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Immunizations Preventative medicine Women's health

Cervical cancer and HPV

Last revised in April 2025

Types of cervical cancer include:Squamous cell carcinoma and Cervical adenocarcinoma

Cervical cancer and HPV: Summary

  • Almost all cases of cervical cancer originate from the ecto- or endocervical mucosa in the cervical 'transformation zone'.
    • Low-grade dysplasia (cervical intraepithelial neoplasia 1 [CIN1]) usually regresses, but it can progress to high-grade dysplasia (CIN2 or 3).
    • Cervical cancer occurs when high-grade dysplastic lesions extend beyond the basement membrane of the cervical cervical epithelium.
    • The two commonest types of cervical cancer are squamous cell carcinoma and adenocarcinoma.
  • The main cause of cervical cancer is persistent infection with one of about 15 high-risk subtypes of human papillomavirus (HPV), which is predominantly transmitted through sexual intercourse.
    • HPV is detected in 99% of cervical cancer, and the high-risk oncogenic subtypes HPV 16 and 18 account for at least two-thirds of cases.
    • Only about 10% of all HPV infections become persistent, which puts the woman at risk of developing precancerous cervical lesions. The time interval between HPV infection and development of precancerous lesions is 1–10 years.
  • Risk factors for development of cervical cancer are increased exposure to HPV infection (such as early age of first intercourse) and an impaired immune response to HPV infection (such as solid organ transplant or HIV infection).
  • Peak incidence rates in the UK are in females aged 30–34 years. The FIGO stage of disease and age at diagnosis affect prognosis.
  • Complications may include psychosocial issues, sexual dysfunction, early menopause and loss of fertility, bladder and bowel dysfunction, pelvic or other pain, renal failure, haemorrhage, fistulae, and lymphoedema.
  • A diagnosis of cervical cancer should be suspected if a woman has:
    • Abnormal vaginal bleeding or discharge which is not secondary to infection or other causes.
    • Pelvic pain and/or dyspareunia.
    • Postmenopausal bleeding not attributable to hormone replacement therapy (HRT).
    • An abnormal appearance of the cervix on examination.
    • Possible symptoms of advanced disease complications (rare presentation).
  • If a woman has suspected cervical cancer:
    • An urgent referral to colposcopy/gynaecology oncology (using a 2-week cancer pathway) should be arranged for confirmation of the diagnosis, staging investigations, and possible treatment with surgery and/or chemoradiotherapy.
  • Management of a woman with a confirmed diagnosis of cervical cancer should include:
    • Advising on sources of information and support.
    • Considering testing for HIV.
    • Advising to stop smoking.
    • Asking about adverse effects of treatment.
    • Assessing for and managing any complications.
    • Advising about and assessing for symptoms of recurrent disease.
    • Managing symptoms of advanced disease.
  • Prevention of cervical cancer should include advice on:
    • Participation in the national cervical screening programme.
    • Participation in the national HPV vaccination programme.
    • Consistent use of condoms and practising safer sex.

Have I got the right topic?

From age 16 years onwards (Female).

This CKS topic covers the prevention, diagnosis, and management of cervical cancer in primary care.

This CKS topic does not cover the management of cervical intraepithelial neoplasia (CIN) or the detailed staging or management of cervical cancer or recurrent disease in secondary care.

This CKS topic does not cover detail on screening for human papillomavirus (HPV) infection as part of the NHS cervical screening programme. There is a separate CKS topic on Cervical screening.

This CKS topic does not cover in detail the national childhood immunization programme for HPV vaccination to prevent HPV infection. There is a separate CKS topic on Immunizations - childhood which includes detail about HPV infection.

There are separate CKS topics on Gynaecological cancers - recognition and referral, Palliative care - general issues, Palliative cancer care - pain, and Vaginal discharge.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

Previous changes

February 2022 — reviewed. A literature search was conducted in January 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Some minor structural changes have been made to the topic. The recommendations on assessment and management have been updated in line with current evidence in the literature. A new section on Assessment has been added to the Diagnosis section.

July 2021 — minor update. Text updated to reflect national policy change from use of the quadrivalent vaccine to the nine valent Gardasil® 9 based on Public Health England (PHE) advice in Annex A: HPV vaccine information and guidance for healthcare professionals (2021).

May 2021 — minor update. Information that cervical dysplasia is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association joint publication Adult HIV testing guidelines 2020.

September 2020 — minor update. The topic has been updated in line with the PHE guidance Cervical screening: programme and colposcopy management to incorporate details of primary HPV screening.

March to April 2017 — reviewed. A literature search was conducted in March 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.

November 2016 — minor update. The National Institute for Health and Care Excellence (NICE) quality standards for suspected cancer have been added to this topic.

March 2014 — minor update. Update to the text to state that Gardasil® is the HPV vaccine of choice in line with guidance from the Department of Health.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

September 2012 — minor update. Text revised in the Prevention of cervical cancer section to reflect the Department of Health recommendation to switch from Cervarix® to Gardasil® human papillomavirus (HPV) vaccine for the National Childhood Immunization Programme from September 2012.

September to December 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 February 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 February 2022.

