Share ThisEditor's Update: This article was first published May 12, 2022. It was most recently reviewed and updated September 21, 2023.
“It’s important to know that, in the majority of women, cervical cancer is preventable through HPV vaccination, routine gynecologic screening and Pap smears,” explains Dr. Thomas Krivak, chairperson and surgical lead, Gynecologic Oncology, AHN Women’s Institute and AHN Cancer Institute. “With regular screening, even if we find cancer, it’s more likely to be at an early stage, when it can be treated successfully with surgery and radiation.”
While all women are at risk, cervical cancer occurs most often in women over 30, and the primary cause is human papillomavirus (HPV) infection. HPV can also cause penile, oral, anal, and other cancers, which is why the HPV vaccine is sometimes called a “cancer-preventing vaccine.”
With Dr. Krivak’s help, let’s explore the topic of cervical cancer — from risk factors to HPV vaccination and screenings to treatment. You can also listen to Dr. Krivak talk about cervical cancer on the KDKA Radio Morning Show below:
“The majority of cervical cancer cases involve HPV infection,” explains Dr. Krivak. Indeed, the CDC estimates that HPV is responsible for more than 90% of cervical cancers. A longer list of risk factors for cervical cancer includes:
It is estimated that between 75% and 85% of people will become infected with HPV during their lifetime. However, there are many different strains of HPV, and not all of them lead to cancer. In many cases, the body’s immune system can clear the virus before it causes cancer or even precancerous cells called dysplasia.
HPV is most commonly transmitted through sexual contact, but it can also be transmitted without sexual contact. Due to the prevalence of HPV in the general population, and the fact that there are other causes of cervical cancer, it is a mistake to assume that you don’t have to worry about it if you only had one sexual partner or are careful to use condoms.
Cervical cancer may not have any symptoms early on — which is why regular screenings are so important. The most common symptom of advanced-stage cervical cancer is irregular vaginal bleeding or discharge. While that can also have causes that are not cancer, if you experience irregular bleeding or discharge, it is always a good idea to schedule an appointment with your gynecologist or primary care physician (PCP).
An annual gynecologic exam can help you keep up with recommended screenings, including for sexually transmitted infections if appropriate, while also getting answers to any questions or concerns.
HPV infection, the primary risk factor for cervical cancer, has no treatment, but there is a vaccine that is highly effective in preventing infection. In fact, the vaccine, recommended for all children around age 11-12, protects against multiple cancers and also genital and anal warts caused by HPV infection.
A key thing to know about the HPV vaccine is that it’s most effective if delivered at an early age, when it is much less likely that there has been an exposure to the virus. Additionally, kids who are vaccinated before age 15 only require two doses of the vaccine. After 15, they need three doses.
“The vaccine isn’t a cure for an existing HPV infection, and once you’ve been exposed to HPV, the benefits are reduced,” notes Dr. Krivak. “That’s why it’s best for kids to be vaccinated within the recommended age range. Young adults can also benefit, even if already sexually active — CDC guidelines currently recommend vaccination up to age 26. Some individuals may benefit beyond that age, and your PCP can help guide you in that decision.”
HPV vaccines have been approved since 2006, so there is a proven record of safety and effectiveness. While understanding that people may have questions about the HPV vaccine, Dr. Krivak adds that he had no hesitation about getting both of his children vaccinated.
Although the HPV vaccine greatly reduces the risk of cervical cancer, it’s not a substitute for regular screenings and gynecological exams.
“For adults, whether vaccinated or not, screenings are the most important action you can take to minimize your risk, prevent cervical cancer, and make sure that if you do have cancer, we catch it at the stage when it is easiest to treat,” says Dr. Krivak.
There are two types of screening related to cervical cancer: the Pap test (or Pap smear) and the HPV test. The Pap test detects precancerous cells, so they can be treated before they become cancerous. The HPV test identifies the presence of HPV infection.
Typically, a Pap test is recommended starting at age 21, and the HPV test is added at age 30. Regular screening should continue through age 65, and may be recommended beyond that, particularly if a woman has had dysplasia or cancer during her lifetime.
The tests are administered the same way. The doctor uses a plastic or metal speculum to widen the vagina for examination. Then, they carefully remove cells by gently brushing the sides of the cervix. Those cells are sent to the lab for testing.
