Cervical cancer natural history, complications and prognosis: Difference between revisions

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==Overview==
==Overview==
Prognosis depends on the stage of the cancer. With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are alive 5 years after diagnosis. Only 25 to 35% of women with stage III cancer and 15% or fewer of those with stage IV cancer are alive after 5 years.
Cervical cancer is the most common [[cancer]] mainly among women in developing countries, there is an estimate of almost 260,000 deaths annually, about 80% occurred in developing countries. Common complications of cervical cancer include [[pain]], [[vaginal bleeding]], [[fistula]] and [[renal failure]].  
[[Prognosis]] is generally good, and the 5 year [[survival rate]] of patients with cervical cancer is approximately 70%. Studies has proven that there is an association between age of the patients and socioeconomic status of women with higher incidence of [[infection]] with high risk [[HPV]] in underserved poulation in the US.
 
==Natural history==
* Cervical cancer is the most common cancer mainly among women in developing countries, there is an estimate of almost 260,000 deaths annually, about 80% occurred in developing countries.<ref name="pmid11577044">{{cite journal |vauthors=Sherris J, Herdman C, Elias C |title=Cervical cancer in the developing world |journal=West. J. Med. |volume=175 |issue=4 |pages=231–3 |date=October 2001 |pmid=11577044 |pmc=1071564 |doi= |url=}}</ref>
* [[Infection]] by high risk strain of [[oncogenic]] [[HPV]] types is an established cause of neoplastic lesions of the [[cervix]], [[vagina]] and [[vulva]], [[anus]], [[penis]] and [[oropharynx]]. [[HPV]] 16 and 18,  are the most common cause of approximately 70% of all cervical cancers worldwide. [[HPV]] is highly transmissible through direct [[skin]] to [[skin]] contact and [[intercourse]], women with persistent high-risk [[HPV]] [[infection]]<nowiki/>s are at greatest risk for developing cervical cancer.
* Since the identification of [[HPV]] as main cause of cervical cancer, [[prevention]] strategies had been developed by the introduction of [[HPV]] testing and [[cytology]] screening and utilizing [[HPV]] [[vaccines]] in [[preadolescent]] girls and young women whom are at greater risk.<ref name="BoschBroker2013">{{cite journal|last1=Bosch|first1=F. Xavier|last2=Broker|first2=Thomas R.|last3=Forman|first3=David|last4=Moscicki|first4=Anna-Barbara|last5=Gillison|first5=Maura L.|last6=Doorbar|first6=John|last7=Stern|first7=Peter L.|last8=Stanley|first8=Margaret|last9=Arbyn|first9=Marc|last10=Poljak|first10=Mario|last11=Cuzick|first11=Jack|last12=Castle|first12=Philip E.|last13=Schiller|first13=John T.|last14=Markowitz|first14=Lauri E.|last15=Fisher|first15=William A.|last16=Canfell|first16=Karen|last17=Denny|first17=Lynette A.|last18=Franco|first18=Eduardo L.|last19=Steben|first19=Marc|last20=Kane|first20=Mark A.|last21=Schiffman|first21=Mark|last22=Meijer|first22=Chris J.L.M.|last23=Sankaranarayanan|first23=Rengaswamy|last24=Castellsagué|first24=Xavier|last25=Kim|first25=Jane J.|last26=Brotons|first26=Maria|last27=Alemany|first27=Laia|last28=Albero|first28=Ginesa|last29=Diaz|first29=Mireia|last30=Sanjosé|first30=Silvia de|title=Comprehensive Control of Human Papillomavirus Infections and Related Diseases|journal=Vaccine|volume=31|year=2013|pages=I1–I31|issn=0264410X|doi=10.1016/j.vaccine.2013.07.026}}</ref>
* The most important risk factors associated with the [[infection]] by [[HPV]] are sexual intercourse at early age at the start of the first sexual relationships, having high number of sexual partners throughout life, or women being with men having multiple sexual partners. [[Male]] circumcision and use of condoms are factors that can reduce, but not preventing the transmission of [[human papilloma virus]].<ref name="Castellsagué2008">{{cite journal|last1=Castellsagué|first1=Xavier|title=Natural history and epidemiology of HPV infection and cervical cancer|journal=Gynecologic Oncology|volume=110|issue=3|year=2008|pages=S4–S7|issn=00908258|doi=10.1016/j.ygyno.2008.07.045}}</ref>
* There is an association between age and socioeconomic status of women in underserved areas of the US and higher [[incidence]] of infection with HPV. <ref name="pmid28410118">{{cite journal |vauthors=Karuri AR, Kashyap VK, Yallapu MM, Zafar N, Kedia SK, Jaggi M, Chauhan SC |title=Disparity in rates of HPV infection and cervical cancer in underserved US populations |journal=Front Biosci (Schol Ed) |volume=9 |issue= |pages=254–269 |date=June 2017 |pmid=28410118 |pmc=5935458 |doi= |url=}}</ref>
 
