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Cervical Cancer

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Anatomy of the female reproductive system. Source: NCI
Electron micrograph of a negatively stained human papilloma virus. Source: NCI

Cervical cancer is a disease in which abnormal cells grow on the inner wall of the cervix. The cells are called epithelial cells. The cervix is the lower, narrow end of the uterus (the hollow, pear-shaped organ where a fetus grows). The cervix leads from the uterus to the vagina (birth canal). Cervical cancer usually develops slowly over time. Before cancer appears in the cervix, the cells of the cervix go through changes known as dysplasia, in which normal cells begin to have changes that are pre-malignant or are not yet cancerous. A more updated term for dysplasia is cervical intraepithelial neoplasia (CIN), which can typically be detected through a Pap smear. Depending on the grade of CIN, it may progress to cancer. If CIN is not detected early enough by a Pap smear, these cells may transform into cancer cells which may continue to grow and spread more deeply into the cervix to surrounding tissue.

The Pap smear is the most effective screening test for cervical cancer, and with regularly scheduled testing, it decreases the incidence of cervical cancer by 70%. This type is the third most common cancer of the female genital tract. Cervical cancer is most often caused by tranmission of the human papilloma virus (HPV), which is a sexually transmitted disease (STD). With early detection, it typically can be treated.


Contents

Types

Histological section showing squamous cell carcinoma in the cervix. Source: NCI

There are two main types of cervical cancer that are named after the type of cell in the cervix that becomes cancerous:

Squamous cell carcinoma

Squamous cells are cells that cover the outer surface of the cervix. This is the most common type of cervical cancer.

Adenocarcinoma

Adenomatous cells are gland cells that produce mucus. These cells scattered along the inside of the passageway that runs from the cervix to the uterus (womb). Adenocarcinoma is cancer of the gland cells. It is less common than squamous cell cancer. According to the Seattle Cancer Care Alliance, 10 to 15%of cases of cervical cancer are adenocarcinoma. It is treated similarly to squamous cell cancer of the cervix.

Adenosquamous carcinomas (mixed carcinomas)

Rare cervical cancers that have features of both squamous cell carcinomas and adenocarcinomas.

Stages of Cervical Cancer

When tissue of the cervix is identified to have abnormal tissue, physicians use a "staging" system to categorize the tissue into levels of severity. For example, they look at the type of cell the cancer is, such as squamous cell carcinoma. They also place the cancer into groups based on its size and how much it has spread. There are five stages.

Stage 0 (carcinoma in situ)

Abnormal cells are found in the innermost lining of the cervix. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ. This is also known as a higher grade of CIN.

Stage I

Cancer is found in the cervix only. Stage I is further divided into stages IA and IB, based on the amount of cancer that is found.

  • Stage IA: A very small amount of cancer that can only be seen with a microscope is found in the tissues of the cervix. Stage IA is divided into stages IA1 and IA2, based on the size of the tumor.
    • In stage IA1, the cancer is not more than 3 millimeters deep and not more than 7 millimeters wide.
    • In stage IA2, the cancer is more than 3 but not more than 5 millimeters deep, and not more than 7 millimeters wide.
  • Stage IB: In stage IB, cancer can only be seen with a microscope and is more than 5 millimeters deep or more than 7 millimeters wide, or can be seen without a microscope. Cancer that can be seen without a microscope is divided into stages IB1 and IB2, based on the size of the tumor.
    • In stage 1B1, the cancer can be seen without a microscope and is not larger than 4 centimeters.
    • In stage 1B2, the cancer can be seen without a microscope and is larger than 4 centimeters.

Stage II

The cancer has spread beyond the cervix but not to the pelvic wall (the tissues that line the part of the body between the hips) or to the lower third of the vagina. Stage II is divided into stages IIA and IIB, based on how far the cancer has spread.

  • Stage IIA: Cancer has spread beyond the cervix to the upper two-thirds of the vagina but not to tissues around the uterus.
  • Stage IIB: Cancer has spread beyond the cervix to the upper two-thirds of the vagina and to the tissues around the uterus.

Stage III

The cancer has spread to the lower third of the vagina, may have spread to the pelvic wall, and/or has caused the kidney to stop working. Stage III is divided into stages IIIA and IIIB, based on how far the cancer has spread.

