Cervical cancer

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 17 Apr 2025

Last updated: 14 Feb 2025

Cervical cancer is a human papillomavirus (HPV)-related malignancy, preventable by HPV vaccination and screening.

Cervical cancer screening may detect preinvasive disease. Cytology testing, DNA testing for high-risk HPV subtypes, or co-testing with cytology and HPV testing are used for routine screening.

Patients are commonly asymptomatic at presentation, and identified following screening. Patients with advanced disease may present with symptoms such as abnormal vaginal bleeding, postcoital bleeding, vaginal discharge, pelvic or back pain, dyspareunia, or obstructive uropathy.

Staging using International Federation of Gynecology and Obstetrics criteria is based on clinical assessment. Where available, imaging (ultrasound, magnetic resonance imaging, positron emission tomography [PET], PET/computed tomography [CT], CT) are used to evaluate the local extent of disease and to screen for metastases, which may guide treatment planning.

For microinvasive disease, treatment with cone biopsy or extrafascial (simple) hysterectomy is recommended.

For early stage invasive disease, surgery is recommended.

For locally advanced disease, chemoradiation therapy is significantly superior to radiation therapy alone.

Definition

Cervical cancer is a human papillomavirus-related malignancy of the uterine cervical mucosa.

History and exam

Key diagnostic factors

abnormal vaginal bleeding
postcoital bleeding
pelvic or back pain
dyspareunia
cervical mass
cervical bleeding

Full details

Other diagnostic factors

mucoid or purulent vaginal discharge
bladder, renal, or bowel obstruction
bone pain

Full details

Risk factors

human papillomavirus (HPV) infection
age group
HIV infection
early onset of sexual activity (younger than 18)
multiple sexual partners
cigarette smoking
immunosuppression
history of STI
oral contraceptive pill use
high parity
uncircumcised male partner
micronutrient malnutrition
low serum folate
low vitamin C and E levels
alcohol use
low socioeconomic status

Full details

Diagnostic tests

1st tests to order

vaginal or speculum examination
colposcopy
biopsy
human papillomavirus (HPV) testing

Full details

Tests to consider

CBC
renal function testing
liver function tests
chest x-ray
intravenous pyelogram
renal ultrasound
barium enema
sigmoidoscopy
cystoscopy
MRI pelvis
PET whole body
PET/CT whole body
CT of chest/abdomen/pelvis with intravenous/oral contrast
molecular testing

Full details

Emerging tests

p16 and Ki67 biomarker expression

Treatment algorithm

ACUTE

nonpregnant stage IA1 without LVSI: desiring fertility

nonpregnant stage IA1 without LVSI: not desiring fertility

nonpregnant, stage IA1 with LVSI: desiring fertility

nonpregnant, stage IA1 with LVSI: not desiring fertility

nonpregnant stage IA2: desiring fertility

nonpregnant stage IA2: not desiring fertility

nonpregnant stage IB1: desiring fertility

nonpregnant stage IB1: not desiring fertility

nonpregnant stage IB2: desiring fertility

nonpregnant, stage IB2: not desiring fertility

nonpregnant stage IIA1

nonpregnant stage IB3 or IIA2

nonpregnant stage IIB to IVA

nonpregnant, stage IVB (metastatic disease)

nonpregnant local or regional recurrent disease

pregnant

Contributors

Authors

Richard T. Penson, MD, MRCP

Clinical Director

Medical Gynecologic Oncology

Division of Hematology Oncology

Massachusetts General Hospital

Boston

Disclosures

RTP reports serving on scientific advisory boards for AstraZeneca, Eisai, GSK Inc., ImmunoGen Inc., Merck & Co., Mersana, Novocure, Roche Pharma, Sutro Biopharma, Vascular Biogenics Ltd; data and safety monitoring boards for AstraZeneca and Roche Pharma; institutional research funding (as Principal Investigator) for Array BioPharma Inc., AstraZeneca, Eisai Inc., Genentech Inc., Regeneron, Sanofi-Aventis US LLC, Tesaro Inc., Vascular Biogenics Ltd; and royalties from BMJ Publishing, UptoDate, Elsevier Ltd, Wolters Kluwer Health, and Wiley-Blackwell.

Andrea L. Russo, MD

Director

Gynecologic Radiation Oncology

Associate Clinical Director

Department of Radiation Oncology

Massachusetts General Hospital

Boston

Disclosures

ALR declares that she has no competing interests.

Acknowledgements

Dr Richard T. Penson and Dr Andrea L. Russo would like to gratefully acknowledge Dr Larissa J. Lee, their co-contributor who is sadly deceased, and to acknowledge Dr Neil S. Horowitz and Dr Anthony H. Russell, previous contributors to this topic.

Disclosures

NSH and AHR declare that they have no competing interests.

Peer reviewers

Tracilyn Hall, MD

Assistant Professor of Gynecologic Oncology

Dan L Duncan Comprehensive Cancer Center

Baylor College of Medicine Houston

Houston

Disclosures

TH declares that she has no competing interests.

Linda Yang, MD

Fellow

Minimally Invasive Gynecologic Surgery

Magee Women's Hospital

University of Pittsburgh Medical Center

Disclosures

LY declares that she has no competing interests.

Deirdre Lyons, MB, BCh, BAO, MRCOG

Consultant in Obstetrics & Gynaecology

Lead Clinician in Colposcopy

Imperial College Healthcare NHS Trust

London

Disclosures

DL declares that she has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Marth C, Landoni F, Mahner S, et al. Cervical cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017 Jul 1;28(suppl 4):iv72-83.Full text Abstract

Fontham ETH, Wolf AMD, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society CA Cancer J Clin. 2020 Sep;70(5):321-46.Full text Abstract

Bhatla N, Aoki D, Sharma DN, et al. Cancer of the cervix uteri: 2021 update. Int J Gynaecol Obstet. 2021 Oct;155 Suppl 1(suppl 1):28-44.Full text Abstract

National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: cervical cancer [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Human papillomavirus (HPV) infection
- Pelvic infection
- Nabothian cyst
More Differentials
Guidelines
- Screening for cervical cancer
- Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV
More Guidelines
Patient information
Cervical cancer
HPV (human papillomavirus) vaccine
More Patient information
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Cervical cancer

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

nonpregnant stage IA1 without LVSI: desiring fertility

nonpregnant stage IA1 without LVSI: not desiring fertility

nonpregnant, stage IA1 with LVSI: desiring fertility

nonpregnant, stage IA1 with LVSI: not desiring fertility

nonpregnant stage IA2: desiring fertility

nonpregnant stage IA2: not desiring fertility

nonpregnant stage IB1: desiring fertility

nonpregnant stage IB1: not desiring fertility

nonpregnant stage IB2: desiring fertility

nonpregnant, stage IB2: not desiring fertility

nonpregnant stage IIA1

nonpregnant stage IB3 or IIA2

nonpregnant stage IIB to IVA

nonpregnant, stage IVB (metastatic disease)

nonpregnant local or regional recurrent disease

pregnant

Contributors

Authors

Richard T. Penson, MD, MRCP

Disclosures

Andrea L. Russo, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Tracilyn Hall, MD

Disclosures

Linda Yang, MD

Disclosures

Deirdre Lyons, MB, BCh, BAO, MRCOG

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice