Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Cervical cancer presentation, staging and treatment
Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Major bleeding or obstructive organ failure is an oncology emergency
Cervical tumour can cause torrential vaginal haemorrhage, sepsis, venous thromboembolism, ureteric obstruction with renal failure or spinal and neurological compromise from advanced disease.
Action: Resuscitate with senior gynaecology and anaesthetic support, activate major haemorrhage care when needed, use packing or interventional control as directed, and obtain urgent oncology, urology or critical-care input for obstruction and organ dysfunction.
Overview
Recognise symptomatic cervical cancer, secure tissue diagnosis and accurate FIGO stage, and relate fertility-preserving surgery, radical treatment and palliative care to disease extent.
Persistent high-risk HPV causes most cervical squamous carcinomas and adenocarcinomas, but symptoms rather than screening status determine diagnostic urgency. Ask about bleeding timing and volume, discharge, pain, urinary and bowel symptoms, fertility priorities, pregnancy possibility, smoking, immunosuppression and previous HPV, cytology or excision. Inspect the cervix with consent. A suspicious appearance enters the cancer pathway; do not take a routine screening sample and wait for it to adjudicate a visible lesion.
Early disease may be screen detected or asymptomatic. Symptomatic disease commonly produces postcoital, intermenstrual or postmenopausal bleeding, watery or blood-stained discharge and dyspareunia. More extensive tumour can cause pelvic or back pain, haematuria, bowel disturbance, leg oedema, weight loss, hydronephrosis and renal impairment. These features overlap benign conditions, so examination and histology are needed rather than diagnosing from symptom pattern alone.
Practice
Two practice questions
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Question 1 of 2
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Obstetrics and gynaecologyOriginal SBA
Assigning nodal FIGO stage
A cervical tumour is confined locally to the cervix, but FDG-PET-CT shows a metastatic pelvic lymph node and no para-aortic or distant disease. Which FIGO designation best captures this finding?
Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Obtain tissue before definitive treatment. Colposcopy-directed punch biopsies are appropriate for a visible lesion and multiple samples can improve yield. When a lesion is not grossly visible but microinvasion must be measured, an intact cone or loop excision permits assessment of invasion depth, horizontal extent, lymphovascular space invasion and margins. A fragmented specimen or severe diathermy artefact may prevent confident staging. Confirmed cancer is reviewed by a specialist gynaecological oncology MDT.
FIGO staging integrates clinical, imaging and pathological information. Stage I is confined to the cervix. Stage IA is microscopic invasion no deeper than 5 mm: IA1 is no deeper than 3 mm and IA2 is deeper than 3 mm but no deeper than 5 mm. Stage IB is deeper invasion confined to the cervix: IB1 is no larger than 2 cm, IB2 is larger than 2 cm but no larger than 4 cm, and IB3 is larger than 4 cm.
Stage II extends beyond the uterus without reaching the lower vaginal third or pelvic wall. IIA involves the upper two-thirds of the vagina without parametrial invasion, divided at 4 cm; IIB invades parametria. Stage III includes lower-vaginal, pelvic-wall or hydronephrotic disease and nodal metastasis: IIIA is lower third of vagina, IIIB pelvic wall or hydronephrosis or a non-functioning kidney, IIIC1 pelvic nodes and IIIC2 para-aortic nodes. Stage IVA reaches bladder or rectal mucosa; IVB is distant spread. Bullous oedema alone does not establish bladder invasion.
Pelvic MRI is the preferred local staging study because it shows tumour size, stromal ring, parametria, vagina and adjacent pelvic organs. Cross-sectional CT evaluates abdomen and chest, while FDG-PET-CT is particularly useful for nodal and distant staging in larger or locally advanced disease and before chemoradiotherapy. Examination under anaesthesia, cystoscopy or proctoscopy is selected when biopsy, examination tolerance or suspected mucosal invasion makes it useful; it is not an automatic staging ritual for every case.
