedmoreoften.Theyshould
followtherecommendationsoftheirhealthcareteam.

Womenover65yearsofagewhohavehadregularscreeningintheprevious10years
shouldstopcervicalcancerscreeningaslongastheyhaventhadanyseriousprecancers
(likeCIN2orCIN3)foundinthelast20years(CINstandsforcervicalintraepithelial
neoplasiaandisdiscussedlaterinthesectionWorkupofanabnormalPaptestresult
undertheheadingHowbiopsyresultsarereported).WomenwithahistoryofCIN2or
CIN3shouldcontinuetohavetestingforatleast20yearsaftertheabnormalitywas
found.

Womenwhohavehadatotalhysterectomy(removaloftheuterusandcervix)should
stopscreening(suchasPaptestsandHPVtests),unlessthehysterectomywasdoneasa
treatmentforcervicalprecancer(orcancer).Womenwhohavehadahysterectomy
withoutremovalofthecervix(calledasupracervicalhysterectomy)shouldcontinue
cervicalcancerscreeningaccordingtotheguidelinesabove.

WomenofanyageshouldNOTbescreenedeveryyearbyanyscreeningmethod

WomenwhohavebeenvaccinatedagainstHPVshouldstillfollowtheseguidelines.

Somewomenbelievethattheycanstopcervicalcancerscreeningoncetheyhavestoppedhaving
children.Thisisnottrue.TheyshouldcontinuetofollowAmericanCancerSocietyguidelines.
Althoughannual(everyyear)screeningshouldnotbedone,womenwhohaveabnormal
screeningresultsmayneedtohaveafollowupPaptest(sometimeswithaHPVtest)donein
6monthsorayear.
TheAmericanCancerSocietyguidelinesforearlydetectionofcervicalcancerdonotapplyto
womenwhohavebeendiagnosedwithcervicalcancer,cervicalprecancer,orHIVinfection.
Thesewomenshouldhavefollowuptestingandcervicalcancerscreeningasrecommendedby
theirhealthcareteam.

Importance of being screened for cervical cancer

Screeningtestsofferthebestchancetohavecervicalcancerfoundatanearlystagewhensuccessful

treatmentislikely.Screeningcanalsoactuallypreventmostcervicalcancersby

findingabnormalcervixcellchanges(precancers)sothattheycanbetreatedbeforetheyhave
achancetoturnintoacervicalcancer.
Ifitsdetectedearly,cervicalcancerisoneofthemostsuccessfullytreatablecancers.Inthe
UnitedStates,thecervicalcancerdeathratedeclinedbymorethan50%overthelast30
years.ThisisthoughttobemainlyduetotheeffectivenessofPaptestscreening.
Despitetherecognizedbenefitsofcervicalcancerscreening,notallAmericanwomentake
advantageofit.MostcervicalcancersarefoundinwomenwhohaveneverhadaPaptestor
whohavenothadonerecently.Womenwithouthealthinsuranceandwomenwhohaverecently
immigratedarelesslikelytohavetimelycervicalcancerscreening.
Cervicalcancerdeathsarehigherinpopulationsaroundtheworldwherewomendonothave
routinecervicalcancerscreening.Infact,cervicalcanceristhemajorcauseofcancerdeaths
inwomeninmanydevelopingcountries.Thesewomenareusuallydiagnosedwithlatestage
cancers,ratherthanprecancersorearlycancers.

The HPV DNA test

Asmentionedearlier,themostimportantriskfactorfordevelopingcervicalcancerisinfection
withHPV.DoctorscannowtestforthetypesofHPV(highriskorcarcinogenictypes)thatare
mostlikelytocausecervicalcancerbylookingforpiecesoftheirDNAincervicalcells.The
testisdonesimilarlytothePaptestintermsofhowthesampleiscollected,anditsometimes
canevenbedoneonthesamesample.
TheHPVDNAtestismostoftenusedin2situations:

TheHPVgenetestcanbeusedincombinationwiththePaptesttoscreenforcervicalcancer.
TheAmericanCancerSocietyrecommendsthiscombinationforwomen30andolder.Inthe
AmericanCancerSocietyguidelines,theHPVtestdoesnotreplacethePaptestformostwomen.
TheAmericanCancerSocietydoesnotrecommendusingtheHPVDNAtesttoscreenfor
cervicalcancerinwomenunder30.Thatisbecausewomenintheir20swhoaresexuallyactive
aremuchmorelikely(thanolderwomen)tohaveanHPVinfectionthatwillgoawayonitsown.
Fortheseyoungerwomen,resultsofthistestarenotassignificantandmaybemoreconfusing.
Formoreinformation,seetheAmericanCancerSocietydocument
HPVandHPVTesting.

