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CONTINUING PROFESSIONAL DEVELOPMENT
Page 58 Page 59 Page 60
Cervical cancer multiple Read Lisa Scott’s Guidelines on how to
choice questionnaire practice profile on write a practice profile
fracture management
Cervical cancer:prevention,diagnosis,
treatment and nursing care
NS483 Hughes C (2009) Cervical cancer: prevention, diagnosis, treatment and nursing care.
Nursing Standard. 23, 27, 48-56. Date of acceptance: November 25 2008.
Summary
This article provides an update on cervical cancer, broadly covering
aspects of the disease ranging from epidemiology to aetiology and
prevention to treatment.
Author
Cathy Hughes is cancer lead, National Patient Safety Agency,
London. Email: cathy.hughes@npsa.nhs.uk
Keywords
Cervical cancer; Human papillomavirus; Prevention; Screening
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.
Aims and intended learning outcomes
This article aims to provide an update on
cervical cancer, including the incidence,
aetiology, diagnosis, treatment and prevention
of the disease. The role of the nurse is also
considered. After reading this article you should
be able to:
Describe the risk factors associated with
cervical cancer.
Outline the developments in the human
papillomavirus (HPV) vaccination.
Detail the aims and main components of
the NHS cervical screening programme.
Identify the treatment options available
for women with cervical cancer.
48 march 11 :: vol 23 no 27 :: 2009
Introduction
The application of cervical screening
programmes in developed countries has reduced
the incidence of cervical cancer. Although the
number of women diagnosed with the disease in
the UK has fallen by about 44% since 1975
(Cancer Research UK (CRUK) 2008), awareness
and prevention of cervical cancer remain
important issues for women and healthcare
professionals. All women in the UK over the age
of 25 years will have been routinely invited, at
some point, to attend cervical screening. With the
introduction of the HPV vaccination programme,
girls over the age of 12 years are now being made
aware of the disease and the effect it could have
on their lives.
Incidence
Globally, cervical cancer is the second most
common cancer in women after breast cancer.
Around half a million women are diagnosed with,
and one quarter of a million women die from,
the disease each year – the vast majority
of whom live in the developing world (World
Health Organization (WHO) 2008). Cervical
screening has significantly reduced the number of
women who develop or die from the disease but
only in countries where there is easy access to
cervical cytology or an organised cervical
screening programme.
In the UK, more than 2,800 women were
diagnosed with cervical cancer and around 1,000
died from the disease in 2005 (CRUK 2008).
The highest number of cases of cervical cancer
occurred in women aged between 30 and 34 years
and around 70% of cases occurred in women
under the age of 60 years (CRUK 2008) (Figure 1).
NURSING STANDARD

Time out 1
Draw and label a diagram of the
female pelvis using a general
anatomy and physiology textbook.
Consider the structures in close
proximity to the cervix and how they
might be affected by cervical cancer.
Anatomy
The uterus is a pear-shaped hollow organ
designed to accept and nourish a fertilised egg.
It is located in the female pelvis in front of the
rectum and behind the bladder. The cervix is the
name given to the lower third of the uterus, which
forms the narrow neck of the uterus. The lower
part of the cervix, known as the ectocervix,
protrudes into the vagina and can be seen by using
a vaginal speculum to part the folded tissue of the
vaginal walls. The opening on the ectocervix is
called the external os and varies in size and shape
depending on the age, parity and hormonal status
of the woman. The passageway between the
external os and the cavity of the uterus is called
the endocervical canal.
The epithelial surface of the cervix is lined with
two types of cells: stratified squamous cells, which
line the vaginal walls and the ectocervix; and
columnar or glandular cells, which line the
endocervical canal and extend outwards onto the
ectocervix. These two types of epithelial cells meet
at the squamocolumnar junction. During puberty
the cervix changes. The thin glandular epithelium
of the endocervical canal becomes exposed and is
gradually replaced by squamous epithelium. This
process is called squamous metaplasia and results
in the formation of a new squamocolumnar
FIGURE 1
Incidence of cervical cancer in the UK in 2005 (adapted from Cancer Research UK 2008)
400
368
350
300
Number of cases
250 237
200
150
100
61
50
5
0
25-29
20-24
15-19
30-34
NURSING STANDARD
junction. The area between the original
squamocolumnar junction and the new
squamocolumnar junction is called the
transformation zone (Figure 2).