Economic appraisals

No new economic appraisals since 1 February 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 February 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 February 2022.

New policies

No new policies or guidelines since 1 February 2022.

New safety alerts

No new safety alerts since 1 February 2022.

Changes in product availability

No changes in product availability since 1 February 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Be aware when to suspect a diagnosis of cervical cancer.
  • Arrange urgent colposcopy/gynaecology oncology referral (using a 2-week cancer pathway) if cervical cancer is suspected.
  • Provide information and advice following a diagnosis of cervical cancer.
  • Offer symptom relief and support to women with advanced cervical cancer.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

NICE quality standards relevant for this CKS topic are:

  • GPs have direct access to diagnostic endoscopy, ultrasound, MRI, X-ray and CT for people with suspected cancer.
  • People with suspected cancer who are referred to a cancer service are given written information encouraging them to attend.

[NICE, 2017]

Background information

What is it?

  • The cervix is the lowermost part of the uterus and is composed of the ectocervix which projects into the vagina (lined by squamous epithelium), and the endocervical canal which extends from the internal os to the external os (lined by columnar epithelium) [Bhatla, 2021].
    • Almost all cases of cervical cancer originate from the ecto- or endocervical mucosa in the 'transformation zone' (the area of the cervix between the old and new squamocolumnar junction) [Bhatla, 2021].
    • The main cause is persistent infection with a high-risk human papillomavirus (HPV) subtype [Marth, 2017; Bhatla, 2021].
    • Low-grade dysplasia (cervical intraepithelial neoplasia 1 [CIN1]) usually regresses, but it can progress to high-grade dysplasia (CIN2 or 3). Cervical cancer occurs when high-grade dysplastic lesions extend beyond the basement membrane of the cervical epithelium [Wipperman, 2018].
  • There are several types of cervical cancer, which include [Marth, 2017]:
    • Squamous cell carcinoma — accounts for about 70–80% of cases.
    • Adenocarcinoma — accounts for over 20–25% of cases.
    • Other epithelial tumours — including adenosquamous carcinoma, neuroendocrine tumours, and undifferentiated carcinoma (rare).

What causes it?

  • The main cause of cervical cancer is persistent infection with one of about 15 high-risk subtypes of human papillomavirus (HPV), which is predominantly transmitted through sexual intercourse [Marth, 2017] [PHE, 2019] [Bhatla, 2021].
    • HPV is detected in 99% of cervical cancer, and the high-risk oncogenic subtypes HPV 16 and 18 account for at least two-thirds of cases [Marth, 2017]. HPV subtypes 31, 33, 45, 52, and 58 account for the majority of remaining cases [Bhatla, 2021].
    • 'Persistent infection' describes the presence of the same type-specific HPV DNA on repeat sampling after 6–12 months. About 90% of incident HPV infections are short-lived and resolve spontaneously within 2 years. Only about 10% of all HPV infections become persistent, which puts the woman at risk of developing precancerous cervical lesions [Bhatla, 2021].
    • The time interval between HPV infection and development of precancerous lesions is 1–10 years, and progression to invasive carcinoma is usually more than 10 years [PHE, 2019].

What are the risk factors?

The two most important risk factors for developing cervical cancer are increased exposure to infection with human papillomavirus (HPV) and/or an impaired immune reponse to HPV infection, leading to decreased ability to clear the virus [Wipperman, 2018] [Cohen, 2019].

  • Risk factors for acquiring HPV infection include [Wipperman, 2018] [Cohen, 2019]:
    • Early age of first sexual intercourse.
      • Infection with at least one type of HPV occurs soon after the start of sexual activity, with nearly 40% of women infected within 2 years [PHE, 2019].
    • Multiple sexual partners or a high-risk sexual partner.
    • History of sexually transmitted infection (STI).
    • Lack of use of barrier methods of contraception, such as condoms. See the CKS topic on Contraception - barrier methods and spermicides for more information.
    • History of HPV-related vaginal or vulval dysplasia.
    • Conditions causing immunocompromise or immunosuppresion, such as solid organ transplant or HIV infection. See the CKS topic on HIV infection and AIDS for more information.
  • Factors which increase the risk of progression to cervical cancer include [Wipperman, 2018] [Cohen, 2019]:
    • Co-infection with other STIs.
    • Smoking — increases the risk of developing precancerous lesions and squamous cell carcinoma.
    • High parity (more than five full-term births) and young age at first birth (less than 17 years of age).
    • Family history in a first-degree relative.
    • Conditions causing immunocompromise or immunosuppression, such as solid organ transplant or HIV infection — increases the risk of persistent HPV infection, precancerous lesions, and invasive cervical cancer. See the CKS topic on HIV infection and AIDS for more information.
    • Use of the combined oral contraceptive pill for longer than 5 years — may be related to the effect of sex steroids on oncogene expression.

How common is it?

Cervical cancer is the 14th most common cancer in females in the UK [Cancer Research UK, 2021].

