All About Cervical Cancer

Author: OncoLink Team
Last Reviewed: February 11, 2019

What is the cervix?

The cervix is the name for the lowest part of the uterus. Only women have a uterus. The uterus is where a baby grows and develops when a woman is pregnant. During pregnancy, the uterus grows enormously 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 be both 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. These cells can also invade nearby tissues or spread throughout the body. Large collections of cells that grow abnormally are called tumors. Usually, cervical 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 originates from cells that lie on the surface of the cervix known as squamous cells. Squamous cell cervical cancer makes up 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, but they are extremely uncommon.

What causes cervical cancer and am I at risk?

Cervical cancer is much more common in developing nations than it is in developed nations. 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. It is fairly rare in the United States. Every year, an estimated 13,170 cases of cervical cancer are diagnosed in the United States. This number is dropping each year. 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 testing and/or HPV testing) in the developed nations.

One of the most important risk factors for cervical cancer is infection with a virus called HPV (human papilloma virus). 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. HPV is a sexually transmitted infection (STI) that is incredibly common in the population. In fact, 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. Often, infection with HPV causes no symptoms at all, until a woman develops a pre-cancerous lesion of the cervix. 

Because having an STI is a risk factor for cervical cancer, any risk factor for developing STI’s is also risk factors for developing cervical cancer. These include:

  • Having had multiple male sexual partners.
  • Starting to have sexual intercourse at an early age.
  • Having had male sexual partners who are considered high risk (they have had many sexual partners and/or began having sexual intercourse at an early age) 
  • Being diagnosed with any other sexually transmitted diseases (like herpes, gonorrhea, syphilis, or Chlamydia) increases a woman's risk. 

HIV infection (also an STI) is another risk factor for cervical cancer, but for a slightly different reason. It appears 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 cervical tumors. Finally, women who live in poverty seem to be at an increased likelihood for developing and dying from cervical cancer. This could be related to higher smoking rates, or perhaps because there are more barriers to getting annual screening exams. 

Remember that all risk factors are based on probabilities. Even someone without any risk factors can get cervical cancer. Timely screening and early detection are our best weapons in reducing the number of new cases of cervical cancer.

How can I prevent cervical cancer?

There are several things women can do to decrease the risk of getting cervical cancer. This includes:

  • Have regular Pap testing: 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. Screening will be discussed more in the next section.
  • Get vaccinated: 
    • Three vaccines, called Gardasil, Gardasil 9, and Ceravix have been developed. 
    • The HPV vaccine is recommended for all individuals age 12-45. However, not all insurance companies cover the HPV vaccine for individuals over the age of 26. 
    • 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. Even if you already have HPV, you can still be vaccinated. The vaccine can protect you from other types of HPV
  • In addition to cervical cancer, HPV is also be 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.
  • 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. 
  • Condom and/or dental dam (barrier method) use may decrease areas that are exposed but cannot prevent exposure entirely.

What screening tests are used for cervical cancer?

Cervical cancer is considered a preventable disease. It usually takes a very long time for pre-cancerous lesions to progress to invasive cancers. 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 develop 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 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, even 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.

The American Cancer Society has made the following recommendations for cervical cancer screening:

  • All women should begin cervical cancer screening at age 21.
  • Age 21-29: Pap testing done every 3 years. HPV testing is only used if the Pap test is abnormal.
  • Age 30-65: Pap testing and HPV test done every 5 years. Alternatively, a woman could have a Pap test alone every 3 years.
  • Over age 65: Women who have had normal Pap results can stop testing all together.  
  • Women over age 65 who have a history of a serious cervical pre-cancer should continue to be tested for 20 years after that diagnosis, even if this means screening will continue past age 65.
  • Women who have had their uterus & cervix removed for reasons not related to cervical cancer and have no history of cervical cancer or pre-cancer do not need screening tests.
  • Women who have had a hysterectomy with their cervix removed do not need to be screened.
  • Even if you have had the HPV vaccine, you should still continue to have Pap testing based on your age in the above guidelines.

Some 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 been previously treated for certain cervical abnormalities or cancer.

What are the signs of cervical cancer?

