• Incidence: 10.00 cases per 100,000 person-years
  • Peak incidence: 30-40 years
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+


Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include:
  • smoking
  • human immunodeficiency virus
  • early first intercourse, many sexual partners
  • high parity
  • lower socioeconomic status
  • combined oral contraceptive pill*

*the strength of this association is sometimes debated but a large study published in the Lancet (2007 Nov 10;370(9599):1609-21) confirmed the link


Mechanism of HPV causing cervical cancer
  • HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
  • E6 inhibits the p53 tumour suppressor gene
  • E7 inhibits RB suppressor gene

Clinical features

- persistent biliary colic symptoms
- associated with anorexia, jaundice and weight loss
- a palpable mass in the right upper quadrant (Courvoisier sign),
- periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen

Screening and prevention

The cervical cancer screening programme has undergone a significant evolution in recent years. For many years the smears were examined for signs of dyskaryosis which may indicate cervical intraepithelial neoplasia - management was based solely on the degree of dyskaryosis. The introduction of HPV testing allowed patients with mild dyskaryosis to be further risk-stratified, i.e. as HPV is such a strong risk factor patients who were HPV negative could be treated as having normal results.

The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.

Management of results

Negative hrHPV
  • return to normal recall, unless
    • the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
    • the untreated CIN1 pathway
    • follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
    • follow-up for borderline changes in endocervical cells

Positive hrHPV
  • samples are examined cytologically
  • if the cytology is abnormal → colposcopy
    • this includes the following results:
    • borderline changes in squamous or endocervical cells.
    • low-grade dyskaryosis.
    • high-grade dyskaryosis (moderate).
    • high-grade dyskaryosis (severe).
    • invasive squamous cell carcinoma.
    • glandular neoplasia
  • if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
    • if the repeat test is now hrHPV -ve → return to normal recall
    • if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
    • If hrHPV -ve at 24 months → return to normal recall
    • if hrHPV +ve at 24 months → colposcopy

If the sample is 'inadequate'
  • repeat the sample within 3 months
  • if two consecutive inadequate samples then → colposcopy

The follow-up of patients who've previously had CIN is complicated but as a first step, individuals who've been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.