  • Stage IIIA: Cancer has spread to the lower third of the vagina but not to the pelvic wall.
  • Stage IIIB: Cancer has spread to the pelvic wall and/or the tumor has become large enough to block the ureters (the tubes that connect the kidneys to the bladder). This blockage can cause the kidneys to enlarge or stop working. Cancer cells may also have spread to lymph nodes in the pelvis.

Stage IV

The cancer has spread to the bladder, rectum, or other parts of the body. Stage IV is divided into stages IVA and IVB, based on where the cancer is found.

  • Stage IVA: Cancer has spread to the bladder or rectal wall and may have spread to lymph nodes in the pelvis.
  • Stage IVB: Cancer has spread beyond the pelvis and pelvic lymph nodes to other places in the body, such as the abdomen, liver, intestinal tract, or lungs.

Signs and Symptoms

Early cervical cancer may not cause noticeable signs or symptoms. Later signs of cervical cancer include vaginal bleeding and pelvic pain. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following occur:

  • Abnormal vaginal bleeding
  • Unusual vaginal discharge
  • Pelvic pain
  • Pain during sexual intercourse

Causes

The cause of cervical cancer is unknown but it is related to multiple sexual partners. There is a strong association with two types of human papilloma virus (HPV). HPV is considered a sexually transmitted disease (STD). There are many types of HPV, and not all cause cervical cancer. Some of them cause genital warts, and some may not cause any symptoms.

Goodkin and Antoni [1] observed a "modest correlation" between psychological stress and promotion of cervical intraepithelial neoplasia to invasive squamous cell carcinoma of the cervix. This correlation was "greatly enhanced by significant interactions with low levels of cooperative coping style and for high levels of premorbid pessimism, future despair, somatic anxiety, and life threat reactivity".

Diagnosis

Exams and tests

Tests that examine the cervix are used to detect (find) and diagnose cervical cancer. Women should have yearly check-ups, including a Pap smear to check for abnormal cells in the cervix. The prognosis (chance of recovery) is better when the cancer is found early.

These are routine screening tests:

  • Pap Smear: A procedure to collect cells from the surface of the cervix and vagina. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina. The cells are viewed under a microscope to find out if they are abnormal. This procedure is also called a Pap test.
  • Pelvic Examination: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. The doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. A speculum is also inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
  • HPV DNA test—a newer lab test that detects the most common types of HPV that are likely to lead to cervical cancer. The American College of Obstetricians and Gynecologists (ACOG) released guidelines in August 2003 recommending that women 30 years or older be offered the HPV DNA test in addition to their Pap smear and pelvic exam. Recent studies have indicated that the HPV DNA test is more accurate than Pap smears for detecting early stages of cervical cancer.[2][3]

If the Pap Test is abnormal, the following procedures may be performed to obtain more information.

  • Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas. Tissue samples may be taken using a curette (spoon-shaped instrument) and checked under a microscope for signs of disease.
  • Biopsy: If abnormal cells are found in a Pap smear, 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 doctor's office. A woman may need to go to a hospital for a cervical cone biopsy (removal of a larger, cone-shaped sample of cervical tissue).
  • Endocervical curettage: A procedure to collect cells or tissue from the cervical canal using a curette (spoon-shaped instrument). Tissue samples may be taken and checked under a microscope for signs of cancer. This procedure is sometimes done at the same time as a colposcopy.

Staging Cervical Cancer

The stages of cervical cancer have been discussed. Now, tests need to be performed to find out the stage of the cancer. Once cervical cancer has been diagnosed, these tests are done to find out if cancer cells have spread within the cervix or to other parts of the body. This process used to find out if cancer has spread within the cervix or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Staging also is used to develop a prognosis. The following tests and procedures may be used in the staging process:

  • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • Lymphangiogram: A procedure used to x-ray the lymph system. A dye is injected into the lymph vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels, and x-rays are taken to see if there are any blockages. This test helps find out whether cancer has spread to the lymph nodes.
  • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Pretreatment surgical staging: Surgery (an operation) is done to find out if the cancer has spread within the cervix or to other parts of the body. In some cases, the cervical cancer can be removed at the same time. Pretreatment surgical staging is usually done only as part of a clinical trial.

The results of these tests are used together with the results of the original tumor biopsy to determine the cervical cancer stage.

