What Is Cervical Cancer?

Cervical cancer starts in the cells lining the cervix -- the lower part of the uterus (womb). The cervix connects the body of the uterus (the upper part where a fetus grows) to the vagina (birth canal). Cancer starts when cells in the body begin to grow out of control. 

The cervix is made of two parts and is covered with two different types of cells.

• The endocervix is the opening of the cervix that leads into the uterus. It is covered with glandular cells.
• The exocervix (or ectocervix) is the outer part of the cervix that can be seen by the doctor during a speculum exam. It is covered in squamous cells.

The place where these two cell types meet in the cervix is called the transformation zone. The exact location of the transformation zone changes as you get older and if you give birth. Most cervical cancers begin in the cells in the transformation zone.

 

Abnormal changes in cells of the cervix

Cells in the transformation zone do not suddenly change into cancer. Instead, the normal cells of the cervix first gradually develop abnormal changes that can turn into cancer. Doctors use several terms to describe these cell changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia. You might hear these abnormal changes referred to as pre-cancers or pre-cancer changes.

When these abnormal changes in the cervix are found, they are graded on a scale of 1 to 3 based on how much of the cervical tissue looks abnormal.

• In CIN1 (also called mild dysplasia or low grade SIL), not much of the tissue looks abnormal. Most often, these cells will change back to normal cells.
• In CIN2 or CIN3 (also called moderate/severe dysplasia or high-grade SIL) more of the tissue looks abnormal. With these cell changes, there is higher risk that the cells can become cancer cells and will need to be watched closely or removed.

Although cervical cancers start from cells with abnormal changes, only some women with these changes of the cervix will develop cancer. For most women, these abnormal cells will go away without any treatment. But, in some women these abnormal cells can turn into true (invasive) cancers. Treating abnormal changes in cervical cells can prevent almost all cervical cancers.

The goal of cervical cancer screening is to find abnormal cells in the cervix or cervical cancer early when it is more treatable and curable. Regular screening can prevent cervical cancers and save lives. The tests for cervical cancer screening are the HPV test and the Pap test. Pre-cancerous changes can be detected by the Pap test and treated to prevent cancer from developing. The HPV test looks for infection by high-risk types of HPV that are more likely to cause pre-cancers and cancers of the cervix. HPV infection has no treatment, but a vaccine can help prevent it.

Types of cervical cancer

Cervical cancers and cervical pre-cancers are classified by how they look in the lab s with a microscope. The main types of cervical cancers are squamous cell carcinoma and adenocarcinoma.

• Most (up to 9 out of 10) cervical cancers are squamous cell carcinomas. These cancers develop from cells in the exocervix. Squamous cell carcinomas most often begin in the transformation zone (where the exocervix joins the endocervix).
• Most of the other cervical cancers are adenocarcinomas. Adenocarcinomas are cancers that develop from glandular cells. Cervical adenocarcinoma develops from the mucus-producing gland cells of the endocervix.
• Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.

Although almost all cervical cancers are either squamous cell carcinomas or adenocarcinomas, other types of cancer also can develop in the cervix. These other types, such as melanoma, sarcoma, and lymphoma, occur more commonly in other parts of the body.

Only the more common cervical cancer types are covered here.

Key Statistics for Cervical Cancer

How common is cervical cancer?

The American Cancer Society's estimates for cervical cancer in the United States for 2025 are:

• About 13,360 new cases of invasive cervical cancer will be diagnosed.
• About 4,320 women will die from cervical cancer.

Cervical pre-cancers are diagnosed far more often than invasive cervical cancer.

Cervical cancer is most frequently diagnosed in women between the ages of 35 and 44, with the average age being 50. It rarely develops in women younger than 20.

Many older women don't realize that they are still at risk of developing cervical cancer as they age. More than 20% of cervical cancers are found in women over 65. However, these cancers rarely occur in women who have been getting regular tests to screen for cervical cancer before they were 65.

Incidence rates for cervical cancer

Cervical cancer incidence rates decreased by more than half from the mid-1970s to the mid-2000s, largely because of the increased use of screening, but they have stabilized over the past decade. In women ages 30 to 44, however, rates have increased 1.7% each year from 2012 to 2019.

In contrast, rates declined 11% each year for women ages 20 to 24, probably reflecting the first signs of cancer prevention from HPV vaccination.

What's New in Cervical Cancer Research?

New ways to prevent and treat cancer of the cervix are being researched. Some of the promising new developments are covered here.

 

Immunotherapy

Treatment of cervical cancer includes immunotherapy with drugs called checkpoint inhibitors. These drugs are generally only given to people with metastatic or recurrent disease, with or without chemo. Research is being done to determine if immunotherapy would work better with different combinations of chemo, or if it can be used for people with earlier-stage disease.

Targeted therapy

Current targeted therapy includes finding cells with changes in the RET and NTRK genes. Scientists are studying how other gene mutations found in cervical cancer cells can be targeted by specific drugs. Genes called oncogenes and tumor suppressor genes, which control cell growth, are of particular interest.

Radiation therapy

Studies are being done to determine the best ways to use external beam therapy and brachytherapy to treat cervical cancer and still limit damage to normal tissue. Doctors are also looking for ways to use more focused radiation along with other treatments, like immunotherapy, to treat advanced cervical cancers.

Chemotherapy

Many clinical trials are looking for better chemo drugs to treat cervical cancer. Research is ongoing to understand which specific combinations of chemo drugs allow for the best treatment results.

HPV vaccines

Vaccines have been developed to prevent infection with some of the high risk HPV types  that are associated with cervical cancer. The current vaccines are intended to produce immunity to HPV types that cause about 90% of cervical cancers.

Other vaccines are meant to help women who already have advanced cervical cancer. These vaccines produce an immune reaction to the parts of the virus (E6 and E7 proteins) that make the cervical cancer cells grow abnormally. It is hoped that this reaction will kill the cancer cells or stop them from growing. It is also being studied in early-stage cervical cancer to see if it can help decrease the chance of the cancer returning.

What Causes Cervical Cancer?

In recent years, there has been a lot of progress in understanding what happens in cells of the cervix when cancer develops. In addition, several risk factors have been identified that increase the odds that a woman might develop cervical cancer.

The development of normal human cells mostly depends on the information contained in the cells’ DNA. DNA is the chemical in our cells that makes up our genes, which control how our cells work. We look like our parents because they are the source of our DNA. But DNA affects more than just how we look.

Some genes control when cells grow, divide, and die:· 

• Genes that help cells grow, divide, and stay alive are called oncogenes.
• Genes that help keep cell growth under control or make cells die at the right time are called tumor suppressor genes.

Cancers can be caused by DNA mutations (gene defects) that turn on oncogenes or turn off tumor suppressor genes.

Human papillomaviruses (HPV) have two proteins known as E6 and E7 which turn off some tumor suppressor genes, such as p53 and Rb. This may allow the cells lining the cervix to grow too much and to develop changes in additional genes, which in some cases can lead to cancer.

But HPV is not the only cause of cervical cancer. Most women with HPV don’t get cervical cancer, and other risk factors, like smoking and HIV infection, influence which women exposed to HPV are more likely to develop cervical cancer.

Can Cervical Cancer Be Prevented?

The two most important things you can do to prevent cervical cancer are to get the HPV vaccine if you are eligible, and to be tested regularly.

The most common form of cervical cancer starts with pre-cancerous changes and there are ways to stop this from developing. The first way is to find and treat pre-cancers before they become invasive cancers, and the second is to prevent the pre-cancers.

Finding cervical pre-cancers

A well-proven way to prevent cervical cancer is to have screening tests. Screening is having tests to find conditions that may lead to cancers and can find pre-cancers before they can turn into invasive cancer. The Pap test (or Pap smear) and the human papillomavirus (HPV) test are specific tests used during screening for cervical cancer. These tests are done the same way. A health professional uses a special tool to gently scrape or brush the cervix to remove cells for testing. If a pre-cancer is found it can be treated, keeping it from turning into a cervical cancer.

The HPV test looks for infection by high-risk types of HPV that are more likely to cause pre-cancers and cancers of the cervix. There are certain HPV tests approved to be a primary HPV test and others approved as part of a co-test.  The type you get most often depends on which test is available in your area.

The Pap test or smear is a procedure used to collect cells from the cervix so that they can be looked at closely in the lab to find cancer and pre-cancer. It's important to know that most invasive cervical cancers are found in women who have not had regular Pap tests. A Pap test can be done during a pelvic exam, but not all pelvic exams include a Pap test.

The result of the HPV test, along with your past test results, determines your risk of developing cervical cancer. If the test is positive, this could mean more follow-up visits, more tests to look for a pre-cancer or cancer, and sometimes a procedure to treat any pre-cancers that might be found.