  • Cervical cancer mainly affects sexually active women aged 30–45 years [Reed, 2021].
  • In high-income countries, the incidence and mortality of cervical cancer have more than halved over the past 30 years since the introduction of formal screening programmes. Further decreases in incidence are expected following the introduction of the HPV vaccination programme [Cohen, 2019]. See the CKS topic on Immunizations - childhood for more information.
    • A cancer register-based observational study of data from 13.7 million years of follow up of women aged 20–30 years in England (2006–19) found [Falcaro, 2021]:
      • An estimated relative reduction in cervical cancer of 34% for vaccine offered at age 16–18 years, 62% for 14–16 years, and 87% for 12–13 years compared with a reference unvaccinated cohort.
      • An estimated relative reduction in cervical carcinoma in situ (cervical intraepithelial neoplasia 3 [CIN3]) of 39% for vaccine offered at age 16–18 years, 75% for 14–16 years, and 97% for 12–13 years compared with a reference unvaccinated cohort.
      • An estimated 448 fewer than expected cases of cervical cancer, and 17,235 fewer than expected cases of CIN3 in vaccinated cohorts in England by 2019.

What is the prognosis?

The FIGO stage (including the extent of disease spread and lymph node involvement) is the most important prognostic factor in cervical cancer survival [Marth, 2017].

  • Approximately 20% of women with high-grade dysplasia will develop invasive cervical cancer within 5 years if left untreated [Wipperman, 2018].
  • There are around 850 deaths from cervical cancer in the UK each year, based on 2016–18 data [Cancer Research UK, 2021].
  • Based on survival data for women with cervical cancer in England from 2013–17 [Cancer Research UK, 2021]:
    • 81.1% of women survived for 1 year or more.
    • 61.4% of women survived for 5 years or more.
    • 51.2% of women survived for 10 years or more.
  • When comparing cervical cancer survival rates at different stages of disease [Cancer Research UK, 2021]:
    • 96% of women will survive for 1 year or more when diagnosed at stage I (disease confined to the cervix).
    • 50% of women will survive for 1 year or more when diagnosed at stage IV (disease extended beyond the pelvis).
  • When comparing cervical cancer survival rates at different ages of diagnosis in England based on data from 2009–13 [Cancer Research UK, 2021]:
    • Survival is highest in women diagnosed under 40 years of age.
    • Around 90% of women diagnosed aged 15–39 years survived for 5 years or more, compared with around 25% of women diagnosed aged 80 years and over.
  • Recurrence can occur as local or metastatic disease, usually within 3 years of treatment, and often has a poor prognosis [Wipperman, 2018].

What are the complications?

Complications of a confirmed diagnosis of cervical cancer may include:

Diagnosis of cervical cancer and HPV

When should I suspect a diagnosis of cervical cancer?

  • Cervical cancer is often asymptomatic in its early stages, and many cases are diagnosed through the NHS cervical screening programme.
  • Suspect a diagnosis of cervical cancer if a woman presents with any of the following:
    • Persistent unexplained abnormal vaginal bleeding, intermenstrual bleeding, and/or postcoital bleeding which is not secondary to infection or other causes.
    • Unexplained persistent vaginal discharge (may be blood-stained) which is not secondary to infection or other causes.
    • Pelvic pain and/or dyspareunia.
    • Postmenopausal bleeding and not taking hormone replacement therapy (HRT).
    • Postmenopausal bleeding if there is an increase in heaviness, duration of bleeding or irregular bleeding if taking sequential HRT; or bleeding beyond 6 months or bleeding after a spell of amenorrhoea if taking continuous combined HRT.
      • See the CKS topic on Menopause for more information. 
    • Abnormal appearance of the cervix on examination, such as inflamed or friable appearance with contact bleeding; or a visible ulcerating or necrotic lesion on the cervix.
  • Consider a diagnosis of cervical cancer if a woman presents with a possible complication of advanced disease, depending on clinical judgement.

Basis for recommendation

The recommendations on diagnosis are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2021], the British Gynaecological Cancer Society (BGCS) publication Cervical cancer guidelines: recommendations for practice [Reed, 2021], the Public Health England (PHE) guidance Cervical screening: programme and colposcopy management [PHE, 2021], the European Society for Medical Oncology (ESMO) clinical practice guidelines Cervical cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up [Marth, 2017], the FIGO cancer report on cervical cancer [Bhatla, 2021], the British Menopause Society (BMS) publication on hormone replacement therapy (HRT) [Ayres, 2020], and expert opinion in review articles on cervical cancer [Wipperman, 2018; Cohen, 2019].

Diagnosis through the cervical screening programme

  • This information is based on the ESMO clinical practice guidelines [Marth, 2017], the BGCS guidelines [Reed, 2021], the PHE guidance [PHE, 2021], and expert opinion in a review article [Cohen, 2019].

Clinical features of cervical cancer

  • These recommendations are largely based on the NICE guideline on suspected cancer [NICE, 2021], the ESMO clinical practice guidelines [Marth, 2017], the BGCS guidelines [Reed, 2021], the PHE guidance [PHE, 2021], and expert opinion in review articles [Wipperman, 2018; Cohen, 2019].
    • Symptoms of abnormal vaginal bleeding or abnormal vaginal discharge may be due to infection or other benign gynaecological conditions, which should also be considered and excluded, depending on clinical judgement [PHE, 2021; Reed, 2021].
    • The PHE guidance notes that postcoital bleeding alone has a poor predictive value for cervical cancer, the majority of cases are not due to malignancy, and underlying infection or hormonal contraception-related adverse effects are more likely to be the cause.
    • The information on suspicious postmenopausal bleeding when taking HRT is extrapolated from the BGCS guidelines and the BMS publication on HRT [Ayres, 2020]. CKS notes that the NICE guideline on suspected cancer recommends urgent referral of women with postmenopausal bleeding to exclude endometrial cancer.
    • The NICE guideline recommends considering a diagnosis of cervical cancer if the cervix has an abnormal appearance on examination.

Clinical features of advanced disease

How should I assess a woman with suspected cervical cancer?

If a woman presents with clinical features suggesting a diagnosis of cervical cancer:

  • Ask about:
    • The presenting symptoms.
    • Previous smear history. See the CKS topic on Cervical screening for more information.
    • Any risk factors including family history.
    • Any comorbidities which increase the risk of progression or invasive cancer.
    • Smoking status.
    • Any previous colposcopy assessments or cervical treatments.
  • Examine the woman:
    • Offer to perform an abdominal, speculum, and bimanual pelvic examination.
      • Be aware that some early cervical cancers are not easily detected, and the cervix may look normal on speculum examination if the disease is microinvasive or in the endocervical canal.
    • Assess for lymphadenopathy — enlarged, indurated inguinal and supraclavicular lymph nodes may be palpated in advanced disease.
  • Do not arrange an unscheduled cervical smear if a woman has clinical features of suspected cervical cancer.
    • An urgent referral for colposcopy/gynaecology oncology assessment should be arranged (using a 2-week cancer pathway). See the section on Referral for more information.

Basis for recommendation

The recommendations on assessment are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2021], the British Gynaecological Cancer Society (BGCS) publication Cervical cancer guidelines: recommendations for practice [Reed, 2021], the Public Health England (PHE) guidance Cervical screening: programme and colposcopy management [PHE, 2021], the European Society for Medical Oncology (ESMO) clinical practice guidelines Cervical cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up [Marth, 2017], and expert opinion in a review article on cervical cancer [Cohen, 2019].

Clinical features on history taking

  • These recommendations are based on the BGCS guidelines [Reed, 2021] and expert opinion in a review article [Cohen, 2019].

Clinical features on examination

  • These recommendations are based on the BGCS guidelines [Reed, 2021], the ESMO clinical practice guidelines [Marth, 2017], and expert opinion in a review article [Cohen, 2019].
    • The information that some early cervical cancers are not easily detected on examination is based on the ESMO clinical practice guidelines [Marth, 2017] and expert opinion in a review article [Cohen, 2019].

Not arranging an unscheduled cervical smear

  • This recommendation is based on the BGCS guidelines [Reed, 2021] and the PHE guidance on cervical screening [PHE, 2021].
    • The information that an urgent referral using a 2-week cancer pathway should be arranged is based on the NICE guideline on suspected cancer [NICE, 2021] and the BGCS guidelines.

What else might it be?

Other conditions which may present similarly to cervical cancer include:

Basis for recommendation

The information on the differential diagnosis of cervical cancer is largely based on the British Gynaecological Cancer Society (BGCS) publication Cervical cancer guidelines: recommendations for practice [Reed, 2021] and the Public Health England (PHE) guidance Cervical screening: programme and colposcopy management [PHE, 2021]. It is also pragmatic, based on what CKS considers to be good clinical practice.

Management

Scenario: Prevention

From age 16 years onwards (Female).

What should I advise about prevention of cervical cancer?

  • Encourage women to participate in the NHS cervical screening programme, which is available to women aged 25–64 years in England.
  • Encourage girls aged 12–13 years to receive immunization with the human papillomavirus (HPV) vaccine as part of the national childhood immunization programme.
    • Advise that for optimum effectiveness, HPV vaccination must be given before the girl or woman becomes sexually active.
    • Advise that HPV vaccination with the nine-valent HPV vaccine also provides additional protection against anogenital warts and other vaginal, vulval, and anal HPV-related cancers. See the CKS topic on Immunizations - childhood for more information.
  • Advise girls and women who are sexually active about the importance of using additional barrier methods of contraception such as condoms, to reduce the risk of HPV infection. See the CKS topic on Contraception - barrier methods and spermicides for more information. Advise that:
    • Condom use reduces the risk of HPV infection but does not fully eliminate the risk of sexual transmission.
    • Condom use also protects against other sexually transmitted infections (STIs) such as HIV, which is a risk factor for progression of HPV infection to cervical cancer. See the CKS topic on HIV infection and AIDS for more information.
    • Limiting the number of sexual partners also reduces potential exposure to HPV infection.

Basis for recommendation

The recommendations on prevention are based on the Public Health England (PHE) guidance Human papillomavirus (HPV): the green book, chapter 18a [PHE, 2019] and Cervical screening: programme and colposcopy management [PHE, 2021], the European Society for Medical Oncology (ESMO) clinical practice guidelines Cervical cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up [Marth, 2017], the FIGO cancer report on cervical cancer [Bhatla, 2021], and expert opinion in review articles on cervical cancer [Wipperman, 2018; Cohen, 2019].

