Cervical cancer: symptoms, treatment and survival

Cervical cancer is a malignant tumour of the cervix — the lower part of the uterus that connects to the vagina. It is caused by persistent infection with high-risk strains of human papillomavirus (HPV) in 99.7% of cases. Around 3,200 women are diagnosed in the UK each year and approximately 850 die annually. It is one of the most preventable cancers through HPV vaccination and NHS cervical screening.

Persistent infection with high-risk HPV strains — particularly HPV 16 and 18, which together cause approximately 70% of cervical cancers — is responsible for 99.7% of all cervical cancers. HPV is transmitted sexually. Most HPV infections clear spontaneously; it is persistent high-risk HPV infection that causes pre-cancerous cellular changes (CIN) which, if untreated over 10–20 years, can progress to invasive cancer. Smoking, immunosuppression and long-term combined oral contraceptive use modestly increase the risk of progression from HPV infection to cervical cancer.

Early cervical cancer may cause no symptoms. The NHS advises seeing a GP promptly if you experience: bleeding after sex (post-coital bleeding); bleeding between periods (inter-menstrual bleeding) or after the menopause (any post-menopausal bleeding is abnormal); unusual vaginal discharge (particularly if it is bloodstained, watery or has an unpleasant odour); or pelvic pain not associated with your period. These symptoms do not necessarily indicate cancer but always require medical assessment.

Human papillomavirus (HPV) is an extremely common group of viruses transmitted through skin-to-skin genital contact. Most people clear HPV naturally without any symptoms or health consequences. High-risk HPV strains (16, 18, 31, 33, 45 and others) integrate into cervical cell DNA, causing abnormal cell changes — cervical intraepithelial neoplasia (CIN) — over years. Without treatment, CIN can progress to invasive cervical cancer. The process takes 10–20 years in most cases, providing a long window for screening to detect and treat pre-cancerous changes.

The NHS offers the Gardasil-9 HPV vaccine — protecting against nine high-risk HPV strains including types 16 and 18 (responsible for ~70% of cervical cancers) plus types 31, 33, 45, 52 and 58 — to all girls and boys aged 11–13 through the school vaccination programme. Vaccination before first sexual activity provides near-complete protection. People who missed school vaccination can request it free until age 25. Vaccination is the most effective prevention measure for cervical cancer.

A cervical smear test (now called a cervical sample or cervical screening) is a procedure in which a small brush is used to collect a sample of cells from the cervix. The NHS now tests the sample first for high-risk HPV: if HPV-negative, the result is normal and the person is recalled in 3 or 5 years. If HPV-positive, cells are examined for CIN. The whole procedure takes a few minutes and is performed by a nurse or doctor. It is done at your GP surgery or sexual health clinic.

An abnormal result most commonly means high-risk HPV was detected in the sample. This does not mean you have cancer — HPV is very common and most infections clear without causing harm. If HPV is found alongside abnormal cells (CIN), you will be referred for colposcopy. CIN (cervical intraepithelial neoplasia) describes pre-cancerous changes that, if treated, rarely progress to cancer. The NHS Two Week Wait pathway is for actual suspected cancer — a colposcopy referral for CIN is not an urgent cancer referral.

CIN (cervical intraepithelial neoplasia) is pre-cancerous change in the cells of the cervix caused by persistent HPV infection. It is graded CIN1 (mild dysplasia — often regresses spontaneously), CIN2 (moderate dysplasia) and CIN3 (severe dysplasia/carcinoma in situ — the highest-grade pre-cancer, requiring treatment). CIN is not cancer and causes no symptoms. It is detected through cervical screening and treated before it can progress. LLETZ (large loop excision) treats CIN2 and CIN3 effectively in outpatients.

Colposcopy is a detailed examination of the cervix using a colposcope — a magnifying instrument that illuminates and magnifies the cervix. A colposcopist applies acetic acid (vinegar) and/or iodine solution to highlight areas of abnormal cells. The procedure is similar to a smear test — you lie on a couch and a speculum is inserted. It is not painful for most women, though some feel discomfort. Biopsies may be taken from abnormal areas to determine the CIN grade. Results are usually given within four weeks.

