Red Flags
- Postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding — speculum examination, biopsy any visible cervical lesion, urgent gynaecology[1]
- Visible cervical mass or ulceration — same-day gynaecological oncology referral; biopsy without delay[1]
- Locally advanced cervical cancer with hydronephrosis or pelvic side wall involvement — multidisciplinary urgent oncology[1]
- Pregnancy with abnormal screen or biopsy — colposcopy with biopsy if invasive cancer suspected; defer treatment of CIN until postpartum unless invasive disease[1]
First-line treatment
Interventions
- Universal HPV vaccination[1]Girls (and increasingly boys) aged 9–14 years 2-dose schedule (0, 6 months); ≥15 years 3-dose; catch-up through age 26 (or 45 per IAP); reduces cervical cancer incidence by >70%
- Treatment of CIN (HSIL, CIN 2/3)[1]Excisional (LEEP/LLETZ, cone biopsy) preferred over ablative for CIN2/3 in non-pregnant women; cryotherapy or thermal ablation acceptable in screen-and-treat where excision unavailable; postnatal management for CIN in pregnancy
- Stage-driven cancer treatment (FIGO 2018)[1]Stage IA1: simple hysterectomy or fertility-sparing cone biopsy. IA2–IB1: radical hysterectomy + pelvic lymphadenectomy or fertility-sparing radical trachelectomy. IB2–IVA: concurrent chemoradiation (cisplatin) ± brachytherapy. IVB: systemic therapy (chemotherapy, immunotherapy, anti-angiogenic)
- Screen-and-treat in low-resource settings[1]WHO single-visit approach: VIA + cryotherapy/thermal ablation at same visit for VIA-positive lesions <75% cervix, no extension to canal, no suspicion of invasion
- Posttreatment surveillance[1]After CIN treatment: HPV test or co-test at 6 months and 12 months; thereafter every 3 years if negative for 25 years post-treatment. After cancer: per stage and oncology pathway
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| HPV vaccine (Gardasil-9, Cervavac, others)[1] | Recombinant subunit vaccine | Adults ≥15 years: 0.5 mL IM at 0, 1–2, 6 months (3 doses) | Adolescents 9–14 years: 0.5 mL IM × 2 doses 6 months apart | Primary prevention; reduces high-risk HPV infection and cervical cancer incidence; counsel both girls and boys per latest schedules; included in UIP rollout |
| Cisplatin (concurrent chemoradiation)[1] | Platinum chemotherapy | 40 mg/m² IV weekly during external-beam radiotherapy (5–6 cycles) | — | Standard radiosensitiser for stage IB2–IVA; renal function, magnesium, potassium monitoring; antiemetic protocol |
| Pembrolizumab (recurrent/metastatic)[1] | Anti-PD-1 monoclonal antibody | 200 mg IV every 3 weeks or 400 mg IV every 6 weeks | — | Selected PD-L1-positive recurrent or metastatic cervical cancer; in combination with chemotherapy ± bevacizumab; immune-related adverse events |
| Bevacizumab (advanced/recurrent)[1] | Anti-VEGF monoclonal antibody | 15 mg/kg IV every 3 weeks added to chemotherapy | — | GOG-240 demonstrated survival benefit; risks of fistula, perforation, hypertension, proteinuria, thromboembolism |
HPV vaccine (Gardasil-9, Cervavac, others)[1]
Recombinant subunit vaccine
- Adult
- Adults ≥15 years: 0.5 mL IM at 0, 1–2, 6 months (3 doses)
- Paediatric
- Adolescents 9–14 years: 0.5 mL IM × 2 doses 6 months apart
Primary prevention; reduces high-risk HPV infection and cervical cancer incidence; counsel both girls and boys per latest schedules; included in UIP rollout
Cisplatin (concurrent chemoradiation)[1]
Platinum chemotherapy
- Adult
- 40 mg/m² IV weekly during external-beam radiotherapy (5–6 cycles)
- Paediatric
- —
Standard radiosensitiser for stage IB2–IVA; renal function, magnesium, potassium monitoring; antiemetic protocol
Pembrolizumab (recurrent/metastatic)[1]
Anti-PD-1 monoclonal antibody
- Adult
- 200 mg IV every 3 weeks or 400 mg IV every 6 weeks
- Paediatric
- —
Selected PD-L1-positive recurrent or metastatic cervical cancer; in combination with chemotherapy ± bevacizumab; immune-related adverse events
Bevacizumab (advanced/recurrent)[1]
Anti-VEGF monoclonal antibody
- Adult
- 15 mg/kg IV every 3 weeks added to chemotherapy
- Paediatric
- —
GOG-240 demonstrated survival benefit; risks of fistula, perforation, hypertension, proteinuria, thromboembolism
Safety-net
- HPV vaccination + screening together can virtually eliminate cervical cancer — pursue both even after sexual debut and treated abnormal screens[1]
- Postcoital, intermenstrual, or postmenopausal bleeding warrants gynaecology review — cervical cancer is highly treatable when caught early[1]
- After a normal screen, do not skip the next one — most cervical cancers occur in unscreened or under-screened women[1]
Referral criteria
- Suspicious cervical lesion or biopsy-proven cancerGynaecological oncology[1]
- HPV-positive screen (especially HPV 16/18)Colposcopy clinic within 4–6 weeks[1]
- Abnormal screen in pregnancyColposcopy with senior input; biopsy if invasion suspected[1]
- Locally advanced cancer or recurrent diseaseTertiary cancer centre with chemoradiation and brachytherapy[1]
Clinical summary
Primary HPV-based screening, VIA in low-resource settings, HPV vaccination, and treatment pathway for cervical cancer in adult women.