All About Cervical Cancer

Christopher Dolinsky, MD and Christine Hill-Kayser, MD
Updated By Lara Bonner Millar, MD and Christina Bach, MSW, LCSW, OSW-C
Last Modified: February 23, 2017

What is the cervix?

The cervix is the name for the lowest part of the uterus. The uterus is an organ that only women have, and it is where a baby grows and develops when a woman is pregnant. During pregnancy, the uterus has an enormous increase in size. When a woman is not pregnant, the uterus is a small, pear-shaped organ that sits between a woman's rectum and her bladder. The cervix connects the uterus with the birth canal (the vagina). The cervix can both be visualized and sampled by your healthcare provider during a routine pelvic examination.

What is cervical cancer?

Cervical cancer develops when cells in the cervix begin to grow out of control and can then invade nearby tissues or spread throughout the body. Large collections of cells that grow abnormally are called tumors. Some tumors are not cancer, because they cannot spread or threaten someone's life. These are called benign tumors. The tumors that can spread throughout the body or invade nearby tissues are considered cancer and are called malignant tumors. Usually, cervix cancer is very slow growing, although in certain circumstances it can grow and spread quickly.

Cancers are characterized by the cells that they originally form from. The most common type of cervical cancer is called squamous cell carcinoma; it comes from cells that lie on the surface of the cervix known as squamous cells. Squamous cell cervical cancer compromises about 80% of all cervical cancers. The second most common form is adenocarcinoma; it comes from cells that make up glands in the cervix. The percentage of cervical cancers that are adenocarcinomas has risen since the 1970s, although no one knows exactly why. About 3% to 5% of cervical cancers have characteristics of both squamous and adenocarcinomas and are called adenosquamous carcinomas. There are a few other very rare types like small cell and neuroendocrine carcinoma that are so infrequent that they will not be discussed further here.

Am I at risk for cervical cancer?

Cervical cancer is vastly more common in developing nations than it is in developed nations, and it is fairly rare in the United States. In the U.S. in 2016, an estimated 12,990 women in the United States were diagnosed with cervical cancer and 4,120 women in the United States died from cervical cancer. However, cervical cancer is the 2nd most common cause of cancer death in developing nations, with 84% of all cervical cancer cases occurring in Africa, Latin American and the Caribbean underdeveloped areas.  Decades ago, cervical cancer was the number one cause of cancer deaths in women in the U.S. There has been a 75% decrease in incidence and mortality from cervical cancer in developed nations over the past 50 years. Most of this decrease is attributed to the effective institution of cervical cancer screening programs (pap and/or HPV testing) in the wealthier nations.

Although there are several known risk factors for getting cervical cancer, no one knows exactly why one woman gets it and another doesn't. One of the most important risk factors for cervical cancer is infection with a virus called HPV (human papilloma virus). HPV is a sexually transmitted disease that is incredibly common in the population; most college-aged men and women have been exposed to HPV. HPV is the virus that causes genital warts, but having genital warts doesn't necessarily mean you are going to get cervical cancer. There are different subtypes, or strains, of HPV. Only certain subtypes are likely to cause cervical cancer, and the subtypes that cause warts are unlikely to cause a cancer. Often, infection with HPV causes no symptoms at all, until a woman develops a pre-cancerous lesion of the cervix. It should be stressed that only a very small percentage of women who have HPV will develop cervical cancer; so simply having HPV doesn't mean that you will get cancer. However, almost all cervical cancers have evidence of HPV virus in them, so infection is a major risk factor for developing it.