Treatment

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) depends on the following:

  • Stage of the cancer
  • Type of cervical cancer
  • Size of the tumor

Treatment options depend on the following:

  • The stage of the cancer
  • The size of the tumor
  • The patient's desire to have children
  • The patient's age

Treatment of cervical cancer during pregnancy depends on the stage of the cancer and the trimester the pregnancy is in ( or how far along the mother is). For cervical cancer found early or for cancer found during the last trimester of pregnancy, treatment may be delayed until after the baby is born.

Different types of treatment are available for patients with cervical cancer. Some treatments are standard (the currently used treatment), and some are being tested in a clinical trial. Before starting treatment, patients may want to think about taking part in a clinical trial. This is a research study meant to improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Medications

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs target cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Therapies

Surgical (removing the cancer in an operation) procedures are:

  • Conization: A procedure to remove a cone-shaped piece of tissue from the cervix and cervical canal. A pathologist views the tissue under a microscope to look for cancer cells. Conization may be used to diagnose or treat a cervical condition. This procedure is also called a cone biopsy.
  • Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
  • Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
  • [[Loop electrosurgical excision procedure|Loop electrosurgical excision procedure (LEEP): A treatment that uses electrical current passed through a thin wire loop as a knife to remove abnormal tissue or cancer.

The first three procedures are used more often for cases that present at earlier stages of cervical cancer confined to the cervix. For higher stage cancers, the following procedures may be necessary:

  • Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
  • Bilateral salpingo-oophorectomy: Surgery to remove both ovaries and both fallopian tubes.
  • Radical hysterectomy: Surgery to remove the uterus, cervix, and part of the vagina. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed.
  • Pelvic exenteration: Surgery to remove the lower colon, rectum, and bladder. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to reconstruct the vagina after this operation.

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Psychotherapy was found to have effects on cancergrowth or survival in some studies. In other studies such effects were not seen. As yet, no specific psycho-medical intervention studies have been done in Cervical Cancer. Sofar, we have no reasons to suggest that psychotherapy would be less useful in specific types of cancer. Spiegel and his collegues (1989) at Stanford university have seen double length of survival in women with breast cancer after group psychotherapy.These groups, initiated by Yalom, were directed at mutual support, emotional expression and sharing and existential issues. Two studies by Goodwin (2001) and Kissane (2007)with oncologically less experienced therapists, did not see effects on survival, nor dit Edelman (1999) using cognitive psychotherapy (CBT). In Colon cancer and other gastro-intestinlal cancers, positive effects of individual, peri-operative bed-side psychotherapy were seen by Kuchler (2007). Fawzy and co-workers (1993) noticed longer disease free periods in melanoma patients after a course in problem focused coping. So far experiential, existential and problem focused counseling by oncologically experienced psychotherapsts may be a useful adjunct to treatment. More information is avaliable under Psycho-Oncology.


Treatment Options by Stage

Treatment of stage 0 cervical cancer may include:

  • Loop electrosurgical excision procedure (LEEP)
  • Laser surgery
  • Conization
  • Cryosurgery
  • Total hysterectomy for women who cannot or no longer want to have children
  • Internal radiation therapy for women who cannot have surgery

Treatment of Stage IA cervical cancer may include:

  • Total hysterectomy with or without bilateral salpingo-oophorectomy
  • Conization
  • Radical hysterectomy and removal of lymph nodes
  • Internal radiation therapy

Treatment of Stage IB cervical cancer may include the following:

  • A combination of internal radiation therapy and external 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 clinical trial of high- dose internal radiation therapy combined with external radiation therapy

Treatment of stage IIA cervical cancer may include the following:

  • A combination of internal radiation therapy and external 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 clinical trial of high- dose internal radiation therapy combined with external radiation therapy

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

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

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

Treatment of stage IVB cervical cancer may include the following:

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the trialsNCI Web site.

Recurrent Cervical Cancer

Recurrent cervical cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the cervix or in other parts of the body.

Treatment of recurrent cervical cancer may include the following:

  • Pelvic exenteration followed by radiation therapy combined with chemotherapy
  • Chemotherapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life
  • Clinical trials of new anticancer drugs or drug combinations

Prevention

Because cervical cancer is thought to be primarily caused by the HPV virus, avoiding exposure to the virus is the best way to prevent cervical cancer. Because the virus is sexually transmitted, abstinence and limiting the number of sexual partners will limit exposure to the disease. Barrier methods of birth control (condom, diaphragm, foam, sponge) will not necessarily protect against HPV infection.

