Guideline sources The following summarized guidelines for the evaluation and management of cervical cancer are prepared by our editorial team based on guidelines from the U.S. Preventive Services Task Force (USPSTF 2018), the European Society of Medical Oncology (ESMO 2017), and the Canadian Task Force on Preventive Health Care (CTFPHC 2013). 3 4 5 6 6 6 6 7 Definition Cervical cancer refers to malignant disease arising from the cervical epithelium, and principally comprises SCCs. 6 Epidemiology Over 90% of cervical cancers are caused by infection of the cervical epithelium by a high-risk subtype of HPV, which leads to overexpression and integration of E6 and E7 viral oncogenes, resulting in transformation to CIN, squamous intraepithelial lesions, and invasive cervical carcinoma. 6 Pathophysiology The incidence of cervical cancer in women is estimated at 7.4 cases per 100,000 person-years. 7 https://web.pathway.md/diseases/recEZET6Q13R7eNi7 1/5 6/29/23, 3:49 AM Cervical cancer Pathway Disease course Clinical manifestations of localized disease include abnormal vaginal bleeding, menorrhagia, and dyspareunia, while more advanced disease can lead to systemic symptoms. 6 Prognosis and risk of recurrence The 5-year survival is estimated at 87% for patients with stage 1 node-negative and 73% for patients with stage 1, node-positive disease. In patients with more advanced disease (stages 2B- 4A), 5-year survival with chemoradiation therapy is estimated at 70%. 6 Calculator Calculator Calculator Eastern Cooperative Oncology G Karnofsky performance status s TNM class Guidelines 1. Screening and diagnosis Indications for screening: As per USPSTF 2018 guidelines, screen for cervical cancer every 3 years with cervical cytology alone in women 21-29 years of age. A Show 4 more As per CTFPHC 2013 guidelines, avoid routine screening for cervical cancer in women < 20 years of age. D Show 4 more 2. Classification and risk stratification Risk stratification: tumour risk assessment includes tumour size, stage, depth of tumour invasion, lymph node status, lymphovascular space invasion, and histological subtype. Lymph node status and the number of lymph nodes involved as the most important prognostic factors. 3. Medical management Chemoradiation therapy: administer chemoradiation therapy as the standard care for patients with bulky IB2-IVA disease, as it has demonstrated an improvement in both disease-free survival and overall survival over standard radiation therapy/hydroxyurea. A Adjuvant chemoradiation therapy: https://web.pathway.md/diseases/recEZET6Q13R7eNi7 2/5 6/29/23, 3:49 AM Cervical cancer Pathway Offer adjuvant chemoradiotherapy in patients with high-risk cervical cancer. A Avoid adjuvant chemoradiotherapy in patients with intermediate-risk cervical cancer. D Neoadjuvant chemotherapy: study results suggest that neoadjuvant chemotherapy may offer a benefit over surgery alone in cervical cancer patients, reducing the need for adjuvant radiotherapy. B Palliative chemotherapy: Offer palliative chemotherapy with the aim of relieving symptoms and improving quality of life in patients with metastatic cervical cancer, a performance status score < 2, and no formal contraindications. Use paclitaxel and cisplatin combined with bevacizumab as the preferred first-line regimen in metastatic or recurrent cervical cancer, based on the balance between efficacy and toxicity profile. A 4. Surgical interventions Indications for surgery: reserve surgery only in patients with earlier stages of cervical cancer up to FIGO IIA, without risk factors necessitating adjuvant therapy, which results in a multimodal therapy without improvement of survival but increased toxicity. A First-line surgical treatment: perform conisation or simple trachelectomy as fertility-preserving treatment for patients with stage 1A1 disease. B Show 3 more Fertility-sparing treatment: perform conisation or simple trachelectomy as fertility-preserving treatment for patients with stage 1A1 disease. B Show 4 more 5. Preventative measures Primary prevention: primary prevention of cervical cancer is now possible via immunisation with