LLETZ (large loop excision of the transformation zone) is the standard outpatient treatment for CIN2 and CIN3. Under local anaesthetic injected into the cervix, a thin wire loop carrying an electrical current removes the area of abnormal cells from the cervix. The procedure takes approximately 15 minutes and is performed at a colposcopy clinic. The removed tissue is sent for histopathology to confirm complete excision of the abnormal area. LLETZ is highly effective — approximately 90–95% of women require no further treatment.

Treatment depends on stage. Early-stage (IA–IB1): surgery — LLETZ, cone biopsy, radical trachelectomy (fertility-preserving) or radical hysterectomy with lymph node dissection. Locally advanced (IB3–IVA): concurrent chemoradiotherapy — weekly cisplatin chemotherapy and external beam radiotherapy, followed by brachytherapy (internal radiotherapy directly to the cervix). Recurrent/metastatic: platinum-based chemotherapy ± bevacizumab (NICE-approved); pembrolizumab for PD-L1-positive recurrent disease.

Five-year survival rates in England: Stage I — over 80%; Stage II — approximately 65%; Stage III — approximately 35–45%; Stage IV — approximately 15–20%. Overall five-year survival for all stages combined is approximately 63%. Survival has improved with the introduction of chemoradiotherapy, bevacizumab and immunotherapy. Women diagnosed through cervical screening (pre-cancer or very early cancer) have survival rates approaching 100%.

HPV vaccination provides very high protection against the HPV strains most commonly causing cervical cancer (16, 18 and others), but does not protect against all HPV strains. It is therefore still recommended that vaccinated women attend NHS cervical screening as scheduled — the combination of vaccination and screening gives the highest possible protection. Women vaccinated before first sexual activity with Gardasil-9 have near-complete protection against the HPV strains it covers.

HPV can pass through intimate skin contact as well as penetrative sex. If you have a cervix, discuss your screening invitation and personal circumstances with the screening team. Seek advice for symptoms regardless of sexual history or screening eligibility.

Cervical cancer is very rare in women under 25. Pre-cancerous CIN changes in women under 25 are common but very likely to resolve without treatment, and the benefits of screening this age group do not outweigh the risks of overtreatment. The NHS starts screening at 25 based on this evidence. Young women under 25 should still consult their GP if they develop symptoms (post-coital bleeding, inter-menstrual bleeding or unusual discharge). HPV vaccination at 11–13 provides the best protection for this age group.

Treatment for early cervical cancer can be designed to preserve fertility in some women. Radical trachelectomy — surgical removal of the cervix while preserving the uterus — is an option for carefully selected women with Stage IA2–IB1 cervical cancer who wish to have children. Pregnancy after radical trachelectomy is possible but carries higher risk of preterm labour. LLETZ treatment for CIN does not significantly affect fertility but may slightly increase the risk of preterm birth in subsequent pregnancies. Hysterectomy and radiotherapy both end the possibility of pregnancy.

Long-term use of the combined oral contraceptive pill is associated with a modest increase in the risk of progression from HPV infection to cervical cancer — approximately doubling the risk after 10+ years of use (though this may partly reflect higher sexual activity and therefore higher HPV exposure in pill users). This increased risk disappears within about 10 years of stopping the pill. The absolute risk increase is small, and the contraceptive pill's benefits (including reduced risk of ovarian and endometrial cancer) usually outweigh this risk when weighed individually.

Cervical cancer is the fourth most common cancer in women worldwide and the leading cause of cancer death in women in many low-income countries. Over 340,000 women die from cervical cancer globally each year — 90% of them in low- and middle-income countries where HPV vaccination and cervical screening are largely unavailable. World Aid Network funds cancer treatment through locally-licensed oncologists. Expanding access to cancer care in the regions WAN operates reduces this inequality.