Because infection with a sexually transmitted disease is a risk factor for cervical cancer, any risk factors for developing sexually transmitted diseases are also risk factors for developing cervical cancer. Women who have had multiple male sexual partners, began having sexual intercourse at an early age, or have had male sexual partners who are considered high risk (meaning that they have had many sexual partners and/or began having sexual intercourse at an early age) are at a higher risk for developing cervical cancer. Also, contracting any other sexually transmitted diseases (like herpes, gonorrhea, syphilis, or Chlamydia) increases a woman's risk. HIV infection is another risk factor for cervical cancer, but it may be so for a slightly different reason. It seems that any condition that weakens your immune system also increases your risk for developing cervical cancer. Conditions that weaken your immune system include HIV, having had an organ transplantation, and Hodgkin's disease. Another important risk factor for developing cervical cancer is smoking. Smokers are at least twice as likely as non-smokers to develop cervix tumors. Smoking may also increase the importance of the other risk factors for cancer. Finally, being in a low socioeconomic group seems to increase the likelihood for developing and dying from cervical cancer. This may be because of increased smoking rates, or perhaps because there are more barriers to getting annual screening exams. Cervical cancer is one of the few cancers that affects young women (in their twenties and even their teens), so no one who is sexually active is really too young to begin screening. Additionally, the risk for cervical cancer continues throughout life, so no one is too old to continue screening. However, women over 65 who have had normal pap and HPV test results are at very low risk and can stop screening. Remember that all risk factors are based on probabilities, and even someone without any risk factors can still get cervical cancer. Proper screening and early detection are our best weapons in reducing the mortality associated with this disease.

How can I prevent cervical cancer?

Fortunately, there are several actions that women can take to decrease the risk of dying from cervix cancer. The first of these is undergoing regular Pap testing. Pap tests will be discussed further in the next section, but the reason that women have had such a drastic drop in cervical cancer cases and deaths in this country has been because of the Pap test and annual screening.

Three vaccines, called Gardasil, Gardasil 9, and Ceravix have been developed. These vaccines have been demonstrated to be effective in preventing infection with some strains of HPV, when given before a person is exposed to HPV. For this reason, the vaccines are recommended for girls and young women ages 11– 26 years. Vaccination is also recommended for boys, ages 9-21. In addition to cervical cancer, HPV is also a cause of vulvar, vaginal, penile and anal cancers and some head & neck cancers. It also causes genital warts and leads to abnormal Pap test results that result in further testing or treatment.

For further prevention, women should try to reduce risk factors as much as possible. Don't start smoking, and if you are already a smoker, it is time to quit. Smoking has been shown to decrease the immune system’s ability to clear an HPV infection. Women can limit their numbers of sexual partners, and delay the onset of sexual activity to reduce risk, as more partners increases the likelihood of infection. Condoms can lower the chance of contracting HPV, but cannot eliminate it as HPV can infect areas that are not covered by a condom.

What screening tests are available?

Cervical cancer is considered a preventable disease. It usually takes a very long time for pre-cancerous lesions to progress to invasive cancers and we have effective screening methods that can detect pre-cancerous lesions that can generally be cured without serious side effects. Effective screening programs in the United States have led to the drastic decline in the numbers of cervical cancer deaths in the last 50 years. For women who do end up with cervical cancer in developed nations, 60% of them either have never been screened or haven't been screened in the last five years. The importance of regular cervical cancer screening cannot be overstated.

The mainstay of cervical cancer screening is the Pap test. Pap is short for Papanicolaou, the inventor of the test, who published a breakthrough paper back in 1941. A Pap test is easily performed in your provider's office. During a pelvic examination, your provider uses a wooden spatula and/or a brush to get samples of cervical cells. These cells are placed on a slide, or in a liquid preservative, and sent to a laboratory where an expert in examining cells under a microscope can look for cancerous changes. Many women find the exam uncomfortable, but rarely painful. Depending on the results of the test, your provider may need to perform further examinations.

Although the Pap test is highly effective, it isn't a perfect test. Sometimes, the test may miss cells that have potential to become an invasive cancer. The test shouldn't be performed when you are menstruating; and if collection goes perfectly, even the best laboratories can miss abnormal cells. This is why women need to have the tests performed on a regular basis.

In addition, HPV testing may be done along with the Pap test. HPV testing can theoretically find the vast majority of women who are at risk for developing cervical cancer by identifying those with high risk HPV infections. There are over 100 subtypes of HPV and certain types are more likely to lead to a cervical cancer. The DNA of cervical cells can be tested to identify the presence of high-risk types of HPV. The HPV DNA test can be used for follow-up testing of women with abnormalities identified on a pap test. HPV DNA tests are also used for general cervical cancer screening of women over the age of 30, when done together with a Pap test.