Avoidance of tobacco (smoking) may also prevent the development of cervical cancer.

Women should know if they are at risk of contracting cervical cancer. All women should have routine Pap smears and pelvic exams and be sure to follow up with their health care provider after any abnormal tests. At-risk women should be especially vigilant about screening and follow-up so that if cervical cancer does occur, it can be diagnosed and treated as early as possible.

Vaccine

Since HPV infection is the most important risk factor for cervical cancer, a vaccine to prevent HPV has long been sought. Because there are different types of HPV, multiple vaccines have been developed. Two vaccines that have received the most study are: Gardasil, protecting against HPV types 6, 11, 16 and 18; and Cervarix, protecting against types 16 and 18.

Gardasil has been approved for use in this United States by the FDA. It requires a series of 3 injections over a 6-month period. In clinical trials, Gardasil prevented genital warts caused by HPV types 6 and 11 and prevented pre-cancers and cancers of the cervix caused by HPV types 16 and 18. This vaccine only works to prevent HPV infection -- it will not treat an infection that is already there.

Since HPV infection is sexually transmitted, to be effective the HPV vaccine should be given before a person starts having sex. Some organizations, including the Federal Advisory Committee on Immunization Practices (ACIP) and the American Cancer Society (ACS) have recommended that the vaccine be given routinely to girls age 9-13. Merck, the company that manufactures Gardasil®, embarked on a campaign to make the vaccine mandatory in most states, but after opposition (see Controversy below) abandoned the campaign.

Living with Cervical Cancer

There are several support groups and websites that may be helpful when dealing with a diagnosis of cervical cancer. Here are some suggestions:

Chances of Developing Cervical Cancer

Risk Factors

(HPV) infection is the major risk factor for development of cervical cancer. Infection of the cervix with HPV is the most common cause of cervical cancer. Not all women with HPV infection, however, will develop cervical cancer. Women who do not regularly have a Pap smear to detect HPV or abnormal cells in the cervix are at increased risk of cervical cancer.

Cervical cancer is strongly correlated with sexual behavior (likely due to increased risk of HPV infection). Factors such as beginning sexual activity at a young age, multiple sex partners, and sex with partners who themselves have many partners all are strong risk factors for cervical cancer. Oral contraceptive use is also a risk factor, although this may be due to increased sexual activity among oral contraceptive users.[4][5]

One of the strongest risk factors is the age at first intercourse. One study reported over five-fold elevated risk for women reporting their first intercourse before age 18 compared with those aged over 22 years.[6]

Other possible risk factors include the following:

Clinical Trials

For a list of completed, ongoing, and upcoming trials related to cervical cancer, go here

Research

There is ongoing research on cervical cancer. The HPV vaccine was a recent development in the field. Here are some links to more articles and ongoing research:

Controversy

There has been much recent controversy over the HPV vaccine — Gardasil (see Vaccine above). The controversy centers not on use of the vaccine itself, but on mandatory requirements for all girls. Many organizations support requiring girls to have the vaccine before school, as this will dramatically reduce the future incidence of cervical cancer. Opposition to making the vaccine mandatory centers on these points:

  • the vaccine doesn’t protect against all cancer-causing types of HPV, so routine Pap tests are still necessary. Ultimately, the vaccine may not reduce cervical cancer as much as is hoped because types of HPV not covered by the vaccine may come to predominate.
  • the vaccine is very expensive and would be a significant burden on families and funds that help pay for vaccination in low-income children.
  • some are opposed because they believe behavioral change (including abstinence) is a more effective prevention tool.
  • the long-term safety of the vaccine is still in doubt, although the FDA has approved it as safe for use.

Epidemiology

Statistics

  • According to the American Cancer Society, over 11,000 cases of advanced cervical cancer will be diagnosed this year.
  • About 3800 women will die from cervical cancer in 2008. Non-invasive cases of cervical cancer are four times more common than invasive cancer cases.
  • The incidence of cervical cancer increases with age.
  • The disease is more common in Hispanic and African-American women than in Caucasian women.
  • Although cervical cancer is a common cause of cancer death in women, the death rate has been declining by about 4% a year since 1955. This decline can be attributed to better screening (PAP test) and treatment methods.
  • The five year survival rate (percentage of women who live five years or more after their cancer diagnosis) for invasive cervical cancer is 92% for early stages and 72% for all stages combined. This highlights the importance of early diagnosis and treatment.