The transformation zone can be seen on
speculum examination and is the site where most
cervical cellular abnormalities occur. The
vast majority of cervical cancers arise from the
squamous epithelium and are squamous cell
carcinomas. Around 10-15% of cervical cancers
are adenocarcinomas arising from the columnar
epithelium of the endocervix (WHO 2008).
The remainder of cervical cancers are made up of
more unusual cell types such as clear cell
carcinoma, small cell carcinoma, glassy cell
carcinoma, and melanoma (Vizcaino et al 1998,
2000, Sasieni and Adams 2001).
Time out 2
Before reading the next section,
make a list of what you think are
the main risk factors associated
with developing cervical cancer.
Risk factors
Risk factors for cervical cancer include sexual
behaviour, multiple pregnancies, smoking,
immunosuppression, oral contraceptive use and
low socioeconomic status.
Human papillomavirus HPV infection is
recognised as the main risk factor in the
development of cervical cancer, and has been
found in 99.7% of cases (Walboomers et al 1999).
There are more than 100 types of HPV. Some
cause skin warts or papillomas, which are benign.
About 40 HPV types are transmitted through
364
329
242
198 185
163 168
141
117 119
106
35-39
45-49
40-44
70-74
65-69
50-54
55-59
60-64
80-84
85+
75-79
Age range in years
march 11 :: vol 23 no 27 :: 2009 49

learning zone oncology
sexual or intimate contact and are thought to be
the most common sexually transmitted infections
found in at least 50% of sexually active
individuals, who are usually asymptomatic
(Centers for Disease Control and Prevention
2008). There are 13 sexually transmitted HPV
types with sufficient evidence to be classed as high
risk for the development of cervical cancer
(WHO 2008). Persistent infection with high-risk
sexually transmitted HPVs, including types 16
and 18, can lead to the development of abnormal
cell change, which may lead to cervical cancer.
However, most women who are infected with
high-risk HPVs do not go on to develop cervical
cancer (WHO 2006, 2008).
HPV infection is most commonly related to
sexual behaviour. The age at which women have
their first sexual encounter may increase their risk
of infection. Women who have had many sexual
partners or who have had sex with someone who
FIGURE 2
Transformation zone developments
2
2 Prevention
3 1
3
The cervical epithelium is made At puberty the junction of these
up of multilayered squamous two types of epithelium lies at the
epithelium on the ectocervix and external os.
thinner columnar epithelium in
the endocervix.
2 prophylactic vaccines. Two products are now
5 2007). Gardasil® also targets HPV types 6 and
4 11, which cause most cases of genital warts.
6 5
Lateral view of the cervix – the numbers relate to:
1. Squamous epithelium. 4. Everted columnar epithelium.
2. Columnar epithelium. 5. Transformation zone.
3. Squamocolumnar junction. 6. Glands opening in the
transformation zone.
(Diagram courtesy of the British Society for Clinical Cytology)
50 march 11 :: vol 23 no 27 :: 2009
has had many partners, have a greater risk of
contracting HPV (Brinton et al 1987). There may
also be an increased risk of HPV infection during
puberty, pregnancy or when taking the oral
contraceptive pill because of the enlarged
transformation zone at these times.
Immunosuppression Immunosuppression
has been shown to increase the risk of
cervical cancer especially in the presence of
human immunodeficiency virus, and where
immunosuppression is associated with organ
transplantation (Busnach et al 2006,
Leitao et al 2008). Women who smoke have an
increased risk of developing cervical cancer,
particularly in the presence of HPV infection, as
do women who have other sexually transmitted
infections (Plummer et al 2003, Haverkos 2005).
Socioeconomic status A meta-analysis by Parikh
et al (2003) found an increased risk of about
100% for low social class groups compared to
high social class groups for the development of
cervical cancer and a 60% increase in the
development of abnormal cervical cells. This
disparity is more pronounced in North America
and in low and middle income countries in
Europe. Lifestyle factors of women and their
partners are significant especially in the absence
of an accessible screening programme.
