Cervical cancer is usually a squamous cell carcinoma caused by human papillomavirus infection; less

often, it is an adenocarcinoma. Cervical neoplasia is asymptomatic; the first symptom of early cervical
cancer is usually irregular, often postcoital vaginal bleeding. Diagnosis is by a cervical Papanicolaou
test and biopsy. Staging is clinical. Treatment usually involves surgical resection for early-stage disease
or radiation therapy plus chemotherapy for locally advanced disease. If the cancer has widely
metastasized, chemotherapy is often used alone.

Cervical cancer is the 3rd most common gynecologic cancer and the 8th most common cancer among
women in the US. Mean age at diagnosis is 50, but the cancer can occur as early as age 20. The American
Cancer Society estimates that in the US, 13,170 new cases of invasive cervical cancer and 4,250 deaths
from cervical cancer will occur in 2019.

Cervical cancer results from cervical intraepithelial neoplasia (CIN), which appears to be caused by
infection with human papillomavirus (HPV) type 16, 18, 31, 33, 35, or 39.

Risk factors for cervical cancer include

 Younger age at first intercourse

 A high lifetime number of sex partners

 Cigarette smoking

 Immunodeficiency

Regardless of sexual history, clinicians should assume that women have been exposed to someone with
HPV because it is ubiquitous.

Pathology

CIN is graded as

 1: Mild cervical dysplasia

 2: Moderate dysplasia

 3: Severe dysplasia and carcinoma in situ

CIN 3 is unlikely to regress spontaneously; if untreated, it may, over months or years, penetrate the
basement membrane, becoming invasive carcinoma.

About 80 to 85% of all cervical cancers are squamous cell carcinoma; most of the rest are
adenocarcinomas. Sarcomas and small cell neuroendocrine tumors are rare.

Invasive cervical cancer usually spreads by direct extension into surrounding tissues or via the lymphatics
to the pelvic and para-aortic lymph nodes. Hematogenous spread is possible but rare.

If cervical cancer spreads to the pelvic or para-aortic lymph nodes, the prognosis is worse, and the
location and size of the radiation therapy field is affected.
Symptoms and Signs

Early cervical cancer can be asymptomatic.

When symptoms occur, they usually include irregular vaginal bleeding, which is most often postcoital but
may occur spontaneously between menses. Larger cancers are more likely to bleed spontaneously and
may cause a foul-smelling vaginal discharge or pelvic pain. More widespread cancer may cause
obstructive uropathy, back pain, and leg swelling due to venous or lymphatic obstruction.

Pelvic examination may detect an exophytic necrotic tumor in the cervix.

Diagnosis

 Papanicolaou (Pap) test

 Biopsy

 Clinical staging, usually by biopsy, pelvic examination, and chest x-ray

Cervical cancer may be suspected during a routine gynecologic examination. It is considered in women
with

 Visible cervical lesions

 Abnormal routine Pap test results

 Abnormal vaginal bleeding

Reporting of cervical cytology results is standardized (see table Bethesda Classification of Cervical
Cytology [1]). Further evaluation is indicated if atypical or cancerous cells are found, particularly in
women at risk. If cytology does not show any obvious cancer, colposcopy (examination of the vagina and
cervix with a magnifying lens) can be used to identify areas that require biopsy. Colposcopy-directed
biopsy with endocervical curettage is usually diagnostic. If not, cone biopsy (conization) is required; a
cone of tissue is removed using a loop electrical excision procedure (LEEP), laser, or cold knife.

Cervical Cancer
SCIENCE PHOTO LIBRARY

Loop Electrosurgical Excision Procedure (LEEP)

TABLE

Bethesda Classification of Cervical Cytology*

Staging

Cervical cancers are clinically staged based on biopsy, physical examination, and chest x-ray results (see
table Bethesda Classification of Cervical Cytology). In the International Federation of Gynecology and
Obstetrics (FIGO) staging system, stage does not include information about lymph node status. Although
not included as staging, lymph node status is one of the most important prognostic factors in early-stage
cervical cancer (stages IA1 to IB1); it is required for treatment planning and affects the radiation therapy
field.

If the stage is > IA2, CT or MRI of the abdomen and pelvis is typically done to identify metastases,
although results are not used for staging. PET with CT (PET/CT) is being used more commonly to check
for spread beyond the cervix. If PET/CT, MRI, or CT is not available, cystoscopy, sigmoidoscopy, and IV
urography, when clinically indicated, may be used for staging.

