Cervical cancer is a malignancy that begins in the cells lining the cervix, the lower part of the uterus that opens into the vagina. Almost all cases are linked to persistent infection with high-risk human papillomavirus (HPV) types, with HPV 16 and 18 driving roughly 70 percent of disease worldwide and a similar share in Indian cohorts (NCI PDQ cervical cancer treatment, IARC Monograph 100B on HPV). India carries one of the largest absolute burdens of cervical cancer globally. GLOBOCAN 2022 estimates around 127,000 new cases and 79,000 deaths every year in the country, making it the second most common cancer among Indian women after breast (GLOBOCAN 2022 cervix uteri fact sheet). The disease is largely preventable through HPV vaccination and screening, yet most Indian patients still present at locally advanced stages because organised screening coverage remains low outside selected districts (ICMR-NCDIR cancer registry report, WHO cervical cancer elimination strategy). This page explains how cervical cancer is staged using the FIGO 2018 system that the Indian oncology community follows, what each stage means in plain language, how symptoms typically evolve from early to metastatic disease, and what to expect during diagnosis and treatment at cancer centres across Delhi, Gurgaon and Noida.
What Cervical Cancer Staging Actually Means
Staging in cervical cancer is the process of measuring how far the tumour has grown within and beyond the cervix, whether it has reached regional lymph nodes, and whether it has spread to distant organs. Unlike most solid tumours that use the AJCC TNM system as the primary framework, cervical cancer has historically been staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which was for decades a purely clinical classification based on pelvic examination, sometimes performed under anaesthesia. The FIGO 2018 revision changed this by formally allowing cross-sectional imaging such as pelvic MRI and 18F-FDG PET-CT as well as pathology findings to assign stage, and by adding a new IIIC subgroup for lymph node positive disease found on imaging or surgical pathology (Bhatla et al., revised FIGO staging 2019). The result is that a woman whose pelvic examination shows a 3 cm cervical tumour confined to the cervix (clinical stage IB2) can be upstaged to IIIC1 if her PET-CT reveals positive pelvic lymph nodes, which changes both the treatment approach and the prognosis. NCR centres including leading cancer centres Saket, leading cancer centres all report the FIGO 2018 stage at the gynaecologic oncology tumour board, and many also record the corresponding UICC TNM 8th edition stage for registry purposes (ESGO-ESTRO-ESP cervical cancer guidelines 2023).
Why Cervical Cancer Uses FIGO 2018 With Imaging and Pathology Staging
Before 2018, FIGO cervical cancer staging was strictly clinical. Parametrial invasion was judged by rectovaginal examination, hydronephrosis by intravenous urography, and lymph node status was not formally part of the staging system at all. This created a disconnect between what imaging and surgical pathology could reveal and what the stage captured. The 2018 revision addressed this in three ways. First, it permitted the use of any imaging modality to determine tumour size and local extension, which means contrast-enhanced 3T MRI of the pelvis is now part of the formal staging workup rather than supplementary information. Second, it allowed pathological findings, specifically lymph node status from surgical sampling or sentinel node biopsy, to upstage disease. Third, it created stage IIIC1 for pelvic lymph node involvement and IIIC2 for paraaortic node involvement, with annotation as to whether the nodal status was determined by imaging alone (r for radiology) or by pathology (p). This moved many women previously classified as IB or IIB into IIIC, which means their treatment shifts from surgery alone or surgery plus adjuvant therapy to definitive chemoradiation. Indian centres also still perform examination under anaesthesia for protocol consistency, particularly at leading cancer centres in the region where MRI slots are rationed and a clinical assessment is documented before imaging results return (NCI PDQ cervical cancer staging).
Squamous Cell Carcinoma Dominates: WHO 2020 Cervical Cancer Histologic Subtypes
Most cervical cancers are squamous cell carcinomas, accounting for roughly 70 to 75 percent of cases in Indian surgical series, arising from the squamous epithelium of the ectocervix at the transformation zone where squamous and columnar cells meet. This is the histology most tightly linked to persistent HPV 16 infection and the one for which the progression from cervical intraepithelial neoplasia (CIN 1 through CIN 3) to invasion is most thoroughly characterised. Adenocarcinoma makes up about 20 to 25 percent of cervical cancers and starts in the glandular cells of the endocervical canal. Adenosquamous carcinoma shows features of both squamous and glandular differentiation and accounts for 3 to 5 percent of cases. The WHO 2020 Classification of Female Genital Tumours now formally separates HPV-associated from HPV-independent cervical carcinomas because the latter group carries a worse prognosis stage for stage and is less responsive to standard chemoradiation (NCI SEER cervical cancer histology). All NCR pathology laboratories at a tertiary cancer centre, a tertiary cancer centre referral centres, leading cancer centres report under the WHO 2020 framework with p16 immunohistochemistry as the surrogate for HPV association.