Encouraging cervical screening
  • The recommendation to encourage cervical screening is based on the PHE guidance on screening [PHE, 2021], the FIGO cancer report [Bhatla, 2021], and expert opinion in a review article [Cohen, 2019].
    • Cervical screening programmes allow early detection of precancerous lesions such as high-grade cervical intraepithelial neoplasia (CIN) and adenocarcinoma in situ, which enables effective treatment to prevent invasive cancer and associated morbidity and mortality [Bhatla, 2021].
Encouraging HPV vaccination
  • The information on the benefits of human papillomavirus (HPV) vaccination is based on the PHE guidance on HPV [PHE, 2019], the ESMO clinical practice guidelines [Marth, 2017], the FIGO cancer report [Bhatla, 2021], and expert opinion in a review article [Cohen, 2019].
    • The recommendation to offer vaccination before girls and women become sexually active is based on the fact HPV infection is predominantly sexually transmitted [Bhatla, 2021].
    • HPV vaccination can prevent infection and disease associated with the HPV vaccine subtypes, such as cervical cancer, and some vaginal, vulval, and anal cancer 'HPV correlates' [Marth, 2017; Bhatla, 2021].
Encouraging barrier methods of contraception
  • The recommendations on using condoms and practising safer sex are based on the PHE guidance on HPV [PHE, 2019] and expert opinion in review articles [Wipperman, 2018; Cohen, 2019].
    • HIV infection is a risk factor for progression of HPV infection to cervical cancer [Cohen, 2019].

Scenario: Management

From age 16 years onwards (Female).

When should I refer?

  • If a woman has clinical features of suspected cervical cancer:
    • Arrange an urgent referral to colposcopy/gynaecology oncology for specialist assessment (using a 2-week cancer pathway).
      • All women with unexplained postmenopausal bleeding should be referred to gynaecology for specialist assessment.
      • Do not delay referral because a woman has had a previously normal cervical screening result.
      • Do not delay referral until after pregnancy if a woman is pregnant.

Specialist assessment

Specialist assessment of suspected cervical cancer may be undertaken by a multidisciplinary team, including gynaecology oncologists, general gynaecologists, clinical oncologists, radiologists, and clinical nurse specialists [Reed, 2021].

  • Following referral to colposcopy or gynaecology oncology, initial assessment may include:
    • Punch or excisional biopsy procedures such as loop electrosurgical excision and conization of suspicious lesions [Marth, 2017; PHE, 2021; Reed, 2021].
  • If a diagnosis of cervical cancer is confirmed, further specialist investigations may be arranged to determine the extent of disease. Staging using clinical, radiological, or pathological findings (the revised Féderation Internationale de Gynécologie et d'Obstrétrique 2018 FIGO staging system) allows specialist treatment planning and counselling about prognosis [Marth, 2017; Cibula, 2018; Cohen, 2019; Bhatla, 2021; Reed, 2021].
    • Clinical staging is based on the tumour size, lymph node status, vaginal or parametrial involvement (into uterine blood vessels, connective tissue, or lymphatic channels), bladder/rectum extension, and distant metastases.
    • MRI can determine tumour size and extension of disease. Chest X-ray and assessment for hydronephrosis (using renal ultrasound, CT, or MRI) may be arranged pre-treatment to help decide if initial surgery or primary chemoradiotherapy is needed.
    • Examination under anaesthesia (EUA) may be needed in some cases to gain tissue for diagnosis and to assess for vaginal or parametrial extension.
    • Sentinel node biopsy and PET/CT may be needed to check for lymph node involvement and distant metastases (typically to the lungs, liver, or bone).

Basis for recommendation

The recommendations on referral are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2021], the British Gynaecological Cancer Society (BGCS) publication Cervical cancer guidelines: recommendations for practice [Reed, 2021], the Public Health England (PHE) guidance Cervical screening: programme and colposcopy management [PHE, 2021], the European Society for Medical Oncology (ESMO) clinical practice guidelines Cervical cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up [Marth, 2017], the European Society of Gynaecological Oncology (ESGO) joint publication Guidelines for the management of patients with cervical cancer [Cibula, 2018], the FIGO cancer report on cervical cancer [Bhatla, 2021], and expert opinion in a review article on cervical cancer [Wipperman, 2018].

  • The recommendation to arrange a 2-week cancer pathway referral is based on the NICE guideline on suspected cancer [NICE, 2021], the BGCS guidance [Reed, 2021], and the PHE guidance [PHE, 2021].
    • The recommendation for women with postmenopausal bleeding is extrapolated from the NICE guideline, which also highlights this symptom may be a sign of endometrial cancer. It is also extrapolated from the PHE guidance, which stresses these women should not have a cervical screening sample arranged, but need direct visual inspection of the cervix and gynaecology referral.
    • The recommendation not to delay referral to colposcopy if a woman is pregnant is based on the BGCS guidance, which states the aim is to exclude invasive cervical cancer which needs biopsy for diagnosis. If referral is delayed, the cancer may be at a higher stage when finally diagnosed, which may have a worse prognosis. Treatment may be deferred until after delivery if preinvasive disease is detected [Reed, 2021]. This approach is supported by the PHE guidance.
    • The FIGO cancer report states that the principles of management in pregnancy are similar to those for non-pregnant women. Surgery or chemotherapy may be offered, depending on the stage of disease, gestational age, and the woman's desire for pregnancy continuation [Bhatla, 2021].

