Cervical cancer is the cancer of the female reproductive system that originates in the cervix. It is the fourth leading cause of cancer in women after breast, lung, and colorectal cancer. It is easily preventable, owing to the universal application of Papanicolaou smear screening that has resulted in early detection of pre-cancerous lesions, which can be removed before it progresses to invasive cancer. However, it is still a common genital cancer encountered in clinical practice in the women of low and middle-income countries (LMICs) due to a lack of extensive screening. Cervical cancers are often squamous-cell carcinomas that arise from infection with high-risk Human Papilloma Virus (HPV) serotype-16 and 18.
Anatomy Of Cervix
Natural History And Pattern Of Spread
Cervical cancer incidence has dramatically declined in regions where screening programs have been implemented. About 70 percent of the current burden of cervical cancer comes from the low-socioeconomic areas where screening programs are not well-established. Cervical cancer is most common in females who have multiple sexual partners and do not use condoms. High-risk sexual practices result in infection by the HPV. HPV integrates its DNA into the basal cells of the columnar junction (in the transformation zone of the cervix), and this results in the production of proteins (E6 and E7) that eventually cause dysplasia. Dysplasia of the cervical epithelium is also called cervical intraepithelial neoplasia(CIN). CIN can progress to cervical cancer, but it takes 10 to 20 years.
CIN does not necessarily develop in all women who get infected with HPV. The immune system clears off most of the HPV infection. The risk of CIN increases with the type of HPV (HPV 6 and 11 are low-risk types, whereas 16 and 18 are high-risk types), duration of infection, environmental factors like smoking, and immunosuppression in the patient. Fortunately, vaccination against HPV is available, which immunizes against several HPV types linked with cervical cancer, including HPV 16. As compared to other gynecological cancer, cervical cancer occurs in younger women.
The mean age of diagnosis of cervical cancer is about 49 years. Most of these women will be diagnosed with early-stage cancer and cured, though they might have to carry the burden of potential treatment-related side effects(e.g., infertility). The majority of the women who are cervical cancer survivors are diagnosed with early-stage or locally advanced cancer. The median survival of women diagnosed with metastatic or recurrent cervical cancer is generally less than two years. The most common areas of metastases from cervical cancer are the lymph nodes, liver, lungs, and bones.
About 95% of the women with cervical cancer are infected with one or more HPV subtype, HPV 16 and 18 are most common (HPV-16 in 50% of women and HPV-18 in 10 to 15% of women).
High-Risk HPV (Oncogenic/Cancer-associated): type 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69 and 82
Low-Risk HPV (Non-Oncogenic): type 6, 11, 40, 42, 43, 44, 54, 61, 72 and 81
However, not all women who harbor HPV infection will develop cervical cancer. Most HPV infections 16, 18 are symptomless and clear within two years. The presence of persistent infection and those who have associated co-factors like cigarette smoking or immunodeficiency are at higher risk for the progression of lesions to the development of invasive cancer. Apart from HPV 16 and 18 being the most common etiology discussed, a lot of studies have been conducted showing how cervical tar exposure can act synergistically with the co-existing HPV infection to cause cervical squamous cell cancer (co-carcinogenesis). The various ways of cervical tar exposure being cigarette smoking, use of tar-based vaginal sanitization products, and fumes from burning of wood, dung, coal in poorly ventilated kitchens. Various other clinical characteristics that predispose an individual to cervical cancer are
Incidence And Mortality
Cervical cancer is the fourth leading cause of cancer in women worldwide. In 2018, the incidence was approximately 569,847 and 311,365 deaths due to cervical cancer, which made it the fourth leading cause of cancer death in women. About 84% of cervical cancer are from low socio-economic regions. This is because of the advent of PAP smear testing and HPV vaccination in developed countries, which have reduced the incidence and mortality by 75% in the last 50 years. In developing countries, cervical cancer is the second most common cause of cancer and the third most common cause of cancer mortality in women. In the United States, amongst gynecological cancers, cervical cancer ranks third in incidence and mortality.