HPV-Associated Versus HPV-Independent Cervical Carcinoma
The distinction between HPV-associated and HPV-independent cervical carcinoma is central to the 2020 WHO classification and has direct consequences for prognosis and treatment planning. HPV-associated squamous cell carcinoma and HPV-associated adenocarcinoma, which together account for more than 90 percent of cervical cancers, show strong and diffuse block-type p16 overexpression on immunohistochemistry and are the histologies for which FIGO staging, standard chemoradiation protocols and the clinical trial data on pembrolizumab, cemiplimab and tisotumab vedotin were generated. HPV-independent carcinomas include gastric-type adenocarcinoma, clear cell carcinoma, mesonephric carcinoma and endometrioid carcinoma. Gastric-type adenocarcinoma is the most clinically important of these because it tends to present at a higher stage, shows lobular or mucinous growth patterns that can be difficult to detect on cervical screening, and responds poorly to cisplatin-based chemoradiation. p16 staining is negative or patchy in HPV-independent tumours, and HPV genotyping confirms the absence of high-risk HPV DNA. NCR centres including leading cancer centres now routinely add HPV genotyping when the pathology shows an adenocarcinoma with ambiguous p16 staining to identify this prognostically unfavourable group early (WHO Classification of Tumours, Female Genital, 5th edition, IARC 2020).
Adenocarcinoma of the Cervix: Rising Incidence and Screening Challenges
Cervical adenocarcinoma incidence has been rising in younger women in both global and Indian registries over the past two decades, even as squamous cell carcinoma rates have declined in countries with established screening programmes. The reason is that adenocarcinoma arises higher in the endocervical canal, beyond the reach of visual inspection with acetic acid (VIA), and its glandular precursors, adenocarcinoma in situ (AIS), are harder to detect on conventional Pap smears than squamous intraepithelial lesions. HPV DNA testing, which detects the virus regardless of where the lesion sits, is more sensitive for adenocarcinoma precursors than cytology and is the recommended primary screening modality in the WHO 2021 cervical screening guideline. In NCR, opportunistic screening at private hospitals using liquid-based cytology and HPV co-testing on the cobas 4800 or Roche cobas 6800 platforms picks up adenocarcinoma precursors more reliably than VIA-based public screening camps under the National Programme for Prevention and Control of NCDs (WHO screening and treatment of cervical pre-cancer guideline 2021). Surgical management of AIS requires a cone biopsy with clear endocervical margins, and patients are counselled that even with negative margins the recurrence rate warrants long-term surveillance.
Rare Cervical Histologies: Small Cell Neuroendocrine, Clear Cell and Gastric-Type
Small cell neuroendocrine carcinoma of the cervix accounts for fewer than 3 percent of cervical cancers but carries the worst prognosis of any cervical histology. It is managed using protocols adapted from small cell lung cancer, typically cisplatin and etoposide with concurrent pelvic radiotherapy for localised disease, rather than the standard cervical cancer chemoradiation backbone. Clear cell carcinoma of the cervix is associated with in utero diethylstilboestrol (DES) exposure in the historical cohort, though sporadic cases unrelated to DES occur and are HPV-independent. Gastric-type adenocarcinoma, reclassified in the WHO 2020 system, tends to arise in older women without HPV infection, shows minimal symptoms until advanced stage, and produces bulky barrel-shaped tumours or peritoneal spread that mimics ovarian cancer. Because of its poor response to standard cisplatin-based chemoradiation, oncologists at leading cancer centres in the region consider upfront surgery for resectable gastric-type tumours and explore clinical trial options for advanced cases. Other rare cervical histologies include adenoid basal carcinoma with a generally indolent course, adenoid cystic carcinoma and primary cervical lymphoma, all of which are managed on a case-by-case basis at NCR multidisciplinary tumour boards.