TheHPVDNAtestcanalsobeusedinwomenwhohaveslightlyabnormalPaptest
results(ASCUS)tofindoutiftheymightneedmoretestingortreatment.Seethe
sectionWorkupofabnormalPaptestresults.

AnHPVDNAtesthasbeenapprovedbytheFDAtobeusedwithoutaPaptesttoscreenfor
cervicalcancer.Atthistime,theAmericanCancerSocietyisconsideringtheevidence
supportingtheuseofthistestforscreeningandmayissueupdatestoourscreeningguidelines
in2015.

Follow-up of HPV testing

IfyourPaptestresultisnormal,butyoutestpositiveforHPV,themainoptionsare:

Repeatcotesting(withaPaptestandanHPVtest)inoneyear

TestingtoseeifyoutestpositiveforHPVtypes16or18(thiscanoftenbedoneonthe
sampleinthelab).Ifyouare,colposcopywouldberecommended(colposcopyis
discussedinthesection,WorkupofabnormalPaptestresults).Ifyoutestnegative,
youshouldgetrepeatcotestinginoneyear.

The Pap (Papanicolaou) test

ThePaptestisthemainscreeningtestforcervicalcancerandprecancerouschanges.A
womanshouldknowhowitisdoneandhowoftentheyshouldhaveaPaptest.

How the Pap test is done

ThePaptestisaprocedureusedtocollectcellsfromthecervixsothattheycanbelookedat
underthemicroscopetofindcancerandprecancer.
Thehealthcareprofessionalfirstplacesaspeculuminsidethevagina.Thespeculumisametal
orplasticinstrumentthatkeepsthevaginaopensothatthecervixcanbeseenclearly.Next,
usingasmallspatula,asampleofcellsandmucusislightlyscrapedfromtheexocervix.Asmall
brushoracottontippedswabistheninsertedintotheopeningofthecervixtotakeasample
fromtheendocervix(seeillustrationinWhatiscervicalcancer?section).Ifyourcervixhas
beenremoved(becauseyouhadatrachelectomyorhysterectomy)asapartofthetreatmentfor
acervicalcancerorprecancer,thecellswillbesampledfromtheupperpartofthevagina
(knownasthevaginalcuff).
Thecellsamplesarethenpreparedsothattheycanbeexaminedunderamicroscopeinthe
laboratory.Thisthisisdoneeitherby:

Smearingthesampledirectlyontoaglassmicroscopeslideandsprayingitwitha
preservative.Theslideisthensenttothelaboratory.Thisiscalledconventional
cytology.

Puttingthesampleofcellsfromthecervixintoaspecialpreservativeliquid(insteadof
puttingthemonaslidedirectly).Thebottlecontainingthecellsandtheliquidissent
tothelab.Thecellsintheliquidarespreadontoslidesinthelab.Thisiscalledliquid
basedcytology,oraliquidbasedPaptest.

Liquidbasedtestingdoesnotfindmorecancersorprecancersthanconventionalcytologybutit
doeshavesomeadvantages.TheseincludealowerchancethatthePaptestwillneedtobe
repeated,andtheabilitytousethesamesampleforHPVtesting.Adrawbackoftheliquid
basedtestisthatitismorelikelytofindcellchangesthatarenotprecancerousbutthatwill

needtobecheckedoutfurtherleadingtounnecessarytests.Thismethodisalsomoreexpens
ivethanconventionalcytology.