How should I manage a woman with confirmed cervical cancer?

If a woman has a confirmed diagnosis of cervical cancer following specialist assessment:

  • Provide advice on sources of information and support, such as:
    • Cancer Research UK (www.cancerresearchuk.org) patient information on Cervical cancer including symptoms; stages, types, and grades of disease; treatments; and other resources and support.
    • Jo's Cervical Cancer Trust (www.jostrust.org.uk) is a UK charity dedicated to women affected by cervical cancer and cervical abnormalities and provides patient information on different aspects of Cervical cancer.
    • Macmillan Cancer Support (www.macmillan.org.uk) has patient information on different aspects of Cervical cancer including symptoms, diagnosis, staging, and treatment.
  • Consider testing for HIV if a woman has a diagnosis of cervical dysplasia or cervical cancer. See the CKS topic on HIV infection and AIDS for more information.
  • Advise the woman to stop smoking, if needed. See the CKS topic on Smoking cessation for more information.
  • Ask about any adverse effects of specialist treatment.
  • Ask about any complications, and manage as appropriate. If there is any uncertainty about management, seek specialist advice or refer to an appropriate specialist.
    • Offer emotional and psychological support. See the CKS topics on Depression and Generalized anxiety disorder for more information.
    • Offer advice on analgesia options for the management of chronic pelvic pain. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information.
    • Offer advice on management of sexual dysfunction, including use of vaginal lubricants, vaginal dilatation (if vaginal stenosis after chemoradiotherapy), topical oestrogen, and/or referral to psychosexual counselling, depending on clinical judgement. See the CKS topic on Menopause for more information on prescribing low-dose vaginal oestrogen preparations.
    • Offer advice on management of early menopause, such as use of hormone replacement therapy (HRT). See the CKS topic on Menopause for more information on prescribing HRT.
    • Offer management of bladder and bowel symptoms, such as use of laxatives if constipation or loperamide if diarrhoea. Consider arranging referral to gastroenterology, colorectal surgery, urology, gynaecology, and/or a continence nurse, depending on clinical judgement. See the CKS topics on Incontinence - urinary, in women, Constipation, Diarrhoea - adult's assessment, and Faecal incontinence in adults for more information.
    • Offer management of lymphoedema, such as referral to a specialist lymphoedema clinic.
  • Advise about and assess for symptoms suggestive of recurrent disease (such as vaginal discharge, vaginal bleeding, dyspareunia, low back pain, pelvic pain, and unexplained weight loss).
  • If a woman has advanced disease, see the section on Management of advanced disease for more information.

Specialist management

Specialist management of confirmed cervical cancer is undertaken by a multidisciplinary team, which may include gynaecology oncologists, general gynaecologists, clinical oncologists, radiologists, and clinical nurse specialists [Reed, 2021]. Treatment decisions are based on the woman's wishes and age, the FIGO (2018) staging system including lymph node involvement, any comorbidities, and her desire for fertility preservation [Marth, 2017] [Cibula, 2018] [Wipperman, 2018].

  • Management options include [Cohen, 2019] [PHE, 2021] [Reed, 2021] [Singh, 2021]:
    • Stage IA1 (microinvasive disease) 
      • Loop electrosurgical excision and conization with the aim of achieving negative margins to both cancer and dysplasia.
      • Simple hysterectomy may be offered if the woman does not wish to preserve fertility.
    • Stages IA2–IB2 (early stage disease)
      • Radical hysterectomy (resection of the cervix, uterus, parametria, and cuff of upper vagina) and bilateral salpingectomy (if fertility-sparing surgery is appropriate in low-risk disease) and/or bilateral oophorectomy with bilateral pelvic lymphadenectomy. Radical trachelectomy (removal of the cervix) and lymphadenectomy may be considered instead of radical hysterectomy for smaller tumours.
      • The woman may be considered for adjuvant chemotherapy or radiotherapy if intermediate or high risk of recurrence, depending on factors such as tumour size, margin involvement, and lymph node involvement.
    • Stage IB3–IVA (locally advanced disease) 
      • Treatment with external beam radiotherapy, intracavity brachytherapy (radiation source placed in the uterus and vagina), and concomitant chemotherapy is usually used first-line to reduce recurrence risk, increase chance of cure, and prolong life.
      • Surgery is not recommended as it is unlikely to be curative, and the combination of radical surgery and chemoradiotherapy has a high risk of adverse effects and associated morbidity.
    • Stage IVB (spread to distant organs) 
      • Systemic chemotherapy is usually offered first-line.
  • Management options for recurrent or metastatic disease are based on the woman's wishes, previous treatment(s), location of disease, the disease-free interval, symptoms, comorbidities, and performance status. Treatment of recurrent disease confined to the cervix or upper vagina may be curative. Options may include [Wipperman, 2018; Cohen, 2019; Reed, 2021]:
    • Salvage surgery — pelvic exenteration (removal of female reproductive organs, the lower urinary tract, and a portion of the rectosigmoid bowel) is possible if the relapse is confined to the central pelvis and chemoradiotherapy have failed.
    • Chemotherapy and/or radiotherapy if initial surgery has not controlled disease.