==Complications==
==Complications==
Advanced stage of cervical cancer can cause varieties of complications, some of these are include:<ref name="SchmitzIsaacs1957">{{cite journal|last1=Schmitz|first1=Herbert E.|last2=Isaacs|first2=John H.|title=Complications of Advanced Cervical Cancer and Their Management|journal=Radiology|volume=69|issue=3|year=1957|pages=324–329|issn=0033-8419|doi=10.1148/69.3.324}}</ref>
* [[Pain]]
* Vaginal [[hemorrhage]]
* Enterovaginal, [[Rectovaginal fistula|rectovaginal]], and vesico- or ureterovaginal [[fistula]]<nowiki/>s
* [[Renal failure]] and/or [[uremia]]
* [[Malnutrition]]
* [[Anemia]]
* Mental [[depression]]


* Some types of cervical cancer do not respond well to treatment.
*  
* The cancer may come back (recur) after treatment.
* Women who have treatment to save the uterus have a high risk of the cancer coming back (recurrence).
* Surgery and radiation can cause problems with sexual, bowel, and bladder function.


==Prognosis==
==Prognosis==
According to the International Federation of Gynecology and Obstetrics, survival improves when radiotherapy is combined with cisplatin-based chemotherapy.<ref>{{cite journal |author=Committee on Practice Bulletins-Gynecology |title=ACOG practice bulletin. Diagnosis and treatment of cervical carcinomas, number 35, May 2002 |journal=Obstetrics and gynecology |volume=99 |issue=5 Pt 1 |pages=855-67 |year=2002 |pmid=11978302 |doi=}}</ref>
* The [[prognosis]] for patients with cervical cancer is generally good, and the 5 year [[survival rate]] of patients with cervical [[cancer]] is approximately 67.9%, this is heavily because of annual [[screening]] wiht [[Pap smear]] and introduction of new preventive methods like [[HPV]] [[vaccination]] to decrease the mortality and incidence rates.
 
* Majority of cervical cancer cases can be detected early through the use of screening by [[Pap test]] and [[HPV]] [[DNA]] testing.  
As the cancer metastasizes to other parts of the body, prognosis drops dramatically because treatment of local lesions is generally more effective than whole body treatments such as chemotherapy.
 
Interval evaluation of the patient after therapy is imperative. Recurrent cervical cancer detected at its earliest stages might be successfully treated with surgery, radiation, chemotherapy, or a combination of the three. Thirty-five percent of patients with invasive cervical cancer have persistent or recurrent disease after treatment.<ref name=AMN>{{cite web | title =Cervical Cancer| work =Cervical Cancer: Pathology, Symptoms and Signs, Diagnosis, Prognosis and Treatment | url=http://www.health.am/cr/cervical-cancer/ | publisher=Armenian Health Network, Health.am }}</ref>
 
Average [[years of potential life lost]] from cervical cancer are 25.3 (SEER Cancer Statistics Review 1975-2000, National Cancer Institute (NCI)).  Approximately 4,600 women were projected to die in 2001 in the US of cervical cancer (DSTD), and the annual incidence was 13,000 in 2002 in the US, as calculated by SEER.  Thus the ratio of deaths to incidence is approximatley 35.4%.
 
