Cervical cancer

Overview

Cervical cancer is a malignant disease that develops in the cells of the cervix — the lower, narrow part of the uterus that connects the uterus to the vagina. It is the fourth most common cancer in women worldwide, with approximately 604,000 new cases and around 342,000 deaths reported globally each year (WHO, 2024). Despite these numbers, cervical cancer is considered one of the most preventable and treatable forms of cancer, largely due to effective screening programs and the availability of the HPV vaccine.

The disease typically develops slowly over many years, often beginning with precancerous changes (dysplasia) that can be detected and treated before cancer ever forms. This is why regular screening is so critical — when caught early, cervical cancer has one of the highest treatment success rates of all cancers.

What Causes Cervical Cancer?

The overwhelming majority of cervical cancer cases — more than 95% — are caused by persistent infection with certain high-risk strains of the human papillomavirus (HPV). HPV is an extremely common sexually transmitted infection; most sexually active people will contract it at some point in their lives. In most cases, the immune system clears the virus naturally within one to two years. However, when a high-risk HPV infection persists, it can cause abnormal changes in cervical cells that may eventually progress to cancer.

HPV types 16 and 18 are responsible for approximately 70% of all cervical cancer cases worldwide (Walboomers et al., 1999).

Risk Factors

While HPV infection is the primary cause, several factors increase the likelihood that an HPV infection will progress to cancer:

Types of Cervical Cancer

Cervical cancer is classified based on the type of cell in which it originates:

• Squamous cell carcinoma (80–90% of cases): Develops from the flat, thin squamous cells lining the outer part of the cervix (ectocervix). Almost always linked to HPV.
• Adenocarcinoma (10–25% of cases): Develops from the glandular cells of the cervical canal that produce mucus. Its incidence has been rising, particularly in younger women.
• Mixed (adenosquamous) carcinoma: Contains features of both types; less common.

How Does It Look?

Understanding what cervical cancer looks like requires considering three perspectives: what a doctor sees during examination, what the tumor looks like macroscopically, and what the cells look like microscopically.

Appearance During Gynecological Examination

One of the most important things to understand is that early cervical cancer and precancerous changes usually cannot be seen with the naked eye. A cervix with early-stage cancer or high-grade dysplasia often appears completely normal during a standard speculum examination. This is precisely why Pap smears and HPV tests exist — they detect cellular changes long before any visible abnormality develops.

When visible changes do occur, a doctor examining the cervix may observe:

• A red, inflamed, or raw-looking area on the cervical surface
• An ulcer or erosion — a shallow open sore that may bleed when touched
• A raised, irregular growth or mass protruding from the cervix
• A “cauliflower-like” (fungating) lesion — a bumpy, wart-like tumor growing outward from the cervical surface
• Areas that bleed easily on contact (e.g., when touched by a swab)
• White patches (leukoplakia) after application of acetic acid during colposcopy — these “acetowhite” areas indicate abnormal cell activity
• Abnormal blood vessels visible under colposcopic magnification — irregular, twisted, or “punctation/mosaic” patterns

Appearance in Advanced Stages

In more advanced disease, the tumor may:

• Replace a large portion of the cervix with an obvious friable (easily crumbling), bleeding mass
• Grow inward as an endophytic tumor, expanding the cervix into a barrel shape without a clearly visible external lesion
• Produce a foul-smelling discharge due to tissue breakdown (necrosis)
• Extend visibly into the upper vagina or surrounding tissues

Microscopic Appearance

Under the microscope, pathologists identify cancer by observing:

• Cells with enlarged, irregular, dark-staining nuclei
• Loss of normal cell organization and layering
• Uncontrolled cell division (frequent mitotic figures)
• Invasion of abnormal cells through the basement membrane into deeper tissue — the defining feature of invasive cancer versus precancerous change (CIN/carcinoma in situ)

Important note for patients: You cannot diagnose cervical cancer by looking at yourself or by any visual sign at home. The cervix is not visible without medical instruments, and most early disease is invisible even to clinicians. Only laboratory testing and professional examination can detect it.