“The point is to find abnormalities, which we call cervical dysplasia, before they become cancer,” Dr. Krivak says. “More frequent screening can mean a higher incidence of dysplasia, but that’s a good thing if it means we’re able to take care of it before it becomes cervical cancer. In parts of the world where there is less access to screening, or among individuals who aren’t screening regularly, that’s when we find higher incidence of cervical cancer.”
As Dr. Krivak points out, cervical cancer screening guidelines have been adjusted, and may be adjusted again as the science continues to evolve. Additionally, while the guidelines apply to most people, some women may have additional risk factors or health issues that need to be considered. And the Pap smear only screens for cervical cancer, not other gynecologic cancers like ovarian and uterine cancer. With all that in mind, he emphasizes that the best starting point for all women is an annual gynecologic exam, starting when she becomes sexually active or at age 21.
“If you go in for an annual gynecologic exam, your gynecologist is in the best position to advise you on screenings and other aspects of care,” he says. “They can also address any concerns or questions about testing. Some women choose to have their gynecologist be their PCP — they’re really able to look at your whole health picture, which obviously goes far beyond any one screening or condition.”
That’s a point worth emphasizing. An annual gynecologic exam can cover many aspects of your health at once. For example, a trusted gynecologist can also give you guidance on whether to get screened for sexually transmitted diseases (see sidebar).
Dr. Thomas Krivak, chairperson and surgical lead, Gynecologic Oncology, AHN Women’s Institute and AHN Cancer Institute.
Some women may avoid cervical cancer screenings out of a fear of the unknown. Here again, Dr. Krivak emphasizes that, in most cases, regular screening means that even when abnormalities are found, the next steps are relatively simple and outcomes are good.
After a Pap test, it may take about three weeks to get lab results. If results are normal, depending on other risk factors, your doctor may suggest that you can wait a few years until your next screening. If anything in the test is not normal, your doctor will follow up.
“Not normal doesn’t mean that you have cancer,” Dr. Krivak explains. “There is a transitional stage between normal cells and cancer called dysplasia, and within that there are different grades of dysplasia. Not all dysplasia will result in cancer, because the body itself will often replace the abnormal cells with healthy cells.”
Depending on the level of dysplasia and other risk factors, next steps may simply include additional testing and monitoring; in more moderate and severe dysplasia, a routine procedure can remove abnormal cells.
If you are diagnosed with cervical cancer, you will be referred to a gynecologic oncologist like Dr. Krivak and his colleagues. Treatment options include surgery, radiation therapy, chemotherapy, targeted drug therapy, and immunotherapy. Depending on the stage of cancer and other factors, more than one form of treatment may be involved. It is always good to discuss the options with your medical team to understand potential risks and side effects, including details related to your sex life and ability to have children.
“In early-stage cervical cancer, surgery may be recommended, along with radiation and sometimes chemotherapy,” Dr. Krivak says. “As you get into more advanced stages, treatment is predominantly radiation and chemo.”
He adds that there is promise in using immunotherapy for all gynecological cancers, including cervical cancer, but cautions that, so far, it is not the best path for everyone.
“Immunotherapy helps a small percentage of patients, and for those patients it often works very well, but we have to match the right immunotherapy with the right cancer markers,” he says.
He adds that, immunotherapy aside, other ongoing improvements in training, surgical instrumentation, intraoperative and postoperative care are all helping to improve outcomes in cervical cancer patients. As an example, he notes that minimally invasive surgical approaches mean that women now heal from surgery more quickly and, if necessary, are then able to initiate chemotherapy sooner.
“Treatment options will continue to improve,” he says, “but prevention is the best outcome. So get the HPV vaccine or get it for your daughter, visit your gynecologist annually, and follow through on the screening they recommend.”
Thomas Krivak, MD is the chairperson and surgical lead, Gynecologic Oncology, AHN Women’s Institute and AHN Cancer Institute. He specializes in treating ovarian, uterine and other gynecologic cancers and has particular expertise in minimally invasive surgical techniques, as well as non-invasive options.
Dr. Krivak received his medical degree at Ohio State University College of Medicine and performed his residency at David Grant Medical Center, Travis Air Force Base in California. He completed his fellowship at the Walter Reed Army Medical Center in Washington, DC and at the National Cancer Institute, Rockville, Maryland. Dr. Krivak is board-certified by the American Boards of Obstetrics and Gynecology and Gynecologic Oncology. He has been named one of Pittsburgh Magazine's "Best Doctors."
Below is a 2023 “Big K Morning” podcast episode with Dr. Krivak on the topic of ovarian cancer:
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