Cervical cancer is the fourth most common cancer in women. In 2022, an estimated 660 000 women were diagnosed with cervical cancer worldwide and about 350 000 women died from the disease.

Cervical cancer is more common in younger females. Most cervical cancer cases diagnosed in females aged 30 to 40 and 20% of cases diagnosed after the age of 60.

Almost all cervical cancer cases (99%) are linked to infection with high-risk human papillomaviruses (HPV), an extremely common virus transmitted through sexual contact.

Although most infections with HPV resolve spontaneously and cause no symptoms, persistent infection can cause cervical cancer in women.

Effective primary (HPV vaccination) and secondary prevention approaches (screening for and treating precancerous lesions) will prevent most cervical cancer cases.

With a comprehensive approach to prevent, screen and treat, cervical cancer can be eliminated as a public health problem within a generation.

Early stages of cervical cancer do not usually involve symptoms and are hard to detect. As it grows, cervical cancer might cause signs and symptoms, such as:

• Vaginal bleeding after intercourse, between periods or after menopause.
• Watery, bloody vaginal discharge that may be heavy and have a foul odor.
• Pelvic pain or pain during intercourse (dyspareunia).

If cancer has spread to nearby tissues or organs, symptoms may include:

• Difficult or painful urination, sometimes with blood in urine.
• Diarrhea, or pain or bleeding from your rectum when pooping.
• Fatigue, loss of weight and appetite.
• A general feeling of illness.
• Dull backache or swelling in your legs.
• Pelvic/ abdominal pain.
• Bone pain

If you experience abnormal bleeding, unusual vaginal discharge or any other unexplainable symptoms, you should contact a healthcare provider.

Most cervical cancers are caused by HPV, a sexually transmitted infection. HPV spreads through sexual contact (anal, oral or vaginal) and can lead to cancer. Most people will get HPV at some point in their lives and not realize it because their bodies fight the infection. But if your body doesn’t fight the infection, it can cause the cells of your cervix to change to cancerous cells.

Risk factors for cervical cancer include:

• Smoking: Smoking increases the risk of cervical cancer. When HPV infections happen in people who smoke, the infections tend to last longer and are less likely to go away. HPV causes most cervical cancers.
• Haven't been vaccinated against HPV
• Increasing number of sexual partners. The greater your number of sexual partners, and the greater your partner's number of sexual partners, the greater your chance of getting HPV.
• Early sexual activity: Having sex at an early age increases your risk of HPV.
• Other sexually transmitted infections. Having other sexually transmitted infections, also called STIs, increases the risk of HPV, which can lead to cervical cancer. Other STIs that increase the risk include herpes, chlamydia, gonorrhea, syphilis and HIV. 
• Take birth control pills, especially for longer than 5 years 
• A weakened immune system: You may be more likely to develop cervical cancer if your immune system is weakened by another health condition and you have HPV.
• Family history: Cervical cancer may have a genetic component.

Regular cervical cancer screenings with a Pap test can detect most cases of cervical cancer. The goal of cervical cancer screening is to detect cell changes on your cervix before they become cancer.

Most medical organizations suggest beginning screening for cervical cancer and precancerous changes at age 21. The tests are usually repeated every few years.

Screening tests include:

• Pap test. During a Pap test, a member of your health care team scrapes and brushes cells from your cervix. The cells are then examined in a lab to check for cells that look different.

A Pap test can detect cancer cells in the cervix. It also can detect cells that have changes that increase the risk of cervical cancer. These are sometimes called precancerous cells.

• HPV DNA test. The HPV DNA test involves testing cells from the cervix for infection with any of the types of HPV that are most likely to lead to cervical cancer.

If your screenings come back as abnormal, your healthcare provider will want to run more tests to confirm you have cervical cancer. The main tests include:

1.Colposcopy: A colposcope magnifies the cells of your cervix so your healthcare provider can see irregular cells. If the cells look suspicious or unusual, they’ll remove a sample of cervical cells and send them to a lab for further testing.

2. Biopsy: Any of the following methods can be used to get a sample of tissue from your cervix:

• Punch biopsy: Your provider uses a cutting tool with a round top to cut out the precancerous cells.
• Endocervical curettage: A procedure that involves your provider scraping the lining of your cervix with a spoon-shaped tool called a curette.
• Loop electrosurgical excision procedure (LEEP): Your provider uses an electrical wire loop to remove the abnormal cervical tissue.
• Cone biopsy: Your provider removes a slightly larger, cone-shaped piece of tissue from your cervix.

If you're diagnosed with cervical cancer, you might need other tests to find out the extent of the cancer, also called the stage. Your health care team uses the information from staging tests to plan your treatment.