Regular screening has meant that pre cancerous changes and early stage cervical cancers have been detected and treated early. Figures suggest that cervical screening is saving 5,000 lives each year in the UK by preventing cervical cancer.<ref name=chelp>{{cite web | title =Cervical cancer statistics and prognosis | url=http://www.cancerhelp.org.uk/help/default.asp?page=9260 | publisher=Cancer Research UK | accessdate=2007-03-24}}</ref>
 
It's important for you to take care of yourself by eating well and staying as active as you can during the sometimes rough treatment of cervical cancer. You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy. However, you may not feel like eating during or soon after treatment. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. Your doctor, a registered dietitian, or another health care provider can suggest ways to cope with these problems. Research shows that people with cancer feel better when they stay active. Walking, yoga, swimming, and other activities can keep you strong and increase your energy. Exercise may reduce nausea and pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start.
 
You'll need regular checkups after treatment for cervical cancer. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, you should contact your doctor. Your doctor will check for the return of cancer. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Checkups may include a physical exam, Pap tests, and chest x-rays.
 
===5-Year Survival===
 
* Between 2004 and 2010, the 5-year relative survival of patients with cervical cancer was 69.6 %.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
 
* When stratified by age, the 5-year relative survival of patients with cervical cancer was 71.9% and 48% for patients <65 and ≥ 65 years of age respectively.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
 
* The survival of patients with cervical cancer varies with the stage of the disease.  Shown below is a table depicting the 5-year relative survival by the stage of cervical cancer:<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
|style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 10%" align=center |'''Stage'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 10%" align=center | '''5-year relative survival (%), (2004-2010)'''
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''All stages'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |67.9%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Localized'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left  |90.9%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Regional'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |57.4%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left  |'''Distant'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left  |16.1%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left  |'''Unstaged'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |54.3%
|}


* Shown below is an image depicting the 5-year conditional relative survival (probability of surviving in the next 5-years given the cohort has already survived 0, 1, 3 years) between 1998 and 2010 of cervical cancer by stage at diagnosis according to [[SEER]]. These graphs are adapted from [[SEER]]: The Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
* [[Prognosis]] of cervical cancer depends upon the [[clinical]] stage of the disease and distant [[metastasis]].<ref name="YuanWang1999">{{cite journal|last1=Yuan|first1=Chiou-Chung|last2=Wang|first2=Peng-Hui|last3=Lai|first3=Chiung-Ru|last4=Tsu|first4=En-Jie|last5=Yen|first5=Ming-Shyen|last6=Ng|first6=Heung-Tat|title=Recurrence and Survival Analyses of 1,115 Cervical Cancer Patients Treated with Radical Hysterectomy|journal=Gynecologic and Obstetric Investigation|volume=47|issue=2|year=1999|pages=127–132|issn=0378-7346|doi=10.1159/000010076}}</ref><ref name="B.K.B.2016">{{cite journal|last1=B.K.|first1=Vishma|last2=B.|first2=Prakash|last3=Kulkarni|first3=Praveen|last4=M.|first4=Renuka|title=Survival and prognostic factors for cervical cancer: a hospital based study in Mysuru, India|journal=International Journal of Community Medicine and Public Health|year=2016|pages=218–223|issn=2394-6032|doi=10.18203/2394-6040.ijcmph20151566}}</ref><ref name="JungWon2013">{{cite journal|last1=Jung|first1=Kyu-Won|last2=Won|first2=Young-Joo|last3=Kong|first3=Hyun-Joo|last4=Oh|first4=Chang-Mo|last5=Shin|first5=Aesun|last6=Lee|first6=Jin-Soo|title=Survival of Korean Adult Cancer Patients by Stage at Diagnosis, 2006-2010: National Cancer Registry Study|journal=Cancer Research and Treatment|volume=45|issue=3|year=2013|pages=162–171|issn=1598-2998|doi=10.4143/crt.2013.45.3.162}}</ref>


