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Cervical Cancer


General Information


  • invasive carcinoma originating in transformation zone of cervix, most commonly in squamous cells3
  • fourth most common cancer in women worldwide, most common cause of female cancer mortality in developing countries4



General references used

  1. Marth, C, Landoni, F, Mahner, S, et al; European Society for Medical Oncology (ESMO) Guidelines Working Group. Cervical cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017 Jul 1;28(suppl_4):iv72OpenInNew, correction can be found in Ann Oncol 2018 Oct 1;29(Supplement_4):iv262OpenInNew
  2. Wipperman J, Neil T, Williams T. Cervical Cancer: Evaluation and Management. Am Fam Physician. 2018 Apr 1;97(7):449-454OpenInNewfull-textOpenInNew
  3. Berman TA, Schiller JT. Human papillomavirus in cervical cancer and oropharyngeal cancer: One cause, two diseases. Cancer. 2017 Jun 15;123(12):2219-2229OpenInNewfull-textOpenInNew
  4. Koh W, Abu-Rustum NR, Bean S, et al. Cervical Cancer. Version 3.2019. In: National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines). NCCN 2018 from NCCN websiteOpenInNew (free registration required)

Recommendation grading systems used

  • National Comprehensive Cancer Network (NCCN) categories of evidence and consensus
    • Category 1 - based on high-level evidence, there is uniform NCCN consensus that the intervention is appropriate
    • Category 2A - based on lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate
    • Category 2B - based on lower-level evidence, there is NCCN consensus that the intervention is appropriate
    • Category 3 - based on any level of evidence, there is major NCCN disagreement that the intervention is appropriate
  • European Society for Medical Oncology (ESMO) grades of recommendation
    • grades of recommendation
      • Grade A - strong evidence for efficacy with substantial clinical benefit, strongly recommended
      • Grade B - strong or moderate evidence for efficacy but with a limited clinical benefit, generally recommended
      • Grade C - insufficient evidence for efficacy or benefit does not outweigh the risk or the disadvantages, optional
      • Grade D - moderate evidence against efficacy or for adverse outcomes, generally not recommended
      • Grade E - strong evidence against efficacy or for adverse outcomes, never recommended
    • levels of evidence
      • Level I - evidence from ≥ 1 large, randomized, controlled trial of good methodological quality (low potential for bias) or meta-analyses of well-conducted randomized trials without heterogeneity
      • Level II - small randomized trials or large randomized trials with a suspicion of bias (lower methodological quality) or meta-analyses of such trials or of trials with demonstrated heterogeneity
      • Level III - prospective cohort studies
      • Level IV - retrospective cohort studies or case-control studies
      • Level V - studies without control group, case reports, expert opinions
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (June 2007 to June 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - clinicians may provide the service to select patients depending on individual circumstances; however, only small benefit is likely for most individuals without signs or symptoms
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew
  • American Society for Colposcopy and Cervical Pathology (ASCCP) recommendation ratings
    • strength of recommendation
      • Grade A - recommendation for use based on good evidence for efficacy and substantial clinical benefit
      • Grade B - recommendation for use based on moderate evidence for efficacy or only limited clinical benefit
      • Grade C - evidence for efficacy insufficient to support a recommendation for or against use, but recommendation may be made on other grounds
      • Grade D - recommendation against use based on moderate evidence showing either lack of efficacy or adverse outcome
      • Grade E - recommendation against use based on good evidence showing either lack of efficacy or adverse outcome
    • quality of evidence
      • I - evidence from ≥ 1 randomized controlled trial
      • II - evidence from any of
        • ≥ 1 clinical trial without randomization
        • cohort or case-control studies (preferably from > 1 center)
        • multiple time-series studies
        • dramatic results from uncontrolled experiments
      • III - opinions of respected authorities based on any of
        • clinical experience
        • descriptive studies
        • reports of expert committees
    • Reference - ASCCP 2012 updated consensus guideline on management of abnormal cervical cancer screening tests and cancer precursors (23519301J Low Genit Tract Dis 2013 Apr;17(5 Suppl 1):S1OpenInNew [correction can be found in J Low Genit Tract Dis 2013 Jul;17(3):367], also published in 23635684Obstet Gynecol 2013 Apr;121(4):829OpenInNew), editorial can be found in 23635667Obstet Gynecol 2013 Apr;121(4):703OpenInNew, commentary can be found in 23969811Obstet Gynecol 2013 Aug;122(2 Pt 1):393OpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114831, Cervical Cancer; [updated 2018 Nov 30, cited place cited date here]. Available from Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Types

