Assess and manage cervical cancer, including recurrent disease and post-treatment care

In one line

Cervical cancer is an HPV-driven malignancy staged by FIGO 2018 (now incorporating imaging and nodal status); cure depends on getting the first treatment right — radical surgery for genuinely early disease, definitive cisplatin-based chemoradiation plus brachytherapy (never surgery plus radiation if avoidable) for everything locally advanced — and in South Africa most patients still present too late for surgery to be the question.

This chapter assumes the premalignant groundwork: HPV carcinogenesis, CIN and colposcopy. Revise those at cervical carcinogenesis and CIN pathophysiology, and the screening/colposcopy interface at Cervical premalignancy colposcopy. The focus here is the consultant decision: defending a treatment plan.

Assessment

• History/examination: abnormal bleeding (postcoital, intermenstrual, postmenopausal), discharge, pelvic/back pain or leg oedema (advanced). Examine the cervix directly; a friable, contact-bleeding lesion needs a biopsy, not a smear — cytology is a screening tool and a normal smear never excludes a visible cancer.
• Tissue diagnosis: punch/wedge biopsy of the lesion; cone/LLETZ where microinvasion is suspected and depth of invasion must be measured. Squamous (~70%) and adenocarcinoma (~25%, rising); note neuroendocrine and rare histologies, which behave aggressively.
• Staging is FIGO 2018, now hybrid clinical–radiological–pathological. The 2018 revision removed lateral extension from stage IA (depth only), split IB into IB1 (<2 cm), IB2 (2–<4 cm), IB3 (≥4 cm), and created stage IIIC for nodal disease (IIIC1 pelvic, IIIC2 para-aortic) — any tumour size with positive nodes upstages to IIIC. Suffixes r (imaging) and p (pathology) record how nodal status was assigned.
• Imaging: pelvic MRI is best for local tumour size, parametrial and stromal invasion; PET-CT (or CT where unavailable) for nodal and distant disease. In SA, MRI access is uneven — at district/regional level, examination under anaesthesia with cystoscopy/proctoscopy and CT still carry staging weight, and the r notation is honest about that.
• Baseline: FBC, U&E/creatinine (hydronephrosis from ureteric obstruction = stage IIIB and a renal-function threat), and an HIV test in every patient — non-negotiable in SA, where HIV both drives incidence and shapes treatment tolerance.

The advanced assessment — subtype, severity and the judgement calls

The diagnosis is rarely the difficulty; the harder consultant task is reading the histological subtype, the stromal/nodal geometry and the host and letting those change the plan. With the "how to take a biopsy and read a smear" groundwork assumed, the advanced layer is what follows.

Histological subtype changes prognosis and the threshold for adjuvant treatment, not just the label. The trials that built modern practice (SHAPE, the Sedlis intermediate-risk criteria) were derived overwhelmingly from squamous disease, so the further the patient is from squamous, the more you should distrust a reassuring stage:

• Squamous (~70%) — radiosensitive, the reference subtype for every chemoradiation trial; the one where omitting brachytherapy is most clearly fatal to local control.
• Usual-type (HPV-associated) adenocarcinoma (~25% and rising) — behaves broadly like squamous, but be alert to skip lesions and a higher rate of ovarian and peritoneal spread; the cervix can look deceptively normal with an endocervical (barrel) tumour growing upward, so a normal-looking ectocervix with an abnormal smear and a bulky cervix on bimanual is adenocarcinoma until proven otherwise.
• Gastric-type / HPV-independent adenocarcinoma — the dangerous mimic: HPV-negative, vaccine-irrelevant, often cytology-negative (it is not picked up by an HPV-based screen at all), associated with Peutz–Jeghers/STK11, frequently presents with watery discharge and a deeply infiltrative tumour, and is relatively chemoradiation-resistant. The Silva pattern-based classification of endocervical adenocarcinoma (pattern A purely glandular/indolent → pattern C destructive/node-positive) is the modern way to stratify these and decide who can be spared lymphadenectomy.
• Small-cell / large-cell neuroendocrine carcinoma — a different disease: early haematogenous and nodal spread, treated like small-cell lung cancer (platinum–etoposide systemic chemotherapy integrated with local therapy) regardless of how "early" the stage looks. Staging it as an ordinary IB1 and doing a radical hysterectomy alone is a classic error — even small NEC needs systemic therapy.