The FIGO Stage I Substages in Cervical Cancer: IA1 Through IB3
FIGO stage I means the cervical cancer is confined to the cervix. Stage IA is microinvasive disease defined by stromal invasion depth measured on a cone or hysterectomy specimen: IA1 has invasion up to 3 mm and IA2 between 3 and 5 mm. These substages are important because they determine whether a simple hysterectomy or fertility-sparing cone biopsy is sufficient, or whether a pelvic lymph node assessment must be added. Stage IB is a clinically visible or measurable lesion still confined to the cervix. IB1 is a tumour up to 2 cm, IB2 between 2 and 4 cm, and IB3 is greater than 4 cm. The IB3 threshold matters enormously in clinical practice because it marks the boundary between early disease typically managed with radical hysterectomy and locally advanced disease treated with definitive chemoradiation. A woman with a 4.5 cm cervical mass and no parametrial extension is classified as IB3 and will receive chemoradiation rather than surgery at leading cancer centres in the region Saket, a leading cancer centre and most NCR centres, following the principle that surgery after chemoradiation increases morbidity without improving outcomes (NCCN cervical cancer guidelines v2.2025).
FIGO Stage II, III and IIIC: Parametrial Invasion, Pelvic Wall and Nodal Disease in Cervical Cancer
Stage II cervical cancer extends beyond the uterus but has not reached the pelvic side wall or the lower third of the vagina. IIA1 involves the upper two thirds of the vagina without parametrial invasion and the tumour is up to 4 cm; IIA2 is above 4 cm with the same vaginal involvement. IIB is the substage where the tumour has spread into the parametrium, the connective tissue alongside the cervix that contains the uterine artery and the ureter. The clinical determination of parametrial invasion has been one of the most subjective elements of cervical cancer staging. On rectovaginal examination under anaesthesia, the examiner assesses whether the parametrium feels nodular, shortened or fixed, but this clinical assessment has a sensitivity of only 40 to 50 percent compared with MRI. The FIGO 2018 update now allows MRI findings of parametrial signal abnormality to define IIB, which has improved staging accuracy across NCR centres that have access to 3T pelvic MRI. The distinction between IIA and IIB is treatment-defining: IIA1 can still be managed with radical hysterectomy and pelvic node dissection, while IIB is treated with definitive concurrent chemoradiation and brachytherapy (ESGO-ESTRO-ESP cervical cancer management guidelines). The creation of stage IIIC in the FIGO 2018 revision was the single change that most affected staging practice and treatment allocation in cervical cancer. Previously, lymph node status was not part of the formal FIGO stage, even though it was one of the strongest independent prognostic factors. Now, IIIC1 denotes pelvic lymph node involvement and IIIC2 paraaortic node involvement, regardless of the T stage. An annotation of r (radiology) or p (pathology) indicates how the nodal disease was identified: IIIC1r means pelvic nodes seen on PET-CT or MRI, IIIC1p means confirmed by surgical sampling or sentinel node biopsy. This change moved a substantial proportion of women previously staged as IB or IIB with incidentally found positive nodes into stage IIIC, which triggers extended-field radiation to cover paraaortic nodes when IIIC2 is identified, and adds concurrent cisplatin and potentially pembrolizumab under the KEYNOTE-A18 protocol for high-risk IIIC disease. at leading cancer centres in the region, the radiation oncologist and gynaecologic oncologist jointly review PET-CT and MRI at the cervical cancer tumour board before assigning the IIIC substage and deciding radiation field extent (Bhatla et al., FIGO 2018 staging, Int J Gynaecol Obstet 2019).
The M Descriptor: Lung, Liver, Bone and Supraclavicular Spread in Cervical Cancer
Stage IVB cervical cancer denotes distant metastatic disease. The most common sites of distant spread in cervical cancer are the lungs, followed by the liver, bone and supraclavicular lymph nodes. Lung metastases may present as multiple small nodules on chest CT or as a single metastasis that is sometimes amenable to stereotactic body radiotherapy or resection in selected cases. Liver metastases are less common than in gastrointestinal cancers but carry a poor prognosis. Bone metastases, particularly to the lumbar spine and pelvis, cause pain and pathological fracture risk. Supraclavicular lymph node enlargement, particularly left-sided (Virchow node), can be the presenting finding in a woman who has not yet been diagnosed. Any distant metastasis places the patient in stage IVB, and treatment shifts from curative-intent chemoradiation to palliative systemic therapy with platinum, paclitaxel, bevacizumab and pembrolizumab. PET-CT is the investigation of choice for detecting distant metastases at staging in women with FIGO IB3 and above, and at leading cancer centres in the region it is requested routinely for any cervical cancer above 4 cm or with suspicious pelvic nodes (NCI cervical cancer overview).