highly efficacious HPV vaccines. B Secondary prevention: secondary prevention has gained impetus with the advent of sensitive HPV DNA testing to improve traditional Pap cytology screening programs. B 6. Follow-up and surveillance Serial clinical assessment: Schedule follow-up visits during which a patient history and a complete physical examination (including a pelvic-rectal exam) should be obtained. Return to annual population-based general physical and pelvic examinations after 5 years of recurrence-free follow-up. B https://web.pathway.md/diseases/recEZET6Q13R7eNi7 3/5 6/29/23, 3:49 AM Cervical cancer Pathway Serial imaging assessment: Consider follow-up visits every 3-6 months in the first 2 years after diagnosis, and every 6-12 months in years 3-5 after diagnosis. Obtain CT or positron emission tomography/CT scan as clinically indicated. Clinical findings Symptoms Past medical history Acute back pain HPV infection Heavy or prolonged menstrual bleeding Diagnostic procedures Pelvic pain Schiller's test Postcoital bleeding Vaginal discharge Social history Multiple sexual partners References 1. Cibula D, P tter R, Planchamp F et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients with Cervical Cancer. Virchows Arch. 2018 Jun;472 6 919 936. Open 2. Cibula D, P tter R, Planchamp F et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients With Cervical Cancer. Int J Gynecol Cancer. 2018 May;28 4 641 655. Open 3. 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-iv83. Open 4. US Preventive Services Task Force, Curry SJ, Krist AH et al. Screening USPSTF for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Aug 21;320 7 674 686. Open 5. Dickinson J, Tsakonas E, Conner Gorber S et al. Recommendations on screening for cervical cancer. CMAJ. 2013 Jan 8;185 1 35 45. Open 6. Cohen PA, Jhingran A, Oaknin A et al. Cervical cancer. Lancet. 2019 Jan 12;393 10167 169 182. Open 7. Yoo W, Kim S, Huh WK et al. Recent trends in racial and regional disparities in cervical cancer incidence and mortality in United States. PLoS One. 2017 Feb 24;12 2):e0172548. Open 8. Mayrand MH, Duarte-Franco E, Rodrigues I et al. Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer. N Engl J Med. 2007 Oct 18;357 16 1579 88. Open https://web.pathway.md/diseases/recEZET6Q13R7eNi7 4/5 6/29/23, 3:49 AM Cervical cancer Pathway 9. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC et al. Screening USPSTF for Gynecologic Conditions With Pelvic Examination US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317 9 947 953. Open 10. American Association of Family Physicians. Choosing Wisely AAFP recommendations. Choosing Wisely. 2018. Open 11. Society of Gynecologic Oncology. Choosing Wisely SGO recommendations. Choosing Wisely. 2013. Open 12. American College of Preventive Medicine. Choosing Wisely ACPM recommendations. Choosing Wisely. 2015. Open 13. American Association of Family Physicians. Choosing Wisely AAFP recommendations. Choosing Wisely. 2013. Open 14. American Society for Clinical Pathology. Choosing Wisely ASCP recommendations. Choosing Wisely. 2013. Open 15. American Society for Colposcopy and Cervical Pathology. Choosing Wisely ASCCP recommendations. Choosing Wisely. 2019. Open 16. American Society for Colposcopy and Cervical Pathology. Choosing Wisely ASCCP recommendations. Choosing Wisely. 2017. Open 17. Cibula D, P tter R, Planchamp F et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients with Cervical Cancer. Virchows Arch. 2018 Jun;472 6 919 936. Open 18. Cibula D, P tter R, Planchamp F et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients With Cervical Cancer. Int J Gynecol Cancer. 2018 May;28 4 641 655. Open 19. Surendra S Shastri, Sarah Temin, Maribel Almonte et al. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Guideline Update. JCO Glob Oncol. 2022 Sep;8:e2200217. Open 20. Linus T Chuang, Sarah Temin, Jonathan S Berek et al. Management and Care of Patients With Invasive Cervical Cancer: ASCO Resource-Stratified Guideline Rapid Recommendation Update. JCO Glob Oncol. 2022 Mar;8:e2200027. Open 21. 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