Severity stratification beyond the FIGO number. Two patients can share a stage and need opposite plans. The features you can read pre-operatively on imaging and act on are: tumour ≥4 cm (IB3), parametrial reach on MRI, and suspicious pelvic or para-aortic nodes on PET-CT. Deep stromal invasion and extensive LVSI predict the same adjuvant radiation, but they are histological features that are not visible on imaging and only declare themselves on the operative specimen. Because any one of these predicts the patient will earn adjuvant radiation after surgery, and stacking surgery and radiation is the "double whammy" to be designed out before the first incision, gross nodal or parametrial disease on imaging is the signal to go straight to primary chemoradiation. Conversely, the SHAPE-eligible patient (genuinely ≤2 cm, <10 mm stromal invasion or <50% on MRI, node-negative) is the one in whom you can now de-escalate.

The host is part of the stage in South Africa. An immunosuppressed woman with a low CD4 count, anaemia and renal impairment from ureteric obstruction tolerates pelvic chemoradiation differently from a fit HIV-negative woman with the same FIGO stage. Quantify host reserve — CD4 and viral load, haemoglobin, eGFR, nutritional state — because these, not the FIGO digit, predict whether she will complete treatment within the time window that determines cure.

FIGO 2018 staging & grading — recap

Staging = the anatomical extent (how far the cancer has spread) and is what drives treatment; grading (G1–G3) = how abnormal the cells look down the microscope and refines prognosis. For cervix, grade is not part of the FIGO stage. The recap below is grouped by stage so the jump at each boundary is clear.

The r and p suffixes (new in 2018 — staging is now hybrid). Cervical staging is no longer purely clinical; imaging and pathology are allowed in, and FIGO records how a stage-defining feature was found. An r (radiology) suffix means it was seen on imaging — a pelvic node on MRI/CT/PET makes it IIIC1r; a p (pathology) suffix means it was confirmed histologically — the same node proven at surgery is IIIC1p. In one line: r = imaged, p = biopsy-proven.

What the 2018 revision changed: IA is now depth-only (lateral spread ignored); IB split into IB1/2/3 by size; and IIIC was created for nodal disease — positive nodes upstage any tumour to IIIC regardless of local size.

Grading. Squamous and adenocarcinomas are graded G1 (well) → G2 (moderate) → G3 (poorly) differentiated; poor differentiation and extensive LVSI raise the risk of nodal spread and adjuvant radiation, but — unlike endometrial cancer — grade does not move the FIGO stage.

Worked staging — three quick scenarios.

1. A 1.8 cm tumour invading 7 mm deep, no spread beyond the cervix → IB1. Once invasion exceeds 5 mm the lesion leaves the microscopic IA band and becomes IB; a tumour ≤2 cm makes it IB1. Depth, not size, promoted it.
2. That same 1.8 cm tumour, but with one positive pelvic node on MRI → IIIC1r. A positive pelvic node upstages any size tumour straight to IIIC1; the r records that the node was seen on imaging, not yet proven at surgery.
3. A 5 cm tumour reaching the pelvic side-wall with hydronephrosis → IIIB. Pelvic-wall extension and/or hydronephrosis defines IIIB on its own — tumour size stops counting once the side-wall is involved.

Management

Organise the answer immediate → ongoing → long-term, and the single most important decision is avoiding the "double whammy" of radical surgery followed by adjuvant radiation: if pre-operative features predict adjuvant chemoradiation, go straight to primary chemoradiation and spare the patient the morbidity of both.