Symptoms

Early-Stage Symptoms

A crucial fact that everyone should know: early cervical cancer usually causes no symptoms at all. Most women with early-stage disease feel completely healthy. This is why screening should never be skipped simply because “nothing feels wrong.”

When symptoms do begin to appear, the earliest and most characteristic ones include:

• Abnormal vaginal bleeding, particularly:
• Bleeding after sexual intercourse (postcoital bleeding) — often the first warning sign
• Bleeding or spotting between periods
• Heavier or longer menstrual periods than usual
• Any vaginal bleeding after menopause
• Unusual vaginal discharge — watery, pink, blood-tinged, or with an unpleasant odor
• Pain during sexual intercourse (dyspareunia)

Symptoms of Advanced Disease

As the cancer grows and spreads to nearby tissues or distant organs, additional symptoms may develop:

• Persistent pelvic pain or lower back pain
• Pain or difficulty during urination, or blood in the urine
• Changes in bowel habits, including pain during bowel movements or blood in the stool
• Swelling of one or both legs (due to lymphatic or vascular compression)
• Unexplained weight loss and loss of appetite
• Persistent fatigue and general weakness
• Bowel or urinary incontinence (in very advanced cases involving fistula formation)
• Bone pain if the cancer has spread to the bones
• Shortness of breath or coughing if the cancer has spread to the lungs

⚠️ When to see a doctor immediately: Any vaginal bleeding after sex, bleeding after menopause, or persistent unusual discharge warrants prompt medical evaluation. These symptoms do not necessarily mean cancer — they can have many benign causes — but they must always be investigated.

Stages of Cervical Cancer (FIGO Classification)

Doctors use the International Federation of Gynecology and Obstetrics (FIGO) staging system to describe how far the cancer has spread (Bhatla et al., 2019):

Diagnosis

1. Screening Tests

• Pap test (Pap smear / cervical cytology): Cells are gently collected from the cervix and examined for abnormalities. Detects precancerous changes before cancer develops.
• HPV DNA test: Checks for infection with high-risk HPV strains. Now recommended as the primary screening method in many countries.

2. If Screening Is Abnormal

• Colposcopy: The cervix is examined with a special magnifying instrument; acetic acid is applied to highlight abnormal areas.
• Biopsy: A small tissue sample is taken for microscopic analysis. Types include punch biopsy, endocervical curettage, LEEP (loop electrosurgical excision procedure), and cone biopsy (conization).

3. If Cancer Is Confirmed

Staging investigations determine the extent of disease:

• MRI — best for assessing local tumor size and spread
• CT scan — evaluates lymph nodes and distant organs
• PET-CT scan — detects metabolically active cancer spread
• Cystoscopy or sigmoidoscopy — if bladder or bowel involvement is suspected (advanced cases)
• Chest X-ray and blood tests

Treatment

Treatment depends on the stage of the disease, the tumor’s size and type, the patient’s age and general health, and whether she wishes to preserve fertility.

Treatment by Stage Overview

Main Treatment Modalities

• Surgery: Ranges from removing a cone-shaped piece of tissue (preserving fertility) to radical hysterectomy (removal of the uterus, cervix, part of the vagina, and surrounding tissue). Pelvic lymph nodes are often sampled.
• Radiation therapy: External beam radiation combined with brachytherapy (internal radiation placed directly against the tumor). Often given together with weekly low-dose chemotherapy.
• Chemotherapy: Cisplatin is the most commonly used drug, often combined with paclitaxel.
• Targeted therapy: Bevacizumab blocks blood vessel growth that feeds the tumor.
• Immunotherapy: Pembrolizumab helps the immune system recognize and attack cancer cells; used for advanced or recurrent disease expressing PD-L1.