In the current guidelines for screening, the U.S. Preventive Services Task Force are that all women should begin cervical cancer screening at age 21 with the following methods:

  • Women age 21-65 should be screened with Pap smear every 3 years (if results are normal)
  • For women age 30-65 years, who want to lengthen the screening interval, a combination screening of HPV testing and Pap smear can be performed every five years (if HPV is negative)

Guidelines also note that women with certain risk factors may need more frequent screening. These risk factors include being infected with human immunodeficiency virus (HIV), being immunosuppressed, having been exposed to diethylstilbestrol (DES) before birth, and having previously been treated for certain cervical abnormalities or cancer.

What are the signs of cervical cancer?

Unfortunately, the early stages of cervical cancer usually do not have any symptoms. This is why it is important to have screening Pap tests. As a tumor grows in size, it can produce a variety of symptoms including:

  • abnormal bleeding (including bleeding after sexual intercourse, in between periods, heavier/longer lasting menstrual bleeding, or bleeding after menopause)
  • abnormal vaginal discharge (may be foul smelling)
  • pelvic or back pain
  • pain on urination
  • blood in the stool or urine
  • pain during sex

Many of these symptoms are non-specific, and could represent a variety of different conditions; however, your provider needs to see you if you have any of these problems.

How is cervical cancer diagnosed and staged?

The most common reason for your provider to pursue the diagnosis of cervical cancer is if you have an abnormal Pap test. Pap tests exist to find pre-cancerous lesions in your cervix. A pre-cancerous lesion means that there are abnormal appearing cells, but they haven't invaded past a tissue barrier in your cervix; thus a pre-cancerous lesion cannot spread or harm you. However, if left untreated, a pre-cancerous lesion can evolve to an invasive cancer. Pap tests are reported as no abnormal cells, atypical (abnormal) cells of undetermined significance, low grade abnormal cells or high grade abnormal cells. Depending on your specific case, your provider will decide how to proceed.

A report of no abnormal cells equates to a negative test, meaning you simply need to have the next screening in three years. Atypical cells of undetermined significance can be handled in three different ways. Women can either get a repeat Pap test in 4-6 months, they can get HPV testing, or they can be referred for colposcopy. Colposcopy is a procedure done during a pelvic exam with the aid of a colposcope, which is like a microscope. By using acetic acid on the cervix and examining it with a colposcope, your provider can look for abnormal areas of your cervix. Then, the most abnormal areas can be biopsied. A biopsy is the only way to know for sure if you have cancer, because it allows your provider to get cells that can be examined under a microscope. Once the tissue is removed, a pathologist will examine the specimen. Colposcopy is uncomfortable, but not painful, and can be done in your gynecologist's office. Your provider will decide how to proceed with the workup of a Pap test showing abnormal cells of undetermined significance, depending on the details of your case. If repeat Pap tests are not normal, then you will be referred for colposcopy. If you test positive for HPV, you will be referred for colposcopy. Generally, most patients with low grade abnormal cells, or high grade abnormal cells will be immediately referred for colposcopy. If you are pregnant, an adolescent, HIV positive, or post-menopausal, your provider may have slightly different recommendations. In some cases, the Pap test will have cells that look abnormal, but could have come from higher in your uterus. There is a chance that if this happens, you will need to have your uterine lining sampled. Talk to your provider about your Pap test results, and next steps after an abnormal Pap smear.

If you are having symptoms (bleeding/discharge) from a cervical cancer, then it can probably be seen during a pelvic exam. Any time your provider can see a cervical tumor on pelvic exam, it will be biopsied. When abnormal appearing tissue is noticed during a colposcopy, it will be biopsied as well. There are a few different ways to do a biopsy. A punch biopsy may be used to remove a small section of the cervix. A LEEP (loop electrosurgical excision procedure) is another method to do a biopsy where a thin slice of the cervix is removed. Finally, a conization or cone biopsy may be performed. A cone biopsy removes a thicker section of the cervix, and allows the pathologist to see if cancerous cells have invaded through the cervix. The cone biopsy has the added value of sometimes being able to cure a pre-cancerous lesion that is localized to a small area. Treatments for cervical cancer and pre-cancerous lesions will be discussed further in the next section.

