Cervical cancer: FIGO 2018 staging, surgery vs chemoradiotherapy, and survival (fellowship depth)

A 38-year-old woman walks into your clinic with three months of postcoital bleeding. She has not had a Pap or HPV test in eight years. Your job is not to reassure her that "it's probably an ectropion" — it is to take a speculum view, take a Pap and HPV test, and biopsy any visible lesion today, then stage her with FIGO 2018 and route her to the right treatment pathway. The whole of cervical cancer turns on three watershed decisions: who to biopsy, who to operate, and who to chemoradiate. This page defends each.^[2][8]

Overview and definition

Cervical cancer is a malignant epithelial tumour arising at the cervical transformation zone — the area between the old and new squamocolumnar junction — where almost all cases originate. It is the fourth most common cancer in women worldwide after breast, colorectal and lung cancers (GLOBOCAN 2020 estimates via Sung 2021), with the great majority of cases and deaths occurring in low- and middle-income countries.^[1]

The defining biological fact — and the reason this cancer is unusual among solid tumours — is that it is virtually always caused by a persistent infection with high-risk human papillomavirus (HPV) — the HPV-type meta-analysis in over 115,000 HPV-positive women grounds the type-distribution teaching.^[2] Because the cause, the precursor (CIN), and an effective vaccine are all known, cervical cancer is in principle a largely preventable, and if caught early, curable disease. Persistence of high mortality in low-resource settings reflects failures of screening access and treatment, not of biological understanding.

Squamous cell carcinoma is the commonest type. Adenocarcinoma includes HPV-associated and HPV-independent variants such as the rare gastric type. Neuroendocrine carcinoma (small-cell and large-cell) is rare and aggressive with a high fatality rate. All are managed by the same stage-driven algorithm below.^[2]

References17ShowHide

1. [1]Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin, 2021.PMID 33538338
2. [2]Guan P, Howell-Jones R, Li N, et al. Human papillomavirus types in 115,789 HPV-positive women: a meta-analysis from cervical infection to cancer. Int J Cancer, 2012.PMID 22323075
3. [3]Arbyn M, Xu L, Simoens C, Martin-Hirsch PPL. Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors. Cochrane Database Syst Rev, 2018.PMID 29740819
4. [4]Paavonen J, Naud P, Salmerón J, et al. Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women. Lancet, 2009.PMID 19586656
5. [5]Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med, 2015.PMID 25693011
6. [6]Drolet M, Bénard É, Pérez N, et al. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet, 2019.PMID 31255301
7. [7]Ronco G, Dillner J, Elfström KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet, 2014.PMID 24192252
8. [8]Bhatla N, Berek JS, Cuello Fredes M, et al. Revised FIGO staging for carcinoma of the cervix uteri. Int J Gynaecol Obstet, 2019.PMID 30656645
9. [9]Chemoradiotherapy for Cervical Cancer Meta-Analysis Collaboration (CCCMAC). Reducing uncertainties about the effects of chemoradiotherapy for cervical cancer: a systematic review and meta-analysis of individual patient data from 18 randomized trials. J Clin Oncol, 2008.PMID 19001332
10. [10]Keys HM, Bundy BN, Stehman FB, et al. Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J Med, 1999.PMID 10202166
11. [11]Morris M, Eifel PJ, Lu J, et al. Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer. N Engl J Med, 1999.PMID 10202164
12. [12]Ramirez PT, Frumovitz M, Pareja R, et al. Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer. N Engl J Med, 2018.PMID 30380365
13. [13]Tewari KS, Sill MW, Penson RT, et al. Bevacizumab for advanced cervical cancer: final overall survival and adverse event analysis of a randomised, controlled, open-label, phase 3 trial (Gynecologic Oncology Group 240). Lancet, 2017.PMID 28756902
14. [14]Colombo N, Dubot C, Lorusso D, et al. Pembrolizumab for Persistent, Recurrent, or Metastatic Cervical Cancer. N Engl J Med, 2021.PMID 34534429
15. [15]Sidonie M, et al. Oncologic, pregnancy, and reproductive outcomes of fertility-sparing surgery in early-stage cervical cancer: a systematic review. Surg Oncol, 2026.PMID 42114502
16. [17]Eleje GU, Eke AC, Igberase GO, Igwegbe AO Palliative interventions for controlling vaginal bleeding in advanced cervical cancer. Cochrane Database Syst Rev, 2019.PMID 30888060
17. [18]Australian Centre for the Prevention of Cervical Cancer National Cervical Screening Program Guidelines: Cervical Screening Pathway Quick Reference Guide ACPCC / Cancer Council Australia NCSP Guidelines, 2022.Source