It is best to talk to your healthcare provider about your screening test results in more detail to fully understand your risk of developing cervical cancer and next steps.

Things to do to prevent pre-cancers and cancers

Based on your age, overall health, and personal risk for cervical cancer, there are some things that can be done that may prevent pre-cancers and conditions that lead to pre-cancers.

Get an HPV vaccine

Vaccines are available that can help protect children and young adults against certain HPV infections. These vaccines protect against infection with the HPV types most commonly linked to cancer, as well as some types that can cause anal and genital warts.

These vaccines only work to prevent HPV infection − they will not treat an infection that is already there. That is why, to be most effective, the HPV vaccines should be given before a person becomes exposed to HPV (such as through sexual activity).

These vaccines help prevent pre-cancers and cancers of the cervix. Some HPV vaccines are also approved to help prevent other types of cancers and anal and genital warts.

The vaccines require a series of injections (shots). Side effects are usually mild. The most common ones are short-term redness, swelling, and soreness at the injection site. Rarely, a young person might faint shortly after the injection.

The ACS recommends:

• HPV vaccination of children between the ages of 9 and 12. 
• Children and young adults age 13 through 26 who have not been vaccinated, or who haven’t gotten all their doses, should get the vaccine as soon as possible.Vaccination of young adults will not prevent as many cancers as vaccination of children and teens.
• The ACS does not recommend HPV vaccination for persons older than 26 years.

It’s important to know that no vaccine provides complete protection against all cancer-causing types of HPV, so routine cervical cancer screening is still needed.

Limit exposure to HPV

HPV is passed from one person to another during skin-to-skin contact with an infected area of the body. Although HPV can be spread during skin to skin contact − including vaginal, anal, and oral sex − sex doesn't have to occur for the infection to spread. All that is needed is skin-to-skin contact with an area of the body infected with HPV. This means that the virus can be spread without sex. It is even possible for a genital infection to spread through hand-to-genital contact.

Also, HPV infection seems to be able to spread from one part of the body to another. This means that an infection may start in the cervix and then spread to the vagina and vulva.

It can be very hard not to be exposed to HPV. It may be possible to prevent HPV infection by not allowing others to have contact with your anal or genital area, but even then there might be other ways to become infected that aren’t yet clear. 

Limiting the number of sex partners and avoiding sex with people who have had many other sex partners may lower your risk of exposure to HPV.  But again, HPV is very common, so having sexual activity with even one other person can put you at risk. Remember that someone can have HPV for years and still have no symptoms. So it's possible someone can have the virus and pass it on without knowing it.

Use a condom

Condoms (“rubbers”) provide some protection against HPV but they don’t completely prevent infection. One reason that condoms cannot protect completely is because they don’t cover every possible HPV-infected area of the body, such as skin of the genital or anal area. Still, condoms provide some protection against HPV, and they also help protect against HIV and some other sexually transmitted infections. 

Don't smoke

Not smoking is another important way to reduce the risk of cervical pre-cancer and cancer.

Can Cervical Cancer Be Found Early?

The best way to find cervical cancer early is to have regular screening tests. The tests for cervical cancer screening are the HPV test and the Pap test. These tests can be done alone or at the same time (called a co-test). Regular screening has been shown to prevent cervical cancers and save lives. The most important thing to remember is to get screened regularly, no matter which test you get.

Early detection greatly improves the chances of successful treatment of pre-cancers and cancer. Being aware of any signs and symptoms of cervical cancer can also help avoid delays in diagnosis.

Screening Tests for Cervical Cancer

The best way to find cervical cancer early is to have regular screening tests. Regular screening has been shown to prevent cervical cancers and save lives. Early detection greatly improves the chances of successful treatment and can prevent any early cervical cell changes from becoming cancer. Being alert to any signs and symptoms of cervical cancer can also help avoid unnecessary delays in diagnosis.

The tests for cervical cancer screening are the HPV test and the Pap test. These tests can be done alone or at the same time (called a co-test) and are done during a pelvic exam. 

Signs and Symptoms of Cervical Cancer

Women with early cervical cancers and pre-cancers usually have no symptoms. Symptoms often do not begin until the cancer becomes larger and grows into nearby tissue. When this happens, the most common cervical cancer symptoms are:

• Abnormal vaginal bleeding, such as bleeding after vaginal sex, bleeding after menopause, bleeding and spotting between periods, or having (menstrual) periods that are longer or heavier than usual. Bleeding after douching may also occur.
• An unusual discharge from the vagina − the discharge may contain some blood and may occur between your periods or after menopause.
• Pain during sex
• Pain in the pelvic region

Signs and symptoms of cervical cancer seen with more advanced disease can include:

• Swelling of the legs
• Problems urinating or having a bowel movement
• Blood in the urine

These signs and symptoms can also be caused by conditions other than cervical cancer. Still, if you have any of these cervical cancer symptoms, see a health care professional right away. Ignoring symptoms may allow the cancer to grow to a more advanced stage and lower your chance for successful treatment.

For the best chances for treatment to be successful, don't wait for symptoms and signs of cervical cancer to appear. Have regular screening tests for cervical cancer.

Cervical Cancer Stages

After someone is diagnosed with cervical cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes the extent of the cancer in the body. It helps determine how serious the cancer is and how best to treat it. The stage is one of the most important factors in deciding how to treat the cancer and determining how successful treatment might be.

To determine the cancer’s stage after a cervical cancer diagnosis, doctors try to answer these questions:

• How far has the cancer grown into the cervix?
• Has the cancer reached nearby structures?
• Has the cancer spread to the nearby lymph nodes or to distant organs?

Information from exams and tests is used to determine the size of the tumor, how deeply the tumor has invaded tissues in and around the cervix, and its spread to distant places (metastasis).

The FIGO (International Federation of Gynecology and Obstetrics) staging system is used most often for cancers of the female reproductive organs, including cervical cancer. For cervical cancer, the clinical stage is used and is based on the results of the doctor's physical exam, biopsies, imaging tests, and a few other tests that are done in some cases, such as cystoscopy and proctoscopy. It is not based on what is found during surgery. If surgery is done, a pathologic stage can be determined from the findings at surgery, but it does not change your clinical stage. Your treatment plan is based on the clinical stage.

Cervical cancer stage ranges from stages I (1) through IV (4). 

As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means a more advanced cancer. And within a stage, an earlier letter means a lower stage. Cancers with similar stages tend to have a similar outlook and are often treated in much the same way.

Cervical cancer staging can be complex. If you have any questions about your stage, please ask your doctor to explain it to you in a way you understand. (An explanation of the FIGO system is in the stage table below.) 

 

FIGO Stage		Stage description
I		The cancer cells have grown from the surface of the cervix into deeper tissues of the cervix. Cancer has not spread to nearby lymph nodes. Cancer has not spread to distant sites.
	IA	There is a very small amount of cancer, and it can be seen only under a microscope. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IA1	The area of cancer can only be seen with a microscope and is less than 3 mm (about 1/8-inch) deep. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IA2	The area of cancer can only be seen with a microscope and is between 3 mm and 5 mm (about 1/5-inch) deep. It not has not spread to nearby lymph nodes. It has not spread to distant sites.
	IB	This includes stage I cancer that has spread deeper than 5 mm (about 1/5 inch) but is still limited to the cervix. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IB1	The cancer is deeper than 5 mm (about 1/5-inch) but not more than 2 cm (about 4/5-inch) in size. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IB2	The cancer is at least 2 cm in size but not larger than 4 cm. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IB3	The cancer is at least 4 cm in size and limited to the cervix. It has not spread to nearby lymph nodes. It has not spread to distant sites.
II		The cancer has grown beyond the cervix and uterus, but hasn't spread to the walls of the pelvis or the lower part of the vagina. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IIA	The cancer has grown beyond the cervix and uterus but has not spread into the tissues next to the cervix (called the parametria). It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IIA1	The cancer is not larger than 4 cm (about 1 3/5 inches). It not has not spread to nearby lymph nodes. It has not spread to distant sites.
	IIA2	The cancer is 4 cm or larger. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IIB	The cancer has grown beyond the cervix and uterus and has spread into the tissues next to the cervix (the parametria). It has not spread to nearby lymph nodes. It has not spread to distant sites.
III		The cancer has spread to the lower part of the vagina or the walls of the pelvis. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). It might or might not have not spread to nearby lymph nodes. It has not spread to distant sites.
	IIIA	The cancer has spread to the lower part of the vagina but not the walls of the pelvis. It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IIIB	The cancer has grown into the walls of the pelvis and/or is blocking one or both ureters causing kidney problems (called hydronephrosis). It has not spread to nearby lymph nodes. It has not spread to distant sites.
	IIIC	The cancer can be any size. Imaging tests or a biopsy show the cancer has spread to nearby pelvic lymph nodes (IIIC1) or para-aortic lymph nodes (IIIC2). It has not spread to distant sites.
IV		The cancer has grown into the bladder or rectum or to far away organs like the lungs or bones.
	IVA	The cancer has spread to the bladder or rectum or it is growing out of the pelvis.
	IVB	The cancer has spread to distant organs outside the pelvic area, such as distant lymph nodes, lungs or bones.