Stage IA Cervical Cancer: Asymptomatic Disease Found on Screening
Pre-invasive cervical disease (CIN 2, CIN 3, adenocarcinoma in situ) and very early stage IA cervical cancer almost never produce symptoms. They are picked up only on a Pap smear, HPV DNA test, or colposcopy done for screening or during an unrelated gynaecology visit. A woman with stage IA1 cervical cancer has stromal invasion of 3 mm or less, which is invisible to the naked eye and diagnosed only after a pathologist measures invasion depth on a cone biopsy specimen. Stage IA2 extends the invasion to between 3 and 5 mm, still without any symptom that the patient would notice. This is why cervical screening programmes exist: without screening, these curable microinvasive cancers will grow silently through the stages until they produce bleeding, discharge or pain. In Delhi NCR, opportunistic screening at private clinics using liquid-based cytology and HPV co-testing detects precancerous and microinvasive disease in asymptomatic women, while population screening under the national NCD programme relies on VIA at primary health centres and community health centres, which has lower sensitivity for endocervical lesions. The practical message for NCR families is that a woman with no symptoms who tests positive on screening and is found to have stage IA cervical cancer has one of the highest cure rates in all of oncology (ICMR-NCDIR national cancer registry report).
Stage IB and II Cervical Cancer: Abnormal Bleeding, Discharge and Pelvic Pain
Once cervical cancer becomes frankly invasive, the most common early symptom is abnormal vaginal bleeding. Patients describe bleeding after sexual intercourse, bleeding between menstrual periods, or any bleeding after menopause. A persistent watery, blood-tinged or foul-smelling vaginal discharge is another frequent complaint and is often mistaken for a routine vaginal infection in primary care settings across Delhi NCR. As tumours grow into stage IB2, IB3 and stage II, women notice deeper pelvic pain, pain during intercourse, and heavier or more prolonged bleeding episodes. Stage IIA disease, where the tumour extends into the upper two thirds of the vagina, may present with contact bleeding from the vaginal walls during examination. Stage IIB, with parametrial involvement, can compress or displace the ureter and begins to cause the flank discomfort that becomes more pronounced in stage III. The challenge in Indian practice is that many women tolerate abnormal bleeding for months before seeking care, attributing it to irregular periods, menopause or a routine infection, and by the time they reach a gynaecology OPD at a district hospital or an NCR tertiary centre the tumour has grown beyond early stage (NCI cervical cancer symptoms and signs).
Stage III and IV Cervical Cancer: Hydronephrosis, Fistula and Distant Metastases
Stage III cervical cancer, where the tumour reaches the pelvic side wall, the lower third of the vagina or causes hydronephrosis from ureteric obstruction, brings a distinct set of symptoms. Flank pain or dull low back pain on one side signals ureteric compression or pelvic side wall involvement. Leg swelling from lymphatic or venous obstruction by bulky pelvic nodes is common in stage IIIB and IIIC. Reduced urine output or complete obstruction of one kidney may be detected only on imaging when the patient presents with rising creatinine. Stage IVA disease, where the tumour invades the bladder or rectal mucosa, can cause haematuria, rectal bleeding or the distressing symptoms of a vesicovaginal or rectovaginal fistula, where urine or stool leaks through the vagina. Stage IVB metastatic cervical cancer presents with organ-specific symptoms: bone pain from skeletal metastases, breathlessness or cough from lung deposits, jaundice from liver involvement, or a palpable supraclavicular lymph node. Constitutional symptoms including progressive weight loss and fatigue tend to appear late in cervical cancer and should not be relied on as early warning signs. Women presenting with stage III or IV cervical cancer at leading cancer centres in the region or any NCR centre undergo urgent renal function assessment and bilateral ureteric stenting when hydronephrosis threatens kidney function before chemoradiation can begin.