Prevention

Cervical cancer is one of the few cancers that is largely preventable:

1. HPV Vaccination

• Protects against the most dangerous HPV types, including 16 and 18 (and 5 additional types with the 9-valent vaccine).
• Most effective when given before sexual activity begins — routinely recommended for girls and boys aged 9–14.
• Catch-up vaccination is available for older age groups (up to 26 routinely; up to 45 based on individual decision).

2. Regular Screening

(Note: national guidelines vary; follow your country’s recommendations.)

3. Lifestyle Measures

• Avoid smoking
• Use condoms (reduces, but does not eliminate, HPV transmission)
• Limit number of sexual partners
• Attend all screening appointments and follow up on abnormal results

Prognosis and Survival

The outlook depends heavily on the stage at diagnosis. Approximate 5-year relative survival rates (based on US data — survival is often lower in countries without organized screening):

These figures underscore the central message of this article: cervical cancer caught early is highly curable.

Key Takeaways

• Cervical cancer is caused by persistent high-risk HPV infection and usually develops slowly over years.
• Early disease has no symptoms — screening is essential even if you feel healthy.
• The first warning signs are typically bleeding after sex, bleeding between periods, or bleeding after menopause.
• The HPV vaccine + regular screening combination makes this one of the most preventable cancers.
• When detected early, more than 9 out of 10 women survive at least 5 years.
• Never ignore abnormal bleeding — see a doctor promptly.

References

American Cancer Society (2024) Cervical Cancer: Causes, Risk Factors, and Prevention. Atlanta, GA: American Cancer Society. Available at: https://www.cancer.org/cancer/types/cervical-cancer.html

Bhatla, N., Berek, J.S., Cuello Fredes, M., Denny, L.A., Grenman, S., Karunaratne, K., Kehoe, S.T., Konishi, I., Olawaiye, A.B., Prat, J., Sankaranarayanan, R., Brierley, J., Mutch, D., Querleu, D., Cibula, D., Quinn, M., Botha, H., Sigurd, L., Rice, L., Ryu, H.S., Ngan, H., Maenpaa, J., Andrijono, A., Purwoto, G., Maheshwari, A., Bafna, U.D., Plante, M. and Natarajan, J. (2019) ‘Revised FIGO staging for carcinoma of the cervix uteri’, International Journal of Gynaecology and Obstetrics, 145(1), pp. 129–135.

Fontham, E.T.H., Wolf, A.M.D., Church, T.R., Etzioni, R., Flowers, C.R., Herzig, A., Guerra, C.E., Oeffinger, K.C., Shih, Y-C.T., Walter, L.C., Kim, J.J., Andrews, K.S., DeSantis, C.E., Fedewa, S.A., Manassaram-Baptiste, D., Saslow, D., Wender, R.C. and Smith, R.A. (2020) ‘Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society’, CA: A Cancer Journal for Clinicians, 70(5), pp. 321–346.

National Cancer Institute (2023) Cervical Cancer Treatment (PDQ®) – Patient Version. Bethesda, MD: National Cancer Institute. Available at: https://www.cancer.gov/types/cervical

NHS (2023) Cervical cancer. London: National Health Service. Available at: https://www.nhs.uk/conditions/cervical-cancer/

Sung, H., Ferlay, J., Siegel, R.L., Laversanne, M., Soerjomataram, I., Jemal, A. and Bray, F. (2021) ‘Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries’, CA: A Cancer Journal for Clinicians, 71(3), pp. 209–249.

Walboomers, J.M.M., Jacobs, M.V., Manos, M.M., Bosch, F.X., Kummer, J.A., Shah, K.V., Snijders, P.J.F., Peto, J., Meijer, C.J.L.M. and Muñoz, N. (1999) ‘Human papillomavirus is a necessary cause of invasive cervical cancer worldwide’, The Journal of Pathology, 189(1), pp. 12–19.

World Health Organization (2024) Cervical cancer. Geneva: WHO. Available at: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer