Cervical cancer
How common cervical cancer is, what causes it, its signs, screening with smear and HPV testing, the HPV vaccine schedule and how treatment is planned.
Where is the cervix?
The cervix is the lower, neck-like part of the womb, joining it to the vagina.
How common is cervical cancer?
Worldwide, cervical cancer is the fourth most common cancer in women, after breast, lung and bowel cancer. Among gynaecological cancers it is the most frequently diagnosed. In 2020, 604,127 women worldwide received a diagnosis of cervical cancer and 341,831 women died from it. That it causes the death of one woman every two minutes says a great deal about why it matters. In Türkiye that same year, 2,532 women were diagnosed and 1,245 died from the disease. It becomes more common after the age of 30, peaking between 30 and 50.
Cervical cancer is, however, preventable and treatable as long as it is detected early and managed effectively.
What causes it?
HPV — the human papillomavirus — is responsible for around 98% of cervical cancers. HPV is most often transmitted sexually; more than 50% of adults are affected at some point. When the body encounters HPV, the immune system usually clears the virus, and the infection may pass without ever being noticed. Some HPV types get the better of that defence, and these can lead to cervical cancer. HPV has more than 150 types: some produce no noticeable signs, some cause genital warts, and some can lead to cancer if left untreated. Taking precautions against HPV and attending regular health checks and screening helps to catch the disease before it develops, or at an early stage when treatment works well.
Other risk factors include:
- having several sexual partners
- first sexual intercourse before the age of 20
- smoking
- a weakened immune system
- chlamydia infection
- a high number of births
- low socioeconomic status
- vitamin A and vitamin C deficiency
What are the signs?
Cervical cancer may produce no signs at all in its early stages, and its symptoms can be confused with those of other conditions. That is one of the things that makes early diagnosis harder. When symptoms do begin, they are most often mistaken for period pain or a urinary tract infection. Signs that appear later include:
- bleeding during or immediately after sexual intercourse
- discharge, with or without an odour
- pain in the pelvic area
- passing urine more often than before, and difficulty holding it
- burning and pain on passing urine
- heavy, prolonged bleeding
- bleeding outside the menstrual period — including after the menopause
- bleeding during a shower, after intercourse or during a pelvic examination
- persistent back and lower back pain with no known cause
How can it be prevented?
- HPV vaccination, particularly for girls between the ages of 9 and 14
- regular medical check-ups, with regular smear tests and HPV testing
- avoiding cigarettes and tobacco products
- supporting the immune system
- taking care against sexually transmitted infections
- eating well
- taking steps against obesity
- although condoms do not give complete protection against HPV, using one is preferable, both against HPV and against other sexually transmitted infections
The HPV vaccine
To protect against HPV, vaccination is recommended for girls, boys and adults between the ages of 9 and 26. The quadrivalent vaccine contains virus-like particles of types 16 and 18 — the types most often behind cancer — together with types 6 and 11, which cause warts, so it also protects against warts. The more recent nine-valent vaccine adds virus-like particles of further high-risk types — 31, 33, 45, 52 and 58 — to types 6, 11, 16 and 18, giving immunity against more of the HPV types that cause cervical cancer and therefore a higher degree of protection. These vaccines also provide some cross-reactive immunity against other HPV types. The nine-valent vaccine has recently become available in Türkiye.
For children aged 9 to 13, two doses are sufficient, with 6 months between the first and the second. Over the age of 14, three doses are recommended, at 0, 2 and 6 months.
Having the vaccine before any encounter with HPV can prevent most cases of cervical cancer. It also protects against cancers of the vagina and vulva. The quadrivalent and nine-valent vaccines can prevent genital warts and anal cancers in both women and men. Because some HPV types are also linked to cancers of the mouth and throat, they offer protection against those as well. The CDC recommends routine HPV vaccination for girls and boys from around the age of 9. The ideal time is before sexual activity begins — that is, before any contact with the virus. Once HPV has been acquired, the vaccine may not be as effective as it would have been at the recommended time.
How is the diagnosis made?
At an advanced stage, cervical cancer can be identified on gynaecological examination. At an early stage the route is different: a positive result on high-risk HPV DNA testing, or an abnormality on a smear test, leads to colposcopic examination and biopsy. When it is caught and treated early the success rate is 80-85%, and biopsy is central both to diagnosis and to planning treatment correctly.
The first step is to confirm the diagnosis and establish the stage. A biopsy is taken from the cervix and the cancer is staged according to how far it has spread in the body. Staging rests on pelvic and rectal examination alongside imaging and any other diagnostic tests that are needed.
Smear test, HPV DNA test and colposcopy
The smear test is a very straightforward screening method, and having one matters a great deal in protecting against cervical cancer.
All women over the age of 21 who are sexually active should have smear tests. If sexual activity began before that age, a smear test is recommended within the first three years from when it started. For women whose smear is normal and who have no other risk factor, a test every 3 years is sufficient. Testing should not be neglected during the menopause either. After the age of 65, if the woman has had at least three normal smear results by then, testing may be stopped in consultation with her doctor. Where something suspicious is seen on a smear, testing may be repeated at shorter intervals or further investigation carried out.
Colposcopy means examining the cervix through a special magnifying instrument, so that the epithelium lining it — the surface cell layer — can be inspected under magnification. Cervical cancer does not begin in a single day: the changes in the cells start slowly and increase over time. Colposcopy makes it possible to see and follow those changes. Assessed together with a smear, colposcopy reduces the error rate markedly.
How is it treated?
Depending on the lesion — the tissue change — found on examination, treatment can be planned so that the condition is dealt with entirely before cancer has developed.
Where cancer is found, surgery, radiotherapy and chemotherapy are used, alone or in combination. What matters most for the outcome is catching the disease at an early stage. That is precisely why regular examinations and check-ups should not be put off.
This page is for information. It does not replace an examination or individual medical advice.