Cancer of the cervix has long been known to be related to sexual activity. Early age at coitarche and multiple sexual partners are known risk factors. In addition, women who are partners with males who had a previous partner with cervical cancer are at higher risk themselves for this disease. The causative agent of the vast majority of cervical precancerous and cancerous lesions is the human papilloma virus (HPV). Certain high-risk genotypes of HPV, most commonly types 16 and 18, are more frequently associated with cancer of the cervix, while other types, such as types 6 and 11, are usually associated with condyloma and nonprogressive mild dysplasia. Cigarette smoking is also associated with an increased risk of cervical cancer, although the exact causal factor is still unknown.

Postcoital bleeding has been considered to be a frequent finding with cervical cancer; however, patients are more likely to present with either postmenopausal bleeding or irregular menses than a specific complaint of bleeding after intercourse. Patients may also complain of an abnormal vaginal discharge. Only about 20% of women are asymptomatic at the time of diagnosis. Pain, urinary symptoms, leg edema, and weight loss are symptoms of advanced disease.

The general physical examination is usually normal with cervical cancer, particularly with early-stage disease. Cervix cancer spreads most frequently by local extension and contiguous nodal spread to the pelvic, then aortic lymph nodes. Occasionally a patient will have an enlarged scalene lymph node at the time of diagnosis which is palpable on physical examination. Other signs of advanced disease may include ascites, enlarged inguinal nodes, leg edema or pleural effusion. The speculum examination may reveal a lesion with any of the following characteristics: ulcerative, endophytic, exophytic, papillary, necrotic or friable. Occasionally, the exocervix may appear completely normal if the cancer is endocervical in origin. In this situation, the Pap smear might also be normal. However, on examination, the cervix is often very firm or the endocervix might be expanded. It is not uncommon in this situation for a diagnosis of cervical fibroids to be erroneously made. The speculum examination also notes if there is disease spread onto the vaginal mucosa. The bimanual examination is important for determining the dimensions of the cervical tumor; however, the rectovaginal examination is critical for the clinical staging of cancer of the cervix. The rectovaginal examination evaluates the lateral support tissue of the cervix, the parametria, as this is the most likely area of local spread. Differentiation between disease into the parametria (stage IIb) versus disease to the pelvic sidewall (IIIb) has prognostic and therapeutic significance.

As with any type of cancer, cervical carcinoma is a histologic diagnosis. The Pap test is a screening procedure only, and false negatives in the presence of invasive cancer may be as high as 20%. Because of this, all lesions of the cervix require biopsy. Biopsies should be taken from the center of an ulcerative lesion, as this is the area most likely to yield adequate tumor for diagnosis. Cone biopsy is contraindicated in the presence of overt carcinoma. Whenever the endocervix is palpably abnormal, even in the presence of a normal pap smear, it is advisable to perform an endocervical curettage or core biopsies of the endocervix prior to assuming that the diagnosis is cervical fibroids.

Squamous cell carcinoma is the most frequent histologic type of cervical cancer, comprising 75–80% of all cases. Adenocarcinomas of the cervix are increasing in frequency, comprising 20–25% of cases. Adenosquamous cancer accounts for about 25% of the adenocarcinomas. Clear cell and small cell neuroendocrine cancers of the cervix are quite rare.

Microinvasive (FIGO stage Ia) cervical cancer is defined as a clinically occult tumor that invades less than 5 mm into the cervical stroma and is less than 7 mm in width. It is a diagnosis which requires a cone biopsy specimen with clear margins. Stage Ia1 is a subset of microinvasive cancer where the lesion has no more than 3 mm of cervical stromal invasion and is less than 7 mm wide. Women with such tumors that also have no lymph-vascular space involvement can be managed conservatively, especially if the histology is squamous. Cone biopsy with negative margins is sufficient if future fertility is desired or simple hysterectomy may be performed otherwise. For adenocarcinomas meeting these criteria, conservative management has not been as well established. However, there is an emerging body of data suggesting that similar conservative management might be in order for adenocarcinomas as well. In the latter case, it is very important that the histopathology slides are evaluated by a pathologist with expertise in cervical cancer, as the measurement of depth of invasion in cervical cancer is frequently difficult to determine. For tumors with a depth of invasion between 3 and 5 mm or in the presence of lymph-vascular space invasion (LVSI), a modified radical hysterectomy with lymph node dissection is the preferred management. Last, for women desirous of future fertility who have stage Ia1 cancers with LVSI, stage Ia2 cancers or small (2 cm or less) stage IB1/IIa cancers, radical trachelectomy with pelvic lymphadenectomy is an option.

Staging work-up