Physical Exam and Medical History
Your doctor will begin by asking you various questions about your personal circumstances and the medical history of your family. This information is used to assess your risk factors and determine whether there are any symptoms that may indicate cervical cancer. A physical exam is then carried out, including a pelvic exam and Pap test if you have not already had one. Your doctor will also check your lymph nodes for signs of swelling.
The Pap test is a screening test and not a diagnostic exam. Abnormal Pap results may simply mean more testing is needed to determine if cancer or pre-cancerous cells are actually present. Colposcopy tests and endocervical scraping are most commonly used for this purpose. If the biopsy does show pre-cancerous cells, your doctor will take steps to keep cervical cancer from developing.
If you display any symptoms of cervical cancer or your Pap result was abnormal, your doctor will recommend a colposcopy test. This test is similar to a pelvic exam, where your doctor examines the cervix with a speculum instrument. A colposcope is used to examine your cervix. This instrument does not enter the body, but it has a magnifying lens that is similar to binoculars, allowing your doctor to see the cervix surface more clearly. He or she will also use a solution of acetic acid, which is similar to vinegar but weaker, on the cervix so that any abnormal areas will be easier to examine.
The colposcopy exam should not cause you any more discomfort than a regular speculum exam. There are no side-effects, and your doctor can do the exam safely even on a woman who is pregnant. However, it is better not to do this exam, or a Pap exam if you are menstruating. If your doctor sees an abnormal area on the cervix, they will order that a biopsy be done. With a biopsy, the doctor removes a small piece of tissue from the cervix, and this sample is sent to a lab for further examination. Doing a biopsy is the only sure way of knowing if the abnormal area has pre-cancerous or cancerous cells or not. Cervical biopsies may cause some discomfort, such as cramping or pain, although this should not last long. If the biopsy can completely remove the abnormal tissue that is present, this may be the only treatment that is needed.
With this type of biopsy, the cervix is examined using a colposcope to find any abnormal areas. Using forceps, a small section of the abnormal area is removed from the surface of the cervix and sent for testing to a lab. This procedure may cause some cramping, discomfort or bleeding afterward; however, a local anesthetic is often used on the cervix before the procedure.
Some areas of the cervix, particularly those at risk for HPV infection, cannot always be seen clearly with the colposcope, therefore other measures must be taken to check the area for cancer. The procedure involves lightly scraping the endocervix by inserting a curette, which is a narrow instrument, into the endocervical canal. This canal is the part of the cervix which is closest to the uterus. The instrument then scrapes the inner canal to remove gently a sample of tissue, which is sent to a lab for further examination. Some patients experience a bit of pain and cramping after this procedure, and light bleeding is common.
With a cone biopsy, your doctor removes a small cone-shaped sample of tissue from your cervix. The exocervix forms the base of the cone, which is the outer part of the cervix, and the apex of the cone is known as the endocervical canal. When the tissue is removed, it includes the zone, known as the transformation zone, where pre-cancers and cancers in the cervix are most likely to develop.
Cone biopsies may also be used to treat or remove much pre-cancerous tissue and even early stage cancers. A cone biopsy procedure will not prevent most women from getting pregnant; however, in cases where a large amount of tissue has been removed, it may lead to a higher risk of premature births.
One of the most common methods used for cone biopsies is LEEP or the loop electrosurgical excision procedure. In a LEEP procedure, the tissue is removed from the cervix with a thin loop of wire that is heated using electrical currents to act as a scalpel. A local anesthetic is used for this procedure, which can be done in your doctor’s office. It only takes about 10 minutes, and you might have some mild cramping during or after the procedure. Some women also experience mild or moderate bleeding for some weeks afterward.
With a cold knife cone biopsy, your doctor will use a scalpel or laser instead of the heated wire to remove a sample of tissue from the cervix. You will be given either general anesthesia or an epidural anesthesia during this operation, which is typically done in a hospital. However, it is done as an outpatient procedure, which means that you do not have to stay in a hospital overnight. When the procedure is done, you may have some cramping and light bleeding for a few weeks afterward.
Reporting biopsy results
Any pre-cancerous changes that are noted in a biopsy are referred to as cervical intraepithelial neoplasia or CIN. Many doctors use the term dysplasia instead of CIN. A CIN is typically graded on a scale of 1 to 3, depending the extent to which the cervical tissue looks abnormal when analyzed by the lab.
For CIN1, very little of the tissue appears abnormal. This is considered to be a mild dysplasia, the least serious form of cervical pre-cancer.
For CIN2, there is a more moderate dysplasia, and a greater portion of the tissue appears abnormal.
For CIN3, most of the cervical tissue appears abnormal. This is the most serious pre-cancer stage and includes carcinoma in situ.
If cancer is discovered in a biopsy, it will be identified as either a squamous cell carcinoma or as adenocarcinoma.
Diagnostic tests for cervical cancer
If a biopsy reveals that cancerous cells are present, your doctor will likely order further tests to ascertain if and how far the cancer has spread. Some of the tests which are outlined below are not needed for every patient. It is important to note that decisions on which test to use should be based on the results of the biopsy and any physical exam done by your physician.