AlthoughthePaptesthasbeenmoresuccessfulthananyotherscreeningtestinpreventinga
cancer,itsnotperfect.OneofthelimitationsofthePaptestisthattheresultsneedtobe
examinedbyhumans,soanaccurateanalysisofthehundredsofthousandsofcellsineach
sampleisnotalwayspossible.Engineers,scientists,anddoctorsareworkingtogethertoimprove
thistest.Becausesomeabnormalitiesmaybemissed(evenwhensamplesarelookedatinthe
bestlaboratories),itsnotagoodideatohavethistestlessoftenthanAmericanCancerSociety
guidelinesrecommend.Unfortunately,manyofthewomenmostatriskforcervicalcancerare
notbeingtestedoftenenoughoratall.

MakingyourPaptestsmoreaccurate
YoucandoseveralthingstomakeyourPaptestasaccurateaspossible:

Trynottoscheduleanappointmentforatimeduringyourmenstrualperiod.Thebest
timeisatleast5daysafteryourmenstrualperiodstops.

Don't use tampons, birthcontrol foams or jellies, other vaginal creams,

moisturizers,orlubricants,orvaginalmedicinesfor2to3daysbeforethetest.

Don'tdouchefor2to3daysbeforethetest.

Donthavesexualintercoursefor2daysbeforethetest.

ApelvicexamisnotthesameasaPaptest
ManypeopleconfusepelvicexamswithPaptests.Thepelvicexamispartofawomansroutine
healthcare.Duringapelvicexam,thedoctorlooksatandfeelsthereproductiveorgans,
includingtheuterusandtheovariesandmaydotestsforsexuallytransmitteddisease.Paptests
areoftendoneduringpelvicexams,butyoucanhaveapelvicexamwithouthavingaPaptest.
ApelvicexamwithoutaPaptestwillnothelpfindabnormalcellsofthecervixorcervical
canceratanearlystage.
ThePaptestisoftendoneduringapelvicexam,afterthespeculumisplaced.TodoaPaptest,
thedoctorremovescellsfromthecervixbygentlyscrapingorbrushingitwithaspecial
instrument.Pelvicexamsmayhelpfindothertypesofcancersandreproductiveproblems,buta
Paptestisneededtofindearlycervicalcancerorprecancers.AskyourdoctorifyouhadaPap
testwithyourpelvicexam.

How Pap test results are reported

ThemostwidelyusedsystemfordescribingPaptestresultsistheBethesdaSystem(TBS).There
are3maincategories,someofwhichhavesubcategories:

Negativeforintraepitheliallesionormalignancy,

Epithelialcellabnormalities

Othermalignantneoplasms.

Negativeforintraepitheliallesionormalignancy
Thisfirstcategorymeansthatnosignsofcancer,precancerouschanges,orothersignificant
abnormalitieswerefound.Somespecimensinthiscategoryappearentirelynormal.Others
mayhavefindingsthatareunrelatedtocervicalcancer,suchassignsofinfectionwithyeast,
herpes,orTrichomonasvaginalis(amicroscopicparasite),forexample.Specimensfromsome
womenmayalsoshowreactivecellularchanges,whichisthewaycervicalcellsrespondto
infectionorotherirritation.

Epithelialcellabnormalities
Thismeansthatthecellsliningthecervixorvaginashowchangesthatmightbecancerorapre
cancerouscondition.Thiscategoryisdividedintoseveralgroupsforsquamouscellsand
glandularcells.
Squamouscellabnormalities
Atypicalsquamouscells(ASCs):Thiscategoryincludesatypicalsquamouscellsofuncertain
significance(ASCUS)andatypicalsquamouscellswherehighgradesquamousintraepithelial
lesion(SIL)cantbeexcluded(ASCH).
ASCUSisatermusedwhentherearecellsthatlookabnormal,butitisnotpossibletotell(by
lookingatthecellsunderamicroscope)ifthisiscausedbyinfection,irritation,orifitisapre
cancer.Mostofthetime,cellslabeledASCUSarenotprecancer,butmoretestingisneeded
tobesure.
IftheresultsofaPaptestarelabeledASCH,itmeansthataSILissuspected.
PaptestresultsofeithertypeofASCmeanthatmoretestingisneeded.Thisisdiscussedin
thesection,WorkupofabnormalPaptestresults.
Squamousintraepitheliallesions(SILs):TheseabnormalitiesaresubdividedintolowgradeSIL
(LSIL)andhighgradeSIL(HSIL).InLSIL,thecellsaremildlyabnormal,whileinHSIL,the
cellsareseverelyabnormal.HSILsarelesslikelythanLSILstogoawaywithouttreatment.
Theyarealsomorelikelytoeventuallydevelopintocanceriftheyarenottreated.Treatment
cancuremostSILsandpreventtruecancerfromdeveloping.