[[Image:5-year cervical cancer survival in USA.PNG|5-year conditional relative survival (probability of surviving in the next 5-years given the cohort has already survived 0, 1, 3 years) between 1998 and 2010 of cervical cancer by stage at diagnosis according to SEER]]
* These prognostic factors that affecting [[survival rate]] are include:<ref name="EndoTodo2015">{{cite journal|last1=Endo|first1=Daisuke|last2=Todo|first2=Yukiharu|last3=Okamoto|first3=Kazuhira|last4=Minobe|first4=Shinichiro|last5=Kato|first5=Hidenori|last6=Nishiyama|first6=Noriaki|title=Prognostic factors for patients with cervical cancer treated with concurrent chemoradiotherapy: a retrospective analysis in a Japanese cohort|journal=Journal of Gynecologic Oncology|volume=26|issue=1|year=2015|pages=12|issn=2005-0380|doi=10.3802/jgo.2015.26.1.12}}</ref>
::* [[Patient]] age
::* Maximum [[tumor]] diameter of ≥6 cm
::* [[Pelvic]] [[lymph node]] enlargement, and distant [[metastasis]]
::* Pretreatment [[hemoglobin]] level
::* Concurrent chemoradiotherapy, increases [[survival rate]] significantly in patients with advanced stage of [[cervical]] cancer in comparison with those receiving [[radiation]] therapy alone 
::* Overal treatment period 
::* [[Clinical]] stage
* Other prognostic factors are include:<ref name="KangKim2011">{{cite journal|last1=Kang|first1=Woo Dae|last2=Kim|first2=Cheol Hong|last3=Cho|first3=Moon Kyoung|last4=Kim|first4=Jong Woon|last5=Cho|first5=Hye Yon|last6=Kim|first6=Yoon Ha|last7=Choi|first7=Ho Sun|last8=Kim|first8=Seok Mo|title=HPV-18 is a poor prognostic factor, unlike the HPV viral load, in patients with stage IB–IIA cervical cancer undergoing radical hysterectomy|journal=Gynecologic Oncology|volume=121|issue=3|year=2011|pages=546–550|issn=00908258|doi=10.1016/j.ygyno.2011.01.015}}</ref><ref name="pmid8093678">{{cite journal |vauthors=Maiman M, Fruchter RG, Guy L, Cuthill S, Levine P, Serur E |title=Human immunodeficiency virus infection and invasive cervical carcinoma |journal=Cancer |volume=71 |issue=2 |pages=402–6 |date=January 1993 |pmid=8093678 |doi= |url=}}</ref><ref name="KüblerHeinenberg2015">{{cite journal|last1=Kübler|first1=Kirsten|last2=Heinenberg|first2=Sally|last3=Rudlowski|first3=Christian|last4=Keyver-Paik|first4=Mignon-Denise|last5=Abramian|first5=Alina|last6=Merkelbach-Bruse|first6=Sabine|last7=Büttner|first7=Reinhard|last8=Kuhn|first8=Walther|last9=Schildhaus|first9=Hans-Ulrich|title=<i>c-myc</i> copy number gain is a powerful prognosticator of disease outcome in cervical dysplasia|journal=Oncotarget|volume=6|issue=2|year=2015|issn=1949-2553|doi=10.18632/oncotarget.2706}}</ref>
::* [[Human immunodeficiency virus]] ([[HIV]]) status: Women with [[HIV]] have more aggressive and advanced disease and a poorer [[prognosis]].
::* [[C-myc]] [[overexpression]]: A study of patients with known invasive [[squamous carcinoma]] of the [[cervix]] found that overexpression of the [[C-myc]] [[oncogene]] was associated with a poorer prognosis.
::* [[HPV]]-18 [[DNA]] has been found to be an independent adverse [[molecular]] prognostic factor, studies have shown a worse outcome when [[HPV]]-18 was identified in cervical cancers of patients undergoing radical [[hysterectomy]] and [[pelvic]] [[lymphadenectomy]].


