Cervical cancer screening and management

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.

References

1.ICMR Consensus Document on Cervical Cancer Screening and Management (2022); WHO Cervical Cancer Elimination Strategy 2030; FIGO Cancer of the Cervix Uteri (2022)