TABLE

FIGO Clinical Staging of Cervical Carcinoma*

The purpose of this staging system is to establish a consistent standard and uniform classification of
diagnosis in all regions of the world. The system excludes results of tests that are less likely to be
available worldwide (eg, MRI) because most cases of cervical cancer occur in developing countries.
Because such tests are not used, findings such as parametrial invasion and lymph node metastases are
often missed, and thus understaging is possible.

When imaging tests suggest that pelvic or para-aortic lymph nodes are grossly enlarged (> 2 cm), surgical
exploration, typically with a retroperitoneal approach, is occasionally indicated. Its sole purpose is to
remove enlarged lymph nodes so that radiation therapy can be more precisely targeted and more
effective.

Diagnosis reference

 1. Nayar R, Wilbur DC: The Pap test and Bethesda 2014. Cancer Cytopathology, 123: 271–281,
2015.

Prognosis

In squamous cell carcinoma, distant metastases usually occur only when the cancer is advanced or
recurrent. The 5-year survival rates are as follows:

 Stage I: 80 to 90%

 Stage II: 60 to 75%

 Stage III: 30 to 40%

 Stage IV: 0 to 15%

Nearly 80% of recurrences manifest within 2 years.

Adverse prognostic factors include

 Lymph node involvement

 Large tumor size and volume

 Deep cervical stromal invasion

 Parametrial invasion

 Lymphovascular space invasion (LVSI)

 Nonsquamous histology

Treatment

 Excision or curative radiation therapy if there is no spread to parametria or beyond

 Radiation therapy and chemotherapy if there is spread to parametria or beyond

 Chemotherapy for metastatic and recurrent cancer

Treatment of cervical cancer may include surgery, radiation therapy, and chemotherapy. If hysterectomy
is indicated but patients cannot tolerate it, radiation therapy plus chemotherapy is used.

Cervical intraepithelial neoplasia (CIN) and squamous cell carcinoma stage IA1

Treatment involves

 Conization or simple hysterectomy

Microinvasive cervical cancer, defined as FIGO stage IA1 with no lymphovascular space invasion (LVSI),
has a < 1% risk of lymph node metastases and may be managed conservatively with conization using
LEEP, laser, or cold knife. Conization is indicated for patients who are interested in preserving fertility.
Simple hysterectomy should be done if patients are not interested in preserving fertility or if margins are
positive after conization.

In cases of stage IA1 with lymphovascular space invasion, conization (with negative margins) and
laparoscopic pelvic sentinel lymph node (SLN) mapping plus lymphadenectomy (lymph node dissection)
is a reasonable strategy.

Stages IA2 to IIA

For stage IA2 or IB1 cervical cancer, the standard recommendation is

 Radical hysterectomy with bilateral pelvic lymphadenectomy (with or without SLN mapping)

Radical hysterectomy includes resection of the uterus (including the cervix), parts of the cardinal and
uterosacral ligaments, the upper 1 to 2 cm of the vagina, and the pelvic lymph nodes. Recent results
from a phase III prospective randomized trial (1) show that minimally invasive surgery (MIS) resulted in a
lower overall survival rate and a higher recurrence rate than total abdominal radical hysterectomy
(TARH). Therefore, practice patterns now show a preference for an open approach rather than MIS.

The Querleu & Morrow classification system describes 4 basic types of radical hysterectomy, with a few
subtypes that take nerve preservation and paracervical lymphadenectomy into account (2).

For stage IB2 to IIA cervical cancer, the most common approach is

 Combined chemotherapy and pelvic radiation

Another treatment option is radical hysterectomy and bilateral pelvic lymphadenectomy, sometimes
with radiation therapy (see table Sedlis Criteria for External Pelvic Radiation After Radical Hysterectomy).

If extracervical spread is noted during surgery, radical hysterectomy is not done, and postoperative
radiation therapy with concurrent chemotherapy is recommended to prevent local recurrence.

In some patients who have early-stage cervical cancer and who wish to preserve fertility, a radical
trachelectomy may be done. An abdominal, vaginal, laparoscopic, or robotic-assisted approach can be
used. In this procedure, the cervix, parametria immediately adjacent to the cervix, upper 2 cm of the
vagina, and pelvic lymph nodes are removed. The remaining uterus is reattached to the upper vagina,
preserving the potential for fertility. Ideal candidates for this procedure are patients with the following:
  Histologic subtypes such as squamous cell carcinoma, adenocarcinoma, or adenosquamous
carcinoma

 Stage IA1/grade 2 or 3 with lymphovascular space invasion

 Stage IA2

 Stage IB1 with lesions < 2 cm in size

Invasion of the upper cervix and lower uterine segment should be excluded by MRI before surgery. Rates
of recurrence and death are similar to those after radical hysterectomy. If patients who have this
procedure plan to have children, delivery must be cesarean. After a radical trachelectomy, fertility rates
range from 50 to 70%, and the recurrence rate is about 5 to 10%.

Stages IIB to IVA

For stages IIB to IVA cervical cancer, the standard therapy is

 Radiation therapy plus chemotherapy (eg, cisplatin)

Surgical staging should be considered to determine whether para-aortic lymph nodes are involved and
thus whether extended-field radiation therapy is indicated, particularly in patients with positive pelvic
lymph nodes identified during pretreatment imaging. A laparoscopic retroperitoneal approach is
recommended.

When cancer is limited to the cervix and/or pelvic lymph nodes, the standard recommendation is

 External beam radiation therapy, followed by brachytherapy (local radioactive implants, usually
using cesium) to the cervix

Radiation therapy may cause acute complications (eg, radiation proctitis and cystitis) and, occasionally,
late complications (eg, vaginal stenosis, intestinal obstruction, rectovaginal and vesicovaginal fistula
formation).

Chemotherapy is usually given with radiation therapy, often to sensitize the tumor to radiation.

Although stage IVA cancers are usually treated with radiation therapy initially, pelvic exenteration
(excision of all pelvic organs) may be considered. If after radiation therapy, cancer remains but is
confined to the central pelvis, exenteration is indicated and cures up to 40% of patients. The procedure
may include continent or incontinent urostomy, low anterior rectal anastomosis without colostomy or
with an end-descending colostomy, omental carpet to close the pelvic floor (J-flap), and vaginal
reconstruction with gracilis or rectus abdominis myocutaneous flaps.

Stage IVB and recurrent cancer

Chemotherapy is the primary treatment, but only 15 to 25% of patients respond to it.

In a recent study, adding bevacizumab to combination chemotherapy

(cisplatin plus paclitaxel or topotecan plus paclitaxel) resulted in an improvement of 3.7 months in
median overall survival in patients with recurrent, persistent, or metastatic cervical cancer (3).
Metastases outside the radiation field appear to respond better to chemotherapy than does previously
irradiated cancer or metastases in the pelvis.

Sentinel lymph node mapping for cervical cancer

Sentinel lymph node (SLN) mapping is an alternative to full pelvic lymphadenectomy for patients with
early-stage (IA1 with lymphovascular space invasion or IB1) cervical cancer (4) because only 15 to 20% of
these patients have positive nodes. SLN mapping therefore decreases the number of full pelvic
lymphadenectomies, which can have adverse effects (eg, lymphedema, nerve damage).

For SLN mapping, blue dye or technetium-99 ( 99Tc) is directly injected into the cervix, usually at 3 and 9
o’clock. More recently, indocyanine green (ICG) can be used as the tracer when open or minimally
invasive surgery is done. During surgery, SLNs are identified by direct visualization of blue dye, by a
camera to detect the fluorescence of ICG, or by a gamma probe to detect 99Tc. SLNs are commonly
located medial to the external iliac vessels, ventral to the hypogastric vessels, or in the superior part of
the obturator space.

Ultrastaging of all SLNs is done to detect micrometastasis and isolated tumor cells. Any suspicious node
must be removed regardless of mapping. If there is no mapping on a hemipelvis, a side-specific
lymphadenectomy is done.

Detection rates for sentinel node lymph mapping are best for tumors < 2 cm.

Criteria for radiation therapy after radical hysterectomy

Criteria used to determine whether pelvic radiation with concurrent chemotherapy should be done after
radical hysterectomy include the following (see table Sedlis Criteria for External Pelvic Radiation After
Radical Hysterectomy):

 Presence of lymphovascular space invasion

 Depth of invasion

 Tumor size

Prevention

Screening tests

Two types of screening tests for cervical abnormalities are used:

 Pap test

 HPV test

Routine cervical cancer screening tests are recommended as follows (1):

 From age 21 to 29: Usually every 3 years for the Pap test (HPV testing is not generally
recommended)

 Age 30 to 65: Every 3 years if only a Pap test is done or every 5 years if only an HPV test is done
or if both tests are done (more frequently in women at high risk of cervical cancer)
  After age 65: No more testing if test results have been normal in the preceding 10 years

If women have had a hysterectomy for a disorder other than cancer and have not had abnormal Pap test
results, screening is not indicated. (See also Cervical Cancer Screening Guidelines.)