Incidence

From the National Cancer Institute, the estimated new cases from cervical cancer in the United States in 2008 is 11,070.

Prevalence

Data from the National Health and Nutrition Examination Survey (NHANES) published in the February 28, 2007, Journal of the American Medical Association (JAMA) have provided the first national estimate of the prevalence of human papillomavirus (HPV) infection among women in the United States aged 14 to 59. Investigators found that a total of 26.8% of women overall tested positive for one or more strains of HPV.

Overall prevalence included both low-risk and high-risk HPV types. Low-risk types of HPV can cause genital warts or other nonmalignant conditions. High-risk types of HPV can cause cervical cancer, and up to 70% of cervical cancers worldwide are caused by two high-risk strains alone - HPV types 16 and 18.

Overall, 26.8% of women tested positive for one or more strains of HPV. Prevalence of HPV was highest in women ages 20-24. Among all participating women, the prevalence of high-risk types of HPV was 15.2%. The prevalence of HPV types 6, 11, 16, and 18 - the types targeted by the HPV vaccine Gardasil - was 3.4% overall, translating to an estimated 3.1 million exposed women in the studied age groups

Notable experts

These are many institutions and physicians with expertise in dealing with cervical cancer. Both obstetrician/gynecologists (Ob/Gyns) and family physicians can do Pap smears and even culposcopy with minor procedures (ECC, biopsy). Once cervical cancer is diagnosed, most family physicians will refer to a gynecologist. There is a subspecialty within Obstetrics/Gynecology called Gynecology/Oncology which deals specifically with cancer of the female reproductive tract. Here are some resources to help find a physician and/or medical facility to treat cervical cancer:

Related Videos

This video from the NIH provides the latest on cervical cancer, including screening and the HPV vaccine.


References

  1. ↑ Goodkin, K, and M H Antoni, and P H Blaney. "Stress and hopelessness in the promotion of cervical intraepithelial neoplasia to invasive squamous cell carcinoma of the cervix." Journal of psychosomatic research 30 (1986): 67-76 - Abstract
  2. ↑ Mayrand MH, Duarte-Franco E, Rodrigues I, et al; Canadian Cervical Cancer Screening Trial Study Group. Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer. N Engl J Med. 2007 Oct 18;357(16):1579-88. Full Text
  3. ↑ Naucler P, Ryd W, Törnberg S, et al. Human papillomavirus and Papanicolaou tests to screen for cervical cancer. N Engl J Med. 2007 Oct 18;357(16):1589-97. Abstract
  4. ↑ Cooper D, Hoffman M, Carrara H, et al. Determinants of sexual activity and its relation to cervical cancer risk among South African women. BMC Public Health. 2007 Nov 27;7:341. Full Text
  5. ↑ Sussman AL, Helitzer D, Sanders M, Urquieta B, Salvador M, Ndiaye K. HPV and cervical cancer prevention counseling with younger adolescents: implications for primary care. 2007 Ann Fam Med. Jul-Aug;5(4):298-304. Full Text
  6. ↑ La Vecchia C, Franceschi S, Decarli A, et al. Sexual factors, venereal diseases, and the risk of intraepithelial and invasive cervical neoplasia. Cancer. 1986 Aug 15;58(4):935-41.

External Links

American Cancer Society: What Are the Key Statistics About Cervical Cancer

American College of Obstetricians and Gynecologists: HPV Infection

CancerConsultants.com: Cervical Cancer Information Center

Seattle Cancer Care Alliance

Holistic and alternative treatments

Cancer Treatment Center of America: Traditional and Alternative Treatment

MayoClinic.com: Alternative cancer treatments: 11 alternative treatments worth a try

National Cancer Institute: Complementary and Alternative Medicine

Vaccine controversy

Washington Post: Pro-Family, Pro-Vaccine -- But Keep It Voluntary, Peter Sprigg

Food and Drug Administration: FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus - Rapid Approval Marks Major Advancement in Public Health

British Medical Journal: Cervical cancer vaccines provoke controversy in the US

PewResearchCenter Publications: Quick Cancer Vaccine Mandate Stirs Controversy

American Council on Science and Health: A Triumph in Cancer Prevention Leads to Controversy

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