Cervical cancer occurrence is higher in certain racial groups. A United States national survey found age-corrected standardized mortality rates of hysterectomy to be higher in black women (10.1 per 100,000) as compared to white women (4.7 per 1000,00). The incidence and mortality rates, respectively, per 100,000 in different races are as follows:
Similar to squamous cell carcinoma elsewhere characterized by squamous differentiation where it can be affected by grade and degree of differentiation (well-differentiated, moderately differentiated and poorly differentiated), (ranging from abundant to scant eosinophilic cytoplasm with or without intercellular bridges to small undifferentiated (primitive) cells), hyperchromatic nuclei, high nucleus to cytoplasmic ratio, mitosis (few to high) and abundant to no keratinization. WHO histologically classifies epithelial tumors of the cervix into squamous tumors and its precursor (squamous intraepithelial lesion) and squamous cell carcinoma into keratinizing, non-keratinizing, basaloid, warty, papillary, verrucous, squamotransitional, and lymphoepithelioma-like, each of these type has a specific morphologic and immunohistochemical characteristic.
Some of the features that can help determine invasiveness of squamous cell carcinoma: include the presence of stromal inflammation, stromal desmoplastic reaction, numerous single or small clusters of highly dysplastic epithelial cells look different than the one in the rete ridges, elongated rete ridges, and loss of nuclear polarity.Histological grade (well-differentiated, moderately differentiated, and poorly differentiated) does not correlate with the prognosis (higher grade does not mean worse prognosis).
Cervical cancer is commonly diagnosed in women aged 35 to 45 years. A thorough history reveals the presence of essential risk factors that are associated with cervical cancer, such as an immunocompromised state, high-risk sexual behavior, multiple sexual partners, history of sexually transmitted diseases, and tobacco smoking. Most women are asymptomatic. However, she can present with any of the following symptoms:
On inspection, the cervix often appears normal, or there may be cervicitis or erosion that bleeds with touch. Inguinal lymphadenopathy may be present.
Late complications that result due to the spread of cervical cancer include:
There are three main tests involved in initial cervical cancer screening: cytology, HPV testing, and VIA ( Visual Inspection with Acetic acid). Abnormal results are followed by colposcopic evaluation and collection of specimens for biopsy testing, confirming the abnormal results and based on which further treatment would be planned.
Cervical Cytology (PAP Smear)
PAP test is done by opening the vaginal canal by a speculum and getting cells from the squamocolumnar junction or the transformation zone. The obtained cells are examined under a microscope to look for abnormalities. Any abnormality will warrant further evaluation. The collected specimen can be prepared for cytology by two methods, the conventional pap smear, and the liquid based-thin layer preparation.
It will be performed in:
1. In all women from 21 to 65 years of age as a part of routine screening.
Current recommendations regarding screening for cervical cancer: (2012 ASCCP guidelines)
The following recommendations are valid for the general population, regardless of the age of sexual initiation or other risk factors. It does not concern those with a history of cervical cancer, high-grade cervical precancerous lesions, immunocompromised states like HIV infection, or those with DES exposure in utero.
2. Symptomatic women suspected of having cervical cancer (e.g., those with post-coital bleeding, abnormal vaginal discharge, etc.)
Various cytologic findings are described as
This test detects cellular changes or infections with high-risk HPV. Specimens for HPV testing can be obtained similarly as PAP smears. The sample is usually collected from endocervix using a cervical spatula or a brush, and then the specimen is placed in the HPV transport medium. There are some liquid-based cytology sampling systems where the same sample can be used for both cytology and HPV testing. Urine testing for HPV can also be an alternative in situations where routine cervicovaginal testing is not possible due to economic or cultural barriers. Commercial assays only test for high-risk HPV infections that are known to cause cervical cancer. In a limited resource setting, self-collection of an HPV sample can be used. Self-sampling can be done using a tampon, cotton or dacron swab or a cytobrush. Self-sampling is cost-effective and is one of the proposed strategies in increasing the number of women screened. Self-collected samples are as sensitive as provider collected samples. The collected samples are checked for the presence of high-risk HPV DNA or mRNA. Studies have shown that mRNA based HPV testing has higher specificity than DNA based HPV testing. It is also more cost-effective than DNA-based testing.
The HPV test is recommended in women 30 years and older as a part of routine screening, as mentioned above. It can be used as a primary testing method or along with cytology (co-testing). HPV test has higher sensitivity as compared to cytology testing, but there are concerns about specificity, especially in younger women. Studies/systematic reviews have been conducted to compare the outcomes of HPV testing and cytology-based screening. Conclusions derived from these studies/systematic reviews are as follows:
Though studies have shown increased detection rates with HPV testing, it has also been implicated in a higher rate of false-positive results and colposcopy, which could lead to overdiagnosis and overtreatment.