 

Survival Rates for Cervical Cancer

Survival rates can give you an idea of what percentage of people with the same type and stage of cancer are still alive a certain amount of time (usually 5 years) after they were diagnosed. They can’t tell you how long you will live, but they may help give you a better understanding of how likely it is that your treatment will be successful.

Keep in mind that survival rates are estimates and are often based on previous outcomes of large numbers of people who had a specific cancer, but they can’t predict what will happen in any particular person’s case. These statistics can be confusing and may lead you to have more questions. Ask your doctor how these numbers might apply to you.

What is a 5-year relative survival rate?

A relative survival rate compares women with the same type and stage of cervical cancer to women in the overall population. For example, if the 5-year relative survival rate for a specific stage of cervical cancer is 90%, it means that women who have that cancer are, on average, about 90% as likely as women who don’t have that cancer to live for at least 5 years after being diagnosed.

Where do these numbers come from?

The American Cancer Society relies on information from the Surveillance, Epidemiology, and End Results (SEER) database, maintained by the National Cancer Institute (NCI), to provide survival statistics for different types of cancer.

The SEER database tracks 5-year relative survival rates for cervical cancer in the United States, based on how far the cancer has spread. The SEER database, however, does not group cancers by FIGO stages (stage 1, stage 2, stage 3, etc.). Instead, it groups cancers into localized, regional, and distant stages:

• Localized: There is no sign that the cancer has spread outside of the cervix or uterus.
• Regional: The cancer has spread beyond the cervix and uterus to nearby lymph nodes.
• Distant: The cancer has spread to nearby organs (like the bladder or rectum) or distant parts of the body such as the lungs or bones.

5-year relative survival rates for cervical cancer

Based on women diagnosed with cervical cancer between 2014 and 2020.

SEER* Stage	5-year Relative Survival Rate
Localized	91%
Regional	61%
Distant	19%
All SEER stages combined	67%

*SEER= Surveillance, Epidemiology, and End Results

Understanding the numbers

• Women now being diagnosed with cervical cancer may have a better outlook than these numbers show. Treatments improve over time, and these numbers are based on women who were diagnosed and treated at least five years earlier.
• These numbers apply only to the stage of the cancer when it is first diagnosed. They do not apply later on if the cancer grows, spreads, or comes back after treatment.
• These numbers don’t take everything into account. Survival rates are grouped based on how far the cancer has spread, but your age, overall health, how well the cancer responds to treatment, and other factors will also affect your outlook.

Questions to Ask About Cervical Cancer

It is important for you to have frank, open discussions with your cancer care team. They want to answer all of your questions, to help you make informed treatment and life decisions. Here are some questions to consider.

When you're told you have cervical cancer

• What type of cervical cancer do I have?
• Has my cancer spread outside the cervix?
• Can the stage of my cancer be determined and what does that mean?
• Will I need other tests before we can decide on treatment?
• Do I need to see any other doctors or health professionals?
• If I’m concerned about the costs and insurance coverage for my diagnosis and treatment, who can help me?

When deciding on a treatment plan

• What are my treatment choices?
• What treatment do you recommend and why?
• How much experience do you have treating this type of cancer?
• Should I get a second opinion? How do I do that? Can you recommend someone?
• What would the goal of the treatment be?
• How quickly do we need to decide on treatment?
• What should I do to be ready for treatment?
• How long will treatment last? What will it be like? Where will it be done?
• What risks or side effects are there to the treatments you suggest? Are there things I can do to reduce these side effects?
• How might treatment affect my daily activities?
• Will the treatment put me into menopause early?
• Will I need hormone replacement therapy after treatment? If so, is it safe?
• What are the chances my cancer will recur (come back) with these treatment plans?
• What will we do if the treatment doesn’t work or if the cancer recurs?
• Will I be able to have children after my treatment?
• What are my treatment options if I want to have children in the future?

During treatment

Once treatment begins, you’ll need to know what to expect and what to look for. Not all of these questions may apply to you, but asking the ones that do may be helpful.

• How will we know if the treatment is working?
• Is there anything I can do to help manage side effects?
• What symptoms or side effects should I tell you about right away?
• How can I reach you on nights, holidays, or weekends?
• Do I need to change what I eat during treatment?
• Are there any limits on what I can do?
• Can I have sex during treatment? Will my sex life change after treatment?
• What kind of exercise should I do, and how often?
• Can you suggest a mental health professional I can see if I start to feel overwhelmed, depressed, or distressed?

After treatment

• Will I need a special diet after treatment?
• Are there any limits on what I can do?
• What other symptoms should I watch for?
• What kind of exercise should I do now?
• What type of follow-up will I need after treatment?
• How often will I need to have follow-up exams and imaging tests?
• Will I need any blood tests?
• How will we know if the cancer has come back? What should I watch for?
• What will my options be if the cancer comes back?

Along with these examples, be sure to write down some of your own. For instance, you might want more information about recovery times. Or you might ask if you qualify for a clinical trial.

Keep in mind that doctors aren’t the only ones who can give you information. Other health care professionals, such as nurses and social workers, can answer some of your questions.

Tests for Cervical Cancer

Finding cervical cancer often starts with an abnormal HPV (human papillomavirus) or Pap test result. This will lead to further tests which can diagnose cervical cancer or pre-cancer. The Pap test and HPV test are screening tests, not diagnostic tests. They cannot tell for certain if you have cervical cancer. An abnormal Pap test or HPV test result may mean more testing is needed to see if a cancer or a pre-cancer is present.

Cervical cancer may also be suspected if you have symptoms like abnormal vaginal bleeding or pain during sex. Your primary doctor or gynecologist often can do the tests needed to diagnose pre-cancers and cancers. If you are diagnosed with invasive cancer, your doctor will probably refer you to a gynecologic oncologist, a doctor who specializes in cancers of women's reproductive systems.

Understanding abnormal cervical screening test results

Your current screening test results along with your past test results, determine your risk of developing cervical cancer. Your doctor will use them to figure out your next test or treatment. It could be a follow-up screening test in a year, a colposcopy, or one of the other procedures discussed below to treat any pre-cancers that might be found.  

Because there are many different follow-up or treatment options depending on your specific risk of developing cervical cancer, it is best to talk to your health care provider about your screening results in more detail, to fully understand your cervical cancer risk and the best follow-up plan for you.

Tests for people with symptoms of cervical cancer or abnormal cervical screening test results

Medical history and physical exam

First, the doctor will ask you about your personal and family medical history. This includes information related to risk factors and symptoms of cervical cancer. A complete physical exam will help evaluate your general state of health. You will have a pelvic exam and maybe a Pap test if one has not already been done. In addition, your lymph nodes will be felt to see if the cancer has spread (metastasis). 

Colposcopy

If you have certain symptoms that could mean cancer, if your Pap test result shows abnormal cells, or if your HPV test is positive, you will most likely need to have a procedure called a colposcopy. You will lie on the exam table as you do with a pelvic exam. The doctor will put a speculum in the vagina to help keep it open while examining the cervix with a colposcope. The colposcope is an instrument that stays outside the body and has magnifying lenses. It lets the doctor clearly see the surface of the cervix up close. Colposcopy itself is usually no more uncomfortable than any other speculum exam. It can be done safely even if you are pregnant. Like the Pap test, it is better not to do it during your menstrual period.

The doctor will put a weak solution of acetic acid (similar to vinegar) on your cervix to make any abnormal areas easier to see. If an abnormal area is seen, a small piece of tissue will be removed (biopsy) and sent to a lab to be looked at carefully. A biopsy is the best way to tell for certain if an abnormal area is a pre-cancer, an invasive cancer, or neither.

Types of cervical biopsies

Several types of biopsies can be used to diagnose cervical pre-cancers and cancers. If the biopsy can completely remove all of the abnormal tissue, it might be the only treatment needed.

Colposcopic biopsy

For this type of biopsy, the cervix is examined first with a colposcope to find the abnormal areas. Using a biopsy forceps, a small (about 1/8-inch) section of the abnormal area on the surface of the cervix is removed. The biopsy procedure may cause mild cramping, brief pain, and some slight bleeding afterward.