FurthertestsareneededifSILisseenonaPaptest.Thisisdiscussedinthesection,Workup
ofabnormalPaptestresults.
Squamouscellcarcinoma:Thisresultmeansthatthewomanislikelytohaveaninvasivecancer.
Furthertestingwillbedonetobesureofthediagnosisbeforetreatmentcanbeplanned.

Glandularcellabnormalities
Adenocarcinoma:Cancersoftheglandularcellsarecalledadenocarcinomas.Insomecases,the
pathologistexaminingthecellscantellwhethertheadenocarcinomastartedintheendocervix,in
theuterus(endometrium),orelsewhereinthebody.

Atypicalglandularcells:Whentheglandularcellsdonotlooknormal,buthavefeaturesthat
donotpermitacleardecisionastowhethertheyarecancerous,thetermusedisatypical
glandularcells(AGCs).Thepatientshouldhavemoretestingifhercervicalcytologyresult
showsatypicalglandularcells.
Othermalignantneoplasms
Thiscategoryisforformsofcancerthatonlyrarelyaffectthecervix,suchas
malignantmelanoma,sarcomas,andlymphoma.
OtherdescriptionsofPaptestresultshavealsobeenusedinthepast.

Work-up of abnormal Pap test results

Other tests for women with abnormal test results
ThePaptestisascreeningtestnotadiagnostictestitcannottellforcertainthatcanceris
present.AnabnormalPaptestresultmeansthatothertestswillneedtobedonetofindoutifa
canceroraprecancerisactuallypresent.Theteststhatareusedincludecolposcopy(with
biopsy)andendocervicalscraping.Ifabiopsyshowsaprecancer,doctorswilltakestepsto
keepanactualcancerfromdeveloping.
SometimesthesetestsarealsodonetofollowupapositiveHPVtestresultwhenthePaptest
isnormal.

Colposcopy
IfyouhavecertainsymptomsthatsuggestcancerorifyourPaptestshowsabnormalcells,you
willneedtohaveatestcalledcolposcopy.Inthisprocedureyouwilllieontheexamtableasyou
doforapelvicexam.Aspeculumwillbeplacedinthevaginatohelpthedoctorseethecervix.
Thedoctorwilluseacolposcopetoexaminethecervix.Thecolposcopeisaninstrumentthat
hasmagnifyinglenses(likebinoculars).Althoughitstaysoutsidethewomansbody,itletsthe
doctorseethesurfaceofthecervixcloselyandclearly.Thedoctorwillapplyaweaksolutionof
aceticacid(similartovinegar)toyourcervixtomakeanyabnormalareaseasiertosee.
Colposcopyitselfcausesnomorediscomfortthananyotherspeculumexam.Ithasnoside
effects,andcanbedonesafelyevenifyourepregnant.LikethePaptest,itsrarelydoneduring
yourmenstrualperiod.Ifanabnormalareaisseenonthecervix,abiopsywillbedone.Fora
biopsy,asmallpieceoftissueisremovedfromtheareathatlooksabnormal.Thesampleissent
toapathologisttolookatunderamicroscope.Abiopsyistheonlywaytotellforcertainifan
abnormalareaisaprecancer,atruecancer,orneither.Althoughthecolposcopyprocedureisnot
painful,cervicalbiopsycancausediscomfort,cramping,orevenpaininsomewomen.