Health protection messages relating to cervical
cancer are controversial. The link between
cervical cancer and sexual behaviour has led to
stigmatisation and accusations of promiscuity
despite the common prevalence of HPV. HPV is
spread by skin contact and can be found all round
the genital area, so penetrative intercourse is not
required to transmit the virus, although condoms
have been shown to reduce the rates of infection
by up to 70% (Winer et al 2006).
The identification of HPV in almost all cases
of cervical cancer has led to the development of
licensed and available for use. Gardasil® and
Cervarix® target the two most common high-risk
HPV types 16 and 18, found in 70% of cervical
cancers (WHO and Institut Català d’Oncologia
Information Centre on HPV and Cervical Cancer
Short-term data suggests that the vaccines offer
protection against the development of cervical
intraepithelial neoplasia and few side effects have
been observed (WHO 2007).
In October 2007, the UK government
announced the introduction of an HPV
immunisation programme for females aged
12-13 years, to commence in September 2008.
A ‘catch up’ programme was also announced for
NURSING STANDARD
girls up to 18 years old who missed out on the
initial programme (Department of Health (DH)
2007a). In June 2008, it was announced that the
vaccine Cervarix® would be used in the NHS HPV
immunisation programme (Salisbury 2008).
Cervical screening
All women in the UK between the ages of 25 and
60 years are eligible for a free cervical screening test
every three to five years. The NHS Cancer
Screening Programmes (2008) in England offers
screening at different intervals dependent on age
(Table 1). The age at first screening in England was
raised from 20 years to 25 years based on the results
of a UK audit, which concluded that cervical cancer
was rare in women aged 20-25 years and that the
financial, psychoscocial and morbidity costs were
not justified (Sasieni et al 2003, 2006). Screening
continues in England until the age of 65 years.
In Northern Ireland, women aged 65 years are
offered cervical screening tests every three to
five years (NI Cancer Screening Programmes
2009); in Scotland, cervical screening tests are
offered every three years to women aged
20-60 years (NHS National Services Scotland
2009); and in Wales the target age group is
20-64 years (Cervical Screening Wales 2009).
Abnormal new growth or neoplastic lesions on
the cervix have been identified as leading to cervical
cancer in up to 36% of women with high-grade
lesions (McIndoe et al 1984). Women can be
examined for the presence of neoplasia before
cancer has developed and preventive treatment
can be commenced, so avoiding progression to
invasive disease and reducing the incidence of
cervical cancer.
Guidance on good practice for nurses
performing cervical screening is available (Royal
College of Nursing 2006). The first step in cervical
screening is to take a sample of the cells from the
cervix. All cervical screening samples in the NHS
are now taken using liquid-based cytology.
Liquid-based cytology is a relatively new way of
preparing cervical cell samples. The sample is
collected using a soft brush to remove cells from the
cervix. The head of the brush is broken off or rinsed
directly into preservative fluid and examined in a
laboratory (NHS Cancer Screening Programmes
2008). Liquid-based cytology has been shown to
reduce the reported inadequate smear rate from
9% to 1.2% (Moss et al 2004).
Once the cell sample is taken it can be sent to
the cytology laboratory where the cells are
assessed for the presence of nuclear abnormalities
or dyskaryosis, which are graded as mild,
moderate or severe. The presence of dyskaryosis
suggests that there may be cervical intraepithelial
neoplasia (premalignant changes in the cervix) in
the underlying tissue.
NURSING STANDARD
Referral to colposcopy A woman who has an
abnormal cervical cytology result potentially needs
further assessment. The NHS Cancer Screening
Programmes (2004) guidelines defined the criteria
by which women are referred for colposcopy
assessment (Box 1).
The colposcope is an instrument that
magnifies and illuminates the cervix for closer
examination. Staining the cervix with acetic acid
and iodine allows the abnormal portion of the
epithelium to be viewed and accurately biopsied.
Neoplastic squamous lesions on the cervix are
graded according to severity: cervical
intraepithelial neoplasia (CIN)1, CIN2 and
CIN3. CIN does not in itself cause problems but
with over one third of women with CIN3 likely to
develop cancer it is necessary to treat or observe
according to the degree of risk.
