Cervical Cancer: Symptoms, Diagnosis and Treatment

What is cervical cancer?

Cervical cancer develops from the cervix, the lower part of the uterus that opens into the vagina. Most cases are associated with persistent infection with high-risk types of human papillomavirus (HPV). It is one of the cancers that can be prevented with regular screening and HPV vaccination; when detected at an early stage, treatment options are wider [1][2].

Risk factors

Persistent high-risk HPV infection is the main cause. Smoking, immunosuppression (e.g. HIV), many births and not taking part in screening increase the risk. In Türkiye a national screening programme is run through the Cancer Early Diagnosis, Screening and Training Centres (KETEM) [2][3].

What are the symptoms?

In the early stage there are often no symptoms. Bleeding after intercourse or between periods, bleeding after menopause, foul-smelling discharge and pelvic pain are findings that need assessment. In advanced disease there may be back or leg pain and problems with urination or bowel movements [1][3].

Most of these complaints can also be caused by other conditions; complaints that persist or get worse need to be assessed by a doctor.

How is it diagnosed?

Screening is done with an HPV test and/or a smear (Pap) test. If the result is abnormal, diagnosis is made by colposcopy and biopsy. Pelvic MRI and, when needed, PET-CT are used to assess spread. In advanced disease, PD-L1 (CPS) and tumour characteristics may influence the choice of systemic treatment [1][4].

Staging

Staging follows the FIGO (2018) system; imaging and pathology findings are included in staging. Whether the tumour is confined to the cervix and whether it has spread to surrounding tissues and lymph nodes determine the treatment approach [1][4].

Treatment options

• Early stage: Gynaecological oncology surgery with conisation, trachelectomy (fertility-sparing, in selected patients) or radical hysterectomy.
• Locally advanced stage: The standard treatment is radiotherapy given concurrently with cisplatin, followed by brachytherapy. In high-risk locally advanced disease, adding pembrolizumab to chemoradiotherapy or a short course of induction chemotherapy before chemoradiotherapy is included in guidelines for selected patients.
• Advanced or recurrent disease: Bevacizumab in suitable patients and pembrolizumab in PD-L1-positive tumours may be added to platinum- and paclitaxel-based chemotherapy. In later lines, antibody-drug conjugates such as tisotumab vedotin or other options may be considered [4][5].
• Support: Management of radiotherapy-related bowel and bladder side effects, menopausal symptoms and sexual health are part of follow-up.

Treatment is planned individually, taking into account the stage, tumour characteristics, general condition and the patient’s preferences. Not every option listed here is suitable for every patient.

Recent developments

Adding immunotherapy to chemoradiotherapy and induction chemotherapy in locally advanced disease are developments that have entered guidelines in recent years. Wider HPV vaccination and HPV-based screening are measures expected to reduce the frequency of the disease in the long term [2][5].

Support and follow-up during treatment

During treatment, not only the anti-cancer drugs but also the patient’s general condition is monitored. Nausea, fatigue, loss of appetite, pain, infection risk and changes in mood are asked about at every visit; when needed, preventive medication, nutritional support, physiotherapy and psychosocial support are planned. In situations such as fever, shortness of breath, uncontrollable diarrhoea or vomiting, or new severe pain, it is advisable to contact the treatment team without waiting for the scheduled visit. Herbal products and supplements can interact with some cancer drugs, so the treatment team should be consulted before using them.

After treatment, gynaecological examination is carried out every 3–6 months in the first 2 years and less often thereafter, with imaging when needed.