Endocervical curettage (endocervical scraping)

If colposcopy does not show any abnormal areas or if the transformation zone (the area at risk for HPV infection and pre-cancer) cannot be seen with the colposcope, another method must be used to check that area for cancer.

A narrow instrument (either a curette or a brush) is inserted into the endocervical canal (the part of the cervix closest to the uterus). The curette or brush is used to scrape the inside of the canal to remove some of the tissue, which is then sent to the lab to be checked. During or after this procedure, patients may feel a cramping pain, and they may also have some light bleeding.

Cone biopsy

In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the exocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal. The tissue removed in the cone includes the transformation zone (the border between the exocervix and endocervix, where cervical pre-cancers and cancers are most likely to start). A cone biopsy can also be used as a treatment to completely remove many pre-cancers and some very early cancers.

The methods commonly used for cone biopsies are the loop electrosurgical excision procedure (LEEP), also called the large loop excision of the transformation zone (LLETZ), and the cold knife cone biopsy.

• Loop electrosurgical procedure (LEEP, LLETZ): In this method, the tissue is removed with a thin wire loop that is heated by electricity and acts as a small knife. A local anesthetic is used for this procedure, and it can be done in your doctor's office.
• Cold knife cone biopsy: This is done in a hospital. A surgical scalpel or a laser is used to remove the tissue instead of a heated wire. You will receive anesthesia during the operation (either a general anesthesia, where you are asleep, or a spinal or epidural anesthesia, where an injection into the area around the spinal cord makes you numb below the waist).

Possible complications of cone biopsies include bleeding, infection and narrowing of the cervix. 

Having had any type of cone biopsy will not prevent most women from getting pregnant, but if a large amount of tissue has been removed, women may have a higher risk of giving birth prematurely.

Other tests when cervical cancer is diagnosed

If a biopsy shows that cancer cells are present, your doctor may order certain tests to see if and how far the cancer has spread. Many of the tests described below are not necessary for every patient. Decisions about using these tests are based on the results of the physical exam and biopsy.

Cystoscopy, proctoscopy, and examination under anesthesia

These are most often done when the tumors are large. They are not necessary if the cancer is caught early.

In a cystoscopy, a slender tube with a lens and a light is placed into the bladder through the urethra. This lets the doctor check your bladder and urethra to see if cancer is growing into these areas. Biopsy samples can be removed during cystoscopy for testing in the lab. Cystoscopy can be done under a local anesthetic, but some patients may need general anesthesia. Your doctor will let you know what to expect before and after the procedure.

Proctoscopy is a visual inspection of the rectum through a lighted tube to look for spread of cervical cancer into your rectum.

Your doctor may also do a pelvic exam while you are under anesthesia to find out if the cancer has spread beyond the cervix.

Imaging studies

If your doctor finds that you have cervical cancer, certain imaging studies may be done. These tests can show if and where the cancer has spread, which will help you and your doctor decide on a treatment plan.

• Chest x-ray: Your chest may be x-rayed to see if cancer has spread to your lungs.
• Computed tomography (CT): CT scans are usually done if the tumor is larger or if there is concern about cancer spread.
• Magnetic resonance imaging (MRI): MRI scans look at the soft tissue parts of the body sometimes better than other imaging tests, like a CT scan. Your doctor will decide which imaging test is best to use in your situation.
• Positron emission tomography/ computed tomography (PET/CT) scan: For a PET scan, a slightly radioactive form of sugar (known as FDG) is injected into the blood and collects mainly in cancer cells. Often a PET scan is combined with a CT scan using a special machine that can do both at the same time. This lets the doctor compare areas of higher radioactivity on the PET scan with a more detailed picture on the CT scan. This is the type of PET scan most often used in patients with cervical cancer. This test can help see if the cancer has spread to lymph nodes. PET scans can also be useful if your doctor thinks the cancer has spread but doesn’t know where.
• Intravenous urography: Intravenous urography (also known as intravenous pyelogram, or IVP) is an x-ray of the urinary system taken after a special dye is injected into a vein. This test can find abnormal areas in the urinary tract, caused by the spread of cervical cancer. The most common finding is that the cancer has blocked the ureters (tubes that connect the kidneys to the bladder). IVP is rarely used for patients with cervical cancer because CT and MRI are also good at finding abnormal areas in the urinary tract, as well as others not seen with an IVP.

 

Surgery for Cervical Cancer

Many women with cervical cancer will have some type of surgery. Surgery can be used to:

• Help diagnose cervical cancer
• Help determine how far the cancer has spread
• Help treat the cancer (especially for early-stage cancers)

Surgery for cervical pre-cancers

Two types of procedures can be used to treat pre-cancers of the cervix:

• Ablation destroys cervical tissue with cold temperatures (cryosurgery) or with a laser (laser ablation) rather than removing it.
• Excisional surgery (conization) cuts out and removes the pre-cancer.   

Cryosurgery

Cryosurgery is a type of ablation where a very cold metal probe is placed directly on the cervix. This kills the abnormal cells by freezing them. It is used to treat cervical intraepithelial neoplasia (CIN). This can be done in a doctor’s office or clinic. After cryosurgery, you may have a watery brown discharge for a few weeks. 

Laser ablation

Laser ablation directs a focused laser beam through the vagina to vaporize (burn off) abnormal cells. This might be done in a doctor’s office under local anesthesia (numbing medicine) or in the operating room with general anesthesia since it can cause more discomfort than cryotherapy. It is also used to treat cervical intraepithelial neoplasia (CIN).

Conization

Another way to treat cervical intraepithelial neoplasia (CIN) is with excisional surgery called conization. The doctor removes a cone-shaped piece of tissue from the cervix. The tissue removed in the cone includes the transformation zone where cervical pre-cancers and cancers are most likely to start. A cone biopsy is not only used to diagnose pre-cancers and cancers. It can also be used as a treatment since it can sometimes completely remove pre-cancers and some very early cancers.

The procedure can be done in different ways:

• Using a surgical blade (cold knife cone biopsy)
• Using a laser beam (laser conization)
• Using a thin wire heated by electricity (the loop electrosurgical excision procedure, LEEP or LEETZ procedure).

Surgery for invasive cervical cancer

Procedures to treat invasive cervical cancer are:

• Hysterectomy (simple or radical)
• Trachelectomy

Simple hysterectomy

A simple hysterectomy removes the uterus (both the body of the uterus and the cervix) but not the structures next to the uterus (parametria and uterosacral ligaments). The vagina and pelvic lymph nodes are not removed. The ovaries are usually left in place unless there is another reason to remove them.

Simple hysterectomy can be used to treat certain types of severe CIN or certain types of very early cervical cancer.

There are different ways to do a hysterectomy:

• Abdominal hysterectomy: The uterus is removed through a surgical incision in the front of the abdomen.
• Vaginal hysterectomy: The uterus is removed through the vagina.
• Laparoscopic hysterectomy: The uterus is removed using laparoscopy. First, a thin tube with a tiny video camera at the end (the laparoscope) is inserted into one or more very small surgical incisions made on the abdominal wall to see inside the abdomen and pelvis. Small instruments can be controlled through the tube(s), so the surgeon can cut around the uterus without making a large cut in the abdomen. The uterus is then removed through a cut in the vagina.
• Robotic-assisted surgery: In this approach, the laparoscopy is done with special tools attached to robotic arms that are controlled by the doctor to help perform precise surgery.

General anesthesia is used for all of these operations.

For a laparoscopic or vaginal hysterectomy, the hospital stay is usually 1 to 2 days, followed by a 2- to 3-week recovery period. A hospital stay of 3 to 5 days is common for an abdominal hysterectomy, and complete recovery takes about 4 to 6 weeks.

Possible side effects: Any type of hysterectomy results in infertility (inability to have children). Complications could include bleeding, infection, or damage to the urinary or intestinal systems, such as the bladder or colon.

Hysterectomy does not change the ability to feel sexual pleasure. The uterus and cervix are not needed for someone to reach an orgasm. The area around the clitoris and the lining of the vagina remain as sensitive as before a hysterectomy. 

Radical hysterectomy

For this operation, the surgeon removes the uterus along with the tissues next to the uterus (the parametria and the uterosacral ligaments), the cervix, and the upper part (about 1 inch [2-3cm]) of the vagina next to the cervix. The ovaries are not removed unless there is some other medical reason to do so. More tissue is removed in a radical hysterectomy than in a simple hysterectomy, so the hospital stay may be longer. Often, some pelvic lymph nodes are removed as well. (This procedure is known as lymph node dissection)

This surgery is usually done through a large abdominal incision (also known as open surgery).