HPV 16, HPV 18 and High-Risk HPV Types as the Necessary Cause of Cervical Cancer
Persistent infection with high-risk HPV is the necessary cause of nearly all cervical cancers. HPV 16 and 18 dominate, together responsible for roughly 70 percent of cases worldwide and a similar proportion in Indian cohorts, with types 31, 33, 45, 52 and 58 accounting for most of the remaining HPV-positive disease (IARC Monograph 100B on HPV, IARC HPV Information Centre India). Most HPV infections clear spontaneously within one to two years, driven by a functioning cell-mediated immune response. Only a small fraction of persistent infections progress through the continuum of cervical intraepithelial neoplasia, from CIN 1 (mild dysplasia) through CIN 2 and CIN 3 (moderate to severe dysplasia and carcinoma in situ), to invasive cervical cancer over a timeline that typically spans 10 to 15 years. This long latent period is what makes cervical cancer uniquely suited to screening and prevention: there is a wide window during which precancerous lesions can be detected and treated before invasion occurs. The quadrivalent HPV vaccine covers types 6, 11, 16 and 18, the nonavalent adds 31, 33, 45, 52 and 58, and the indigenous CERVAVAC vaccine developed by the Serum Institute of India targets HPV 6, 11, 16 and 18. All three prevent the viral infections that initiate cervical carcinogenesis but do not treat existing infection or established cancer.
Tobacco, Parity and Immunosuppression: Cofactors for Cervical Cancer Progression
While HPV is the necessary cause, several cofactors determine which HPV-infected women progress to cervical cancer. Tobacco use in any form, including bidi smoking and smokeless tobacco (gutkha, khaini, zarda) which is common in parts of north India, has been shown to increase the risk of squamous cervical cancer by impairing local cervical immunity and concentrating tobacco carcinogens in cervical mucus. Long-term combined oral contraceptive use of five years or more is an established cofactor, with the risk declining after discontinuation. High parity, particularly five or more full-term pregnancies, increases risk through a combination of hormonal influences and repeated cervical trauma during delivery. Early age at first sexual intercourse and multiple sexual partners for either partner increase cumulative HPV exposure. Immunosuppression from HIV infection markedly increases both the incidence of cervical cancer and the speed of progression from CIN to invasion, which is why the WHO cervical cancer elimination strategy specifically targets women living with HIV for earlier and more frequent screening (WHO cervical cancer elimination strategy 2020). Coinfection with Chlamydia trachomatis and chronic cervical inflammation have also been associated with increased risk in epidemiological studies.
India’s Cervical Cancer Screening Gap: ICMR-NCDIR Data and the CERVAVAC Rollout
Indian epidemiology data from ICMR-NCDIR and the National Cancer Registry Programme show a higher age-standardised cervical cancer incidence in rural populations and in women with limited access to screening, with peak incidence between 55 and 69 years. The disparity between urban and rural India is stark: women in Delhi NCR with access to private gynaecology clinics can get HPV DNA testing and liquid-based cytology as part of a routine health check, while women in Uttar Pradesh, Haryana and Rajasthan hinterlands may never have a single cervical screen in their lifetime. The national programme for cervical screening under the Population Based Screening framework recommends VIA every five years for women aged 30 to 65, but implementation coverage remains patchy. HPV vaccination of girls aged 9 to 14 is the single intervention that can eliminate cervical cancer over a generation. The rollout of CERVAVAC through the universal immunisation programme, announced in 2023, aims to close this prevention gap, although operational scale-up across all states is still underway. For women already past screening age or living with established HPV infection, vaccination does not replace the need for regular screening, and NCR oncologists counsel that both interventions are complementary (ICMR-NCDIR registry report 2020, WHO elimination strategy).
VIA, Liquid-Based Cytology and HPV DNA Testing for Cervical Cancer Screening
Cervical cancer screening in India operates on two parallel tracks. In public health programmes under the National Programme for Prevention and Control of Non-Communicable Diseases, visual inspection with acetic acid (VIA) is the primary screening method at primary health centres and community health centres. VIA is a low-cost, provider-dependent test where the health worker applies 3 to 5 percent acetic acid to the cervix and looks for acetowhite lesions after one minute. It is effective for detecting squamous precancers at the ectocervical transformation zone but misses endocervical adenocarcinoma precursors and has a high false-positive rate in postmenopausal women with atrophic cervices. Opportunistic screening at private hospitals in Delhi NCR uses liquid-based cytology (ThinPrep or SurePath) and high-risk HPV DNA testing on the cobas 4800, cobas 6800 or Abbott Alinity m HPV platforms. The WHO 2021 guideline recommends HPV DNA testing as the primary screening modality because of its higher sensitivity for CIN 2+ and its ability to detect both squamous and glandular precursors regardless of lesion location. A positive HPV test followed by triage with cytology, VIA or colposcopy identifies women who need treatment. Self-collection HPV testing kits are being piloted in several Indian states and may improve coverage in underscreened populations where women are reluctant to attend a speculum examination (WHO cervical pre-cancer screening guideline 2021).