HPV testing is the preferred method of follow-up evaluation for all women with ASCUS (atypical
squamous cells of undetermined significance), an inconclusive finding detected by Pap tests. If HPV
testing shows that the woman does not have HPV, screening should continue at the routinely scheduled
intervals. If HPV is present, colposcopy should be done.

HPV vaccine

Preventive HPV vaccines include

 A bivalent vaccine that protects against subtypes 16 and 18 (which cause most cervical cancers)

 A quadrivalent vaccine that protects against subtypes 16 and 18 plus 6 and 11

 A 9-valent vaccine that protects against the same subtypes as the quadrivalent plus subtypes 31,
33, 45, 52, and 58 (which cause about 15% of cervical cancers)

Subtypes 6 and 11 cause > 90% of visible genital warts.

The vaccines aim to prevent cervical cancer but do not treat it.

For patients ≥ 15 years, three doses are given over 6 months (at 0, 1 to 2, and 6 months). For patients <
15 years, two doses are given 6 to 12 months apart.

The HPV vaccine is recommended for boys and girls, ideally before they become sexually active. The
standard recommendation is to vaccinate boys and girls beginning at age 11 to 12 years, but vaccination
can begin at age 9.

KEY POINTS

 Consider cervical cancer if women have abnormal Pap test results, visible cervical lesions, or
abnormal, particularly postcoital vaginal bleeding.

 Do a biopsy to confirm the diagnosis.

 Stage cervical cancer clinically, using biopsy, pelvic examination, and chest x-ray, and if the
stage is > IB1, use PET/CT, MRI, or CT to identify metastases.

 Treatment is surgical resection for early-stage cancer (usually stages IA to IB1), radiation
therapy plus chemotherapy for locally advanced cancer (usually stages IB2 to IVA), and
chemotherapy for metastatic cancer.

 Screen all women by doing Pap and HPV tests at regular intervals.

 Recommend HPV vaccination for girls and boys.

Cervical Cancer: Types of Treatment

This section explains the types of treatments that are the standard of care for cervical cancer. “Standard
of care” means the best treatments known. When making treatment plan decisions, you are encouraged
to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to
treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than
the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or
new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment
and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn
more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan
that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams
include a variety of other health care professionals, such as physician assistants, oncology nurses, social
workers, pharmacists, counselors, dietitians, and others.

Descriptions of the common types of treatments used for cervical cancer are listed below. Your care plan
may also include treatment for symptoms and side effects, an important part of cancer care.

The treatment of cervical cancer depends on several factors, including the type and stage of cancer,
possible side effects, and the woman’s preferences and overall health. Take time to learn about all of
your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor
about the goals of each treatment and what you can expect while receiving the treatment. These types
of talks are called “shared decision making.” Shared decision making is when you and your doctors work
together to choose treatments that fit the goals of your care. Shared decision making is particularly
important for cervical cancer because there are different treatment options. Learn more about making
treatment decisions.

Women with cervical cancer may have concerns about if or how their treatment may affect their sexual
function and ability to have children, called fertility, and these topics should be discussed with the
health care team before treatment begins. A woman who is pregnant should talk with her doctor about
how treatments could affect both her and the unborn child. Treatment may be able to be delayed until
after the baby is born.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. A
gynecologic oncologist is a doctor who specializes in treating gynecologic cancer using surgery. For
cervical cancer that has not spread beyond the cervix, these procedures are often used:

 Conization is the use of the same procedure as a cone biopsy (see Diagnosis) to remove all of the
abnormal tissue. It can be used to remove cervical cancer that can only be seen with a
microscope, called microinvasive cancer.

 LEEP is the use of an electrical current passed through a thin wire hook. The hook removes the
tissue. It can be used to remove microinvasive cervical cancer.
  A hysterectomy is the removal of the uterus and cervix. Hysterectomy can be either simple or
radical. A simple hysterectomy is the removal of the uterus and cervix. A radical hysterectomy is
the removal of the uterus, cervix, upper vagina, and the tissue around the cervix. A radical
hysterectomy also includes an extensive pelvic lymph node dissection, which means lymph
nodes are removed. This procedure can be done using a large cut in the abdomen, called
laparotomy, or smaller cuts, called laparoscopy.

 If needed, surgery may include a bilateral salpingo-oophorectomy. This is the removal of both
fallopian tubes and both ovaries. It is done at the same time as a hysterectomy.