A radical hysterectomy can also be done using laparoscopy or robot-assistance. These techniques are also referred to as minimally invasive surgery. Laparoscopic (or robotic) surgery can result in less pain, less blood loss during the operation, and a shorter hospital stay compared to open surgery. However, studies have shown that patients who have minimally invasive radical hysterectomies for cervical cancer have a higher chance of the cancer recurring and a higher risk of dying from the cancer than those who have surgery through an abdominal incision (open surgery). Having a radical hysterectomy through an abdominal cut is the preferred type of surgery in most cases. Laparoscopic surgery may still be an option for a small specific group of patients with early-stage cancer, but you should discuss your options carefully with your doctor.

A modified radical hysterectomy is similar to a radical hysterectomy but does not remove as much of the vagina and tissues next to the uterus (the parametria and the uterosacral ligaments) and lymph nodes are usually not removed.

Possible side effects: Because the uterus is removed, this surgery results in infertility. Because some of the nerves to the bladder are removed, some patients have problems emptying their bladder after this operation and may need a catheter for a time. Complications could include bleeding, infection, or damage to the urinary and intestinal systems such as the bladder or colon.

When some of the lymph nodes are removed to check for cancer, lymphedema (leg swelling) might be a result. This is not common, but may happen after surgery and treated with different methods.

Radical hysterectomy does not change the ability to feel sexual pleasure. Although the vagina is shortened, the area around the clitoris and the lining of the vagina is as sensitive as before. A uterus or cervix is not needed to reach orgasm. When cancer has caused pain or bleeding with intercourse, the hysterectomy may actually improve a sex life by stopping these symptoms.

Trachelectomy

A radical trachelectomy, allows you to be treated without losing your ability to have children. The operation is done either through the vagina or the abdomen, and is sometimes done using laparoscopy or a robot.

This procedure removes the cervix and the upper part of the vagina but not the body of the uterus. The surgeon then places a permanent "purse-string" stitch inside the uterine cavity to keep the opening of the uterus closed, the way the cervix normally would. 

The nearby lymph nodes are also removed using laparoscopy which may require another incision (cut). The operation is done either through the vagina or the abdomen.

After trachelectomy, some are able to carry a pregnancy to term and deliver a healthy baby by cesarean section, although those who have had this surgery might have a higher risk of miscarriage.

Pelvic exenteration

This operation is done for very specific cases of recurrent cervical cancer. In this surgery, all of the same organs and tissues are removed as in a radical hysterectomy with pelvic lymph node dissection. (Lymph node dissection is discussed in the next section.) In addition, the bladder, vagina, rectum, and part of the colon are also removed, depending on where the cancer has spread.

If your bladder is removed, you will need a new way to store and get rid of urine. This usually means using a short piece of intestine to function as a new bladder. The new bladder may be connected to the abdominal wall so that urine is drained periodically when the patient places a catheter into a urostomy (a small opening). Or urine drains continuously into a small plastic bag attached to the front of the abdomen.

If the rectum and part of the colon are removed, a new way to get rid of fecal waste must be created. This is done by attaching the remaining intestine to the abdominal wall so that fecal material can pass through a small opening (stoma) into a small plastic bag worn on the front of the abdomen. In some cases, it may be possible to remove the cancerous part of the colon (next to the cervix) and reconnect the colon ends so that no bags or external appliances are needed.

If the vagina is removed, a new vagina can be surgically made out of skin, intestinal tissue, or muscle and skin (myocutaneous) grafts.

Sexual impact of pelvic exenteration

Recovery from total pelvic exenteration takes a long time. Most people don't begin to feel like themselves again for about 6 months after surgery. Some say it takes a year or two to adjust completely.

Nevertheless, theystill can lead happy and productive lives. With practice, they can also have sexual desire, pleasure, and orgasms.

 

Surgery to remove nearby lymph nodes

Para-aortic lymph node sampling

Usually during surgery for a radical hysterectomy, the lymph nodes next to the aorta (the large artery in the abdomen) are removed.  This is called para-aortic lymph node sampling.  The lymph nodes may be sent to the lab during the operation for quick testing.  If the para-aortic lymph nodes show cancer, the surgery may be stopped, and systemic therapy, such as chemotherapy with or without immunotherapy, given instead.  If the lymph nodes do not show cancer, then pelvic lymph nodes (see below) are usually removed and the radical hysterectomy completed.  Any tissue removed during surgery will be tested to see if the cancer has spread there. If so, radiation therapy with or without chemotherapy may be recommended.

Pelvic lymph node dissection

Cancer that starts in the cervix can spread to lymph nodes in the pelvis. To check for lymph node spread, the surgeon might remove some of these lymph nodes. This procedure is known as a pelvic lymph node dissection or lymph node sampling. It is done at the same time as a hysterectomy or trachelectomy.

Removing lymph nodes can lead to fluid drainage problems in the legs. This can cause severe leg swelling, a condition called lymphedema.

Sentinel lymph node mapping and biopsy

Sentinel lymph node mapping and biopsy is a procedure in which the surgeon finds and removes only the lymph node(s) where the cancer would likely spread first.  To do this, the surgeon injects a radioactive substance and/or a blue dye into the cervix at the beginning of the surgery. Lymphatic vessels will carry these substances along the same path that the cancer would likely take. The first lymph node(s) the dye or radioactive substance travels to will be the sentinel node(s). Removing only one or a few lymph nodes lowers the risk of side effects from the surgery, such as leg swelling that is known as lymphedema.

After the substance has been injected, the sentinel node(s) can be found either by using a special machine to detect radioactivity in the nodes, or by looking for nodes that have turned blue. To double check, both methods are often used. The surgeon then removes the node(s) containing the dye or radioactivity. 

Sentinel lymph node mapping may be considered for certain cases of stage I cervical cancer.  It is best used for tumors that are less than 2 cm (almost one inch) in size. If your surgeon is planning sentinel lymph node biopsies, you should discuss if this procedure is appropriate for you.

Even if sentinel lymph node mapping does not show any lymph nodes to biopsy, the surgeon will most likely still remove the lymph nodes on that side of the pelvis to make sure cancer is not missed. Also, any enlarged or suspicious lymph nodes need to be removed at the time of surgery, even if they do not take up the dye.

Radiation Therapy for Cervical Cancer

Radiation therapy uses high energy x-rays to kill cancer cells. Depending on the stage of the cervical cancer, radiation therapy may be used:

• As a part of the main treatment. For some stages of cervical cancer, the preferred treatment is radiation and chemo given together (called concurrent chemoradiation) as the chemo helps the radiation work better.
• To treat cervical cancer that has spread or that has come back after treatment. Radiation therapy may be used to lessen symptoms caused by cervical cancers that have spread to other organs and tissues.

The types of radiation therapy most often used to treat cervical cancer are:

• External beam radiation
• Brachytherapy

It is important to know that smoking increases the side effects from radiation and can make treatment less effective. If you smoke, you should stop.

External beam radiation

External beam radiation therapy (EBRT) aims x-rays at the cancer from a machine outside the body. Treatment is much like getting a regular x-ray, but the radiation dose is stronger.

Each radiation treatment lasts only a few minutes, but getting you into place for treatment usually takes longer. The procedure itself is painless.

When EBRT is used as the main treatment for cervical cancer, it is usually combined with chemotherapy (called concurrent chemoradiation). Often, a low dose of the chemo drug called cisplatin is used. Other chemo drugs can be used as well. The radiation treatments are given 5 days a week for about 5 weeks. The chemotherapy is given at scheduled times while radiation is being given. The schedule is determined by which drug is used. If the cancer has not spread to distant areas, brachytherapy, which is discussed below, may also be given after the concurrent chemoradiation is complete. 

EBRT can also be used as the main treatment of cervical cancer in patients who can’t tolerate chemoradiation, can’t safely have surgery, or choose not to have surgery. It can also be used by itself to treat areas where the cancer spread.

Possible side effects of EBRT

Short-term side effects of external beam radiation therapy for cervical cancer can include:

• Fatigue (tiredness)
• Upset stomach
• Diarrhea or loose stools (if radiation is given to the pelvis or abdomen)
• Nausea and vomiting
• Skin changes (mild redness to peeling in the area where the radiation is given)
• Radiation cystitis: Radiation to the pelvis can irritate the bladder (radiation cystitis), causing discomfort, an urge to urinate often, and sometimes blood in the urine.
• Vaginal pain: Radiation can make the vulva and vagina more sensitive and sore, and sometimes causes a discharge.
• Menstrual changes: Pelvic radiation can affect the ovaries, leading to menstrual changes and even early menopause.
• Low blood cell counts: Anemia (low levels of red blood cells) can make you  feel tired. Neutropenia (low levels of white blood cells) increases the risks of serious infection. Thrombocytopenia (low levels of platelets) increases the risk of bleeding. 