Colposcopy, Punch Biopsy and p16 IHC: Confirming the Cervical Cancer Diagnosis
A clinical diagnosis of cervical cancer usually begins at a gynaecology OPD with a per speculum and bimanual examination after a woman reports abnormal bleeding, foul discharge, or a positive screening test. A positive screen is followed by colposcopy, where a trained colposcopist applies 5 percent acetic acid and Lugol iodine to the cervix, grades acetowhite lesions by the Swede or Reid colposcopic index, and takes punch biopsies of suspicious areas along with an endocervical curettage to sample the canal. For a frank growth visible on the cervix, the gynaecologic oncologist proceeds directly to a cervical biopsy or a wedge biopsy under regional anaesthesia. Histopathology confirms the type of cervical carcinoma and reports depth of stromal invasion, lymphovascular space invasion and margin status. Immunohistochemistry with p16 (block-positive staining as the surrogate for HPV association), p63, CK7, PAX8 and Ki-67 is added when the morphology is ambiguous or when an HPV-independent subtype is suspected. The College of American Pathologists protocol for cervical specimens mandates reporting of p16 status alongside histologic type and invasion depth. HPV genotyping is routinely performed at a tertiary cancer centre, a tertiary cancer centre and large NCR private laboratories to flag HPV-independent gastric-type adenocarcinomas, which carry a worse prognosis and may warrant a different treatment approach.
Imaging in Cervical Cancer: Pelvic MRI, PET-CT and the FIGO 2018 Staging Workup
Imaging is now formally incorporated into FIGO 2018 cervical cancer staging. The standard pretreatment workup for any cervical cancer above stage IA includes a contrast-enhanced MRI of the pelvis on a 3T scanner to map tumour size, parametrial extension, vaginal involvement and pelvic lymph node status. MRI is the single investigation with the highest accuracy for assessing parametrial invasion, which is the key determinant between surgical and chemoradiation management. A contrast CT of the abdomen and chest, or a whole-body 18F-FDG PET-CT, is added for stage IB3 and above to detect paraaortic nodal disease and distant metastases. PET-CT has largely replaced separate CT plus bone scan at high-volume NCR centres because it captures nodal and distant disease in a single study and has a higher sensitivity for lymph node metastases than CT alone. Cystoscopy and proctoscopy are added when bladder or rectal invasion is suspected on imaging or examination. The baseline panel also includes renal function tests to detect hydronephrosis, liver function, complete blood count, HIV screening and HPV typing. Tumour markers such as squamous cell carcinoma (SCC) antigen for squamous histology and CA-125 for adenocarcinoma are followed during treatment at some NCR centres but are not used for primary staging decisions (ESGO-ESTRO-ESP cervical cancer guidelines 2023).
FIGO 2018 Cervical Cancer Staging: IA1 Through IVB in Detail
Stage I cervical cancer is confined to the cervix. IA1 has stromal invasion up to 3 mm, IA2 between 3 and 5 mm, IB1 is a measurable lesion up to 2 cm, IB2 between 2 and 4 cm, and IB3 greater than 4 cm. Stage II extends beyond the uterus but not to the pelvic wall or lower vagina. IIA1 reaches the upper vagina with a tumour up to 4 cm, IIA2 above 4 cm, and IIB shows parametrial invasion. Stage III extends to the pelvic side wall, the lower third of the vagina or causes hydronephrosis or a non-functioning kidney. IIIA involves the lower vagina, IIIB the pelvic wall or hydronephrosis, IIIC1 pelvic lymph node involvement and IIIC2 paraaortic nodal involvement. Stage IVA is invasion of the bladder or rectal mucosa, confirmed by biopsy of bullous oedema or visible tumour on cystoscopy or proctoscopy. IVB denotes distant metastases. The IIIC substage is annotated as r (radiology) when nodal disease is identified only by imaging and p (pathology) when confirmed surgically. This annotation matters for clinical trials and registry reporting because the prognosis of IIIC1p differs from IIIC1r. Indian centres report the full FIGO 2018 substage at the multidisciplinary meeting, and many simultaneously record the UICC TNM 8th edition equivalent for international registry harmonisation (Bhatla et al., revised FIGO staging, Int J Gynaecol Obstet 2019).