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 with urination.
  • Blood in the stool or urine.
  • Pain during sex.

Many of these symptoms are non-specific, and can represent a variety of different conditions. If you have any of these symptoms, talk with your healthcare provider.

How is cervical cancer diagnosed?

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 per the screening guidelines. 
  • Atypical cells of undetermined significance can be handled in three different ways: 
    • Repeat Pap test in 4-6 months, they can get HPV testing.
    • 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. Colposcopy is uncomfortable, but not painful, and can be done in your gynecologist's office.
    • 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. Biopsy can be completed in conjunction with colposcopy.

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.

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. 

  • Punch biopsy may be used to remove a small section of the cervix.
  • LEEP (loop electrosurgical excision procedure) is another method to do a biopsy where a thin slice of the cervix is removed. 
  • 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. 

Other tests that may be performed as part of a diagnostic work-up include blood tests, liver function tests and HIV testing.

How is cervical cancer staged?

After these tests are performed, a stage is determined to help decide the treatment plan. The stage of cancer, or extent of disease, is based on information gathered through the various tests done as the diagnosis and work-up of the cancer is being performed.  

Cancer staging assists the provider in making decisions about treatment and plan of care. There are two staging systems used for cervical cancer: the FIGO system (International Federation of Gynecologists and Obstetricians) and 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 from I (one) denoting more limited disease, to IV (four), denoting more advanced disease. Generally, the higher the stage, the more serious the cancer. The staging system is very complex and is provided at the end of this article for your reference. Your stage is reported on your pathology report – you may want to ask for a copy of this report for your personal files. 

How is cervical cancer treated?

Pre-cancerous lesions

Women who have pre-cancerous lesions demonstrated on biopsy after colposcopy have a few different options with how to proceed. You may decide on a specific option depending on whether or not you plan to have children in the future, your current health status and life expectancy, and your 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. 

If you have 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. Talk with your healthcare provider about how often you will need to have these exams.

There are several ways to remove pre-cancerous lesions without removing the entire uterus (and thus preserving your ability to have a baby in the future). Options include:

  • Cryosurgery (freezing off the abnormal lesion). 
  • LEEP (the same type of electrosurgical procedure used for biopsies).
  • Conization (the thicker type of biopsy that gets tissue under the surface).
  • Laser cell removal. 

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 mentioned treatment modalities, but can provide peace of mind to women finished with childbearing.

Surgery

Surgery is generally used in early stage cervical cancers. The purpose of surgery is to remove as much disease as possible. However, 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 type of surgery is dependent on the stage of the tumor. Surgical procedures for cervical cancer include:

  • Trachelectomy (removal of the cervix, upper vagina and tissue surrounding the cervix). Pelvic lymph nodes may also be removed.
  • Hysterectomy (removal of the uterus and cervix). Pelvic lymph nodes may also be removed. 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 occasionally used for recurrent cancers.

Radiation Therapy

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 as well as 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. Radiation also helps to 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 is painless. 

Once again, the type of radiation therapy used is dependent on the stage of the tumor. With all cervical cancers above stage IB, the standard approach with radiation therapy 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 care provider about your options and their opinions as to HDR versus LDR for cervical cancer treatment.

Another use of radiation is for palliation. This means 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 the risk of a recurrence, you may be offered chemotherapy

Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. Most 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 on 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. The most commonly used regimens (combinations) use a drug called cisplatin combined with another medication, typically paclitaxeltopotecancarboplatin and bevacizumab. Pembrolizumab, albumin bound paclitaxel, docetaxel, fluorouracil, gemcitabine, ifosfamide, irinotecan, mitomycin, pemetrexed, and vinorelbine may be used as second line therapy after recurrence.

There are advantages and disadvantages to each of the different regimens that your health care provider 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.

Clinical Trials

There are clinical research trials for most types of cancer, and every stage of the disease. Clinical trials are designed to determine the value of specific treatments. Trials are often designed to treat a certain stage of cancer, either as the first form of treatment offered, or as an option for treatment after other treatments have failed to work. They can be used to evaluate medications or treatments to prevent cancer, detect it earlier, or help manage side effects. Clinical trials are extremely important in furthering our knowledge of disease. It is through clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your provider about participating in clinical trials in your area. You can also explore currently open clinical trials using the OncoLink Clinical Trials Matching Service.

Follow-up Care and Survivorship

Once you have been treated for cervical cancer, you need 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 they want 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

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/

Hope for Two

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

http://www.hopefortwo.org

 

Appendix: Complete AJCC/FIGO Staging for Cervical Cancer (2017)

T(Tumor)

FIGO Stage

Description

TX

 

Primary tumor cannot be assessed

T0

 

No evidence of primary tumor

T1

I

Cervical carcinoma confined to the uterus (extension to corpus should be disregarded)

T1a

IA

Invasive carcinoma diagnosed only by microscopy. Stromal invasion with a maximum depth of 5.0mm measured from the base of the epithelium and a horizontal spread of 7.0mm or less. Vascular space involvement, venous or lymphactic, does not affect classification

T1a1

IA1

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

T1a2

IA2

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

T1b

IB

Clinically visible lesions confined to the cervix or microscopic lesion greater than T1a/IA2. Includes all macroscopically visible lesions even those with superficial invasion

T1b1

IB1

Clinically visible lesion 4.0 cm or less in greatest dimension

T1b2

1B2

Clinical visible lesion more than 4.0 cm in greatest dimension

T2

II

Cervical carcinoma invading beyond the uterus but not toe the pelvic wall or to the lower third of the vagina

T2a

IIA

Tumor without parametrial invasion

T2a1

IIA1

Clinically visible lesion 4.0 cm or less in greatest dimension

T2a2

IIA2

Clinical visible lesion more than 4.0 cm in greatest dimension

T2b

IIB

Tumor with parametrial invasion

T3

III

Tumor extending to the pelvic sidewall* and/or involving the lower third of the vagina and/or causing hydronephrosis or nonfunctioning kidney

T3a

IIIA

Tumor involving the lower third of the vagina but not extending to the pelvic wall

T3b

IIIB

Tumor extending to the pelvic wall and/or causing hydronephrosis or nonfunctioning kidney

T4

IVA

Tumor invading the mucosa of the bladder or rectum and/or extending beyond the true pelvis

* The pelvic sidewall is defined as the muscle, fascia, neurovascular structures, and skeletal portion of the bony pelvis. On rectal examination, there is no cancer-free space between the tumor and pelvic sidewall.

N (Regional Lymph Nodes)

FIGO Stage

Description

NX

 

Regional lymph nodes cannot be assessed

N0

 

No regional lymph node metastasis

N0 (i+)

 

Isolated tumor cells in regional lymph node(s) no greater tan 0.2mm

N1

 

Regional lymph node metastasis

 

M (Distant Metastasis)

FIGO Stage

Description

M0

 

No distant metastasis

M1

IVB

Distant metastasis (including peritoneal spread or involvement of the supraclavicular, mediastinal, or distant lymph nodes; lung; liver; or bone)

 

Stage Grouping

T

N

M

I

T1

Any N

M0

IA

T1a

Any N

M0

IA1

T1a1

Any N

M0

1A2

T1a2

Any N

M0

IB

T1b

Any N

M0

IB1

T1b1

Any N

M0

IB2

T1b2

Any N

M0

II

T2

Any N

M0

IIA

T2a

Any N

M0

IIA1

T2a1

Any N

M0

IIA2

T2a2

Any N

M0

IIB

T2b

Any N

M0

III

T3

Any N

M0

IIIA

T3a

Any N

M0

IIIB

T3b

Any N

M0

IVA

T4

Any N

M0

IVB

Any T

Any N

M1

References

American Cancer Society, Cervical Cancerhttps://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 Health6, 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 Oncology141, 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 Gynecology26(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* Physics91(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* Physics87(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 Medicine31(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 Oncology133(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 Cancer23(9), 1717-1725.

Priebe, A. M. (2013). 2012 cervical cancer screening guidelines and the future role of HPV testing. Clinical Obstetrics and Gynecology56(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 Cancer135(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 Medicine370(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 Oncology136(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 Cancer24(7), 1146-1157.

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