The following procedures may be used to determine the cervical cancer stage:

• PET-CT scan combines the pictures from a positron emission tomography (PET) scan and a computed tomography (CT) scan.
• Magnetic resonance imaging (MRI).
• Computed tomography scan (CT)
• Visual examination of your bladder and rectum . Your doctor may use special scopes to look for signs of cancer inside your bladder and rectum.

The results of these tests also help your healthcare provider stage the cancer. Cervical cancer ranges from Stage I (least severe) to Stage IV (most severe). Staging helps your healthcare provider determine the best treatment plan.

Different types of treatment are available for cervical cancer. You and your cancer care team will work together to decide your treatment plan, which may include more than one type of treatment. Many factors will be considered, such as the stage of the cancer, your overall health, and your preferences. Your treatment plan will include information about your cancer, the goals of treatment, the treatment options and possible side effects, and the expected length of treatment.

If you are concerned about whether treatment will affect your fertility, talk with your cancer care team before treatment begins about what to expect.

Surgery:

Different kinds of surgery are used to treat cervical cancer. Your provider can remove just the cancerous tissues when the cancer is in its early stages. Some of the most common kinds of surgery for cervical cancer include:

• Surgery to cut away the cancer only. For a very small cervical cancer, it might be possible to remove all the cancer with a cone biopsy. This procedure involves cutting away a cone-shaped piece of cervical tissue and leaving the rest of the cervix intact.
• Surgery to remove the cervix, called a trachelectomy. A small cervical cancer might be treated with a radical trachelectomy procedure. This procedure removes the cervix and some surrounding tissue. The uterus remains after this procedure, so it may be possible to become pregnant, if you choose.
• Surgery to remove the cervix and uterus, called a hysterectomy. Most cervical cancers that have not spread beyond the cervix are treated with a radical hysterectomy operation. This involves removing the cervix, uterus, part of the vagina and nearby lymph nodes. 
• Pelvic exenteration: This is the same as a hysterectomy but also includes your bladder, vagina, rectum and part of your colon, depending on where the cancer has spread.

Some people may have a combination of treatments. Your provider may use radiation or chemotherapy to treat cancer that has spread or come back (recurred). Sometimes, your provider will use radiation and chemotherapy before or after surgery.

Radiation therapy:

Radiation therapy uses powerful energy beams to kill cancer cells. Energy can come from X-rays, protons or other sources. Radiation therapy is often combined with chemotherapy as the primary treatment for cervical cancers that have grown beyond the cervix. It also can be used after surgery if there's an increased risk that the cancer will come back.

Radiation therapy can be given:

• Externally, called external beam radiation therapy. A radiation beam is directed at the affected area of the body. Intensity-modulated radiation therapy (IMRT) is a way of giving external radiation therapy that can help keep radiation from damaging nearby healthy tissue. IMRT is a type of 3-dimensional (3-D) radiation therapy that uses a computer to make pictures of the size and shape of the tumor. Thin beams of radiation of different intensities (strengths) are aimed directly at the tumor from many angles.
• Internally, called brachytherapy. A device filled with radioactive material is placed inside your vagina, usually for only a few minutes.
•  advanced cervical cancer.

Chemotherapy:

Chemotherapy (also called chemo) uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. For cervical cancer that has spread beyond the cervix, low doses of chemotherapy are often combined with radiation therapy. This is because chemotherapy may enhance the effects of the radiation. Higher doses of chemotherapy might be recommended to help control symptoms of very advanced cancer. Chemotherapy may be used before surgery to reduce the size of the cancer. Chemo is often given in cycles. The length of the cycle and the schedule or frequency of chemotherapy varies depending on the drug used and where the cancer is in your body.

Targeted therapy:

Targeted drug treatment destroys specific cancer cells without damaging healthy cells. It works by targeting proteins that control how cancer cells grow and spread. Targeted therapy is usually combined with chemotherapy. It might be an option for advanced cervical cancer.

Immunotherapy:

Immunotherapy uses medicine to stimulate your immune system to recognize and destroy cancer cells. Cancer cells pretend to be healthy to hide from your immune system. Immunotherapy helps target these signals so the cancer cells can’t trick your body into thinking it’s a healthy cell.  Biomarker tests can be used to help predict your response to certain immunotherapy drugs. 

Palliative care:

Palliative care is a special type of health care that helps you feel better when you have a serious illness. If you have cancer, palliative care can help relieve pain and other symptoms. A team that can include doctors, nurses and other specially trained professionals provides palliative care. The team's goal is to improve quality of life for you and your family.