Cervicalbiopsies
Severaltypesofbiopsiesareusedtodiagnosecervicalprecancersandcancers.Ifthebiopsy
cancompletelyremovealloftheabnormaltissue,itmaybetheonlytreatmentneeded.Insome
situations,additionaltreatmentofprecancersorcancersisneeded.
Colposcopicbiopsy
Forthistypeofbiopsy,adoctororotherhealthcareprofessionalfirstexaminesthecervixwith
acolposcopetofindtheabnormalareas.Usingabiopsyforceps,thedoctorwillremoveasmall
(about1/8inch)sectionoftheabnormalareaonthesurfaceofthecervix.Thebiopsyprocedure
maycausemildcrampingorbriefpain,andyoumaybleedlightlyafterward.Alocalanesthetic
issometimesusedtonumbthecervixbeforethebiopsy.
Endocervicalcurettage(endocervicalscraping)
Sometimesthetransformationzone(theareaatriskforHPVinfectionandprecancer)cannotbe
seenwiththecolposcope.Inthatsituation,somethingelsemustbedonetocheckthatareafor
cancer.Thismeanstakingascrapingoftheendocervixbyinsertinganarrowinstrument(calleda
curette)intotheendocervicalcanal(thepassagebetweentheouterpartofthecervixandthe
innerpartoftheuterus).Thecuretteisusedtoscrapetheinsideofthecanaltoremovesomeof
thetissue,whichisthensenttothelaboratoryforexamination.Afterthisprocedure,patients
mayfeelacrampingpain,andtheymayalsohavesomelightbleeding.Thisprocedureisusually
doneatthesametimeasthecolposcopicbiopsy.
Conebiopsy
Inthisprocedure,alsoknownasconization,thedoctorremovesaconeshapedpieceoftissue
fromthecervix.Thebaseoftheconeisformedbytheexocervix(outerpartofthecervix),and
thepointorapexoftheconeisfromtheendocervicalcanal.Thetransformationzone(theborder
betweentheexocervixandendocervix)iscontainedwithinthecone.Thisistheareaofthe
cervixwhereprecancersandcancersaremostlikelytodevelop.Theconebiopsycanbeusedas
atreatmenttocompletelyremovemanyprecancersandsomeveryearlycancers.Havingacone
biopsywillnotkeepmostwomenfromgettingpregnant,butifthebiopsyremoveslargeamount
oftissuethesewomenmayhaveahigherriskofgivingbirthprematurely.
Thereare2methodscommonlyusedforconebiopsies:theloopelectrosurgicalexcision
procedure(LEEP)(alsocalledlargeloopexcisionofthetransformationzoneorLLETZ)and
thecoldknifeconebiopsy.
Loopelectrosurgicalprocedure(LEEPorLLETZ):Withthismethod,thetissueisremoved
withathinwireloopthatisheatedbyelectricalcurrentandactsasascalpel.Forthisprocedure,
alocalanestheticisused,anditcanbedoneinyourdoctorsoffice.Itcantakeaslittleas10
minutes.Youmayhavemildcrampingduringandaftertheprocedure,andmildtomoderate
bleedingforseveralweeks.
Coldknifeconebiopsy:Thismethodusesasurgicalscalpeloralaserinsteadofaheatedwire
toremovetissue.Itrequiresgeneralanesthesia(youareasleepduringtheoperation)andisdone

inahospital,butnoovernightstayisneeded.Aftertheprocedure,crampingandsomebleeding
maypersistforafewweeks.

Howbiopsyresultsarereported
ThetermsusedforreportingbiopsyresultsareslightlydifferentfromtheBethesdaSystemfor
reportingPaptestresults.Precancerouschangesonabiopsyarecalledcervicalintraepithelial
neoplasia(CIN),whileonaPaptesttheywouldbecalledsquamousintraepitheliallesion(SIL).
CINisgradedonascaleof1to3basedonhowmuchofthecervicaltissuelooksabnormalwhen
viewedunderthemicroscope.InCIN1,notmuchofthetissuelooksabnormal,andits
consideredtheleastseriouscervicalprecancer.InCIN2moreofthetissuelooksabnormal,and
inCIN3mostofthetissuelooksabnormal.CIN3isthemostseriousprecancer.
SometimesthetermdysplasiaisusedinsteadofCIN.CIN1isthesameasmilddysplasia,
CIN2isthesameasmoderatedysplasia,andCIN3includesseveredysplasiaaswellas
carcinomainsitu.
Thetermsforreportingcancers(squamouscellcarcinomaandadenocarcinoma)arethesame
forPaptestsandbiopsies.