Visual Inspection With Acetic Acid (VIA)
In this test, 5% acetic acid is applied to the cervix. Acetic acid dehydrates the abnormal areas which contain increased nuclear material and protein. These abnormal areas turn acetowhite, whereas healthy cells containing glycogen remain normal. Schiller's iodine can also be employed (VILI-visual inspection with Lugol's iodine). In VILI, healthy cells containing glycogen take up iodine and turn mahogany brown, whereas abnormal areas remain unstained. These abnormal areas can then be biopsied. Dull white plaques with ill-defined borders are considered LSIL, and those with sharp plaques and thick edges are considered HSIL. Though it has low specificity, its false-negative rate is quite low. Hence VIA can prove to be a good alternative in a low-resource setting where pap screening does not exist.
Colposcopy is the magnified visualization of the cervix where abnormal areas, if identified, are biopsied. Colposcope is a binocular instrument with a magnification power of 10-20 times. Colpomicroscope, on the other hand, magnifies 100-300 times. In a colposcopic examination, the patient is put in a lithotomy position, and the cervix is exposed with a bivalve speculum. The colposcope is then focused on the external os at a distance of about 20cm. The cervix is then swabbed and cleaned with normal saline gently to remove mucus but not provoke any bleeding. The squamocolumnar junction is then visualized before and after the application of acetic acid. Acetic acid precipitates proteins, and abnormal areas appear acetowhite. Using a green light filter facilitates a better assessment of the vascular architecture. The cervix is then painted with schiller's iodine, which differentiates darker glycogen laden cells from the paler glycogen-free cells, which are abnormal. In postmenopausal women, a 1-2 week daily estrogen therapy can be given, which will allow the squamocolumnar junction to pout out and hence improve visualization. In the context of cervical cancer, abnormal cells on a pap smear or follow-up of a treated cervical cancer lesion are the most common indications for colposcopy.
Colposcopic reporting is as follows:
Risk Assessment: The next step in evaluation is risk-assessment. Based on history, cytology, and HPV results, the immediate and 5-year risk of developing CIN 3+ is calculated for every individual. Based on this risk percentage, further evaluation is decided.
If the immediate CIN 3+ risk is more than 4%, then further evaluation is carried out based on this percentage
If the immediate CIN 3+ risk is less than 4%, then we look at the 5-year CIN 3+ risk, and further evaluation will be carried out based on this 5-year CIN 3+ risk:
Hence, there are six clinical actions that the provider can use while managing a patient with abnormal cervical cancer screening results 1-year surveillance, 2-year surveillance, 5-year regular screening, colposcopy, optional colposcopy or treatment, and treatment.
Immediate And Five Year Risk Assessment For CIN 3+
At Kaiser Permanente Northern California (KPNC), a prospective longitudinal cohort study was performed (from 2003-2017), where 1.5 million patients were followed-up for more than a decade. Tables of risk estimates have been generated from this study. These risk-assessment tables are based on the patient's history, current, and previous screening results. The applicability of these risk-assessment tables has been confirmed in regions and populations outside of The United States in other data sets obtained from clinical trials and screening programs. These tables are organized under five clinical scenarios:
Scenario 1: Abnormal Screening Result
1. In patients with no/unknown prior HPV test results and a current HPV negative result, the following are management recommendations as per current cytology results:
2. In patients with no/unknown prior HPV test results and a current HPV positive status, the following are management recommendations as per current cytology results:
NILM: 1-year follow up
3. In patients with prior HPV negative screen and a current HPV negative status, the following are the management recommendation as per current cytology results:
4. In patients with prior HPV negative screen and a current HPV positive status, the following are the management recommendation as per current cytology results:
Scenario 2: Surveillance for results not requiring immediate colposcopic referral
1. Follow-Up of HPV negative ASCUS and current HPV negative status, the following are the management recommendation as per current cytology results:
2. Follow-Up of HPV negative ASCUS and current HPV positive status, the following are the management recommendation as per current cytology results:
3. Follow-Up of HPV negative LSIL and current HPV negative status, the following are the management recommendation as per current cytology results:
4. Follow-Up of HPV negative LSIL and current HPV positive status, the following are the management recommendation as per current cytology results:
5. Follow-up of HPV negative LSIL and two negative co-test: 3-year follow up is recommended
6. Follow-Up of HPV positive NILM and current HPV negative status, the following are the management recommendation as per current cytology results:
