Cervical Stump Cancer: Symptoms, Diagnosis, And Treatment
The cervix is the narrow canal between a woman's uterus and vagina, and the cervical stump is the piece of the uterine cervix that remains after a supravaginal hysterectomy (per a 2021 study published in the journal Cureus). A 2017 study published in the journal Preventative Medical Reports describes a supravaginal hysterectomy as a procedure that removes the uterus but not the cervix. The most common reason for undergoing a supravaginal hysterectomy is the presence of uterine fibroids.
Across the world, cancer of the cervix is the fourth most common type of cancer in women, according to the World Health Organization (WHO). Women with a cervical stump can go on to develop cervical cancer, which is known as cervical stump cancer. Cervical stump cancers account for just 1.6 to 4.4% of all cervical cancer cases (per Cureus). With proper screening and early detection, cervical cancer responds well to treatment. According to the National Cancer Institute (NCI), the five-year survival rate for cervical cancer is 92% when it is diagnosed at an early stage. Unfortunately, many women who have undergone a hysterectomy are unaware of whether they have an intact cervix and fail to seek regular screening for cervical cancer (per Preventative Medical Reports).
Causes of cervical stump cancer
Like other cancers, cervical stump cancer occurs when mutated cells start to grow out of control. Mutations are a normal part of cellular aging, but they can also be triggered by environmental factors. Mutations that affect a cell's built-in growth and death regulations can lead to cancer by allowing cells to grow out of control (per the NCI).
Certain risk factors can increase the risk of developing cervical stump cancer. According to the Mayo Clinic, certain strains of the human papillomavirus (HPV) cause most cervical cancer cases. People who have had many sexual partners or began engaging in sexual activity at an early age are more likely to contract HPV, increasing their cancer risk. Other sexually transmitted infections, such as HIV/AIDS, chlamydia, syphilis, and gonorrhea, can also increase the risk of cervical stump cancer. People with a compromised immune system, as well as women whose mothers took a medication known as diethylstilbestrol (DES) while pregnant in the 1950s, are also at higher than normal risk of developing cervical stump cancer.
Most cervical stump cancer cases are either squamous cell carcinomas and adenocarcinomas. Squamous cell carcinomas, the most common type, develop in the thin, flat cells that line the outer part of the vagina. Adenocarcinomas develop in the columnar glandular cells lining the cervix.
You can reduce your risk of cervical stump cancer
While you can never remove all risk of any type of cancer, you can make lifestyle choices to reduce your risk. Because HPV infections cause most cervical stump cancer cases, reducing your risk of HPV infection reduces your risk of cervical stump cancer.
Using a condom or other barrier for protection can help you avoid HPV (per Medical News Today). You can also limit your number of sexual partners and consider getting vaccinated against HPV. According to the Centers for Disease Control and Prevention (CDC), there are three HPV vaccines, and they all protect against the two HPV strains responsible for most cervical cancers.
Early detection of HPV infection and cervical stump cancer can help improve your long-term health outcomes, so consider getting screened annually. An HPV test detects the presence of the virus. There is no cure for HPV, but there are treatments available to remove the warts it causes. Cervical cancer screening is conducted through a Pap smear, which looks for precancerous changes in the cells of your cervix (per the CDC). If you have precancerous cells, you can seek treatment that will usually prevent these cells from developing into cancer. According to the Mayo Clinic, precancerous lesions can be removed by lasers, surgery, freezing, loop electrosurgical excision procedure (LEEP), and cold knife conization.
Symptoms of cervical stump cancer
The American Society of Clinical Oncology (ASCO) provides information about symptoms that may indicate cervical stump cancer. Some symptoms relate to bleeding and menstruation. Changes in your normal menstrual patterns (such as light bleeding or spotting in between periods or after your period, or periods that are longer or heavier than usual) can be signs of cervical stump cancer. Another symptom is bleeding after you have gone through menopause. Bleeding after sexual intercourse, douching, or a pelvic examination can indicate cervical stump cancer, and so can an increase in vaginal discharge.
Other symptoms have to do with pain. If sexual intercourse becomes painful, or if you develop persistent and unexplained back or pelvic pain, you may have cervical stump cancer. Many of these symptoms have other causes as well, so if you experience any symptoms, schedule a visit with your gynecologist. For example, painful intercourse can be caused by a variety of conditions such as endometriosis, ovarian cysts, pelvic inflammatory disease, and hemorrhoids (per the Mayo Clinic). Bleeding in between periods can be caused by contraceptives, thyroid problems, and sexually transmitted infections (per Healthline). Whatever the source of your symptoms, you need a proper diagnosis so you can seek proper treatment.