Basis for recommendation

The recommendations on management in primary care are based on the British Gynaecological Cancer Society (BGCS) publication Cervical cancer guidelines: recommendations for practice [Reed, 2021], the European Society of Gynaecological Oncology (ESGO) joint publication Guidelines for the management of patients with cervical cancer [Cibula, 2018], the British HIV Association (BHIVA) joint publication Adult HIV testing guidelines 2020 [BHIVA, 2020], the charity report Long term consequences of cervical cancer and its treatment 2017 [Jo's Cervical Cancer Trust, 2017], the FIGO cancer report on cervical cancer [Bhatla, 2021], and expert opinion in review articles on cervical cancer [Wipperman, 2018; Cohen, 2019].

Advising on sources of information and support
  • This recommendation is based on the BGCS guidelines [Reed, 2021], the ESGO joint publication [Cibula, 2018], and the charity report [Jo's Cervical Cancer Trust, 2017].
    • Signposting to sources of information and support can help women to feel in control of their diagnosis and treatment options, help them self-manage their condition, educate about symptoms of recurrence, and help women seek early intervention if needed [Reed, 2021].
Considering HIV testing
  • This recommendation is based on the BHIVA joint publication, which notes that cervical dysplasia is an HIV indicator condition and cervical cancer is an AIDS-defining condition in people living with HIV [BHIVA, 2020].
Advising smoking cessation
Assessing for adverse effects of treatment
Managing any complications
  • The recommendation to seek specialist advice if there is any uncertainty about managing complications is extrapolated from the ESGO joint publication [Cibula, 2018].
    • The recommendation to offer psychological and emotional support is based on the BGCS guidelines [Reed, 2021], the ESGO joint publication [Cibula, 2018], and expert opinion in a review article [Wipperman, 2018].
    • The recommendation to manage chronic pelvic pain is based on expert opinion in a review article [Wipperman, 2018].
    • The recommendation to manage sexual dysfunction symptoms is based on the BGCS guidelines [Reed, 2021], the ESGO joint publication [Cibula, 2018], the FIGO cancer report [Bhatla, 2021], and expert opinion in a review article [Wipperman, 2018].
    • The recommendation to manage early menopause symptoms is based on the BGCS guidelines [Reed, 2021], the ESGO joint publication [Cibula, 2018], the FIGO cancer report [Bhatla, 2021], and expert opinion in a review article [Wipperman, 2018].
    • The recommendation to manage bladder and bowel symptoms is based on the BGCS guidelines [Reed, 2021] and the ESGO joint publication [Cibula, 2018].
    • The recommendation to manage lymphoedema is based on the BGCS guidelines [Reed, 2021].
Assessing for disease recurrence
  • This recommendation is based on the BGCS guidelines [Reed, 2021], the ESGO joint publication [Cibula, 2018], the FIGO cancer report [Bhatla, 2021], and expert opinion in review articles [Wipperman, 2018; Cohen, 2019].
    • Further follow up may be needed by the specialist multidisciplinary team, involving clinical assessment, imaging, and/or biochemical testing to assess for disease recurrence.

How should I manage a woman with advanced cervical cancer?

If a woman has advanced cervical cancer, offer management in primary care as part of a multidisciplinary team, which may include gynaecology oncologists, general gynaecologists, clinical oncologists, radiologists, palliative care specialists, and clinical nurse specialists.

  • Offer management of general issues which may affect a woman at the end-of-life. See the CKS topic on Palliative care - general issues for more information.
  • Offer management of complications, taking into account the woman's wishes, previous treatment(s), location of disease, the disease-free interval, symptoms, comorbidities, and performance status.
    • Offer management of pain and consider specialist referral, depending on the underlying cause and clinical judgement. See the CKS topics on Analgesia - mild-to-moderate pain, NSAIDs - prescribing issues, Neuropathic pain - drug treatment, and Palliative cancer care - pain for more information.
      • Specialist management may include nerve-blocking procedures, percutaneous cementoplasty for bony metastases, and palliative radiotherapy for pain due to pelvic disease or bony metastases.
    • Offer management of renal complications due to ureteric obstruction. See the CKS topic on Chronic kidney disease for more information.
      • Specialist management may include percutaneous nephrostomy or retrograde stenting.
    • Offer management of problems associated with haemorrhage.
      • Minor vaginal bleeding due to pelvic disease may respond to oral or topical tranexamic acid or short-course palliative radiotherapy.
      • Severe haemorrhage often requires specialist advice and management, which may include post-operative percutaneous embolization. If the woman is receiving palliative care, midazolam may be used for its anxiolytic effect, and/or diamorphine for its hypotensive effect.
    • Offer management of bladder and bowel symptoms, and seek specialist advice if needed.
      • Surgical intervention with diversion stoma and/or stenting may be considered if there is symptomatic obstructive disease. Bilateral percutaneous nephrostomy may be considered if there is fistula-related urinary incontinence.
      • Defunctioning colostomy may be considered if there is fistula-related faecal incontinence.
    • Offer management of lymphoedema and consider specialist referral to a lymphoedema clinic.
      • Management may include lymphatic therapy with compression bandaging, manual lymph drainage and massage, and good skin care.
      • The Lymphoedema Support Network (www.lymphoedema.org) is a national charity providing support to anyone affected by lymphoedema, and has patient information that may be helpful.