When are these tests used?

Whattests(ortreatment)youwillneeddependsontheresultsofthePaptest.

Atypicalsquamouscells(ASCUSandASCH)
IfthePapresultsshowatypicalsquamouscellsofuncertainsignificance(ASCUS),some
doctorswillrepeatthePaptestin12months.Anotheroptionistotestforhumanpapillomavirus
(HPV).Whatisdonenextdependsonhowoldyouare.Ifyouare21to24yearsold,andHPV
DNAisfound,thedoctorwillrecommendarepeatPaptestinayear.Ifyouareatleast25years
oldandHPVisdetected,thedoctorwillrecommendacolposcopy.IfHPVisnotdetected,then
thedoctorwillrecommendthePaptestberepeatedin3years.Ifyouareatleast25yearsold,an
HPVtestwillbedoneatthesametimeastherepeatPaptest.
IftheresultsofaPaptestarelabeledatypicalsquamouscellscannotexcludehighgrade
squamousintraepitheliallesion(ASCH),itmeansthatahighgradeSILissuspected.Thedoctor
willrecommendcolposcopy.

Squamousintraepitheliallesions(SILs)
TheseabnormalitiesaredividedintolowgradeSIL(LSIL)andhighgradeSIL(HSIL).
ForLSIL,furthertestingdependsuponHPVtesting:

If the HPV test result was negative (meaning the virus wasnt detected), then
repeatingthePaptestandHPVtestinoneyearisrecommended.

IfHPVwasfound,thencolposcopyisrecommended.

IfnoHPVtestwasdoneandthewomanisatleast25yearsold,colposcopyisrecommended.

Ifthewomanisunder25,sheshouldhavearepeatPaptestinayear.

PregnantwomenwithLSILshouldhavecolposcopy.
ForHSIL,eithercolposcopyoraloopelectrosurgicalprocedureisrecommendedforwomen25
andolder.Forwomenunder25,colposcopyisrecommended.

Atypicalglandularcellsandadenocarcinomainsitu(onaPaptest)
IfthePapresultsreadatypicalglandularcellsoradenocarcinomabutthereportsaysthatthe
abnormalcellsdonotseemtobefromtheliningoftheuterus(theendometrium),guidelines
recommendcolposcopywiththebiopsytypecalledendocervicalcurettage(endocervical
scraping).Thedoctormayalsobiopsytheendometrium(thiscanbedoneatthesametimeasthe
colposcopy).Forinformationaboutendometrialbiopsy,seeourdocumentEndometrial
(Uterine)Cancer.
Iftheatypicalglandularoradenocarcinomacellslookliketheyarefromtheendometrium
(basedonhowtheylookunderthemicroscope),expertsrecommendabiopsyofthe
endometriumalongwithanendocervicalcurettage,butacolposcopyisntneededunlessthe
resultsfromtheendometrialbiopsyarenegativeanddonotexplainthePaptestresult..

