QuestionSBA
QuestionChoice
This is correct. All women aged 25 to 49 are invited for "routine recall" if a cervical sample is negative for high-risk HPV
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a
Return for cervical screening in 3 years
QuestionChoice
The NHS employ a "HPV first" system whereby a the sample is first tested for high risk strains of HPV, and cytological examination is only performed if this is positive
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e
Cytological examination of the sample
QuestionChoice
All women aged 25 to 49 are invited for routine cervical screening every 3 years. Between the ages of 50 and 64 this becomes every 5 years
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b
Return for cervical screening in 5 years
QuestionChoice
Colposcopy is only indicated if the cytology of the cells is abnormal, or there are two consecutive inadequate samples. In the current "HPV first" system in the NHS screening programme, the sample is only tested for cytology if it is positive for high risk strains of HPV. As this patient's sample was negative, it was not tested for cytology
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d
Refer for colposcopy
QuestionChoice
All women aged 25 to 49 are invited for screening every 3 years, even if their previous screening was normal
31950
c
Discharge from national screening programme
QuestionComment
This has very recently been changed to 5 years instead of 3 (with quite a bit of controversy)
6241
QuestionComment
its been changed in wales and scotland!
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Dermis Cystic
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Ventral Monoclonal
QuestionComment
For England and Northern Ireland – you get an invite every 3 years if you are aged 25 to 49. After that, you get an invite every 5 years until the age of 64.

For Wales and Scotland – you get an invite every 5 years if you are aged 25 to 64.

16591
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Fibrillation JAK
QuestionComment
Yes I agree, feel this needs to state which country the patient is in as this is varies across the UK 

21091
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RNA Metabolism
QuestionComment
Yeah as per previous comments, in Scotland this is 5 years
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DNA Dominant
Concept
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# Summary
  
 
Cervical cancer is the 3rd most common cancer worldwide and the 4th largest cause of cancer death. It is primarily caused by persistent human papillomavirus (HPV) infection and is commonly squamous cell carcinoma. The key clinical features include vaginal discharge, bleeding, discomfort, and changes in urinary or bowel habits. Investigations involve an urgent colposcopy and CT scans for staging. Management strategies depend on the stage of cancer and the patient's fertility desires, ranging from conisation and radical trachelectomy for early-stage cancers to radiotherapy and chemotherapy for more advanced cases.
  
 
# Definition
  
 
Cervical cancer is a type of cancer that occurs in the cells of the cervix (the lower part of the uterus that connects to the vagina). The majority of cervical cancers are squamous cell carcinomas. 
  
 
# Epidemiology
  
 
Cervical cancer is the 4th most common cancer in women worldwide. In the UK, it is the 14th most common cancer amongst women.
Over 90% of cervical cancer deaths and similarly higher prevalence is seen in low- and middle-income countries (LMICs), highlighting inequity in access to HPV-prevention (vaccination), cervical cancer screening and treatment options between LMICs and high-income countries.  
  
 
# Aetiology
 
Cervical cancer is strongly associated with persistent human papilloma virus (HPV) infection. The majority of cases are squamous cell carcinoma.
  
Risk factors for cervical cancer include: 
 
  - HPV 16 and 18 infection (accounts for 70% of cases)
  - Multiple sexual partners
  - Smoking
  - Immunosuppression (e.g. HIV or organ transplants)
  
 
# Signs and symptoms
  
 
Most cases of cervical cancer are picked up asymptomatically at cervical screening. Other clinical features include:
 
  - Vaginal discharge
  - Bleeding (e.g. postcoital or with micturition or defaecation)
  - Vaginal discomfort
  - Urinary or bowel habit change
  - Suprapubic pain
  - Abnormal white/red patches on the cervix.
  - Pelvic bulkiness on PV examination
  - Mass felt on PR examination
  
 
# Differential diagnosis
  
 
The differential diagnosis for cervical cancer includes other causes of abnormal vaginal bleeding or discharge such as vaginitis, cervicitis, endometrial cancer, and cervical polyps. Key signs and symptoms of these differentials include:
  