When chemotherapy is given with radiation, the blood cell counts tend to be lower and fatigue and nausea tend to be worse. These side effects typically improve in the weeks after treatment is stopped.

Other, long-term side effects are also possible with EBRT. These are described below.

Brachytherapy (internal radiation therapy)

Brachytherapy, or internal radiation therapy, puts a source of radiation in or near the cancer. This type of radiation only travels a short distance. The type of brachytherapy used most often to treat cervical cancer is known as intracavitary brachytherapy. The radiation source is placed in a device in the vagina (and sometimes in the cervix). Brachytherapy is mainly used in addition to EBRT as a part of the main treatment for cervical cancer. Rarely, it might be used alone in very specific cases of early-stage cervical cancers.

There are two types of brachytherapy:

• Low-dose rate (LDR) brachytherapy is completed over a few days. During this time, the patient stays in bed in a private room in the hospital with instruments holding the radioactive material in place. While the radiation therapy is being given, the hospital staff will care for you, but will also take precautions to avoid being exposed to radiation themselves.
• High-dose rate (HDR) brachytherapy is done as an outpatient procedure over several treatments (often at least a week apart). For each high-dose treatment, the radioactive material is inserted for a few minutes and then removed. The advantage of HDR treatment is that you do not have to stay in the hospital or stay still for long periods of time.

To treat cervical cancer in women who have had a hysterectomy, the radioactive material is placed in a tube in the vagina.

To treat someone who still has a uterus, the radioactive material can be placed in a small metal tube (called a tandem) that goes in the uterus, along with small round metal holders (ovoids) placed near the cervix. This is sometimes called tandem and ovoid treatment.

Another option is called tandem and ring. For this, a round holder (like a ring) is placed close to the uterus. The choice of which one to use depends on what type of brachytherapy is planned.

Possible short-term side effects of brachytherapy

Since the radiation only travels a short distance with brachytherapy, the main effects of the radiation are on the cervix and the walls of the vagina. The most common side effect is irritation of the vagina. It may become red and sore, and there may be a discharge. The vulva may become irritated as well.

Brachytherapy can also cause many of the same side effects as EBRT, such as fatigue, diarrhea, nausea, irritation of the bladder, and low blood cell counts. Often brachytherapy is given right after external beam radiation (before the side effects can go away), so it can be hard to know which type of treatment is causing the side effect.  

Long-term side effects of radiation therapy

Side effects related to radiation can sometimes occur months to years after treatment.

Vaginal stenosis: Both EBRT and brachytherapy can cause scar tissue to form in the vagina. The scar tissue can make the vagina narrower (called vaginal stenosis), less able to stretch, or even shorter, which can make vaginal sex painful.

Vaginal stenosis can be helped or prevented by stretching the walls of the vagina several times a week, either by having sex or by using a vaginal dilator (a plastic or rubber tube used to stretch out the vagina). .

Vaginal dryness: Vaginal dryness and painful sex can be long-term side effects from radiation (both brachytherapy and EBRT). Estrogens used locally may help with vaginal dryness and changes to the vaginal lining, especially if radiation to the pelvis damaged the ovaries, and caused early menopause. These hormones are typically applied in the vagina and absorbed into the genital area, rather than taken by mouth. They come in gel, cream, ring, and tablet forms.

Rectal bleeding/rectal stenosis: Radiation to the rectal wall can cause chronic inflammation of the area which can lead to bleeding and sometimes stenosis (narrowing) of the rectum which can be painful. An abnormal opening (called a fistula) also may form between the rectum and vagina, causing stool to come out of the vagina. These problems typically happen during the first 3 years after radiation treatment. Additional treatments, such as surgery, may be needed to fix these complications.

Urinary problems: Radiation to the pelvis can cause chronic radiation cystitis (as mentioned above), blood in the urine, or an abnormal opening between the bladder and vagina (called a fistula). These side effects can be seen many years after radiation therapy.

Weakened bones: Radiation to the pelvis can weaken the bones, leading to fractures. Hip fractures are the most common and might occur 2 to 4 years after radiation. Bone density tests are recommended to monitor the risk of fracture.

Swelling of the leg(s): If pelvic lymph nodes are treated with radiation, it can lead to fluid drainage problems in the leg. This can cause the leg to swell severely, a condition called lymphedema.

If you are having side effects from radiation treatment, discuss them with your cancer care team.

 

Chemotherapy for Cervical Cancer

Chemotherapy (chemo) drugs given intravenously (into a vein) or by mouth are called systemic chemotherapy. The drugs enter the bloodstream and reach throughout the body, making this treatment useful for cancers that have spread.

Chemo drugs commonly used to treat cervical cancer

Treatment choices are made based on each person's needs. Drugs that have been used include:

•  Cisplatin
•  Carboplatin
•  Bevacizumab (Avastin)
•  Paclitaxel (Taxol®)
•  Topotecan (Hycamtin)
•  Docetaxel (Taxotere)
•  Fluorouracil (5-FU)

These drugs can be given:

• At the same time as radiation (for cancer that has not spread to other parts of the body)
• Alone (if cancer has already spread to other parts of the body)

Chemo side effects

Chemo works by attacking cells that are rapidly dividing. This is helpful in killing cancer cells, but can also affect normal cells, leading to some side effects. Side effects of chemo depend on the type of drugs, the amount taken, and the length of time you are treated.

Common side effects of chemotherapy include:

•  Hair loss
•  Mouth sores
•  Loss of appetite
•  Diarrhea
•  Nausea and vomiting
•  Changes in the menstrual cycle, premature menopause, and infertility (inability to become pregnant)

Chemo can also affect the blood-forming cells of the bone marrow, lowering the blood cell counts. This can cause:

•  Increased chance of infections (from low white blood cells)
•  Easy bruising or bleeding (from low blood platelets)
•  Fatigue (caused by low red blood cells)

Most side effects are temporary and stop when the treatment is over, but some can be long-lasting or even permanent.

Long-term side effects of chemotherapy

Menstrual changes: If you have not had your uterus removed as a part of treatment, changes in menstrual periods are a common side effect of chemo. But even if your periods stop while you are getting chemo, you might still be able to get pregnant. Getting pregnant while receiving chemo is not safe, as it might lead to birth defects and interfere with treatment. This is why it’s important to discuss birth control options with your doctor if you are pre-menopausal and sexually active before treatment. Patients who have finished treatment (like chemo) can often go on to have children, but it's important to talk to your doctor about when it is safe to do so.

Premature menopause (not having any more menstrual periods) and infertility (not being able to become pregnant) may occur and may be permanent. Some chemo drugs are more likely to cause this than others. The older a woman is when she gets chemo, the more likely it is that she will become infertile or go through menopause as a result. If this happens, there is an increased risk of bone loss and osteoporosis. Medicines that can treat or help prevent problems with bone loss are available. 

Neuropathy: Some drugs used to treat cervical cancer, including paclitaxel and cisplatin, can damage nerves outside of the brain and spinal cord. This can sometimes lead to symptoms like numbness, pain, burning or tingling sensations, sensitivity to cold or heat, or weakness, mainly in the hands and feet. This is called peripheral neuropathy. In most cases it gets better or even goes away once treatment stops, but it might last a long time in some people.

Nephrotoxicity: Cisplatin, the main chemo drug used to treat cervical cancer, can damage the kidneys (also called nephrotoxicity). Many times the damage is preventable and reversible, but sometimes it may be long-lasting. Often, there are no symptoms, but the damage can be seen on bloodwork done routinely while chemo is given. If the kidneys are damaged, the cisplatin is usually stopped and carboplatin may be used instead. 

Other side effects are also possible. Ask your cancer care team about the chemo you will receive and what side effects you can expect.

Immunotherapy for Cervical Cancer

Immunotherapy is the use of medicines to help a person’s immune system better recognize and destroy cancer cells. Many types of immunotherapy are being tested in clinical trials, and some are used to treat cervical cancer.

Immune checkpoint inhibitors

An important part of the immune system is its ability to keep itself from attacking the body's normal cells. To do this, it uses “checkpoint” proteins on immune cells, which act like switches that need to be turned on (or off) to start an immune response. Cancer cells sometimes use these checkpoints to avoid being attacked by the immune system. Drugs that target these checkpoints (called immune checkpoint inhibitors) can be used to treat some cervical cancers.

PD-1 inhibitors

Pembrolizumab (Keytruda) is a drug that targets PD-1, a checkpoint protein on immune system cells called T cells. PD-1 normally helps keep T cells from attacking other cells in the body (including some cancer cells). By blocking PD-1, this drug boosts the immune response against cancer cells. This can shrink some tumors or slow their growth.