Staging

In order to guide treatment and offer some insight into prognosis, cervical cancer is staged into different groups. The staging systems used for cervical cancer is the FIGO system (International Federation of Gynecologists and Obstetricians) and The AJCC TNM system.  Many healthcare providers also use the TNM system (also called tumor - node - metastasis system). This system describes the size and local invasiveness of the tumor (T), which, if any, lymph nodes are involved (N), and if it has spread to other more distant areas of the body (M). This information is then combined to come up with a stage somewhere from I (one) denoting more limited disease, to IV (four), denoting more advanced disease. Generally, the higher the stage, the more serious the cancer.

T (Tumor)

Category

FIGO stages

Surgical-Pathological Findings

TX

 

Primary tumor cannot be assessed

T0

 

No evidence of primary tumor

T1s

 

Carcinoma in situ

T1

I

Cervical carcinoma confined to the cervix

T1a

IA

Invasive carcinoma diagnosed only by microscopy. Stromal invasion w/max depth 5.0mm from the base of the epithelium and a horizontal spread of 7.0mm or less.

T1a1

IA1

Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread

T1a2

IA1

Measured stromal invasion more than 3.0 mm and not more than 5.0mm with horizontal spread 7.0 mm or less

T1b

IB

Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2

T1b1

IB1

Clinically visible lesion 4.0 cm or less in greatest dimension

T1b2

IB2

Clinically visible lesion more than 4.0 cm in greatest dimension

T2

II

Cervical carcinoma invades beyond uterus but not to pelvic wall or lower third of vagina

T2a

IIA

Tumor without parametrial invasion

T2a1

IIA1

Clinically visible lesion 4.0 cm or less in greatest dimension

T2a2

IIA2

Clinically visible lesion more than 4.0 cm in dimension

T2b

IIB

Tumor with parametrial invasion

T3

III

Tumor extends to pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis or nonfunctioning kidney

T3a

IIIA

Tumor involves lower third of vagina, no extension to pelvic wall

T3b

IIIB

Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney

T4

IVA

Tumor invades mucosa of bladder or rectum and/or extends beyond true pelvis

N (Regional lymph nodes)

Category

FIGO Stages

Surgical-Pathologic Findings

NX

 

Regional lymph nodes cannot be assessed

N0

 

No regional lymph node metastasis

N1

 

Regional lymph node metastasis

M (Distant Metastasis)

Category

FIGO Stages

Surgical-Pathologic Findings

M0

 

No distant metastasis

M1

IVB

Distant metastasis (including peritoneal spread, involvement of supraclavicular mediastinal, or paraaortic lymph nodes, lung, liver or bone

Stage Groupings

Stage

T

N

M

Stage I

T1

N0

M0

State IA

T1a

N0

M0

Stage IA1

T1a1

N0

M0

Stage IA2

T1a2

N0

M0

Stage IB

T1b

N0

M0

Stage IB1

T1b1

N0

M0

Stage IB2

T1b2

N0

M0

Stage II

T2

N0

M0

Stage IIA

T2a

N0

M0

Stage IIA2

T2a2

N0

M0

Stage IIB

T2b

N0

M0

Stage III

T3

N0

M0

Stage IIIA

T3a

N0

M0

Stage IIIB

T3b

Any N

M0

 

T1-3

N1

M0

Stage IVA

T4

Any N

M0

Stage IVB

Any T

Any N

M1

Because the physical exam is so important for staging a cervical cancer, your providers may want to do a more thorough examination while you are under anesthesia. Other times, your providers will want the results of other radiologic tests to better characterize your cancer. Tests like CAT scans (3-D x-rays) or MRIs (like a CAT scans but done with magnets) can examine the cervix and localized lymph nodes. X-rays may be taken of your bones and/or chest. Sometimes, your providers may want to have a look in your bladder and do a cystoscopy, in which a lighted scope is inserted through your urethra into your bladder. You may get also get a proctosigmoidoscopy, which uses a lighted scope to examine your rectum and colon. Each patient is an individual, so the specific tests people get will vary; but overall, your providers want to know as much about your particular tumor as possible so that they can plan the best available treatments.

What are the treatments for cervical cancer?