7. Follow-Up of HPV positive NILM and current HPV positive status, the following are the management recommendation as per current cytology results:
8. Follow-up of HPV positive NILM and 2/3 negative co-test: 3-year follow-up is recommended
Scenario 3: Receipt of Colposcopy/Biopsy Result
1. If the colposcopic biopsy diagnosis is normal or CIN 1, the recommended management is a 1-year follow-up, regardless of the results of preceding colposcopic results. However, patients with high-grade cytologic findings but low-grade histologic findings represent a high-risk group (e.g., CIN 1 preceded by HSIL or ASC-H). They are managed as follows:
Management of histologic LSIL (CIN 1) preceded by HSIL cytology:
Three options can be opted for in such a case
I. Review of cytologic, histologic and colposcopic findings and management of the revised diagnosis as per ASCCP guidelines
II. Observation with colposcopy and cytology at one year in women <25 years and observation with Colposcopy and HPV testing at one year in women 25 years and above. An observation will only be recommended if the entire squamocolumnar junction and upper limit of the lesions are visualized and endocervical sampling is <CIN 2
III. Immediate diagnostic excision (except in pregnant women)
Management Of Histologic LSIL (CIN 1) Preceded By ASC-H Cytology:
I. Review of cytologic, histologic and colposcopic findings and management of the revised diagnosis as per ASCCP guidelines
II. Observation with cytology (for women less than25 years), and with an HPV test (in women 25 years or older) at 1 and 2 years. The observation will only be recommended if the entire squamocolumnar junction and upper limit of the lesions are visualized, and endocervical sampling is negative.
For both HSIL and ASC-H, if an observation has opted and at one year, all tests are negative, then age-appropriate re-testing (i.e., colposcopy and cytology in women less than 25 years and colposcopy and HPV testing in women more than 25 years) is done in 1 year. If all tests are again negative at one and 2-year follow up periods, HPV based testing is recommended in 3 years. Then the patient can proceed with long term surveillance (HPV based testing for three years for at least 25 years even if it continues beyond 65 years of age, discontinuation of screening is recommended if a patient has limited life expectancy). If there is an abnormal result at any point in time during surveillance, repeat colposcopy, and management based on biopsy result is recommended. An excisional biopsy is recommended for HSIL cytology at the 1-year visit if it persists (except in women less than 25 years where observation is preferred for one more year and if it continues at the next 1-year follow-up, diagnostic excision is performed). For ACS-H cytology, which persists at the 2-year visit, an excisional biopsy is recommended.
2. If the colposcopic biopsy result is CIN 2, CIN 3, AIS (adenocarcinoma in situ), or cancer, the patient is referred for treatment.
Scenario 4: Surveillance For Results Less Than CIN 2 (No Treatment)
1. In patients with a previous colposcopy result of <CIN2+ (after referral for low-grade cytology (ASC-US or LSIL, regardless of HPV status, or HPV positive NILM)) and a current HPV negative status, following are the management recommendations as per current cytology results:
2. In patients with a previous colposcopy result of <CIN2+ ( after referral for low-grade cytology) and a current HPV positive status, following are the management recommendations as per current cytology results:
3. In patients with a previous colposcopy result of <CIN2+ (after referral for high-grade results- ASC-H, AGC, HSIL+) and a current HPV negative status, following are the management recommendations as per current cytology results:
4. In patients with a previous colposcopy result of <CIN2+ (after referral for high-grade results- ASC-H, AGC, HSIL+) and a current HPV positive status, following are the management recommendations as per current cytology results:
Scenario 5: Follow-up After Treatment For CIN 2/3
1. In patients with HPV negative status at follow-up, cytology triage is used for guiding management as follows:
2. In patients with HPV positive status at follow-up, cytology triage is used for guiding management as follows:
3. In CIN 2/3 treated-patients with 2-3 negative follow-up results and current negative test results (either a negative co-test or negative HPV test), recommended management is as per previous testing results.
There are three HPV vaccines available. These are
1. Quadrivalent against HPV types 6,11,16 and 18
2. 9-Valent against 6,11,16,18,31,33,45,52 and 58
3. Bivalent against 16 and 18
HPV vaccination is recommended in both males and females. As men cannot develop cervical cancer, but the HPV vaccine may prevent or reduce the risk of genital diseases such as genital warts, penile cancer, anal cancer, and the spread of HPV to sexual partners. It is not recommended in pregnant patients due to inadequate evidence of safety. These vaccines provide excellent seroconversion rates (93 to 100 % in females and 99-100 % in males). Higher antibody titers are obtained for younger individuals. Mild injection site reactions can be expected. It is not effective in clearing out HPV infections, warts, or intraepithelial neoplasia that is already present.