Basis for recommendation

The recommendations on management of advanced disease are based on the British Gynaecological Cancer Society (BGCS) publication Cervical cancer guidelines: recommendations for practice [Reed, 2021], the European Society of Gynaecological Oncology (ESGO) joint publication Guidelines for the management of patients with cervical cancer [Cibula, 2018], and the FIGO cancer report on cervical cancer [Bhatla, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2021], the British Gynaecological Cancer Society (BGCS) publication Cervical cancer guidelines: recommendations for practice [Reed, 2021], the Public Health England (PHE) guidance Cervical screening: programme and colposcopy management [PHE, 2021], the European Society for Medical Oncology (ESMO) clinical practice guidelines Cervical cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up [Marth, 2017], the European Society of Gynaecological Oncology (ESGO) joint publication Guidelines for the management of patients with cervical cancer [Cibula, 2018], the FIGO cancer report on cervical cancer [Bhatla, 2021], and expert opinion in review articles. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomised controlled trials on the primary care diagnosis and management of cervical cancer and HPV.

Search dates

March 2016 - January 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • cervical cancer.tw., exp Uterine Cervical Neoplasms/, cervical carcinoma.tw., cervical neoplasm.tw.
  • Papillomavirus Infections/
  • (cervix OR cervical OR cervico*) AND (cancer OR cancerous OR precancer* OR pre-cancer* OR premalignan* OR carcinoma* OR adenocarcinoma* OR neoplas* OR dysplas* OR dyskaryos* OR squamous)
  • ((HPV* or hrHPV* or Papillomavirus* or Papilloma Virus*)

     

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Ayres, J. Currie, H. (2020) HRT-Guide. British Menopause Society. http://www.thebms.org.uk [Free Full-text]
  • Bhatla, N., Aoki, D., Nand Sharma, D. and Sankaranarayanan, R. (2021) Cancer of the cervix uteri: 2021 update. International Journal of Gynaecology and Obstetrics 155(S1), 28-44. [Abstract]
  • BHIVA/BASHH/BIA (2020) Adult HIV testing guidelines 2020. British HIV Association/British Association for Sexual Health and HIV/British Infection Association. https://www.bhiva.org [Free Full-text]
  • Cancer Research UK (2021) Cervical cancer statistics. Cancer Research UK. http://www.cancerresearchuk.org [Free Full-text]
  • Cibula, D., Potter, R., Planchamp, F., Avall-Lundqvist, E. et al. (2018) 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. International Journal of Gynecological Cancer 28(4), 641-655. [Abstract]
  • Cohen, P.A., Jhingran, A., Oaknin, A. and Denny, L. (2019) Cervical cancer. Lancet 393(10167), 169-182. [Abstract]
  • Falcaro, M., Castanon, A., Ndlela, B., Checchi, M. et al. (2021) The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study. Lancet 398(10316), 2084-2092. [Abstract]
  • Jo's Cervical Cancer Trust (2017) Long term consequences of cervical cancer and its treatment 2017. Jo's Cervical Cancer Trust. http://www.jostrust.org.uk [Free Full-text]
  • Marth, C., Landoni, F., Mahner, S., McCormack, M. et al. (2017) Cervical cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology 28(S4), 72-83. [Abstract]
  • NICE (2017) Quality Standard: Suspected cancer (QS124). National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2021) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • PHE (2019) Human papillomavirus (HPV): the green book, chapter 18a. Public Health England. http://www.gov.uk/government/organisations/public-health-england [Free Full-text]
  • PHE (2021) Cervical screening: programme and colposcopy management. Public Health England. http://www.gov.uk/government/organisations/public-health-england [Free Full-text]
  • Reed, N., Balega, J., Barwick, T., Buckley, L. et al. (2021) British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: recommendations for practice. European Journal of Obstetrics, Gynecology, and Reproductive Biology 256, 433-465. [Abstract]
  • Singh, N., Rous, B. and Ganesan, R. (2021) 2018 FIGO staging system for cervical cancer. Summary and comparison with 2009 FIGO staging system. British Association of Gynaecological Pathologists. http://www.thebagp.org [Free Full-text]
  • Wipperman, J., Neil, T. and Williams, T. (2018) Cervical cancer: evaluation and management. American Family Physician 97(7), 449-454. [Abstract]
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