Pre-cancerous lesions

Women who have pre-cancerous lesions demonstrated on biopsy after colposcopy have a few different options how to proceed. A woman may decide on a specific option depending on whether or not she plans to have children in the future, her current health status and life expectancy, and her concerns about the future and the possibility of having a cancer come back. You should talk to your provider about you fears, concerns and preferences. Sometimes, women with low grade lesions may choose to not have any further treatment, especially if the biopsy removed the entire lesion. If you decide to do this, you will need more frequent pelvic exams and Pap tests. There are several ways to remove pre-cancerous lesions without removing the entire uterus (and thus preserving a woman's ability to have a baby in the future). Women can have cryosurgery (freezing off the abnormal lesion), a LEEP (the same type of electrosurgical procedure used for biopsies), a conization (the thicker type of biopsy that gets tissue under the surface), or have the cells removed with a laser. Your provider can discuss the benefits and drawbacks of each of these modalities. Women who do not have any plans to have children in the future and are particularly worried about their chances of getting an invasive cancer may elect to have a hysterectomy (a surgery that removes your uterus and cervix). This procedure is much more invasive than any of the previous treatment modalities, but can provide peace of mind to women finished with childbearing.

Surgery

Surgery is generally employed in early stage cervical cancers. The purpose of surgery is to remove as much disease as possible, but it usually isn't used unless all of the cancer can be removed at the time of surgery. Cancers that have a high chance of already being in the lymph nodes are not treated with surgery (lymph nodes are small, pea-sized pieces of tissue that filter and clean lymph, a liquid waste product). There are a few different types of surgeries that can be performed. The earliest stage IA tumors can sometimes be treated with only a hysterectomy (removal of the uterus and cervix). Bigger stage IA, stage IB, and occasionally stage IIA tumors can be treated with more extensive hysterectomies coupled with lymphadenectomies (procedures that remove lymph nodes in the pelvis). Depending on the amount of disease, your surgeon may have to remove tissues around the uterus, as well as part of the vagina and the fallopian tubes. One of the benefits of surgery in young women is that sometimes their ovaries can be left, so that they do not go through menopause at an early age. Higher stage disease is usually treated with radiation and chemotherapy, but sometimes surgery is used if cervical cancer comes back after it has already been treated. A pelvic exenteration is reserved for recurrent cervical cancers. A pelvic exenteration is a major surgery in which the uterus, cervix, fallopian tubes, ovaries, vagina, bladder, rectum and part of the colon are removed. This surgery is not commonly used, but is occasionally used for recurrent cancers.

Radiotherapy

Radiation therapy has proven very effective in treating cervical cancer. Radiation therapy uses high energy x-rays to kill cancer cells. Radiation therapy is another option besides surgery for early stage cervical cancer; and when advanced stage cervical cancer needs to be treated, it is usually done with radiation therapy. Surgery and radiation have been shown to be equivalent treatments for early stage cervical cancers, and radiation helps avoid surgery in patients who are too ill to risk having anesthesia. Radiation has the benefit of being able to treat all of the disease in the radiation field; thus lymph nodes can be treated as well as the primary tumor in the course of the same treatment.

Radiation therapy for cervical cancer either comes from an external source (outside of the patient, known as external beam radiation) or an internal source (inside the patient, known as brachytherapy). External beam radiation therapy requires patients to come in 5 days a week for up 6-8 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. With all cervical cancers above stage IB, the standard approach with radiotherapy is to use external beam radiation coupled with internal brachytherapy. Brachytherapy (also called intracavitary irradiation) allows your radiation oncologist to "boost" the radiation dose to the tumor site. This provides an added impact to the tumor, while sparing your normal tissues. This is done by inserting a hollow, metal tube with two egg shaped cartridges into your vagina. Then a small radioactive source is placed in the tube and cartridges. A computer has calculated how long the source needs to be there, but usually for what is called low dose rate (LDR) brachytherapy, you will need to have the source in for a few days. This procedure is done in the hospital, because for those few days you have to remain in bed. Another type of brachytherapy, called high dose rate (HDR) brachytherapy, uses more powerful sources that only stay in for a few minutes. Although this option usually sounds more appealing to patients, there is debate as to which type is more effective and some institutions favor one over the other. Talk to your radiation oncologist about your options and your provider’s opinions as to HDR versus LDR for cervical cancer treatment.