Cystoscopy or proctoscopy
These tests are normally done if a woman has large tumors, but they are not necessary in cases where cancer has been caught early.
Cystoscopy uses a thin tube with a light and lens for internal examinations. The rube is inserted into the bladder by way of the urethra to check whether the cancer has spread to these areas. During a cystoscopy, a sample can be removed for microscopic testing. This procedure can be done while you are under a local anesthetic; however, some patients may need to do it under general anesthesia. Your doctor should explain the procedure to you fully and let you know what to expect.
Proctoscopy is a procedure where your doctor does a visual inspection of the rectal area by using a lighted tube. This is done to check whether the cancer has spread into the rectum. Your doctor may also do a pelvic to check if the cancer has spread outside of the cervix.
If you have cervical cancer, your doctor may recommend you undergo various imaging studies such as a magnetic resonance imaging (MRI) or a computed tomography (CT) scan. These studies can show whether or not the cancer has spread beyond the cervix. A chest x-ray may also be done to determine if the cancer has spread to the lungs, which is quite unlikely unless it is very advanced.
Computed Tomography (CT)
A CT scan is an x-ray that produces highly detailed cross-sectional images of the body. Unlike conventional X-rays, CT scanners do not only take one picture but multiple pictures while it rotates around your body. The images are then digitally combined to show a cross-section of your body. A CT scan can indicate if the cancer has spread to the lymph nodes of the abdomen or pelvis or into other organs such as the liver or lungs.
CT scanners are generally described as having a donut shape, with the long narrow table in the center. It is important to lie very still on the table while getting the scan, to ensure that the images are not warped. A CT scan normally takes longer than a regular x-ray, due to all the technical work that is required for the computer to take the cross-sectional images. However, the best thing to do is just try to relax if you start to feel confined.
The normal procedure is that, before the test, you will have to drink a pint or two of oral contrast liquid. This liquid is used to allow the images to be reflected and to outline the structures in the body. You may receive the contrast liquid intravenously instead of orally. The IV contrast might make you feel a bit warm and cause some redness on your skin, but this should be temporary.
Some people are allergic to the contrast dye and may develop hives. In rare cases, a person might have a serious reaction, such as trouble breathing or low blood pressure. If this is something you or your doctor is concerned about, you may be given certain medicine to prevent these allergic reactions. This is why it is important that you tell your doctor if you have had an allergic reaction to contrast fluids in the past.
A CT scan may used to guide a biopsy needle into an area where it is suspected that cancer has spread. During this procedure, the patient stays on the scanning table while a radiologist directs a biopsy needle to the location of the cancerous mass. The scan will be repeated until the doctor is sure that the needle is in the mass. A sample of tissue may be removed and examined by a lab.
Magnetic Resonance Imaging (MRI)
An MRI scan uses high-frequency radio waves and strong magnets to take pictures of your body. The energy that resonates from the radio waves is absorbed by the body and released to form specific patterns. A computer then translates the radio wave patterns that are given off by the tissues and creates a detailed image of certain parts of the body. Not only can an MRI produce cross-sectional images like a CT scanner does, but it can also produce parallel images of the length of your body.
MRI images may be used to examine pelvic tumors or to detect cancer that may have spread to the brain or spinal cord.
Sometimes, a contrast liquid may be injected the same as with CT scans, but this done less frequently. An MRI scan can take longer than a CT scan; sometimes they last for an hour. For the MRI, you will lie inside a tube-like apparatus, which many people find confining. There are “open” type MRI machines that are less confining, which may be a better option for patients who suffer from claustrophobia. However, you need to be aware that the images from these machines may not be as clear as a traditional MRI machine.
The other problem with MRI machines is that they sometimes make a thumping noise that some people find irritating. But the good news is that sometimes you will be provided with headphones during the procedure so that you can listen to music, which may help to block out the noise. You may also find a mild sedative to be helpful at calming your nerves.
Intravenous urography, sometimes known as intravenous pyelogram, is an x-ray taken of the urinary system after a special dye is injected into a vein. The kidneys will remove this dye from the bloodstream and pass it through the ureters, to empty into the bladder. This test is used to find any abnormalities in the urinary tract, including changes that may be the result of the cancer spreading to the pelvic lymph nodes. This may cause compression or blockage in the ureters. However, this test is rarely used for patients with cervical cancer, as a CT or MRI is deemed sufficient.
Positron Emission Tomography
Positron emission tomography is a scan that uses glucose containing radioactive atoms, which is absorbed by cancer cells in the body. A special camera is used to detect radioactivity from the cancer cells, which can indicate whether the cancer has spread to the lymph nodes. These scans may be helpful if your doctor suspects that the cancer has spread but is unsure where. They can also be used in place of other x-rays because they can scan the whole body. This is why they are sometimes combined with the CT scan, as certain machines can do both scans at the same time. This test is rarely used for cervical cancer patients in early stages, however may be used if the disease is more advanced.