Pembrolizumab can be used along with the chemotherapy drugs cisplatin/carboplatin and paclitaxel with or without bevacizumab to treat cervical cancer that has spread to other parts of the body.

This drug is given as an intravenous (IV) infusion, typically once every 3 or 6 weeks.

Pembrolizumab can also be used by itself to treat some advanced cervical cancers, typically after other treatments have been tried, if there are no other good treatment options, and if the cancer cells have been tested and found to have any of the following:

• A high level of microsatellite instability (MSI-H) or a defect in a mismatch repair gene (dMMR)
• A high tumor mutational burden (TMB-H), meaning the cells have many gene mutations
• A high amount of the PD-L1 protein on the tumor cells' surface (the cancer cells are PD-L1 positive).

Nivolumab (Opdivo) targets PD-1 and can be used to treat advanced cervical cancers, after other treatments have been tried, if the tumor cells are PD-L1 positive. It is given as an IV infusion, typically once every 2 or 4 weeks.

Cemiplimab (Libtayo) also targets PD-1. It can be given to patients with advanced cervical cancer that recurred after initial systemic treatment, regardless of their PD-L1 status. This drug is given as an IV infusion, typically once every 3 weeks.

Possible side effects of immune checkpoint inhibitors

Side effects of PD-1 inhibitors can include:

• Feeling tired or weak
• Fever
• Cough
• Nausea
• Itching
• Skin rash
• Loss of appetite
• Muscle or joint pain
• Shortness of breath
• Constipation or diarrhea

Other, more serious side effects occur less often. These can include:

Infusion reactions: Some people might have an infusion reaction while getting this drug. This is like an allergic reaction, and can include fever, chills, flushing of the face, rash, itchy skin, feeling dizzy, wheezing, and trouble breathing. It’s important to tell your doctor or nurse right away if you have any of these symptoms while getting this drug.

Autoimmune reactions: This drug works by removing one of the safeguards on the body’s immune system. Sometimes this causes a person's immune system to attack other parts of their body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands, kidneys, skin, or other organs.

It’s very important to report any new side effects to your health care team right away. If you do have a serious side effect, treatment may need to be delayed or stopped, and you may be given high doses of corticosteroids to suppress your immune system.

Stage IA1

Treatment for this stage depends on whether or not you want to be able to have children (maintain fertility) and whether or not the cancer has grown into blood or lymph vessels (called lymphovascular invasion).

Treatment options if you want to maintain fertility

A cone biopsy is the preferred procedure if you want to have children after the cancer is treated.

• If the edges of the cone don’t contain cancer cells (called negative margins), the woman can be watched closely without further treatment as long as the cancer doesn’t come back.
• If the edges of the cone biopsy have cancer cells (called positive margins), then cancer may have been left behind. This can be treated with a repeat cone biopsy or a radical trachelectomy.
• If the cone biopsy shows that the cancer has grown into blood or lymph vessels, it would then be treated the same as stage IA2 disease (see below).

Treatment options if you don’t want to maintain fertility

• A simple hysterectomy may be an option if the cancer shows no lymphovascular invasion and the edges of the biopsy have no cancer cells. If the edges of the biopsy have cancer cells present, a repeat cone biopsy or a radical hysterectomy with removal of the pelvic lymph nodes might be an option.
• If the cancer has grown into blood or lymph vessels, you might need a radical hysterectomy along with removal of the pelvic lymph nodes. Sometimes, surgery is not done and external beam radiation to the pelvis followed by brachytherapy is used.

If none of the lymph nodes are found to have cancer, radiation may still be discussed as an option if the tumor is large, if the tumor has grown into blood or lymph vessels, or if the tumor is invading the surrounding connective tissue (the stroma) that supports organs such as the uterus, bladder, and vagina.

If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, or if the tissue removed has positive margins, radiation (EBRT) with chemotherapy is usually recommended. The doctor may also advise brachytherapy after the combined chemo and radiation are done.

Treatment Options for Cervical Cancer, by Stage

The stage of a cervical cancer is the most important factor in choosing treatment. But other factors can also affect your treatment options, including the location of the cancer within the cervix, the type of cancer (squamous cell or adenocarcinoma), your age, your overall health, and whether you want to have children.

Stage IA2

Treatment for this stage depends in part on whether or not you want to continue to be able to have children (maintain fertility).

Treatment options if you want to maintain fertility

• Cone biopsy with removal of pelvic lymph nodes (pelvic lymph node dissection)
• Radical trachelectomy with pelvic lymph node dissection

Treatment options if you don’t want to maintain fertility

• External beam radiation therapy (EBRT) to the pelvis plus brachytherapy
• Radical hysterectomy with removal of pelvic lymph nodes

 If none of the lymph nodes have cancer cells, radiation may still be an option if the tumor is large, if the tumor has grown into blood or lymph vessels, or if the tumor is invading the surrounding connective tissue (the stroma) that supports organs such as the uterus, bladder, and vagina.

If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, or if the tissue removed has positive margins, radiation (EBRT) with chemotherapy is usually recommended. The doctor may also advise brachytherapy after the combined chemo and radiation are done.

Stages IB and IIA

Stages IB1 and IB2: Treatment options if you want to maintain fertility

• Radical trachelectomy with pelvic lymph node dissection and sometimes removal of the para-aortic lymph nodes

Stage IB1, IB2, and IIA1: Treatment options if you don’t want to maintain fertility

• Radical hysterectomy with removal of lymph nodes in the pelvis and sometimes lymph nodes from the para-aortic area. If none of the lymph nodes are found to have cancer, radiation may still be discussed as an option if the tumor is large, if the tumor has grown into blood or lymph vessels, or if the tumor is invading the surrounding connective tissue (the stroma) that supports organs such as the uterus, bladder, and vagina. If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, or if the tissue removed has positive margins, radiation (EBRT) with chemotherapy is usually recommended. The doctor may also advise brachytherapy after the combined chemo and radiation are done.
• Radiation to the pelvis using both brachytherapy and external beam radiation therapy may be an option if a patient is not healthy enough for surgery or decides they do not want surgery. Chemotherapy (chemo) may be given with the radiation (concurrent chemoradiation).

Stages IB3 and IIA2

Treatment options

• Chemoradiation: The chemo may be cisplatin or carboplatin, given concurrently with external beam radiation (EBRT). , This may be followed by brachytherapy.
• Radical hysterectomy with pelvic lymph node dissection and possibly para-aortic lymph node sampling: If cancer cells are found in the removed lymph nodes, or in the edges of the tissue removed (positive margins), surgery may be followed by radiation therapy, which is often given with chemo (concurrent chemoradiation).
• Chemoradiation and brachytherapy followed by a hysterectomy. This is not commonly done, but may be an option for certain patients.

Stages IIB, III, IVA

Treatment options

Chemoradiation: The chemo may be cisplatin or carboplatin, given concurrently (at the same time) with external beam radiation (EBRT). This may be followed by brachytherapy.

Stage IVB

At this stage, the cancer has spread outside the pelvis to other areas of the body. Stage IVB cervical cancer is not usually considered curable. Treatment options include chemo alone or with pembrolizumab if the tumor is PD-L1 positive. If chemo is given alone, it's usually a combination of cisplatin or carboplatin with paclitaxel and bevacizumab. If chemo is given with pembrolizumab, chemo is usually cisplatin or carboplatin with paclitaxel, with or without bevacizumab. Radiation therapy may be given to help relieve symptoms. For disease that recurs after initial systemic therapy, other chemo drugs, or immunotherapy alone, or targeted therapy may also be options.

Clinical trials are testing other combinations of chemo drugs, as well as some other experimental treatments.

Recurrent cervical cancer

Cancer that comes back after treatment is called recurrent cancer. Cancer can come back locally (in or near where it first started, such as the cervix, uterus or nearby the pelvic organs), or it can come back in distant areas (such as the lungs or bone).

If the cancer has recurred in the center of the pelvis only, extensive surgery (such as pelvic exenteration) may be an option for some patients, and offers the best chance for possibly curing the cancer (although it can have major side effects). Radiation therapy (sometimes along with chemo) might be another option. If not, chemo, immunotherapy, or targeted therapy may be used to slow the growth of the cancer or help relieve symptoms, but they aren’t expected to cure the cancer.

No matter which type of treatment your doctor recommends, it's important that you understand the goal of treatment (to try to cure the cancer, control its growth, or relieve symptoms), as well as its possible side effects and limitations. For example, sometimes chemo can improve your quality of life, and other times it might diminish it. You might need to discuss this with your doctor.

New treatments that may benefit patients who have distant recurrence of cervical cancer are being evaluated in clinical trials.