ACIP (Advisory Committee on Immunization Practices) Vaccination Recommendation For HPV
The 9-valent vaccine is the recommended one. For individuals less than15 years of age, two doses are recommended that should be six months apart. For more than 15 years and immunocompromised, three doses are recommended at 0, 1, or 2 and six months. The optimal time to administer the HPV vaccine is before sexual debut. The recommended age of HPV vaccination is from 11 to 12 years of age. For 13-26 years, catch up vaccination is recommended if HPV vaccination not previously received or completed. For older adults, catch up vaccination is usually not recommended. For more than 26 years, the decision to vaccinate is an individual one. But it can be considered in 27-45 year individuals if there is a high-risk. Most insurance providers do no cover HPV immunization in more than 26 years old.
Various trials have been performed to demonstrate the effect of HPV vaccination in patients treated with excision for CIN 2+. Meta-analysis and systematic review of these studies have shown a decreased recurrence of any grade CIN in vaccinated patients who were CIN 2+ treated than those who were unvaccinated ( 6 versus 10 percent). Hence the potential role of the vaccine in CIN managed individuals must be explored further.
Treatment Options For CIN 2,3
Treatment Of Invasive Cervical Cancer
Early-Stage Cervical Cancer: This includes FIGO ( international federation of gynecology and obstetrics) stages IA1, IA2, IB1, and IB2. The preferred management options are as follows:
Now those who undergo modified radical hysterectomy, adjuvant treatment if following risk factors are present:
For those having intermediate-risk factors (i.e., tumor size more than4cm; lymphovascular space invasion or deep cervical stromal invasion, RT is recommended.
For those with high-risk factors (pathologically positive lymph nodes, parametrial invasion, positive surgical margins), chemoradiation is recommended.
Locally-Advanced Cervical Cancer: This includes FIGO stage IB3, stage II, stage III, stage IVA. There is an initial pretreatment evaluation required before the recommended chemoradiation (weekly cisplatin- (40 mg/m^2) with RT) for locally advanced cancer for the following purposes:
For women undergoing chemoradiation, treatment must be completed in eight weeks. Radiotherapy is delivered via External beam Radiotherapy (EBRT). Cervical brachytherapy can also be considered to maximize local control.
Recurrent/ Metastatic Cervical Cancer: About 15 to 61 % of women treated for early-stage cervical cancer develop distant metastases and multiple recurrences. For any suspected case of metastases/recurrence, a PET scan/CT scan is done to identify the metastases. It can be a locoregional recurrence (disease isolated to the pelvis) or disease involving other organs outside of the pelvis. A vaginal recurrence, if suspected, then the suspected area is biopsied to prove the recurrent disease. The treatment options include hysterectomy or pelvic exenteration for those previously treated with radiotherapy. RT will be preferred in those who are non-surgical candidates provided they haven't already received RT. If the patient is a non-surgical candidate and has previously received RT, chemotherapy is the preferred option.
Based on the symptoms/examination findings, a few differential diagnoses of cervical cancer to be kept in mind are:
Approach To Post-Coital Bleeding
The most common symptom of cervical dysplasia/cancer is post-coital bleeding. Benign conditions mostly cause it, but malignant diseases should be ruled out. Post-coital bleeding apart from cervical cancer can be seen in several other states as follows:
For any patient with post-coital bleeding, we need to take the following approach to come to a diagnosis:
1. History: A detailed history, we determine the volume and frequency of bleeding. Details about menstrual cycles, pregnancy, contraception, sexual activity, and previous pap smear testing results should be obtained.
2. Physical Examination: This will reveal the most likely etiology/source of the bleed. It involves inspection of the external genitalia and urethra. Examination of the vagina and cervix with a speculum, the testing of uterus and adnexa bilaterally, and a general physical assessment should be done.
3. Lab Testing: Appropriate lab testing can be carried out based on examination and history, which usually includes
4. Colposcopy: This will be performed in patients with a history of abnormal pap smear test results, a friable cervix on examination, or when no other cause of post-coital bleeding is identified.