Diagnosis of cervical stump cancer
Based on the results of your Pap smear, HPV testing, or the nature of your symptoms, your doctor may conduct a pelvic exam and a rectovaginal exam (per the NCI). They should also go over your family medical history to see if you have a familial risk of cervical stump cancer.
To definitively diagnose you with cervical stump cancer, you will need to undergo more thorough testing. You may need a colposcopy. Here, your doctor will open the vagina with a speculum, then apply a vinegar solution that highlights abnormal tissue. The doctor will use a colposcope to visually examine the cervix. At this time, they will probably take a biopsy for further examination by a pathologist.
There are several ways to biopsy the cervix. A punch biopsy punches out several small, round pieces of the cervix. Endocervical curettage uses a spoon-shaped instrument, the curette, to scoop out several small tissue samples. The loop electrosurgical excision procedure (LEEP) uses a thin wire loop with a current running through it to remove samples of the cervix. These three procedures can be performed in a doctor's office. Another option, the cone biopsy, is performed in a hospital under general anesthesia. This surgical procedure removes a large, cone-shaped sample.
Bloodwork, visual exams, and medical imaging such as a PET or CT scan, MRI, ultrasounds, or chest X-ray can also help diagnose cervical stump cancer. Medical imaging can also show whether the cancer has spread.
Stages of cervical stump cancer
Cancer stages describe how cancer has grown and spread in a particular patient. There are four main stages of cervical stump cancer, each with several sub-stages (per the ASCO). A doctor determines the stage using a physical exam, diagnostic imaging, and biopsy results. Knowing the stage of cervical stump cancer helps determine the right treatment plan and the patient's prognosis.
In Stage I, cancerous cells can only be detected under a microscope and the tumor has not spread beyond the cervix. In Stage II, the cancer has spread to nearby tissues such as the vagina but not to other parts of the body. In stage III, the tumor has spread to the lower third of the vagina and/or the pelvic wall. It may cause the kidneys to swell and stop functioning. It may also spread to nearby lymph nodes. In Stage IVA, the tumor has spread to the bladder or rectum but nowhere else. In Stage IVB, it has spread to other parts of the body.
Recurrent cervical stump cancer is cancer that has returned after previous treatment. Sometimes, it recurs in the pelvis, where it began. Other times, it recurs in other areas such as the lungs, bones, or lymph nodes.
Surgical treatments for cervical stump cancer
Many patients with cervical stump cancer choose to have the cancerous tissue surgically removed. One treatment option is radical trachelectomy, which is also known as radical cervicectomy (per the NCI). This procedure removes the cervix, the upper part of the vagina, nearby tissue, and in some cases, the lymph nodes near the pelvis. Unfortunately, this procedure may not be an option for some cervical stump cancer patients, according to a 2021 study published in the Journal of International Medical Research. Previous hysterectomies leave some patients with anatomical changes that make it difficult for a surgeon to perform a radical trachelectomy. These changes also increase the patient's risk of surgical complications.
Patients who cannot undergo a radical trachelectomy can choose either a laparotomy or laparoscopy. Laparotomy is an open surgery, which is more complex than laparoscopy, which is minimally invasive. The 2021 study compared the two procedures in patients with cervical stump cancer and found that both options effectively treat cervical stump cancer. However, patients treated with laparoscopy experienced fewer complications, recovered more quickly, and required a shorter hospital stay. For these reasons, laparoscopy is a more attractive surgical treatment option when radical trachelectomy is not possible.
Radiation therapy can treat cervical stump cancer
Radiation therapy is an effective treatment for many types of cancer, including cervical stump cancer. High doses of radiation kill cancer cells by damaging their DNA beyond repair (per the NCI). According to a 1991 study published in the International Journal of Radiation Oncology, Biology, Physics, radiation therapy is the standard treatment for cervical cancer and works just as well in cervical stump cancer patients as it does in cervical cancer patients who have an intact uterus.
In cervical cancer patients who have not undergone a hysterectomy, the uterus protects the other organs from radiation. One challenge of treating cervical stump cancer with radiation is that the patients, who lack a uterus, can experience severe radiation reactions. A 1992 study in the journal Gynecologic Oncology found that some patients developed severe radiation reactions in the bladder, rectum, and sigmoid colon. Meanwhile, a 2021 study published in Cureus found that using a type of radiation treatment known as computed tomography-based image-guided brachytherapy (CT-based IGBT) successfully treats cervical stump cancer without these adverse reactions. Brachytherapy is a type of internal radiation therapy in which seeds, ribbons, or capsules containing a radioactive source are placed in the body, either in or near the tumor (per the NCI). The CT imaging allows the doctor to accurately position the radiation source in the tumor and minimize damage to surrounding tissues (per a 2013 study in Nature).