How women with abnormal Pap test results or pre-cancers are

treated
TreatingwomenwithabnormalPaptestresultsandprecancerscanpreventcervicalcancer
fromdeveloping
Ifanabnormalareaisseenduringthecolposcopy,yourdoctorwillbeabletoremoveitwitha
loopelectrosurgicalprocedure(LEEPorLLETZprocedure,whichwerediscussedinthe
previoussection).Otheroptionsincludeaconebiopsyanddestroyingtheabnormalcellswith
cryosurgeryorlasersurgery.
Duringcryosurgery,ametalprobecooledwithliquidnitrogenisplaceddirectlyonthecervix.
Thiskillstheabnormalcellsbyfreezingthem.Thiscanbedoneinadoctorsofficeorclinic.
Aftercryosurgery,youmayhavealotofwaterybrowndischargeforafewweeks.
Inlasersurgery,afocusedlaserbeam,directedthroughthevagina,isusedtovaporize(burn
off)abnormalcellsortoremoveasmallpieceoftissueforstudy.Thiscanbedoneinadoctors
officeorclinicandisdoneunderlocalanesthesia(numbingmedicine).
Foraconebiopsy,aconeshapedpieceoftissueisremovedfromthecervix.Thisisdoneusinga
surgicalorlaserknife(coldknifeconebiopsy)orusingathinwireheatedbyelectricity(theloop
electrosurgical,LEEPorLEETZprocedure).Aftertheprocedure,thetissueremoved(thecone)
isexaminedunderthemicroscope.Ifthemargins(outeredges)oftheconecontainabnormal
(cancerorprecancer)cells(calledpositivemargins),somecancer(orprecancer)mayhave
beenleftbehind,sofurthertreatmentisneeded.
Thesetreatmentsarealmostalwayseffectiveindestroyingprecancersandpreventingthemfrom

developingintotruecancers.Youwillneedfollowupexamstomakesurethattheabnormality
doesnotcomeback.Ifitdoes,thetreatmentscanberepeated.Rarely,surgerytoremovethe

cervix(oftenwiththebodyoftheuterus)isusedtotreatprecancers.These,called
trachelectomyandhysterectomy,aremoreoftenusedtoinvasivecancers,andarediscussed
inourdocumentCervicalCancer.

Cervical cancer prevention and screening:

Financial issues
Financialissuescanplayanimportantroleinwhetherornotwomenarescreenedfor
cervicalcancer.Womenwithlowerincomesandthosewithouthealthinsuranceareless
likelytobescreened.
Manystatesensurethatprivateinsurancecompanies,Medicaid,andpublicemployeehealth
plansprovidecoverageandreimbursementforPaptestscreening.TheAmericanCancer
Societysupportssuchcoverageassurances,becausetheyremovefinancialbarriersforwomen
whohavehealthinsurance,butwhoseinsuranceplanspreviouslydidnotcoverPaptests.
Otherprogramsarealsoavailabletohelpprovidefinancialassistanceforwomenwithlower
incomesandthosewithoutinsurance.

Federal law
CoverageofcervicalcancerscreeningtestsismandatedbytheAffordableCareAct(ACA),but
thatdoesntapplytohealthplansthatwereinplacebeforeitwaspassed.Youcanfindoutthe
dateyourinsuranceplanstartedbycontactingyourhealthinsuranceplanadministrator.Ifyour
planstartedonorafterSeptember23,2010,itsrequiredtocovertherecommendedcervical
cancerscreeningtests.IfyourplanstartedbeforeSeptember23,2010,itmaystillhave
coveragerequirementsmandatedbyyourstate,buteachstateisdifferent.

Self-insured plans
Selfinsured(orselffunded)planspayemployeehealthcarecostsfromtheirownfunds,even
thoughtheyusuallycontractwithanothercompanytotrackandpayclaims.Youcanfindout
ifyourhealthplanisselfinsuredbycontactingyourinsuranceadministratoratworkor

readingyourSummaryofPlanBenefits.

TheseplansaregovernedbytheAffordableCareAct(ACA),somostarerequiredtocover
cervicalcancerscreening.Theexceptionisanyselfinsuredplanthatwasineffectbeforethe
ACA.Theseplansarecalledgrandfathered,andtheydonthavetoprovidecoveragebased
onwhattheACAsays.Theyalsoarenotcoveredbystatelaws,includingthoseabout
cervicalcancerscreening.
Womenwhohaveselfinsuredbasedhealthinsuranceshouldcheckwiththeirhealthplansto
seewhatcervicalcancerscreeningservicesareoffered.

Medicaid
Bystatuteoragencypolicy,Medicaidorpublicassistanceprogramsinall50statesandthe
DistrictofColumbiacoverscreeningforcervicalcancereitherroutinelyoronadoctors
recommendation.ThiscoveragemayormaynotconformtoAmericanCancerSociety
guidelines.PleasecheckwithyourstateMedicaidofficetolearnmoreaboutwhatservicesare
providedforcervicalcancerscreening.