==References==
==Refrences==
{{reflist|2}}
{{Reflist|2}}


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Nima Nasiri, M.D.[2]

Overview

Cervical cancer is the most common cancer mainly among women in developing countries, there is an estimate of almost 260,000 deaths annually, about 80% occurred in developing countries. Common complications of cervical cancer include pain, vaginal bleeding, fistula and renal failure. Prognosis is generally good, and the 5 year survival rate of patients with cervical cancer is approximately 70%. Studies has proven that there is an association between age of the patients and socioeconomic status of women with higher incidence of infection with high risk HPV in underserved poulation in the US.

Natural history

  • Cervical cancer is the most common cancer mainly among women in developing countries, there is an estimate of almost 260,000 deaths annually, about 80% occurred in developing countries.[1]
  • Infection by high risk strain of oncogenic HPV types is an established cause of neoplastic lesions of the cervix, vagina and vulva, anus, penis and oropharynx. HPV 16 and 18, are the most common cause of approximately 70% of all cervical cancers worldwide. HPV is highly transmissible through direct skin to skin contact and intercourse, women with persistent high-risk HPV infections are at greatest risk for developing cervical cancer.
  • Since the identification of HPV as main cause of cervical cancer, prevention strategies had been developed by the introduction of HPV testing and cytology screening and utilizing HPV vaccines in preadolescent girls and young women whom are at greater risk.[2]
  • The most important risk factors associated with the infection by HPV are sexual intercourse at early age at the start of the first sexual relationships, having high number of sexual partners throughout life, or women being with men having multiple sexual partners. Male circumcision and use of condoms are factors that can reduce, but not preventing the transmission of human papilloma virus.[3]
  • There is an association between age and socioeconomic status of women in underserved areas of the US and higher incidence of infection with HPV. [4]

Complications

Advanced stage of cervical cancer can cause varieties of complications, some of these are include:[5]

Prognosis

  • The prognosis for patients with cervical cancer is generally good, and the 5 year survival rate of patients with cervical cancer is approximately 67.9%, this is heavily because of annual screening wiht Pap smear and introduction of new preventive methods like HPV vaccination to decrease the mortality and incidence rates.
  • Majority of cervical cancer cases can be detected early through the use of screening by Pap test and HPV DNA testing.