Women with CIN1 are often kept under
surveillance. Women with CIN2 and CIN3 are
usually treated. In the UK, the most common
approach to treatment would be removal of the
transformation zone with a large loop excision
also known as loop diathermy or a loop
electrosurgical excision procedure. The cervical
tissue that is removed is shaped like a cone, hence
the term cone biopsy. In the UK, the British Society
TABLE 1
Screening guidelines for England
Age group (years) Frequency of screening
25 First invitation
25-49 Every three years
50-64 Every five years
65 and over Only screen if the individual
has not been screened since
the age of 50 years or has
had recent abnormal tests
(NHS Cancer Screening Programmes 2008)
BOX 1
Referral to colposcopy
Routine
Three consecutive inadequate results.
Three tests in a series reported as borderline.
Borderline changes in endocervical cells.
Three abnormal results in a ten-year period.
Any grade of dyskaryosis (some clinicians may
repeat a test showing mild dyskaryosis).
Urgent (seen within two weeks)
Any suggestion of invasion or glandular
abnormality.
(NHS Cancer Screening Programmes 2004)
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for Colposcopy and Cervical Pathology (BSCCP)
sets standards for colposcopy and colposcopists
(NHS Cancer Screening Programmes 2004).
Current recommendations insist that unsupervised
colposcopy should only be performed by those
accredited by the BSCCP, whatever their clinical
background or expertise. Nurses can become
accredited alongside medical colleagues if they
complete the training and maintain practice as
stipulated by the BSCCP (2009). According to the
BSCCP (2009) there are now more than 100
trained nurse colposcopists who are registered
members and this number is increasing.
In England, 3.4 million women were screened
in 2007/08. Around 6.6% of the target group had
an abnormal result, with 122,000 being referred
to colposcopy and 16% of those having severe
dyskaryosis or worse(NHS Information Centre
2008). The cervical screening programme in
England costs about £157million (NHS Cancer
Screening Programmes 2008) but it is thought to
be directly responsible for the 42% drop in
cervical cancer incidence in England and Wales
observed between 1988 and 1997. This equates
to a saving of around 1,300 lives per year
(Sasieni and Adams 1999).
Given the rising rates of sexually transmitted
infections, it is now estimated that the cervical
screening programmes in the UK are preventing
about 5,000 deaths per year (Peto et al 2004).
Screening coverage (the percentage of eligible
women screened in the defined time) has fallen
steadily in England, from 82.5%in 1998 to
79.2% in 2008, but this decline has been more
marked in the 25-29 years age group where
five-year coverage fell from 78.8% to 66.2% and
the three or 3.5-year coverage fell from 66.4% to
58.6% in the same ten-year period (NHS
Information Centre 2008). It is not clear why
some younger women are no longer attending
cervical screening appointments, but falling
mortality rates may have reduced general
awareness of the condition.
Cervical cancer incidence in the UK may
increase in the future because of this fall in
screening attendance and also because of the
increase in eastern European immigration where
there are cohorts of women who have never been
screened. Women should be encouraged to
participate in the screening programme at the
appropriate age and frequency by all healthcare
professionals (DH 2007b).
It takes many years for cervical cancer to develop
following HPV infection. Therefore, it will take
many years before the introduction of a vaccine has
any major effect on the number of cases of cervical
52 march 11 :: vol 23 no 27 :: 2009
cancer. It is vital in the interim that women continue
to be screened for cervical cancer risk.
Time out 3
In the UK, more than
4.5 million women are offered
cervical screening each year
(NHS Cancer Screening Programmes
2008, Cervical Screening Wales 2009,
NHS National Services Scotland 2009 and
NI Cancer Screening Programmes 2009).
Think about the value of screening and the
physical, financial, social and psychological
implications for the individuals. List the
potential advantages and disadvantages of
cervical screening.
Implications Cervical screening may affect
individuals in a number of ways. In relation to
Time out 3 you should have considered:
The overall financial cost of all aspects of
screening, which would include the
administration of services, laboratory staff,
counselling services, clinical staff, out of hours
services or time off work and the management
of treatment complications.
The medicalisation of women’s health, which
refers to the way in which patriarchal systems
control women’s bodies.
The anxiety associated with having a medical
investigation, waiting for a result and the
significance of an inconclusive or abnormal
result.
The number of women who worry about an
abnormal result without ever having cancer,
or ever going on to develop cancer.
The number of women who are treated
unnecessarily, by having CIN removed that
would never have developed into cervical cancer.
The physical and psychological risks and
benefits associated with treatment of CIN.
The number and type of women who do not
attend for cervical screening and how they are
disadvantaged or ignored.
The number of women whose lives have been
saved, and the families that will benefit from this.
Time out 4
Consider how you would
encourage women to participate
in the cervical screening
programme and the advice you
would offer to patients, friends and
family members who are anxious about
undergoing cervical screening.
NURSING STANDARD

Diagnosis and staging
With intraepithelial neoplasia the abnormal cells do
not penetrate or invade the basement membrane
of the cervical epithelium. If this does occur the
lesion is defined as a cancer, or an invasive lesion.
The depth of invasion of the basement
membrane, size of the tumour and extent of spread
determine the disease’s stage and this information
is used to record and plan appropriate treatment.
In gynaecology, the cancer staging system used is
that of the International Federation of Gynecology
and Obstetrics (Benedet et al 2000) (Box 2).
Cervical cancer begins with a microinvasive
stage, which is not visible to the naked eye. Larger
lesions become visible and can extend into the
vagina, bladder, rectum, pelvic walls and distant to
organs (Figure 3). Early cervical cancers are often
without symptoms and only discovered on further
investigation of an abnormal cervical cytology
result. Women with visible cancer of the cervix
often present with symptoms such as bleeding after
sexual intercourse or an offensive discharge.
A woman who is not sexually active may present
at an advanced stage with symptoms such as back
pain, urinary problems, fistulae, lymphoedema or
extremely heavy bleeding. A diagnosis is made on
histological assessment of the abnormal tissue.
The staging of cervical cancer involves an
examination under anaesthetic by a trained
gynaecological oncology surgeon to comply
with UK cancer services guidelines (DH 2004).
Potential spread anteriorally would involve
the bladder and posteriorally the bowel, so
endoscopic assessment of the bladder and rectum is
usually carried out. The vulva and vagina should
be assessed for any other areas of intraepithelial
neoplasia. This could be multifocal disease and
other sites may require treatment. Magnetic
resonance imaging (MRI) is increasingly used to
assess the extent of pelvic disease and a chest X-ray
will reveal any lung metastasis. A renal assessment
should be made if there is no access to MRI. This is
the minimum information required to stage
adequately a woman and ensure that optimum
treatment is planned (Benedet et al 2000).
Time out 5
Outline the types of treatment
for cervical cancer. Consider the
impact of these treatments on
women diagnosed with the disease.
Treatment
In 1995 a Europe-wide study showed that the UK
lagged behind comparable European countries in
the successful treatment of people with cancer
NURSING STANDARD
(Berrino et al 1995). The document
A Policy Framework for Commissioning Cancer
Services (DH 1995) and the NHS Cancer Plan
(DH 2000) attempted to improve cancer
outcomes by reconfiguring services. Women with
cervical cancer should now be referred to, or at
least discussed by, a specialist multidisciplinary
team in a recognised cancer centre with a clinical
nurse specialist (DH 2004).
Treatment choices for cervical cancer are based
on the stage of the disease, but primarily involve
surgery, radiotherapy and chemotherapy.
Although the stage of the tumour is the primary
BOX 2
Staging of cervical cancer
Stage 0
Carcinoma in situ (pre-invasive carcinoma).
Stage I
The carcinoma is strictly confined to the cervix (extension to the corpus
should be disregarded).
Stage Ia – invasive carcinoma diagnosed only by microscopy
(all macroscopically visible lesions, even with superficial invasion, are
stage Ib carcinomas).
Stage Ia1 – stromal invasion of not >3.0mm in depth and extension
of not >7.0mm.
Stage Ia2 – stromal invasion of >3.0mm and not >5.0mm in width,
with an extension of not >7.0mm.
Stage Ib – clinically visible lesion limited to the cervix uteri or
pre-clinical cancers greater than stage Ia.
Stage Ib1 – clinically visible lesions not >4.0cm visually.
Stage Ib2 – clinically visible lesions >4.0cm visually.
Stage II
Cervical carcinoma invades beyond the uterus but not to the pelvic wall
or lower third of the vagina.