 
1.  **Vaginitis:** itching, burning, pain, and abnormal discharge
2.  **Cervicitis:** abnormal discharge, pelvic pain, and postcoital bleeding
3. **Endometrial cancer:** abnormal vaginal bleeding, pelvic pain, and unintentional weight loss
4. **Cervical polyps:** abnormal vaginal bleeding, discharge, and pain during intercourse
  
 
# Investigations

**Bedside:**

* Speculum examination (with sample for cytology and HPV testing) 

**Bloods:**

* FBC (anaemia)
* LFTs (liver involvement)
* U&Es (renal involvement) 

**Imaging:**

* CT chest/abdomen/pelvis (for staging)

**Invasive:** 

* Colposcopy (urgent) and cervical biopsy  
 

# Management
  
 
The treatment for cervical cancer depends on the stage of the cancer, and also whether the woman wants to retain fertility.
  
 
  - For very small cancers in stage IA treatment options include conisation with free margins if aiming to spare fertility. Conisation is done using a scalpel (cold-knife conisation), laser, or electrosurgical loop, and is usually performed as an outpatient.
  - Radical trachelectomy can be done for slightly more advanced, yet still early-stage cancers when the aim is to spare fertility. This involves removal of the cervix, the upper vagina and pelvic lymph nodes.
  - Where maintaining fertility is not an aim a laparoscopic hysterectomy and lymphadenectomy is offered for women for early-stage cancer.
  - For invasive, infiltrating and early metastatic cancer a radical (Wertheim's) hysterectomy can be performed which involves removal of the uterus, primary tumour, pelvic lymph nodes, and sometimes the upper third of the vagina and uterovesical and uterosacral ligaments.
  - If the cancer has spread outside the cervix and uterus, then surgical management is often unlikely to be curative. These cancers are treated with radiotherapy and/or chemotherapy.
  
# Complications 

* Surgical complications: bladder dysfunction, leg oedema (due to lymphadenectomy), preterm birth 
*  Radiation complications: vaginal stenosis, vaginal atrophy, bladder dysfunction, urethral strictures

# Prognosis 

Cervical cancer is preventable through screening. Mortality has decreased significantly as a result of improved treatment and screening programmes. Overall 5-year survival is 67%. However, this varies based on stage of disease at diagnosis:

* Stage I: >90%
* Stage II-III: 50-70%
* Stage IV: <20%

# Cervical Screening
  
 
  - For all women and people with a cervix between the age of 25-64 years. 
  - Cervical sample is taken and tested for high-risk HPV viruses. 
  - From 24 to 49 women are called every three years, and afterwards every five years.
- The idea behind the screening process is to identify dyskaryotic cells which are pre-cancerous allowing management before invasive cancer can develop.
  
 
## Outcomes in screening
  
 
Outcomes from screening can be as follows:
  
 
  - Anybody with a negative HPV test is returned to routine recall.
  - Anybody with a positive HPV test has cytological testing. 
          - Patients who are HPV positive but have negative cytology results should have a repeat HPV test in 12 months and again at 24 months if still positive. If they remain positive at 24 months they should be referred to colposcopy.
  - In some cases the sample may be inadequate, in which case the smear should be repeated. If it still not adequate for the next two samples, then the woman should be referred for colposcopy.
  
 
# HPV Vaccination
  
 
  - Girls and boys aged 12 to 13 years are offered the HPV vaccine as part of the NHS vaccination programme
  - The vaccine helps protect against cancers caused by HPV, including cervical cancer, some mouth and throat cancers and some cancers of the anal and genital areas. It also helps protect against genital warts
  - Gardasil is the vaccination used and protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58
  
# NICE Guidelines
 
  [Click here for NICE CKS on Cervical cancer](https://cks.nice.org.uk/topics/cervical-cancer-hpv/)
  
 
  [Click here for NICE CKS on Cervical cancer screening](https://cks.nice.org.uk/topics/cervical-screening/)
 
 
# References
 
[Cancer UK](https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer)  
[NHS Page](https://www.nhs.uk/conditions/cervical-cancer/)
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Cervical cancer
Topic
26
Gynaecology
6390
Women aged 25 to 49 should return for cervical screening every three years if their HPV test is negative.
A 25 year old female presents to her general practice for her first routine cervical screening. She has no gynaecological symptoms.

On speculum examination, her cervix appears normal.

The sample returns as negative for human papillomavirus (HPV).

What is the next best step?
a