Chemotherapy can treat cervical stump cancer
Chemotherapy is another treatment option for patients with cervical stump cancer. Chemotherapy consists of administering drugs that target and kill rapidly dividing cells such as cancer cells (per the Cleveland Clinic). Patients may take chemotherapy drugs either orally or intravenously. In most cases, doctors administer chemotherapy in cycles, with the length of the cycle and the frequency of administration tailored to each patient's need.
As anyone who has watched someone go through chemotherapy knows, this treatment has many negative side effects (per the American Cancer Society). These side effects stem from the fact that chemotherapy kills all rapidly dividing cells, not just cancer cells. Healthy cells such as bone marrow cells, hair follicles, cells of the reproductive system, and cells of the mouth and digestive tract divide rapidly, so chemotherapy kills these cells, too. Chemotherapy can cause digestive problems such as nausea, vomiting, constipation, diarrhea, and changes in appetite. Patients may develop sores in their mouth, throat, and on the tongue, which can make swallowing painful. Many patients lose their hair, experience fatigue, bruise and bleed easily, and develop anemia.
Everyone is different, so different patients may experience different sets of side effects and to a different degree. There are treatments available to relieve or minimize certain side effects.
Targeted therapy for cervical stump cancer
While chemotherapy kills all rapidly dividing cells, targeted therapy interferes with the growth and division of cancer cells only, leaving healthy cells alone (per the NCI). There are a variety of targeted therapy drugs, and most of them work by interrupting a key step or signal in the cancer cell's growth and division cycle. Some examples of how targeted therapies work include blocking signals telling a cell to divide, interfering with the growth of blood vessels to the tumor, triggering cell death in cancer cells, and delivering chemotherapy, radiation, or toxins to cancer cells while leaving healthy cells untouched.
Even though targeted therapy is meant to affect cancer cells alone, it can still cause side effects. Patients receiving targeted therapy often experience diarrhea and liver problems. Other, less common side effects include fatigue, sores in the couth, fatigue, high blood pressure, problems with blood clotting and wound healing, changes in the nails, loss of hair color, rashes, and dry skin.
According to the American Cancer Society, there are a few targeted therapy drugs available to treat cervical cancer. Bevacizumab (Avastin) is an angiogenesis inhibitor, which means that it interferes with the growth of blood vessels to the tumor. It is often used in conjunction with chemotherapy. Tisotumab vedotin-tftv (Tivdak) binds to the surface of cancer cells and guides chemotherapy directly to them. This treatment is used for patients whose cancer has metastasized or come back after previous treatment.
Immunotherapy can treat cervical stump cancer
According to the Cleveland Clinic, immunotherapy treats cancer by using the body's own immune system to target and kill cancer cells. The immune system already detects and destroys invading cells such as bacteria and fungi as well as viruses. It also seeks out damaged cells that could develop into cancer. Immunotherapy boosts the immune system's ability to seek and destroy cancer cells.
There are several distinct types of immunotherapy treatments available, including monoclonal antibody treatment. Antibodies are proteins that mark invaders so that immune system cells will find and destroy them. Monoclonal antibodies are lab-made proteins that can mark cancer cells for destruction by the immune system or block proteins that are essential to the cancer's growth.
Pembrolizumab (Keytruda) is a monoclonal antibody that can be used to treat cervical stump cancer. The Food and Drug Administration approved this drug for patients with persistent, recurrent, or metastatic cervical cancer in 2021. It can be used in combination with chemotherapy and with or without the targeted therapy drug bevacizumab.
Long-term prognosis for cervical stump cancer patients
When diagnosed early, cervical cancer responds well to treatment, with a five-year survival rate of 92% for patients diagnosed at an early stage (per the NCI). The prognosis for patients with cervical stump is also promising but slightly different. Patients with cervical stump cancer are patients who have already undergone a hysterectomy, so they make up a different demographic than cervical cancer patients as a whole (per a 1991 study published in the International Journal of Radiation Oncology, Biology, Physics). Cervical stump cancer patients have a median age of 63.5 years at diagnosis, which is 8.5 years older than the age at diagnosis for cervical cancer patients with an intact uterus. Cervical stump cancer patients tend to be diagnosed, on average, 26.6 years after their hysterectomies.
Overall, the five-year survival rate for cervical stump cancer is 60% and the ten-year survival rate is 40%. However, several factors influence patients' long-term outcomes. The stage at diagnosis is critical. Patients diagnosed at stage 1A have a 100% survival rate at 10 years, whereas patients diagnosed at stage 3B have a 39% survival rate. Race matters, as Black patients had worse outcomes compared to patients of other races. Health history is also important. Patients who had previously received a prolonged course of external beam irradiation had worse outcomes than other patients.