Another use of radiation is for palliation - meaning that patients with very advanced cases of cervical cancer are treated with the intent of easing their pain or symptoms, rather than trying to cure their disease.

Sometimes, women with early stage are treated with surgery, but after the results of the surgery, it becomes clear that they will need radiation as well. In any setting, radiation is often combined with chemotherapy, and, depending on your case, your provider will decide on the best possible treatment arrangement for your lifestyle and wishes.

Chemotherapy

Despite the fact that tumors are removed by surgery or treated with radiation, there is always a risk of recurrence because there may be microscopic cancer cells left in the body. In order to decrease a patient's risk of a recurrence, she may be offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. Practically all patients who are in good medical condition and receiving radiation for stage IIA or higher cervical cancer will be offered chemotherapy in addition to their radiation. It may even be offered for earlier stage cases depending individual aspects of the patient and her disease. There have been many studies that demonstrate the usefulness of adding chemotherapy to radiation in terms of decreasing mortality from cervical cancer.

There are many different chemotherapy drugs, and they are often given in combinations for a series of months. Depending on the type of chemotherapy regimen you receive, you may get medication every week or every few weeks; you will go to a clinic to get the chemotherapy because the medications have to be given through a vein (IV). The most commonly used regimens (combinations) use a drug called cisplatin combined with another medication, typically paclitaxel, topotecan, carboplatin or gemcitabine. Other chemotherapy medications that may be used to treat cervical cancer include: bevacizumab (a targeted therapy), 5-FU, docetaxel, ifosfamide, irinotecan and mitomycin. There are advantages and disadvantages to each of the different regimens that your gynecologic oncologist or medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects, you may wish to avoid, you can work with your providers to come up with the best regimen for your lifestyle.

ClinicalTrials

Clinical trials are extremely important in furthering our knowledge and the treatment of this disease. It is though clinical trials that we know what we do today, and exciting new therapies are always being tested. Talk to your healthcare provider about participating in clinical trials in your area or search for trials using the OncoLink Clinical Trials Matching program.

Follow-up care and survivorship

Once a patient has been treated for cervix cancer, she needs to be closely followed for a recurrence. At first, you will have follow-up visits fairly often. The longer you are free of disease, the less often you will have to go for checkups. Your provider will tell you when he or she wants follow-up visits, Pap tests, and/ or scans depending on your case. Your provider will also do pelvic exams regularly during your office visits. It is very important that you let your provider know about any symptoms you are experiencing and that you keep all of your follow-up appointments.

Fear of recurrence, relationships and sexual health, financial impact of cancer treatment, employment issues, and coping strategies are common emotional and practical issues experienced by cervical cancer survivors. Your healthcare team can identify resources for support and management of these challenges faced during and after cancer.

Cancer survivorship is a relatively new focus of oncology care. With some 15 million cancer survivors in the US alone, there is a need to help patients transition from active treatment to survivorship. What happens next, how do you get back to normal, what should you know and do to live healthy going forward? A survivorship care plan can be a first step in educating yourself about navigating life after cancer and helping you communicate knowledgeably with your healthcare providers. Create a survivorship care plan today on OncoLink.

Resources for more information

Eyes on the Prize

Provides information and emotional support from the survivors' perspective to women with gynecologic cancers, their families and friends, and healthcare providers. Has a helpful discussion board where you can "chat" with other women.

http://www.eyesontheprize.org/index.html

National Cervical Cancer Coalition

Provides education about HPV and cervical cancer, support through a "pals" program that links a woman with another woman who has a similar diagnosis.

http://www.nccc-online.org/

Foundation for Women’s Cancers

The Foundation offers comprehensive information by cancer type that can help guide you through your diagnosis and treatment. They also offer the ‘Sisterhood of Survivorship’ to connect with others facing similar challenges.

http://www.foundationforwomenscancer.org/

Pregnant with Cancer

Dedicated to providing women diagnosed with cancer while pregnant with information, support and hope.

http://www.pregnantwithcancer.org/

References

American Cancer Society, Cervical Cancer, https://www.cancer.org/cancer/cervical-cancer.html.

NCCN Clinical Practice Guidelines, Cervical Cancer, https://www.nccn.org/professionals/physician_gls/f_guidelines.asp (log in required).