5. Imaging: If the cause is not identified with the above approach, a pelvic ultrasound can be done to visualize the uterus. Hysteroscopy can be done if submucosal fibroids or endometrial polyps are identified on imaging.
One of the most distinctive features of an excellent staging method is defining the anatomical extent of the tumor, differentiating survival outcomes, and guiding its optimal management. As per FIGO, cervical cancer can be staged as follows:
STAGE I: Carcinoma confined only, to the cervix (extension to the corpus is disregarded)
IA: Invasive carcinoma, which can only be detected microscopically, maximum depth less than 5 mm
IB: Invasive carcinoma with measured deepest invasion equal to or greater than 5mm, i.e. (it will be clinically visible), cancer confined to the cervix.
STAGE II: Carcinoma extends beyond the uterus, but the lower third of the vagina and the pelvic walls are not involved.
IIA: Cancer confined to the upper two-thirds of the vagina without the involvement of the parametrium.
IIB: There is parametrial involvement but not up to the pelvic wall.
STAGE 3: Cancer involves one or some or all of the following: the lower third of the vagina, the pelvic sidewalls, hydronephrosis or nonfunctioning kidney, paraaortic, or pelvic lymph nodes.
IIIA: Involvement of lower-third of the vagina with no extension to the pelvic sidewall.
IIIB: Extension to the pelvic sidewalls, hydronephrosis or nonfunctioning kidney
IIIC: Involvement of pelvic, para-aortic lymph nodes, irrespective of tumor size and extent
STAGE IV: Extend beyond the true pelvis or involvement of the bladder or rectal mucosa (biopsy-proven)
IVA: Spread to the adjacent pelvic organs
IVB: Spread to distant organs
The significant prognostic factors that affect the survival in cervical squamous cell carcinoma include:
Staging is the most important prognostic factor, followed by nodal status. It was observed that for the same stage of cancer (stage IB or IIA), the 5-year survival after hysterectomy and lymphadenectomy was lower (50-74 %) in those with lymph node metastases as compared to those without lymph node metastases (88-96%). The involvement of para-aortic nodes is associated with worse outcomes.
As per FIGO 2018 staging of cervical cancer, the 5-year overall survival rates (OS), and 5-year progression-free survival (PFS) rates of patients was determined.
The 5-year overall survival (OS) rates for different stages of cancer were as follows:
The 5-year progression-free survival (PFS) rates were as follows:
Direct Complications Of Cervical Cancer:
Complications Of Treatment:
From many studies, it has been observed that quality of life is better after surgery/ chemotherapy as compared to those treated with either radiotherapy or chemoradiation. Various treatment-associated complications include:
Patient education should be considered an important aspect when it comes to better management of any disease. In the context of cervical cancer, counseling should begin during their regular screening appointments for cervical cancer. Any clinician needs to maintain a good doctor-patient relationship, which will allow them to covey their concerns freely. The patient should be educated about
Various healthcare providers involved in the management of cervical cancer include primary physicians, gynecologists, obstetricians, radiologists, oncologists, and nurses. Effective management of any disease requires excellent interpersonal communication and collaboration between team members for providing improved patient-centered care. There is also a potential role of Emergency room doctors in cervical cancer screening. A study found a high prevalence of cervical dysplasia amongst women screened with pap smears in the urban ED. ED screening has found to be feasible and has yielded a high rate of cancer detection. In cervical cancer, there is a better understanding of etiology, earlier screening, and management exists. Despite this, there are a lot of barriers that exist against its effective management. One of the most important advances in the management of cervical cancer was the routine pap smear screening in sexually active women. However, screening is not routinely done in many LMICs, and as a result, they contribute to 70% of the worldwide burden of cervical cancer. Some of these barriers include:
Managing and eradication these barriers do not only require an active team of health care providers, but the government had a significant role to play in providing resources and funds. Many of these barriers mentioned above are reported from LMICs, where lack of resources is not uncommon. Education regarding cervical cancer screening can be one of the most effective tools, especially in LMICs, where there are various false notions about screening and cervical cancer. Amongst the LMICs, where the patient load is exhaustive, clinicians are often unable to educate every patient thoroughly. In such settings, every member of the health care system must be it the primary provider, the radiologist, or the nurse take the responsibility of educating and explaining the patient regarding the disease and management. Effective communication between a patient and healthcare provider alone can alone be beneficial in removing the taboo and stigma that exists about cervical cancer screening.
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