Stage IA1 and IA2 Cervical Cancer: Conization, LEEP and Radical Trachelectomy
Stage IA1 cervical cancer without lymphovascular space invasion (LVSI) is managed with a simple extrafascial hysterectomy or, in women who wish to preserve fertility, a large loop excision of the transformation zone (LEEP) or a cold knife conization with clear margins. The cone specimen must be evaluated for margin status, invasion depth and LVSI; a positive margin requires re-excision or hysterectomy. Stage IA1 with LVSI and stage IA2 add a pelvic lymph node assessment, either a sentinel lymph node biopsy with indocyanine green mapping or a systematic pelvic lymphadenectomy. For young women who wish to have children, radical trachelectomy with pelvic lymph node dissection is offered at a tertiary cancer centre, a tertiary cancer centre Mumbai, a tertiary cancer centre Delhi and a leading cancer centre Saket, with patient selection guided by tumour size below 2 cm, squamous or usual-type adenocarcinoma histology, and negative lymph nodes on preoperative imaging. The trachelectomy removes the cervix and parametrial tissue while preserving the uterine corpus, allowing future pregnancy with cerclage support. Recurrence rates after trachelectomy for appropriately selected stage IA2 and IB1 cervical cancer are comparable to those after radical hysterectomy in published series (NCCN cervical cancer guidelines v2.2025).
Stage IB1 to IIA1 Cervical Cancer: Open Radical Hysterectomy and the LACC Trial
Stage IB1, IB2 and IIA1 cervical cancer is treated with a type C (Querleu-Morrow classification) radical hysterectomy and bilateral pelvic lymphadenectomy, with paraaortic lymph node sampling for high-risk features such as large tumour size, deep stromal invasion or suspicious imaging findings. The LACC trial, published by Ramirez et al. in the New England Journal of Medicine in 2018, showed that open abdominal radical hysterectomy gave significantly superior disease-free and overall survival compared with minimally invasive (laparoscopic or robotic) radical hysterectomy for early-stage cervical cancer. This trial changed global practice, and most NCR gynaecologic oncology units at leading cancer centres in the region Saket, a leading cancer centre and a leading cancer centre have moved away from laparoscopic and robotic radical hysterectomy for cervical cancer, reserving minimally invasive approaches for other gynaecologic malignancies. Adjuvant pelvic radiotherapy with concurrent weekly cisplatin is added for intermediate-risk features meeting the Sedlis criteria (a combination of deep stromal invasion, large tumour size and LVSI), and full concurrent chemoradiation is given for high-risk features including positive surgical margins, parametrial involvement or positive lymph nodes per the Peters criteria (Ramirez et al., LACC trial, NEJM 2018).
Locally Advanced Cervical Cancer: Definitive Chemoradiation and EMBRACE Brachytherapy
Locally advanced cervical cancer, which covers stages IB3, IIA2, IIB, IIIA, IIIB and IIIC, is treated with definitive concurrent chemoradiation. The treatment backbone is external beam radiotherapy of 45 to 50.4 Gy delivered in 25 to 28 fractions using intensity-modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT) on Varian TrueBeam, Elekta Versa HD or Halcyon linear accelerators, given alongside weekly cisplatin at 40 mg per square metre of body surface area. This is followed by a high-dose-rate intracavitary brachytherapy boost using an iridium-192 source, typically delivered in three to four insertions over one to two weeks, to bring the total dose to point A to 80 to 90 Gy equivalent in 2 Gy fractions. Image-guided adaptive brachytherapy (IGABT) using MRI-based contouring of the residual tumour volume, as validated in the EMBRACE-I and EMBRACE-II multicentre studies, has improved local control rates above 90 percent for tumours under 5 cm and significantly reduced late bladder and rectal toxicity compared with point-based dosimetry. MRI-guided brachytherapy is now standard at a tertiary cancer centre, a tertiary cancer centre and several NCR private centres including a leading cancer centre, a leading cancer centre a leading cancer centre and a leading cancer centre. The total treatment duration from start of external beam to completion of brachytherapy should not exceed 56 days, as prolongation beyond this threshold is associated with a measurable drop in cure rates for locally advanced cervical cancer (Potter et al., EMBRACE-I, Lancet Oncol 2021).