Refrences

  1. ↑ Sherris J, Herdman C, Elias C (October 2001). "Cervical cancer in the developing world". West. J. Med. 175 (4): 231–3. PMC 1071564. PMID 11577044.
  2. ↑ Bosch, F. Xavier; Broker, Thomas R.; Forman, David; Moscicki, Anna-Barbara; Gillison, Maura L.; Doorbar, John; Stern, Peter L.; Stanley, Margaret; Arbyn, Marc; Poljak, Mario; Cuzick, Jack; Castle, Philip E.; Schiller, John T.; Markowitz, Lauri E.; Fisher, William A.; Canfell, Karen; Denny, Lynette A.; Franco, Eduardo L.; Steben, Marc; Kane, Mark A.; Schiffman, Mark; Meijer, Chris J.L.M.; Sankaranarayanan, Rengaswamy; Castellsagué, Xavier; Kim, Jane J.; Brotons, Maria; Alemany, Laia; Albero, Ginesa; Diaz, Mireia; Sanjosé, Silvia de (2013). "Comprehensive Control of Human Papillomavirus Infections and Related Diseases". Vaccine. 31: I1–I31. doi:10.1016/j.vaccine.2013.07.026. ISSN 0264-410X.
  3. ↑ Castellsagué, Xavier (2008). "Natural history and epidemiology of HPV infection and cervical cancer". Gynecologic Oncology. 110 (3): S4–S7. doi:10.1016/j.ygyno.2008.07.045. ISSN 0090-8258.
  4. ↑ Karuri AR, Kashyap VK, Yallapu MM, Zafar N, Kedia SK, Jaggi M, Chauhan SC (June 2017). "Disparity in rates of HPV infection and cervical cancer in underserved US populations". Front Biosci (Schol Ed). 9: 254–269. PMC 5935458. PMID 28410118.
  5. ↑ Schmitz, Herbert E.; Isaacs, John H. (1957). "Complications of Advanced Cervical Cancer and Their Management". Radiology. 69 (3): 324–329. doi:10.1148/69.3.324. ISSN 0033-8419.
  6. ↑ Yuan, Chiou-Chung; Wang, Peng-Hui; Lai, Chiung-Ru; Tsu, En-Jie; Yen, Ming-Shyen; Ng, Heung-Tat (1999). "Recurrence and Survival Analyses of 1,115 Cervical Cancer Patients Treated with Radical Hysterectomy". Gynecologic and Obstetric Investigation. 47 (2): 127–132. doi:10.1159/000010076. ISSN 0378-7346.
  7. ↑ B.K., Vishma; B., Prakash; Kulkarni, Praveen; M., Renuka (2016). "Survival and prognostic factors for cervical cancer: a hospital based study in Mysuru, India". International Journal of Community Medicine and Public Health: 218–223. doi:10.18203/2394-6040.ijcmph20151566. ISSN 2394-6032.
  8. ↑ Jung, Kyu-Won; Won, Young-Joo; Kong, Hyun-Joo; Oh, Chang-Mo; Shin, Aesun; Lee, Jin-Soo (2013). "Survival of Korean Adult Cancer Patients by Stage at Diagnosis, 2006-2010: National Cancer Registry Study". Cancer Research and Treatment. 45 (3): 162–171. doi:10.4143/crt.2013.45.3.162. ISSN 1598-2998.
  9. ↑ Endo, Daisuke; Todo, Yukiharu; Okamoto, Kazuhira; Minobe, Shinichiro; Kato, Hidenori; Nishiyama, Noriaki (2015). "Prognostic factors for patients with cervical cancer treated with concurrent chemoradiotherapy: a retrospective analysis in a Japanese cohort". Journal of Gynecologic Oncology. 26 (1): 12. doi:10.3802/jgo.2015.26.1.12. ISSN 2005-0380.
  10. ↑ Kang, Woo Dae; Kim, Cheol Hong; Cho, Moon Kyoung; Kim, Jong Woon; Cho, Hye Yon; Kim, Yoon Ha; Choi, Ho Sun; Kim, Seok Mo (2011). "HPV-18 is a poor prognostic factor, unlike the HPV viral load, in patients with stage IB–IIA cervical cancer undergoing radical hysterectomy". Gynecologic Oncology. 121 (3): 546–550. doi:10.1016/j.ygyno.2011.01.015. ISSN 0090-8258.
  11. ↑ Maiman M, Fruchter RG, Guy L, Cuthill S, Levine P, Serur E (January 1993). "Human immunodeficiency virus infection and invasive cervical carcinoma". Cancer. 71 (2): 402–6. PMID 8093678.
  12. ↑ Kübler, Kirsten; Heinenberg, Sally; Rudlowski, Christian; Keyver-Paik, Mignon-Denise; Abramian, Alina; Merkelbach-Bruse, Sabine; Büttner, Reinhard; Kuhn, Walther; Schildhaus, Hans-Ulrich (2015). "c-myc copy number gain is a powerful prognosticator of disease outcome in cervical dysplasia". Oncotarget. 6 (2). doi:10.18632/oncotarget.2706. ISSN 1949-2553.
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