Palliative care specialists work with you, your family and your care team to help you feel better. They provide an extra layer of support while you have cancer treatment. You can have palliative care at the same time as strong cancer treatments, such as surgery, chemotherapy or radiation therapy.

Cervical cancer care at Shefa-El Orman:

Shefa-El Orman doctors offer compassionate, comprehensive care for those with cervical cancer.

Gynecologic oncologists at Shefa-El Orman are equipped with the knowledge and resources to provide comprehensive care for those with cervical cancer. When you seek care at Shefa-El Orman Hospital, you can expect:

• Personalized care. Care for people with cervical cancer is directed by gynecologic oncologists who work as a team with medical oncologists, radiation oncologists and others to make sure all of your individual needs are addressed in your care plan.
• Experience you can trust. Shefa-El Orman doctors are widely respected for their expertise in diagnosing and treating cervical cancer, which comes from treating many people with this disease, including very rare types of cervical cancer.

Seeking care at Shefa-El Orman Hospital gives you access to the most advanced cancer diagnosis and treatment techniques available, including:

• Precise diagnostics. Diagnostic techniques might include advanced imaging, sentinel node biopsy and ultrastaging to give your care team an accurate picture of your condition in order to select the most effective treatment plan.
• A full range of treatment options. The range of treatments offered to those with cervical cancer includes radiation therapy, brachytherapy, chemotherapy, targeted therapy, immunotherapy and many types of surgical procedures, such as simple hysterectomy, radical hysterectomy, and fertility-sparing procedures.
• International guidelines: Shefa El Orman meets the strict standards for international guidelines. These standards recognize a multispecialty approach focused on cancer prevention, diagnosis and treatment.

The program includes:

• Initial presentation in the clinic
• clinical history taking
• review of medical records
• physical examination and examination under anesthesia.
• laboratory tests:
  • complete blood count
  • general urine analysis
  • biochemical blood test
  • inflammation markers (CRP, ESR)
  • blood coagulation analysis (aPTT, PT, INR)
  • tumor markers (CEA, CA19-9, CA125)
• gynecological examination:
  • colposcopy
  • vaginal swab
  • cervical or uterine biopsy with histological analysis (if clinically indicated)
  • pelvic and abdominal ultrasound
  • transvaginal ultrasound
• CT/MRI of the abdomen and pelvic organs (if clinically indicated)
• nursing services
• consultation of related specialists
• treatment by chief physician and all leading experts
• explanation of individual treatment plan

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Previous Biopsy results (if available)

Price from: On request

Type of program: Outpatient

Expected duration of the program: 5 days

________________________________________________________________________

The program includes:

• Initial presentation in the clinic
• clinical history taking
• review of medical records
• physical examination
• CT /MRI (if indicated clinically)  
• laboratory tests:
  • complete blood count
  • general urine analysis
  • biochemical analysis of blood
  • inflammation indicators (CRP, ESR)
  • indicators of blood coagulation
  • tumor markers (CEA, CA19-9, CA125)
• CT and MRI planning of radiation therapy
• Physics calculation  
• full course of conventional radiation therapy (3D, IMRT, or VMAT) or brachytherapy separate or together (sequential) depending on your cancer stage and your treatment options will be explained by treating physician  
• anesthesia assessment in a case of brachytherapy 
• chemotherapy weekly with radiotherapy, the cost of medicines is included  
• symptomatic treatment
• cost of essential medicines and materials including masks and mattress used for fixation.
• nursing services
• control examinations
• consultations of related specialists
• explanation of future recommendations

How program is carried out

During the first visit, the doctor will conduct a clinical examination and go through the results of previous laboratory tests and instrumental examinations. After that, you will undergo an additional examination, including complete blood count, laboratory assessment of liver and kidney function. Based on the received results, the physician will elaborate the chemotherapy regimen, conduct radiotherapy planning with the help of CT or MRI, make the permanent tattoo marks on the skin and conduct CT simulation in order to assess the accuracy of the rays and the radiation dose. If necessary, related medical specialists will be involved in the elaboration of a treatment regimen (tumor board).

Chemotherapy and radiation therapy are carried out as the day hospital procedure, without mandatory admission to the hospital. At each visit, the physician will assess your general condition and the marks on the skin. After that, you will be placed in a shielded radiation therapy room, on a special table.

Each radiation therapy session lasts less than half an hour (including preparation). All this time, doctors and nurses are monitoring your condition, you can communicate with them through a loudspeaker. The procedure is completely painless. Depending on the planned course of treatment, you will visit the hospital from 1 to 3-5 times a week.