Stage IIa – no obvious parametrial involvement.
Stage IIb – obvious parametrial involvement.
Stage III
The carcinoma has extended to the pelvic wall. On rectal examination
there is no cancer-free space between the tumour and the pelvic wall.
The tumour involves the lower third of the vagina. All cases with
hydronephrosis or non-functioning kidney are included, unless they are
known to be the result of another cause.
Stage IIIa – tumour involves lower third of the vagina, with no
extension to the pelvic wall.
Stage IIIb – extension to the pelvic wall and/or hydronephrosis or
non-functioning kidney.
Stage IV
The carcinoma has extended beyond the true pelvis, or has involved the
mucosa of the bladder or rectum (biopsy proven).
Stage IVa – spread of the growth to adjacent organs.
Stage IVb – spread to distant organs.
(Benedet et al 2000)
march 11 :: vol 23 no 27 :: 2009 53

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consideration, other prognostic factors can be
taken into account such as tumour histological
type and lymphovascular space invasion.
Cervical cancer is found in young women who
may not have started or completed a family and
consideration should be given to the preservation
of fertility wherever possible.
Stage Ia1 The treatment for early cervical cancer
in a woman who has completed her family would
involve a hysterectomy. The risk of disease being
present in the lymph nodes at this stage is low.
Where there is a concern for fertility
preservation, a woman can be treated with an
excision biopsy, otherwise known as a cone
biopsy. If the margins of the biopsy are clear of
cancer she will not require any further treatment
but careful follow up should be maintained.
Stage Ia2 There is a definite potential for lymph
node metastasis and any surgical treatments of
the primary tumour should also include removal
of the draining lymph nodes (lymphadenectomy).
Traditionally, women would have been offered a
hysterectomy and although there is a chance of
lymph node involvement there is little chance of
finding disease outside the cervix. D’Argent et al
(1994) were the first to describe fertility sparing
surgery in the form of radical trachelectomy in the
French literature (Shepherd et al 2001), involving
removal of the cervix together with the pelvic
lymph nodes, leaving the body of the uterus
intact. This type of surgery is being offered in
many UK specialist centres to women who have
been carefully assessed and wish to retain their
fertility (Shepherd et al 2006). Following the
procedure a stitch is placed at the base of the
uterus to hold a future pregnancy. The baby
would need to be delivered by Caesarean section
in a specialised obstetric unit.
FIGURE 3
Stages of cervical cancer
Early stage I Late stage I Stage II
Uterus
Cervix
Vagina
Cancer
54 march 11 :: vol 23 no 27 :: 2009
Stage 1b or IIa <4cm These stages have a good
prognosis with surgery or radiotherapy. Most UK
cancer centers will offer a radical (Wertheim’s
hysterectomy) or modified radical hysterectomy
for a woman where surgery is not contraindicated.
Pelvic lymph nodes are removed together with up
to one third of the upper vagina. The ovaries can
be left in younger women, but there is some
evidence that the menopause could occur up to
five years earlier following a hysterectomy
(Farquhar et al 2005).
In all surgical cases, if the lymph nodes are
histologically positive for cancer spread, or if
there are positive margins or other poor
prognostic factors, post-operative radiotherapy
is recommended to reduce pelvic recurrence rates.
Stage IIa and above The cancer is more locally
advanced and the chance of lymph node
involvement is high. Treatment traditionally
involved the use of radical radiotherapy alone.
However, Rose et al (1999) published early
findings of their study to show that platinum-based
chemotherapy, in the form of cisplatin, acted as a
radiosensitiser enhancing the effect of the
radiotherapy. The radiotherapy consists of
external beam and internal radiotherapy
delivered directly to the cervix (brachytherapy).
The dose of pelvic radiotherapy required will
be enough to induce permanent ovarian failure
and will ensure a premenopausal woman
becomes menopausal and infertile. The ovaries
can be moved or transposed before treatment
and, although the success rates are low following
a radical course of pelvic radiotherapy, it is
important for women to be able to explore this
option before treatment. Other fertility
preservation options to consider are embryo
freezing and other experimental methods of
ovarian egg or tissue preservation, all of which
would involve the use of a surrogate.