Treatment seeks cure without combining modalities unnecessarily. For stage IA1 with an intact, fully assessed excision and clear margins, conisation can be definitive when fertility is desired; simple hysterectomy is an option when it is not. Lymphovascular invasion does not change FIGO stage but changes nodal-risk assessment. IA2 to IB2 and selected IIA1 tumours are often managed surgically with pelvic nodal assessment. Selected small node-negative tumours may allow conisation, simple or radical trachelectomy within specialist fertility-preserving pathways.
For IB3, IIA2 and IIB to IVA disease, definitive treatment combines pelvic external-beam radiotherapy, concurrent radiosensitising platinum chemotherapy and image-guided brachytherapy, with nodal fields or boosts determined by imaging. Omitting brachytherapy compromises the cervical tumour dose and cannot be casually replaced by external beam treatment. After radical surgery, positive nodes, parametria or margins are high-risk features leading to adjuvant chemoradiotherapy; intermediate pathological risk requires individual MDT assessment.
Recurrent disease is mapped as central pelvic, nodal or distant and compared with previous surgery and radiation fields. A selected person with isolated central recurrence and no distant disease may be considered for exenterative surgery. Other persistent, recurrent or metastatic disease uses systemic and palliative options based on PD-L1, previous treatment, performance status, renal function and preferences. NICE TA939 supports pembrolizumab with platinum-taxane chemotherapy, with or without bevacizumab, for specified PD-L1 CPS 1 or greater disease; TA1164 adds tisotumab vedotin after progression in its licensed population. Keep these indications separate from curative treatment: NICE TA1177, published 14 July 2026, recommends pembrolizumab with chemoradiotherapy as an option for untreated FIGO 2014 stage III to IVA locally advanced cervical cancer in adults, within its marketing authorisation and commercial arrangement.
Supportive care begins at diagnosis. Discuss fertility preservation before gonadotoxic treatment when delay is safe, ovarian conservation or transposition where appropriate, treatment-related menopause, sexual function, bladder and bowel toxicity, lymphoedema and psychological impact. Explain that surveillance after fertility-sparing treatment is more intensive and that pregnancy after cervical excision or trachelectomy needs specialist obstetric planning.
Key points
Early cervical cancer may be asymptomatic; common symptomatic patterns are postcoital, intermenstrual or postmenopausal bleeding, persistent watery or blood-stained discharge and pelvic or dyspareunic pain.
NICE recommends considering a suspected-cancer pathway when examination shows a cervix consistent with cancer; isolated bleeding should still be examined and safety-netted rather than investigated with a screening test.
Diagnosis requires histology, usually directed punch biopsy; a cone or loop specimen may be needed to establish depth when microinvasion is suspected or the first biopsy is inadequate.
Pelvic MRI defines local tumour, parametrial and adjacent-organ extent; CT or FDG-PET-CT assesses nodal and distant disease according to stage and the planned treatment.
FIGO 2018 stage IIIC records nodal metastasis irrespective of local tumour: IIIC1 is pelvic nodes and IIIC2 para-aortic nodes, with r or p denoting imaging or pathological assignment; micrometastases count but isolated tumour cells do not upstage.
Microscopic stage IA disease can be managed by complete excision in selected cases; operable IA2 to IB2 disease may use surgery and nodal assessment, including fertility-sparing treatment for carefully selected small tumours.
Locally advanced IB3, IIA2 and IIB to IVA disease is treated with definitive external-beam radiotherapy plus concurrent platinum chemotherapy and image-guided brachytherapy; brachytherapy is essential to curative treatment.
Aetiology
01
Persistent oncogenic HPV
Long-standing infection with a carcinogenic HPV type is the dominant cause, with viral oncogene activity disrupting cell-cycle control and allowing progressive squamous or glandular neoplasia.
02
Host and exposure modifiers
Smoking, immunosuppression and reduced screening participation increase persistence or delay precursor detection, while HPV vaccination and organised screening reduce population incidence rather than eliminating individual risk.
03
Rare non-HPV disease
A minority of cervical adenocarcinomas and unusual histologies are HPV independent, which helps explain why symptoms and suspicious examination findings must be investigated despite reassuring HPV history.
Pathophysiology
1
Transformation-zone carcinogenesis
Persistent viral expression in susceptible metaplastic cells promotes genomic instability, progression through high-grade intraepithelial disease and eventual breach of the epithelial basement membrane.
2
Local stromal spread
Invasive tumour expands through cervical stroma into parametria, vagina, bladder or rectum, producing contact bleeding, pain and loss of normal tissue planes.
3
Lymphatic dissemination
Tumour reaches parametrial and pelvic nodes before para-aortic chains in many cases; nodal metastasis independently changes FIGO stage and radiotherapy volume.
4
Obstructive and distant injury
Pelvic sidewall disease can compress ureters and veins, causing hydronephrosis or leg oedema, while haematogenous spread produces lung, liver, bone or other distant metastases.
Clinical features and red flags
Contact-bleeding lesion
A friable irregular cervical growth with postcoital bleeding is a diagnostic cancer presentation even if HPV screening was recently negative or the patient is younger than routine screening age.
Locally advanced pattern
Pelvic pain, parametrial fixation, hydronephrosis, leg oedema and bladder or rectal symptoms suggest spread beyond a small operable cervical primary and require full cross-sectional staging.
Nodal stage
Pelvic nodal metastasis is FIGO IIIC1 and para-aortic nodal metastasis is IIIC2, with imaging-based or pathology-based suffixes preserving how the stage was established.
Microscopic invasion
Stage IA cancer is diagnosed only microscopically and requires an interpretable excision to measure stromal depth, assess margins and identify lymphovascular invasion.
Major treatment fork
Small node-negative disease may be surgical, whereas bulky or parametrial disease generally requires definitive chemoradiotherapy incorporating brachytherapy rather than planned radical surgery.
Red flags requiring action
An irregular, ulcerated, necrotic or friable cervical mass that bleeds on contact requires urgent cancer referral and tissue diagnosis even after a recent negative screen.
Heavy vaginal bleeding with clots, syncope, tachycardia, hypotension or symptomatic anaemia requires emergency stabilisation before staging work-up.
Investigations
01Directed cervical biopsyFirst step
Why
Confirm malignancy and histological subtype before cancer treatment.
Interpretation and limitations
Invasive carcinoma establishes diagnosis; a superficial negative specimen does not override a malignant appearance and should prompt repeat, multiple or excisional biopsy through the specialist team.
02Cone or loop excision
Why
Measure suspected microinvasion and evaluate margins when a small lesion cannot be staged reliably by punch biopsy.
Interpretation and limitations
An intact oriented specimen can define IA depth and completeness; fragmentation, cautery artefact or positive margins limits definitive conservative management.
03Pelvic MRI
Why
Map cervical tumour size, stromal invasion, parametria, vagina and adjacent pelvic structures for local treatment planning.
Interpretation and limitations
MRI refines local FIGO components and operability but cannot replace histology; apparent bladder or rectal involvement may need targeted confirmation when it changes stage.
04CT or FDG-PET-CT
Why
Assess pelvic and para-aortic nodes, distant organs and radiotherapy fields in clinically significant disease.
Interpretation and limitations
A positive pelvic or para-aortic node creates IIIC1r or IIIC2r when based on imaging; suspicious distant disease may need biopsy if it would alter curative intent.
Differential diagnosis
01
Cervical ectropion or polyp
Benign glandular exposure or a polyp can cause contact bleeding, but an irregular friable lesion needs histology rather than visual reassurance alone.
02
Cervicitis
Chlamydia, gonorrhoea and other inflammation may cause mucopus and contact bleeding; infection testing does not remove the need to biopsy a persistent mass.
03
Endometrial or vaginal malignancy
Bleeding may originate above or below the cervix, so a normal cervix redirects rather than ends investigation, especially after menopause.
04
Pregnancy-related bleeding
Ectopic pregnancy, miscarriage and pregnancy-related cervical vascularity can present with bleeding and require hCG-based triage while suspicious tissue is still assessed safely.
05
Trauma or atrophy
Recent instrumentation, sexual trauma and genitourinary syndrome of menopause can bleed, but persistence and focal abnormality require a documented diagnostic explanation.
Management
01Suspicion and diagnosisMove from abnormal cervix to tissueFirst stepSymptoms or examination reveal a lesion potentially consistent with cervical cancer.+
1Assess bleeding severity, pregnancy and infection, perform consented pelvic examination and use emergency care immediately for haemodynamic compromise.
2Refer through the suspected-cancer pathway and obtain directed histology, using an intact excisional specimen when measurement of possible microinvasion cannot otherwise be secured.
3Send confirmed disease to the gynaecological oncology MDT with pathology, renal function and fertility or pregnancy priorities documented before staging and treatment decisions.
02Stage and select treatmentAvoid unnecessary dual-modality morbidityDefinitiveHistology confirms invasive cervical cancer and definitive management is being planned.+
Complications
01
Major tumour haemorrhage
Fragile neovascular tumour can bleed abruptly or chronically, causing shock or severe anaemia and requiring packing, transfusion, embolisation or urgent radiation-led control.
02
Malignant ureteric obstruction
Parametrial or nodal disease can obstruct one or both ureters, leading to infection, electrolyte disturbance and renal failure that may prevent cisplatin delivery.
03
Thromboembolic disease
Pelvic compression, systemic malignancy and treatment increase venous thrombosis risk, including leg thrombosis and pulmonary embolism with respiratory compromise.
04
Treatment-related pelvic morbidity
Surgery and radiotherapy can cause bladder, bowel, sexual and lymphatic dysfunction, infertility, ovarian failure, fistula or stenosis that persists beyond tumour control.
05
Local or distant recurrence
Relapse may occur centrally, in nodes or distant organs and can present with new bleeding, pelvic pain, leg swelling, urinary change or constitutional deterioration.
Monitoring and follow-up
During chemoradiotherapy, track blood count, renal function, electrolytes, hydration, gastrointestinal and urinary toxicity and overall treatment time, escalating interruption risks promptly.
After fertility-sparing surgery, maintain specialist examination, HPV-based and colposcopic surveillance rather than transferring directly to routine screening.
At follow-up, ask explicitly about bleeding, discharge, pelvic or back pain, leg swelling, urinary or bowel change and constitutional decline, then investigate symptoms rather than ordering indiscriminate routine scans.
Assess late pelvic-radiation effects, ovarian failure, bone health, sexual pain, vaginal stenosis, bladder and bowel dysfunction and lymphoedema with referral to relevant rehabilitation services.
For recurrent treatment, reassess response, immune or cytotoxic toxicity, thromboembolic risk, goals of care and the opportunity for early specialist palliative support.
Special situations
Screening status modifies but cannot veto
A recent HPV-negative result lowers risk but does not justify ignoring a malignant-looking cervix, because sampling and biological false negatives occur and screening is not diagnostic.
Stage suffix preserves evidence
The r or p suffix on stage IIIC records whether nodal disease came from imaging or pathology, preventing false equivalence between radiological suspicion and tissue confirmation.
LVSI is not a stage upgrade
Lymphovascular space invasion changes nodal-risk and treatment discussion in early cancer but does not alter the measured FIGO stage by itself.
Brachytherapy completes the dose
Curative treatment of locally advanced cervical cancer relies on internal image-guided brachytherapy to escalate tumour dose while limiting surrounding-organ exposure.
Current systemic guidance is layered
The 2021 BGCS framework remains useful for surgery and radiation, but it must be overlaid with TA1177 for eligible curative treatment and later NICE appraisals and biomarkers for recurrent disease.
Common pitfalls
01
Sending a visibly malignant cervix for routine HPV screening instead of obtaining urgent diagnostic histology.
02
Calling imaging-suspicious nodes pathology-confirmed or omitting the r or p basis when documenting FIGO IIIC stage.
03
Planning radical surgery for a bulky tumour likely to need postoperative chemoradiotherapy without discussing the excess morbidity of combined modalities.
04
Describing external-beam radiation alone as complete definitive treatment when curative locally advanced therapy requires brachytherapy.
05
Assuming conisation is adequate from invasion depth alone when margins, specimen integrity, lymphovascular invasion and nodal risk remain unresolved.
06
Using a superseded development page instead of final TA1177, or applying its FIGO 2014 stage III to IVA recommendation to a different cervical-cancer population.
Recurrent or metastatic therapy is biomarker-, fitness- and goal-dependent: NICE TA939 covers specified PD-L1-positive first-line persistent, recurrent or metastatic disease and TA1164 covers tisotumab vedotin after progression. For untreated FIGO 2014 stage III to IVA disease, NICE TA1177 recommends pembrolizumab with chemoradiotherapy as an option within its marketing authorisation and commercial arrangement.
Flank pain, oliguria, rising creatinine or hydronephrosis can represent malignant ureteric obstruction and needs urgent renal and urological assessment.
Unilateral leg swelling, chest pain, haemoptysis or breathlessness raises concern for cancer-associated venous thromboembolism and requires immediate diagnostic assessment.
New weakness, sensory change, bladder or bowel dysfunction, or severe progressive back pain suggests neural compression or bony metastatic disease requiring emergency imaging.
05
Renal function and urinary tract imaging
Why
Identify treatment-limiting renal impairment and malignant ureteric obstruction in advanced cervical cancer.
Interpretation and limitations
Hydronephrosis or a non-functioning kidney contributes to stage IIIB unless another cause is established and may require urgent stenting or nephrostomy before oncological therapy.
1
Use pelvic MRI for local extent and CT or FDG-PET-CT for nodal and distant assessment according to tumour size and anticipated treatment.
2Offer conservative excision, trachelectomy or radical surgery only within stage-appropriate specialist pathways with nodal assessment and explicit fertility counselling.
3DefinitiveUse definitive external-beam radiotherapy, concurrent platinum and brachytherapy for bulky or locally advanced disease, discuss TA1177 pembrolizumab addition for eligible untreated FIGO 2014 stage III to IVA disease, and choose postoperative therapy from final nodal, margin, parametrial and stromal-risk findings.
03Recurrence or complicationRestore organ function and redefine intentMajor haemorrhage, obstruction, thrombosis, treatment failure or recurrent disease occurs.+
1Stabilise bleeding, infection, thrombosis, renal obstruction or neurological compromise before allowing routine oncology scheduling to dictate urgency.
2Restage the anatomical pattern and review prior radiation and surgery to identify a potentially curative central salvage option versus systemic or symptom-directed care.
3Select current NICE-approved systemic therapy by biomarker, previous exposure, fitness and patient goals while integrating pain, nutrition, menopause, sexual health and palliative support.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Radiosensitises definitive treatment for locally advanced cervical cancer and selected high-risk postoperative disease before brachytherapy completion.
Cisplatin radiosensitisation
Give cisplatin 40 mg/m² intravenously once weekly during pelvic external-beam radiotherapy, commonly for 5 to 6 planned doses, using the treating centre's chemoradiotherapy protocol.
Check renal function, magnesium, hearing, neuropathy, hydration and antiemetic needs before each dose; omit or modify through the oncology protocol for toxicity or renal impairment rather than delaying essential radiotherapy indiscriminately.