Medicare
MedicareprovidescoverageforascreeningPaptest,pelvicexam,andaclinicalbreastexam
every2yearsforMedicarebeneficiaries.Andifawomanisofchildbearingageandhashadan
abnormalPaptestintheprevious3years,orisathighriskforcervicalorvaginalcancer,she
wouldbeeligibleunderMedicaretobecoveredforscreeningeveryyear.Thisscreeningis
providedwithoutcopay,coinsurance,ordeductibleaslongasyougotoadoctorthataccepts
whatMedicarepaysasfullpayment(thisiscalledacceptingassignment).Doctorsthatdont
acceptassignmentarerequiredtotellyouupfront.

National Breast and Cervical Cancer Early Detection Program

Allstatesaremakingcervicalcancerscreeningmoreavailabletomedicallyunderserved
womenthroughtheNationalBreastandCervicalCancerEarlyDetectionProgram
(NBCCEDP).Thisprogramprovidesbreastandcervicalcancerscreeningtowomenwithout
healthinsuranceforfreeoratverylittlecost.TheNBCCEDPattemptstoreachasmany
womeninmedicallyunderservedcommunitiesaspossible,includingolderwomen,women
withouthealthinsuranceandwomenwhoaremembersofracialandethnicminorities.
Thoughtheprogramisadministeredwithineachstate,theCentersforDiseaseControland
Prevention(CDC)providesmatchingfundsandsupporttoeachstateprogram.
EachstatesDepartmentofHealthwillhaveinformationonhowtocontactthenearestprogram
participant.Formoreinformationonthisprogram,youcanalsocontacttheCDCat1800CDC
INFO(18002324636)oronthewebatwww.cdc.gov/cancer/nbccedp.
Ifcervicalcancerisdetectedduringscreeninginthisprogram,moststatescannow
extendMedicaidbenefitstothesewomentocoverthecostsoftreatment.

YoucanlearnmoreaboutthisprograminourdocumentcalledNationalBreastand
CervicalCancerEarlyDetectionProgram.

HPV vaccine costs

ItsexpectedthatinsuranceplanswillcoverthecostoftheHPVvaccineinaccordancewiththe
FederalAdvisoryCommitteeonImmunizationPractices(ACIP)recommendations.ACIPhas
alsorecommendedthattheHPVvaccinebeincludedinthefederalVaccineforChildren(VFC)
entitlementprogram,whichcoversvaccinecostsforchildrenandteenswhodonthaveinsurance
orwhoareunderinsured.

Additional resources
More information from your American Cancer Society
Thefollowinginformationmayalsobehelpfultoyou.Thesematerialsmaybeorderedfrom
ourtollfreenumber,18002272345.
AmericanCancerSocietyRecommendationsforHumanPapillomavirus(HPV)VaccineUseto
PreventCervicalCancerandPreCancers
CervicalCancer(alsoinSpanish)
HPVVaccines
HPVandHPVTesting
WhatWomenShouldKnowAboutCervixCancerandtheHumanPapillomaVirus(also
inSpanish)

National organizations and websites*

AlongwiththeAmericanCancerSociety,othersourcesofinformationandsupportinclude:
FoundationforWomensCancer(formerlyGynecologicCancerFoundation)
Tollfreenumber:18004444441or13125781439
Website:www.foundationforwomenscancer.org
CentersforDiseaseControlandPrevention(CDC)
NationalBreastandCervicalCancerEarlyDetectionProgram
Tollfreenumber:1800CDCINFO(18002324636)
Website:www.cdc.gov/cancer/nbccedp
NationalCervicalCancerCoalition
Tollfreenumber:18006855531or18189093849

Website:www.nccconline.org

PlannedParenthoodFederationofAmerica
Tollfreenumber:18002307526
Website:www.plannedparenthood.org
*InclusiononthislistdoesnotimplyendorsementbytheAmericanCancerSociety.

Nomatterwhoyouare,wecanhelp.Contactusanytime,dayornight,forinformationand
support.Callusat18002272345orvisitwww.cancer.org.

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LastMedicalReview:9/17/2014
LastRevised:12/11/2014
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