Radiotherapy will also affect the tissue in the
vagina indirectly because of a lack of oestrogen
with an induced menopause, and directly with
vaginal tissue damage. This can lead to vaginal
stenosis, which is a shortening and narrowing of
the vagina. A vaginal dilator can be used to help a
woman retain the patency of the vagina for sexual
intercourse and the vaginal examinations
required during follow-up assessment.
Stage IV Cervical cancer diagnosed at this stage
is less common in the UK. Local control of the
disease can be important for symptomatic relief
and quality of life even in the presence of distant
metastasis. Local control usually involves
radiotherapy or surgery. Chemotherapy is
increasing being used to control this cancer in
advanced or recurrent situations but is not
generally used with curative intent. Even
palliative treatment for women with cervical
cancer can appear quite radical but local control
NURSING STANDARD
can help a woman have a reasonable amount usually contraindicated but advice can be sought
of quality time with her family and friends from local gynaecological cancer specialist
because of the relatively slow growing nature teams, which include gynaecological cancer
of the disease. clinical nurse specialists.
Palliative care in cervical cancer often involves Recurrent cervical cancer can be treated with
the management of severe pain, lymphoedema, radiotherapy if the initial treatment involved
foul-smelling discharge, vaginal bleeding, renal surgery alone. Radical radiotherapy cannot be
failure, and fistulae. Fistulae can occur between
the bladder and/or the bowel and the vagina,
TABLE 2
causing urine and/or faeces to leak
uncontrollably. Renal failure can occur as a result Five-year survival by stage of cervical cancer
of compression of the ureters; ureteric stenting Stage Five-year survival
should be considered because women with (approximate percentages)
cervical cancer can be otherwise reasonably well
Ia1 98
and remain so for some time.
Ia2 95

Survival rates Ib1 85

The overall cure rates (five-year survival) for Ib2/IIa 75

women with cervical cancer are high (Table 2). IIb 65
Survivors of cervical cancer will have to live with IIIa/b 30
the effects of the disease and its treatment,
including infertility, lymphoedema, sexual IVa 10
dysfunction or psychological sequelae. Taking IVb 5
hormone replacement therapy or local oestrogens
(World Health Organization 2006)
following a cervical cancer diagnosis is not

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Jones H 3rd, Ngan HY, Pecorelli S
(2000) FIGO staging classifications
and clinical practice guidelines in
the management of gynecologic
cancers. FIGO Committee on
Gynecologic Oncology. International
Journal of Gynaecology and
Obstetrics. 70, 2, 209-262.
Berrino F, Sant M, Verdecchia A,
Capocaccia R, Hakulinen T,
Estève J (1995) Survival of cancer
patients in Europe. The EUROCARE
study. International Agency for
Research on Cancer Scientific
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learning zone oncology
repeated and the role of radiotherapy in a woman
who has had a radical dose is limited when the
recurrence is in the initial radiation field.
A radical surgical procedure called a pelvic
exenteration can be considered if the disease is
central, mobile and shows no evidence of spread
outside the pelvis or to the pelvic side walls. Pelvic
exenteration involves the removal of the cancer
and the uterus (if still present) and possibly the
vagina and the bladder and/or bowel, resulting in
the formation of one or two stomas. Women who
undergo such radical treatment are carefully
assessed and counselled extensively. Five-year
survival rates of up to 50% have been reported
following exenteration (Juretzka et al 2008).
Conclusion
The prevention, diagnosis and treatment of
women with cervical cancer requires the
combined effort of primary and acute services.
Women need to be guided with good health
education through a vaccination programme,
cervical screening, disease diagnostic services,
radical cancer treatments, specialist palliative
care and survivorship issues relating to fertility,
sexual and psychological dysfunction and
early menopause.
Cervical screening programmes should be
implemented worldwide to improve the detection
of women at risk of developing cervical cancer
and promote early treatment of the disease.
However, in countries where this is unlikely to
happen, HPV vaccination may offer a solution
for the future NS

Time out 6 Time out 7

List the ways in which nurses are involved in managing Now that you have completed
cervical cancer. Consider all aspects of health care the article, you might like to write
including health education, school vaccination programmes, a practice profile. Guidelines to help
palliative care, psychological support, fertility and obstetrics. you are on page 60.

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