Practice Essentials

Cervical cancer (see the image below) is the third most common
malignancy in women worldwide, and it remains a leading cause of cancer-
related death for women in developing countries. In the United States,
cervical cancer is relatively uncommon.

Cervical carcinoma with

adnexa.
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Essential update: FDA approves bevacizumab for late-stage cervical
cancer
In August 2014, the US Food and Drug Administration (FDA) approved
bevacizumab (Avastin) for the management of persistent, recurrent or late-
stage (metastatic) carcinoma of the cervix. [1, 2] This agent is approved for
combination chemotherapy with paclitaxel and cisplatin or with paclitaxel
and topotecan. [1, 2]
Approval was based on the GOG-0240 study (n = 452) that assessed the
efficacy and safety of bevacizumab plus chemotherapy (paclitaxel and
cisplatin or paclitaxel and topotecan) in women with persistent, recurrent or
metastatic carcinoma of the cervix. [1, 3] A statistically significant
improvement in overall survival (OS) and an increase in the rate of tumor
shrinkage was shown in women treated with bevacizumab plus
chemotherapy compared with chemotherapy alone. However,
hypertension, thromboembolic events, and gastrointestinal fistulas were
higher in the bevacizumab group. [1, 3]
Signs and symptoms
The most common finding in patients with cervical cancer is an abnormal
Papanicolaou (Pap) test result.
Physical symptoms of cervical cancer may include the following:
Abnormal vaginal bleeding
Vaginal discomfort
Malodorous discharge
 Dysuria
See Clinical Presentation for more detail.
Diagnosis
Human papillomavirus (HPV) infection must be present for cervical cancer
to occur. Complete evaluation starts with Papanicolaou (Pap) testing.
Screening recommendations
Current screening recommendations for specific age groups, based on
guidelines from the American Cancer Society (ACS), the American Society
for Colposcopy and Cervical Pathology (ASCCP), the American Society for
Clinical Pathology (ASCP), the US Preventive Services Task Force
(USPSTF), and the American College of Obstetricians and Gynecologists
(ACOG), are as follows [4, 5, 6, 7] :
< 21 years: No screening recommended
21-29 years: Cytology (Pap smear) alone every 3 years
30-65 years: Human papillomavirus (HPV) and cytology cotesting
every 5 years (preferred) or cytology alone every 3 years (acceptable)
>65 years: No screening recommended if adequate prior screening
has been negative and high risk is not present
See Workup for more detail.
Management
Immunization
Evidence suggests that HPV vaccines prevent HPV infection. [8] The
following 2 HPV vaccines are approved by the FDA:
Gardasil (Merck, Whitehouse Station, NJ): This quadrivalent vaccine is
approved for girls and women 9-26 years of age to prevent cervical
cancer (and also genital warts and anal cancer) caused by HPV types
6, 11, 16, and 18; it is also approved for males 9-26 years of age [9]
Cervarix (GlaxoSmithKline, Research Triangle Park, NC): This bivalent
vaccine is approved for girls and women 9-25 years of age to prevent
cervical cancer caused by HPV types 16 and 18 [10]
The Advisory Committee on Immunization Practices (ACIP)
recommendations for vaccination are as follows:
Routine vaccination of females aged 11-12 years of age with 3 doses
of either HPV2 or HPV4
Routine vaccination with HPV4 for boys aged 11-12 years of age, as
well as males aged 13-21 years of age who have not been vaccinated
previously
Vaccination with HPV4 in males aged 9-26 years of age for prevention
of genital warts; routine use not recommended
Stage-based treatment
The treatment of cervical cancer varies with the stage of the disease, as
follows:
 Stage 0: Carcinoma in situ (stage 0) is treated with local ablative or
excisional measures such as cryosurgery, laser ablation, and loop
excision; surgical removal is preferred
Stage IA1: The treatment of choice for stage IA1 disease is surgery;
total hysterectomy, radical hysterectomy, and conization are accepted
procedures
Stage IA2, IB, or IIA: Combined external beam radiation with
brachytherapy and radical hysterectomy with bilateral pelvic
lymphadenectomy for patients with stage IB or IIA disease; radical
vaginal trachelectomy with pelvic lymph node dissection is appropriate
for fertility preservation in women with stage IA2 disease and those
with stage IB1 disease whose lesions are 2 cm or smaller
Stage IIB, III, or IVA: Cisplatin-based chemotherapy with radiation is
the standard of care [11]
Stage IVB and recurrent cancer: Individualized therapy is used on a
palliative basis; radiation therapy is used alone for control of bleeding
and pain; systemic chemotherapy is used for disseminated disease [11]
See Treatment and Medication for more detail.