Cervical cancer in pregnancy

A small number of cervical cancers are found in pregnant women. Most of these (70%) are stage I cancers. The treatment plan during pregnancy is determined by:

• Tumor size
• If nearby lymph nodes have cancer
• How far along the pregnancy is
• The specific type of cervical cancer

If the cancer is at a very early stage, such as stage IA, most doctors believe it is safe to continue the pregnancy to term and have treatment several weeks after birth. Surgery options after birth for early-stage cancers include a hysterectomy, radical trachelectomy, or a cone biopsy.

If the cancer is stage IB or higher, then you and your doctor must decide whether to continue the pregnancy. If not, treatment would be radical hysterectomy and/or radiation. Sometimes chemotherapy can be given during the pregnancy (in the second or third trimester) to shrink the tumor.

If you decide to continue the pregnancy, the baby should be delivered by cesarean section (C-section) as soon as it is able to survive outside the womb. More advanced cancers typically need be treated immediately.

 

Targeted Drug Therapy for Cervical Cancer

 

Targeted drug therapy is the use of medicines are directed at proteins on cervical cancer cells that help them grow, spread, or live longer. Targeted drugs work to destroy cancer cells or slow down their growth.  They have side effects different from chemotherapy and some are taken as a pill.

Some targeted therapy drugs, for example, monoclonal antibodies, work in more than one way to control cancer cells and may also be considered immunotherapy because they boost the immune system. Different types of targeted drug therapy can be used to treat cervical cancer.

Antibody-drug conjugates

An antibody-drug conjugate (ADC) is a monoclonal antibody linked to a chemotherapy drug. The antibody acts like a homing signal by attaching to a target protein on cancer cells, so that the chemo can be brought directly to the cancer cell and cause damage.

Fam-trastuzumab deruxtecan, T-DXd (Enhertu)

This ADC connects the anti-HER2 antibody to the chemo drug, deruxtecan. T-DXd can be used by itself to treat late-stage, HER2-positive cervical cancer that has recurred after the first systemic treatment . This drug is given in a vein (IV) typically once every 3 weeks.

Common side effects include: Low blood cell counts, nausea/vomiting, diarrhea, fatigue, hair loss, decreased appetite, low potassium level, changes in liver function tests, and cough. A less common, but serious side effect is decreased heart muscle strength, a condition called left ventricular dysfunction.

Tisotumab vedotin-tftv (Tivdak)

This ADC has an antibody that targets tissue-factor (TF) protein on cancer cells. It brings the chemo drug, monomethyl auristatin E (MMAE), directly to the cancer cell. Tisotumab vedotin can be used by itself to treat late-stage cervical cancer that has recurred, after initial chemo treatment. This drug is given in a vein (IV) typically once every 3 weeks.

Common side effects can include: Feeling tired, nausea, vomiting, hair loss, bleeding, diarrhea, rash, nerve damage (peripheral neuropathy), abnormal kidney function, or low blood cell counts. Less common but serious side effects can include vision change or loss.  Patients should have regular eye exams while on this drug and tell their health care team right away if they have any eye symptoms.

RET inhibitors

In a small percentage of cervical cancers, the tumor cells have rearrangement in the RET gene that cause them to make an abnormal form of the RET protein. This abnormal protein helps the tumor cells grow.  

Selpercatinib (Retevmo) is a RET inhibitor and can be used to treat advanced cervical cancer with the RET rearrangement. These drugs are capsules taken by mouth , typically twice a day.

Common side effects can include: Dry mouth, diarrhea or constipation, high blood pressure, tiredness, swelling in hands and/or feet, skin rash, muscle and joint pain, low blood cell counts or changes in other blood tests. Less common but more serious side effects can include liver damage, lung damage, allergic reactions, changes in heart rhythm, bleeding easily, and problems with wound healing.

NTRK inhibitors

A very small number of cervical cancers have changes in one of the NTRK genes, called NTRK gene fusions. Cells with these gene changes make abnormal TRK proteins, which can lead to abnormal cell growth and cancer. Larotrectinib (Vitrakvi) or entrectinib (Rozlytrek) are NTRK inhibitors. TRK inhibitors target and disable the proteins made by the NTRK genes. These drugs are taken as pills, once or twice daily.

Common side effects can include: Abnormal liver test results; decreased white blood cell and red blood cells; muscle and joint pain; tiredness; diarrhea or constipation; nausea and vomiting; and stomach pain. Less common but more serious side effects can include mental changes, such as confusion, changes in mood, and changes in sleep; liver damage; changes in heart rhythm and/or function; vision changes; and harm to a fetus.

 

Living as a Cervical Cancer Survivor

 

For some women with cervical cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You’ll be relieved to finish treatment, yet it’s hard not to worry about the cancer coming back. This is very common if you’ve had cancer.

For other women, the cancer may never go away completely. These women may get regular treatments with chemotherapy, radiation therapy, or other therapies to try to control the cancer for as long as possible. Learning to live with cancer that does not go away can be difficult and very stressful.

Follow-up care

If you have completed treatment, your doctors will still want to watch you closely. It’s very important to go to all of your follow-up appointments. Your doctor visits are a good time to ask questions and talk about any changes or problems you notice or concerns you have. During these visits, your doctors will ask if you are having any problems and may order exams and lab tests or imaging tests to look for signs of cancer or treatment side effects.

Almost any cancer treatment can have side effects. Some might only last for a few days or weeks, but others might last a long time. Some side effects might not even show up until years after you have finished treatment.

It's important to let your doctor know about any new symptoms or problems, because they could be caused by the cancer coming back or by a new disease or a second cancer.

Doctor visits

In women with no signs of cervical cancer remaining, many doctors recommend follow-up visits (which may include imaging tests and blood tests) with a physical exam every 3 to 6 months for the first couple of years after treatment, then every 6 months or so for the next few years. People who were treated for early-stage cancers may need exams less often. Some doctors may advise different follow-up schedules.

Most doctors recommend that women treated for cervical cancer keep getting regular Pap tests no matter how they were treated (surgery or radiation). Although cells for a Pap test are normally taken from the cervix, if you no longer have a cervix (because you had a trachelectomy or hysterectomy), the cells will be taken from the upper part of the vagina.

Imaging tests

Imaging tests may be done if you have worrisome signs or symptoms of the cancer coming back.

Ask your doctor for a survivorship care plan

Talk with your doctor about developing a survivorship care plan for you. This plan might include:

• A suggested schedule for follow-up exams and tests
• A schedule for other tests you might need to look for long-term health effects from your cancer or its treatment
• A list of possible late- or long-term side effects from your treatment, including what to watch for and when you should contact your doctor
• Suggestions for things you can do that might improve your health, including possibly lowering your chances of the cancer coming back

Keeping health insurance and copies of your medical records

Even after treatment, it’s very important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

At some point after your cancer treatment, you might find yourself seeing a new doctor who doesn’t know about your medical history. It’s important to keep copies of your medical records to give your new doctor the details of your diagnosis and treatment.

Can I lower the risk of my cancer progressing or coming back?

If you have (or have had) cervical cancer, you probably want to know if there are things you can do that might lower your risk of the cancer growing or coming back, such as exercising, eating a certain type of diet, or taking nutritional supplements. While there are some things you can do that might be helpful, more research is needed to know for sure.

Get regular physical activity

Some studies have shown that women who are more physically active after being diagnosed with cervical cancer might live longer. More research is being done in this area.  

Quit smoking

It is known that smoking is linked to an increased risk of cervical cancer. While it’s not clear if smoking can affect cervical cancer growth or recurrence, it is still helpful to stop smoking to decrease your risk of getting another smoking-related cancer. Not smoking can also help you tolerate chemotherapy and radiation better and decrease further damage to the cells of the cervix or cervical area.

Adopt other healthy behaviors

Adopting other healthy behaviors such as eating well and staying at a healthy weight might help, but no one knows for sure. However, we do know that these types of changes can have positive effects on your health that can extend beyond your risk of cervical cancer or other cancers.

About dietary supplements

So far, no dietary supplements (including vitamins, minerals, and herbal products) have been shown to clearly help lower the risk of cervical cancer progressing or coming back. This doesn’t mean that no supplements will help, but it’s important to know that none have been proven to do so.

Dietary supplements are not regulated like medicines in the United States – they do not have to be proven effective (or even safe) before being sold, although there are limits on what they’re allowed to claim they can do. If you’re thinking about taking any type of nutritional supplement, talk to your health care team. They can help you decide which ones you can use safely while avoiding those that might be harmful.

If the cancer comes back

If cancer does return at some point, your treatment options will depend on where the cancer is, what treatments you’ve had before, and your health. Surgery, radiation therapy, chemotherapy, targeted therapy, immunotherapy, or some combination of these might be options. Other types of treatment might also be used to help relieve any symptoms from the cancer.