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 metaplastic squamocolumnar junction where the stratified squamous ectocervix meets the columnar endocervix. It is the fourth most common cancer in women worldwide, with an estimated 604,000 new cases and 342,000 deaths in 2020, and the commonest cause of cancer death in women across much of sub-Saharan Africa, South Asia and Melanesia.[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). HPV DNA is detectable in more than 99 percent of cervical carcinomas, and HPV types 16 and 18 alone account for about 70 percent of cases worldwide.[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 accounts for roughly 80 percent of cases and arises from the squamous transformation zone. Adenocarcinoma accounts for 15 to 20 percent, arises from the endocervical glandular epithelium, is harder to detect with conventional cytology, and is rising in relative frequency in young women. Adenosquamous carcinoma and rare small-cell neuroendocrine carcinoma (HPV 18 linked, biologically aggressive, treated like small-cell lung) make up the remainder.[2]

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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
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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
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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