 Radical trachelectomy is a surgical procedure in which the cervix is removed, but the uterus is
left intact. It includes pelvic lymph node dissection (see above). This surgery may be used for
young patients who want to preserve their fertility. This procedure has become an acceptable
alternative to a hysterectomy for some patients.

For cervical cancer that has spread beyond the cervix, this procedure may be used:

 Exenteration is the removal of the uterus, vagina, lower colon, rectum, or bladder if cervical
cancer has spread to these organs after radiation therapy (see below). Exenteration is rarely
required. It is most often used for some people whose cancer has come back after radiation
treatment.

Complications or side effects from surgery vary depending on the extent of the procedure. Occasionally,
patients experience significant bleeding, infection, or damage to the urinary and intestinal systems.
Before surgery, talk with your health care team about the possible side effects from the specific surgery
you will have.

Because these surgical procedures affect a woman's sexual health, women should talk with their doctor
about their symptoms and concerns in detail before the surgery. The doctor may be able to help reduce
the side effects of surgery and provide support resources on coping with any changes. If extensive
surgical procedures have affected sexual function, other surgical procedures can be used to make an
artificial vagina.

Learn more about the basics of cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who
specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Radiation therapy
may be given alone, before surgery, or instead of surgery to shrink the tumor.

The most common type of radiation treatment is called external-beam radiation therapy, which is
radiation given from a machine outside the body. When radiation treatment is given using implants, it is
called internal radiation therapy or brachytherapy. A radiation therapy regimen, or schedule, usually
consists of a specific number of treatments given over a set period of time that combines external and
internal radiation treatments. This combined approach is the most effective to reduce the chances the
cancer will come back, called a recurrence.
For early stages of cervical cancer, a combination of radiation therapy and low-dose chemotherapy is
often used (see below). The goal of radiation therapy combined with chemotherapy is to increase the
effectiveness of the radiation treatment. This combination is given to control the cancer in the pelvis
with the goal of curing the cancer without surgery. It may also be given to destroy microscopic cancer
that might remain after surgery.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose
bowel movements. Side effects of internal radiation therapy may include abdominal pain and bowel
obstruction, although it is uncommon. Most side effects usually go away soon after treatment is finished.
After radiation therapy, the vaginal area may lose elasticity, so some women may also want to use a
vaginal dilator, which is a plastic or rubber cylinder that is inserted into the vagina to prevent narrowing.
Women who have received external-beam radiation therapy will lose the ability to become pregnant,
and unless the ovaries have been surgically moved out of the pelvis, premenopausal women will enter
menopause.

Sometimes, doctors advise their patients not to have sexual intercourse during radiation therapy.
Women may resume normal sexual activity within a few weeks after treatment if they feel ready.

Learn more about the basics of radiation therapy or read the American Society for Radiation Oncology’s
pamphlet, Radiation Therapy for Gynecologic Cancers (PDF; please note that this link takes you to a
separate, external website).

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given
through the bloodstream to reach cancer cells throughout the body. Systemic therapies for cervical
cancer are given by a gynecologic oncologist or medical oncologist, doctors who specialize in treating
cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a
needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for cervical cancer include:

 Chemotherapy

 Targeted therapy

 Immunotherapy

Each of these types of therapies is discussed below in more detail. A person may receive 1 type of
systemic therapy at a time or a combination of systemic therapies given at the same time. They can also
be given as part of a treatment plan that includes surgery and/or radiation therapy.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often
the best way to learn about the medications prescribed for you, their purpose, and their potential side
effects or interactions with other medications. It is also important to let your doctor know if you are
taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and
other drugs can interact with cancer medications. Learn more about your prescriptions by
using searchable drug databases.
Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from
growing, dividing, and making more cells.

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set
period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the
same time. For women with cervical cancer, chemotherapy is often given in combination with radiation
therapy (see above).

Although chemotherapy can be given orally (by mouth), all the drugs used to treat cervical cancer are
given intravenously (IV). IV chemotherapy is either injected directly into a vein or given through a thin
tube called a catheter, which is a tube temporarily put into a large vein to make injections easier.

The side effects of chemotherapy depend on the woman and the dose used, but they can include
fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects
usually go away after treatment is finished.

Rarely, specific drugs may cause some hearing loss. Others may cause kidney damage. Patients may be
given extra fluid intravenously to protect their kidneys. Talk with your doctor about the possible short-
term and long-term side effects based on the drugs and dosages you’ll be receiving.

Learn more about the basics of chemotherapy.

