Cervical cancer is the third most common type of cancer amongst US women. In the United States, its incidence and mortality is well below that of breast, lung, endometrial, colon, and ovarian cancer. The mortality and incidence of cervical cancer have significantly declined after the introduction of routine Papanicolaou (Pap) smear screening. Cervical cancers are most often squamous cell carcinomas that arise from infection with a high-risk human papillomavirus (HPV) serotype. Consequently, the risk factors for cervical cancer are the same as those for HPV (e.g., early onset of sexual activity, multiple sexual partners, history of STDs, and immunosuppression). Growth of cervical carcinoma is preceded by cervical intraepithelial neoplasia (CIN), which can be detected via Pap smear. In the US, Pap smears are recommended for women between the ages of 21 and 64 and are subsidized for uninsured patients. Another method of prevention is vaccination against HPV. Currently, the HPV vaccine is recommended for individuals aged 9–45. Primary (i.e., vaccination) and secondary (i.e., screening) prevention are particularly important given that most patients are asymptomatic during early stages. Advanced cervical cancer typically presents with vaginal bleeding, pelvic pain, and/or lower back pain. Colposcopy, which allows for a cervical biopsy to be obtained, is a valuable diagnostic procedure. Lesions consisting of a high-grade CIN may be excised using conization. The treatment of invasive cervical cancer includes a combination of surgery, radiation therapy, and/or chemotherapy, depending on the stage of disease.
Incidence of gynecological malignancies in the United States
Mortality rate due to gynecological malignancies in the United States
- Mean age at diagnosis: 48 years
- Highest incidence and mortality rates in African-American and Hispanic women
Epidemiological data refers to the US, unless otherwise specified.
Infection with high-risk HPV types: 16 ;, 18
- Production of oncoproteins
- Early onset of sexual activity; multiple sexual partners (strongest risk factors)
- High parity
- Immunosuppression (e.g., HIV infection)
- History of sexually transmitted infections (e.g., herpes simplex, chlamydia)
- Cigarette smoking and/or exposure to second-hand smoke (for squamous cell cancer types only)
- Oral contraceptives
- Low socioeconomic status
- In-utero exposure to diethylstilbestrol (DES) has also been linked to cervical cancer, independently of HPV infection.
Patients are usually asymptomatic in early stages. Symptoms commonly first appear in advanced disease.
- Abnormal vaginal bleeding: menometrorrhagia, postcoital spotting; , irregular vaginal bleeding
- Abnormal vaginal discharge: blood-stained or purulent malodorous discharge (not necessarily accompanied by pruritus)
- Cervical ulceration
- Late symptoms: Tumor spread in this condition commonly occurs per continuitatem to the vagina, bladder, rectum and parametria.
Always consider cervical cancer as a cause of postcoital bleeding!
Pap smear (cervical smear)
The proper technique is essential for obtaining highly specific test results.
- The specimen is collected using a spatula or brush:
- A thin layer is uniformly applied to a glass slide.
- Immediate fixation using 95% ethyl alcohol (or spray fixative). Avoid air-drying!
- Stain with Papanicolaou dye
- Interpretation of cytologic smear according to the
The Bethesda system is used for classifying cytological results. Management guidelines exist for each determined subtype.
|Classification of cervical lesions according to cytology results||Abbreviation||Follow-up|
|Specimen unsatisfactory for evaluation|
|Negative for intraepithelial lesion or malignancy Including non-neoplastic cellular changes, inflammation, or glandular cell status posthysterectomy|| |
|Negative for intraepithelial lesion or malignancy but positive for high-risk HPV type|
Atypical squamous cells of undetermined significance
|Atypical squamous cells (cannot exclude HSIL)|
|Low-grade squamous intraepithelial lesion|| |
|Atypical glandular cells||AGC|
|High-grade squamous intraepithelial lesion|
Cervical intraepithelial neoplasia (CIN) classification
|Cervical intraepithelial neoplasia||Histology||Corresponding Bethesda classification|
- Indications: women > 30 years of age
- Prolonged screening interval: screening every 5 years with HPV co-test (Pap smear + HPV test) instead of every 3 years with Pap smear alone
- Allows for closer visualization of lesions and directed biopsies
- Cervical leukoplakia: atypical cells that form a white membrane that cannot be scraped off
Procedure: excision of a cone of cervical tissue that contains parts of both the ectocervix and endocervix
- May be performed using a cold knife, electrosurgical loop (LEEP), or a laser
- Cone biopsy must include the transformation zone as it is the most common site for CIN:
- Squamous cell carcinoma (∼ 80% of cases)
- Adenocarcinoma (∼ 20% of cases; increasing incidence)
Treatment depends on whether disease is invasive or noninvasive.
|Cervical intraepithelial neoplasia||Management||Definitive treatment||Follow-up|
|CIN I|| |
|CIN III|| |
- For microinvasive carcinoma
- For advanced disease: First-line treatment is chemotherapy, radiation therapy, or a combination of both in patients with advanced disease, lymph node metastases, or who are poor surgical candidates.
|Anatomic location||Recommendations for therapy|
|Surgery||Radiation / Chemotherapy|
|Identified only by microscopy (and width < 7 mm)||Depth ≤ 3 mm|| |
Depth > 3 mm and < 5 mm
|Clinical lesions confined to cervix or lesions greater than IA|| |
Clinical lesion of < 4 cm in size
Clinical lesion of > 4 cm in size
|Involvement of the upper two-thirds of the vagina, without parametrial invasion||Clinically visible lesion ≤ 4 cm|
|Clinically visible lesion > 4 cm|
|Parametrial invasion but not onto pelvic sidewall|
|Involvement of lower third of vagina|
|Invasion of pelvic sidewall or hydronephrosis|
|Spread to adjacent organs|
|Spread to distant organs|| |
* Risk features are based on histology and have been shown to have an impact on prognosis. They are taken into account when choosing the appropriate therapy. They include:
Direct complications of cervical carcinoma
- Infiltration of ureter leading to urinary obstruction → hydronephrosis → kidney failure
- Fistula formation in locally advanced disease, e.g., rectovaginal, vesicovaginal, urethrovaginal
- Compression of veins or lymphatic vessels in the lesser pelvis, leading to congestion in the lower extremities
- CACS) (
- Complications of radiation therapy
We list the most important complications. The selection is not exhaustive.
- Patients without lymph node involvement (N0) have a very good prognosis
- Onset of disease at a young age is associated with a poorer prognosis
- Death most often occurs secondary to bilateral ureteral obstruction (subsequent uremia).
Preventing primary infection with HPV with HPV immunization preferably before first sexual intercourse.
- Women 9–26 years of age and men 9–21 years of age
- Men who have sex with men: up to 26 years of age
Current guidelines: 
Administration of 2 doses of nine-valent HPV vaccine to all individuals between 11–12 years of age
- The 2nd dose should be administered 6–12 months after the 1st dose.
- Immunization can be started as early as 9 years of age.
- Administration of 3 doses of nine-valent HPV vaccine to all unvaccinated individuals between 15–26 years of age.
- Administration of 2 doses of nine-valent HPV vaccine to all individuals between 11–12 years of age
- Previous guidelines
- Bivalent vaccine (Cervarix®): protection against high-risk HPV types 16 and 18
- Tetravalent vaccine (Gardasil®): protection against high-risk HPV types 16 and 18, as well as against low-risk types 6 and 11 (most common cause of genital warts)
- Nine-valent vaccine (Gardasil®9): protection against high-risk HPV types 16, 18, 31, 33, 45, 52, and 58, as well as against low-risk types 6 and 11
- Barrier protection (condoms) during sexual intercourse
Every woman aged 21–65 should undergo screening for cervical cancer.
Thecurrently recommends the following screening for women with previously normal exams:
- < 21 years: no screening required
- 21–29 years: Pap smear every 3 years
- 30–65 years: Pap smear every 3 years OR co-testing (Pap smear with HPV test) every 5 years
- > 65 years: no more testing required if the previous testing was negative
Special patient groups
- Cervical cytology should be obtained from women during pregnancy.
- 1–3% of women suffering from cervical cancer are diagnosed during or shortly after their pregnancy.
- Management should take the patient's wishes into consideration and depends on the stage of pregnancy and disease.
- Early pregnancy
- Late pregnancy
Avoid loop electrosurgical excision in pregnant patients!