SEER Statistics, Cervical Cancer, https://seer.cancer.gov/statfacts/html/cervix.html, retrieved 7 Feb 2017.

U.S. Preventive Task Force Cervical Cancer Screening Guidelines, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening. Retrieved 7 Feb 2017

Banerjee, R., & Kamrava, M. (2014). Brachytherapy in the treatment of cervical cancer: a review. International Journal of Women’s Health, 6, 555-564.

Bixel, K., Denlinger, N., Marsh, L., Quick, A., & Salani, R. (2016). Primary chemoradiation for the treatment of locally advanced cervical cancer: Impact of treatment location and time on outcomes. Gynecologic Oncology, 141, 152.

Boardman, C.H., Matthews, K.J, Windle, M.L., Braden, C.D., Sonoda, Y., (2015). Cervical cancer staging. Medscape, http://emedicine.medscape.com/article/2006486-overview, retrieved 7 Feb 2017.

Eskander, R. N., & Tewari, K. S. (2014). Chemotherapy in the treatment of metastatic, persistent, and recurrent cervical cancer. Current Opinion in Obstetrics and Gynecology, 26(4), 314-321.

Gill, B. S., Kim, H., Houser, C. J., Kelley, J. L., Sukumvanich, P., Edwards, R. P., ... & Beriwal, S. (2015). MRI-guided high–dose-rate intracavitary brachytherapy for treatment of cervical cancer: The University of Pittsburgh experience. International Journal of Radiation Oncology* Biology* Physics, 91(3), 540-547.

Han, K., Milosevic, M., Fyles, A., Pintilie, M., & Viswanathan, A. N. (2013). Trends in the utilization of brachytherapy in cervical cancer in the United States. International Journal of Radiation Oncology* Biology* Physics, 87(1), 111-119.

Jin, X. W., Lipold, L., Foucher, J., Sikon, A., Brainard, J., Belinson, J., ... & Rothberg, M. B. (2016). Cost-Effectiveness of Primary HPV Testing, Cytology and Co-testing as Cervical Cancer Screening for Women Above Age 30 Years. Journal of General Internal Medicine, 31(11), 1338-1344.

Lorusso, D., Petrelli, F., Coinu, A., Raspagliesi, F., & Barni, S. (2014). A systematic review comparing cisplatin and carboplatin plus paclitaxel-based chemotherapy for recurrent or metastatic cervical cancer. Gynecologic Oncology, 133(1), 117-123.

Pieterse, Q. D., Kenter, G. G., Maas, C. P., de Kroon, C. D., Creutzberg, C. L., Trimbos, J. B. M., & Ter Kuile, M. M. (2013). Self-reported sexual, bowel and bladder function in cervical cancer patients following different treatment modalities: longitudinal prospective cohort study. International Journal of Gynecological Cancer, 23(9), 1717-1725.

Priebe, A. M. (2013). 2012 cervical cancer screening guidelines and the future role of HPV testing. Clinical Obstetrics and Gynecology, 56(1), 44-50.

Roura, E., Castellsagué, X., Pawlita, M., Travier, N., Waterboer, T., Margall, N., ... & Tjønneland, A. (2014). Smoking as a major risk factor for cervical cancer and pre‐cancer: Results from the EPIC cohort. International Journal of Cancer, 135(2), 453-466.

Tewari, K. S., Sill, M. W., Long III, H. J., Penson, R. T., Huang, H., Ramondetta, L. M., ... & Michael, H. E. (2014). Improved survival with bevacizumab in advanced cervical cancer. New England Journal of Medicine, 370(8), 734-743.

World Health Organization. (2013). WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention: supplemental material: GRADE evidence-to-recommendation tables and evidence profiles for each recommendation.

Wright, T. C., Stoler, M. H., Behrens, C. M., Sharma, A., Zhang, G., & Wright, T. L. (2015). Primary cervical cancer screening with human papillomavirus: end of study results from the ATHENA study using HPV as the first-line screening test. Gynecologic Oncology, 136(2), 189-197.

Ye, S., Yang, J., Cao, D., Lang, J., & Shen, K. (2014). A systematic review of quality of life and sexual function of patients with cervical cancer after treatment. International Journal of Gynecological Cancer, 24(7), 1146-1157.

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