During the chemotherapy session, after the placement of a venous catheter, you will stay in a comfortable ward. An infusion system will be connected to the catheter, through which the required drug or a drug combination will be administered. All drugs are administered by intravenous drip, slowly, so the total duration of the infusion can be up to several hours. All this time, doctors and nurses will monitor your health condition closely.

After the completion of the chemotherapy and radiation therapy course, you will undergo control examinations aimed at assessing your condition and efficacy of treatment. After that you will receive the medical report with detailed recommendations regarding further follow-up and treatment. In the future, you will be able to have a distant consultation with your attending physician and schedule the next course of treatment, if necessary.

The use of brachytherapy with types of implants may be called, wires, needles, capsules, balloons, or tubes. No matter which type of implant is used, it is placed in your body (transvaginal) , very close to or inside the tumor. This way the radiation harms as few normal cells as possible. The implant procedure is usually done in a hospital operating room designed to keep the radiation inside the room. You’ll get anesthesia, which may be either general (where drugs are used to put you into a deep sleep so that you don’t feel pain) or local (where part of your body is numbed). Imaging tests (an x-ray, ultrasound, MRI, or CT scan) are usually used during the procedure to find the exact place the implant needs to go. High-dose-rate (HDR) brachytherapy allows a person to be treated for several minutes at a time with a powerful radioactive source that’s put in the applicator. The source is removed after 10 to 20 minutes. This may be repeated twice a day over a few days, or once a day over the course of a few weeks. The radioactive material is not left in your body. The applicator might be left in place between treatments, or it might be put in before each treatment. If your implant is held in place by an applicator, you may have some discomfort in that area. 

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Biopsy results (if available)

Price from: on request

Type of program: Outpatient

Expected duration of the program: 39 days

________________________________________________________________________________

The program includes:

• Initial presentation in the clinic
• clinical history taking
• review of medical records
• physical examination
• laboratory tests:

1. complete blood count
2. general urine analysis
3. biochemical analysis of blood
4. inflammation indicators (CRP, ESR)
5. indicators blood coagulation
6. tumor markers (CEA, CA19-9, CA125)

• colposcopy
• vaginal swab
• cervical biopsy with histological analysis (if clinically indicated, additional cost is 2000 €)
• pelvic and abdominal ultrasound
• transvaginal ultrasound
• CT/MRI of the abdomen and pelvic organs (if clinically indicated)

• preoperative care
• operation: 

• hysterectomy with extensive surgical resection
• hysterectomy adnexectomy and lymphadenectomy
• conization 

• histologically and immunohistochemically examination of the excised tissues
• symptomatic treatment
• control examinations
• the cost of essential medicines and materials
• nursing services
• full hospital accommodation
• explanation of future recommendations

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Biopsy results (if available)

Price from: on request

Type of program: Inpatient

Expected duration of the program: 8-10 days

4- chemotherapy or immunotherapy: 

The program includes:

• Initial presentation in the clinic
• clinical history taking
• analysis of medical records
• physical examination
• laboratory tests:
  • complete blood count
  • biochemical analysis of blood
  • tumor markers
  • inflammation indicators
  • indicators of blood coagulation
• ultrasound scan, CT / MRI scan (if indicated).
• 1 course of chemotherapy
• consultations of related specialists
• symptomatic and specific treatment
• the cost of essential medicines and materials
• nursing services
• control examinations
• full hospital accommodation
• recommendations for further treatment

How program is carried out

During the first visit, the doctor will conduct a clinical examination and go through the results of previous laboratory tests. After that, you will undergo an additional examination, including laboratory assessment of liver and kidney function. Based on the received results, the doctor will elaborate the chemotherapy regimen. If necessary, related medical specialists will be involved in the elaboration of a treatment regimen (tumor board).

Chemotherapy is carried out as an outpatient according to chemotherapy protocol type. After the placement of a venous catheter, you will stay in a comfortable ward. An infusion system will be connected to the catheter, through which the required drug or a drug combination will be administered. All drugs are administered by intravenous drip, slowly, so the total duration of the infusion can be up to several hours. All this time, doctors and nurses will monitor your health condition closely.

After the course of chemotherapy, you will stay under medical supervision in the ward for a few more hours. After the completion of the chemotherapy course and control examinations you will receive the medical report with detailed recommendations regarding further treatment. In the future, you will be able to have a distant consultation with your attending physician and schedule the next course of chemotherapy, if necessary.

Required documents

• Medical records
• Colonoscopy data, MRI/CT scan (not older than 3 months)
• Biopsy results 
• Any recent laboratory results.

Price from: On request (regarding chemotherapy protocol)

Type of program: outpatient 

Expected duration of the program: from 1 to 4 days per cycle (regarding chemotherapy protocol)