  • KeyboardArrowRight


    • Who is most affected

    • Incidence/Prevalence

    • KeyboardArrowRight

      Risk factors

      • Overview

      • KeyboardArrowRight

        Abnormal cytology

        • Cervical intraepithelial neoplasia (CIN)

      • KeyboardArrowRight

        Human papillomavirus (HPV) infection

        • Risk factors for HPV infection

        • Persistent HPV infection

      • Cigarette smoking

      • HIV infection

      • Long-term use of hormonal contraceptives

      • Multiparity

      • Lower socioeconomic status

      • Diethylstilbestrol exposure in utero

      • Trichloroethylene exposure

    • Factors associated with decreased risk

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight


      • Chief concern (CC)

      • Past medical history (PMH)

      • Social history (SH)

    • KeyboardArrowRight


      • Pelvic

  • KeyboardArrowRight


    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Blood tests

    • KeyboardArrowRight

      Imaging studies

      • Radiologic assessment

      • Imaging for detecting recurrence

    • Biopsy and pathology

    • Other diagnostic testing

  • Staging

  • KeyboardArrowRight


    • Management overview

    • Counseling

    • KeyboardArrowRight


      • Chemoradiation

      • Neoadjuvant chemotherapy

      • Palliative chemotherapy for advanced or recurrent cancer

      • Endothelial growth factor monoclonal antibodies

      • Immunotherapy

    • KeyboardArrowRight

      Surgery and procedures

      • Indications

      • Hysterectomy

      • Conization

      • Trachelectomy (Dargent's procedure)

      • Pelvic exenteration

      • Additional considerations

    • KeyboardArrowRight

      Radiation therapy

      • General concepts

      • Recommendations from professional organizations

      • Efficacy

      • Radiation sensitizers

      • Palliative radiation therapy

    • Consultation and referral

    • KeyboardArrowRight

      Other management

      • Interventions to reduce radiation-induced diarrhea

      • Vaginal dilation

      • Cervical cancer during pregnancy

      • Enhanced recovery intervention

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • KeyboardArrowRight


      • Disease complications

      • Complications of radiation therapy

    • KeyboardArrowRight


      • Mortality

      • Prognostic models and factors

      • Recurrence

  • KeyboardArrowRight

    Prevention and Screening

    • KeyboardArrowRight


      • KeyboardArrowRight

        Prevention of human papillomavirus (HPV) infection

        • HPV vaccination

        • Other methods for prevention of HPV infection

      • Management of abnormal cervical cytology

      • Management of cervical intraepithelial neoplasia

      • Screen-and-treat approach

      • Dietary interventions for cervical cancer prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Choosing Wisely

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight


      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Australian and New Zealand guidelines

      • Mexican guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight


    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Elliot M. Levine MD, FACOG

Assistant Professor, Department of Obstetrics and Gynecology, Rush University Medical Center; Site Director of Informatics and Director of Informatics and Research, Department of Obstetrics and Gynecology, Advocate Illinois Masonic Medical Center

Conflicts of Interest

Dr. Levine declares no relevant financial conflicts of interest.

Recommendations Editor
Esther Jolanda van Zuuren MD

Head of Allergy, Dermatology, and Venereology, Leiden University Medical Centre; Netherlands

Conflicts of Interest

Dr. van Zuuren declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD, FAAFP

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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Cervical cancer

Cervical cancer

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