Targeted therapy (updated 07/2019)

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue
environment that contributes to cancer growth and survival. This type of treatment blocks the growth
and spread of cancer cells while limiting damage to healthy cells.

Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to
identify the genes, proteins, and other factors in your tumor. This helps doctors better match each
patient with the most effective treatment whenever possible. In addition, research studies continue to
find out more about specific molecular targets and new treatments directed at them. Learn more about
the basics of targeted treatments.

When cervical cancer has come back after treatment, called recurrent cancer, or if cervical cancer has
spread beyond the pelvis, called metastatic disease, it is treated with a platinum-based chemotherapy
combined with the targeted therapy bevacizumab (Avastin). There are 2 drugs similar to bevacizumab,
bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev), that have been approved by the FDA to
treat advanced cervical cancer. These are called biosimilars.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight
the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore
immune system function.

The immune checkpoint inhibitor pembrolizumab (Keytruda) is used to treat cervical cancer that has
recurred or spread to other parts of the body during or after treatment with chemotherapy. Some cancer
cells express the PD-L1 protein, which binds to the PD-1 protein on T cells. T cells are immune system
cells that kill certain cells, like cancer cells. When the PD-1 and PD-L1 proteins bind, the T cell does not
attack the cancer cell. Pembrolizumab is a PD-1 inhibitor, so it blocks the binding between PD-1 and PD-
L1, which allows the T cells to find and attack the cancer cells.

Different types of immunotherapy can cause different side effects. Common side effects include skin
reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side
effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and
financial effects. Managing all of these effects is called palliative care or supportive care. It is an
important part of your care that is included along with treatments intended to slow, stop, or eliminate
the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and
supporting patients and their families with other, non-medical needs. Any person, regardless of age or
type and stage of cancer, may receive this type of care. And it often works best when it is started right
after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often
have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation
techniques, emotional and spiritual support, and other therapies. You may also receive palliative
treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation
therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan.
You should also talk about the possible side effects of the specific treatment plan and palliative care
options.

During treatment, your health care team may ask you to answer questions about your symptoms and
side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a
problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It
can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more
about palliative care in a separate section of this website.

Treatment options by stage

Radiation therapy alone or surgery is generally used for an early-stage tumor. These treatments have
been shown to be equally effective at treating early-stage cervical cancer. Chemoradiation (a
combination of chemotherapy and radiation therapy) is generally used for women with a larger tumor,
an advanced-stage tumor found only in the pelvis, or if the lymph nodes have cancer cells. Commonly,
radiation therapy and chemotherapy are used after surgery if there is a high risk for the cancer coming
back or if the cancer has spread.

Metastatic cervical cancer

If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If
this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have
different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn
more about getting a second opinion before starting treatment, so you are comfortable with your
chosen treatment plan.

Chemotherapy, immunotherapy, and surgery may be used to treat or remove newly affected areas in
both the pelvic area and other parts of the body. Palliative care will also be important to help relieve
symptoms and side effects, especially with radiation therapy to relieve pain and other symptoms.

For most women, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and
your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other
members of the health care team. It may also be helpful to talk with other patients, including through
a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be
called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the
cancer will come back. While many remissions are permanent, it is important to talk with your doctor
about the possibility of the cancer returning. An important part of follow-up care is watching for
recurrence. Understanding your risk of recurrence and the treatment options may help you feel more
prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer returns after the original treatment, it is called recurrent cancer. Recurrent cancer may
come back in the same place (called a local recurrence), nearby (regional recurrence), or in another
place (distant recurrence).

When this occurs, a new cycle of testing will begin again to learn as much as possible about the
recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often
the treatment plan will include the treatments described above, such as surgery, systemic therapy, and
radiation therapy, but they may be used in a different combination or given at a different pace. Your
doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer.
Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side
effects.

Women with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to
talk with the health care team about these feelings and ask about support services to help you cope.
Learn more about dealing with cancer recurrence.

If treatment does not work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease
may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is
important to have open and honest conversations with your health care team to express your feelings,
preferences, and concerns. The health care team has special skills, experience, and knowledge to
support patients and their families and is there to help. Making sure a person is physically comfortable,
free from pain, and emotionally supported is extremely important.

Women who have advanced cancer and who are expected to live less than 6 months may want to
consider hospice care. Hospice care is designed to provide the best possible quality of life for people
who are near the end of life. You and your family are encouraged to talk with the health care team about
hospice care options, which include hospice care at home, a special hospice center, or other health care
locations. Nursing care and special equipment can make staying at home a workable option for many
families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more
about grief and loss.