Synopsis
Recognise symptomatic cervical cancer, secure tissue diagnosis and accurate FIGO stage, and relate fertility-preserving surgery, radical treatment and palliative care to disease extent.
- 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.
- 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.
Key red flags
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.
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.
Investigation priorities
Confirm malignancy and histological subtype before cancer treatment.
Management branches
Symptoms or examination reveal a lesion potentially consistent with cervical cancer.
- Assess bleeding severity, pregnancy and infection, perform consented pelvic examination and use emergency care immediately for haemodynamic compromise.
- Refer through the suspected-cancer pathway and obtain directed histology, using an intact excisional specimen when measurement of possible microinvasion cannot otherwise be secured.
- Send confirmed disease to the gynaecological oncology MDT with pathology, renal function and fertility or pregnancy priorities documented before staging and treatment decisions.