INTERLACE Induction Chemotherapy and KEYNOTE-A18 Pembrolizumab Plus CRT for Cervical Cancer
Two recent trials have expanded the treatment options for locally advanced cervical cancer beyond standard chemoradiation. The INTERLACE trial reported that six weekly cycles of induction carboplatin and paclitaxel given before standard concurrent chemoradiation and brachytherapy improved both progression-free and overall survival compared with chemoradiation alone in women with stage IB3 to IVA cervical cancer. This induction approach is being adopted into 2025 protocols at several NCR centres for women with bulky IB3, IIIB and IIIC disease where the upfront tumour volume is large (McCormack et al., INTERLACE, Lancet 2024). The KEYNOTE-A18 trial added pembrolizumab to concurrent chemoradiation and then continued pembrolizumab as single-agent maintenance for up to two years in women with high-risk locally advanced cervical cancer (FIGO 2014 stage IB2-IIB with node-positive disease, or stage III-IVA). The trial showed a statistically significant improvement in progression-free survival, and pembrolizumab plus chemoradiation is now an NCCN preferred regimen for node-positive IIB and stage III cervical cancer (Lorusso et al., KEYNOTE-A18, Lancet 2024). Both pembrolizumab and carboplatin-paclitaxel induction are available at leading cancer centres in the region in Delhi NCR.
Stage IVA Cervical Cancer: Exenteration for Central Pelvic Recurrence
Stage IVA cervical cancer, where the tumour has invaded the bladder or rectal mucosa, is treated with chemoradiation when the patient is fit and the disease is considered amenable to radical-dose treatment. For women who develop a central pelvic recurrence after prior chemoradiation, where the recurrent tumour is confined to the central pelvis without pelvic side wall fixation or distant disease, pelvic exenteration is the only potentially curative surgical option. This operation removes the uterus, cervix, vagina, bladder and/or rectum depending on the extent of recurrence (anterior exenteration for bladder involvement, posterior for rectal, or total exenteration for both) and requires reconstruction with urinary diversion and colostomy. Pelvic exenteration for recurrent cervical cancer is a complex procedure performed at only a small number of high-volume NCR centres including a tertiary cancer centre Mumbai (which receives referrals from Delhi NCR), a tertiary cancer centre and a tertiary cancer centre. Patient selection is strict: fitness for a prolonged operation, absence of pelvic side wall disease on MRI, no triad of leg oedema, sciatic pain and ureteric obstruction (which indicates unresectable side wall involvement), and willingness to accept permanent stomas. Five-year survival after exenteration for central cervical recurrence ranges from 30 to 50 percent in published series from high-volume centres.
Metastatic and Recurrent Cervical Cancer: GOG 240 Bevacizumab and KEYNOTE-826 Pembrolizumab
Metastatic (stage IVB) and recurrent cervical cancer that is not amenable to local salvage is treated with systemic therapy. The first-line standard was established by the GOG 240 trial, which showed that adding bevacizumab to cisplatin or carboplatin plus paclitaxel improved median overall survival from 13.3 to 17.0 months in women with recurrent, persistent or metastatic cervical cancer (Tewari et al., GOG 240, NEJM 2014). The KEYNOTE-826 trial then added pembrolizumab to the platinum, paclitaxel and bevacizumab backbone for women with PD-L1 combined positive score (CPS) of 1 or more, and demonstrated a significant overall survival benefit, making the four-drug combination of pembrolizumab, platinum, paclitaxel and bevacizumab the new standard first-line regimen for PD-L1-positive metastatic cervical cancer (Colombo et al., KEYNOTE-826, NEJM 2021). PD-L1 CPS testing by 22C3 immunohistochemistry is now performed at diagnosis of advanced cervical cancer at all major NCR centres. For PD-L1-negative disease, platinum plus paclitaxel with or without bevacizumab remains the backbone. Biosimilar bevacizumab from Cipla, Biocon and Reliance Life Sciences is widely used at NCR centres to reduce per-cycle cost.
Second-Line Cervical Cancer: Cemiplimab, Tisotumab Vedotin and Later Options
Women with recurrent or metastatic cervical cancer who progress after first-line platinum-based therapy have several second-line options. Cemiplimab, an anti-PD-1 antibody, showed a survival benefit over investigator’s choice single-agent chemotherapy in the second-line setting in the EMPOWER-Cervical 1 trial, regardless of PD-L1 status and histology (Tewari et al., EMPOWER-Cervical 1, NEJM 2022). Single-agent pembrolizumab is another option for PD-L1-positive disease that has not received prior anti-PD-1 therapy. Tisotumab vedotin, an antibody-drug conjugate targeting tissue factor (a protein overexpressed on cervical cancer cells) conjugated to a monomethyl auristatin E payload, received accelerated approval based on innovaTV 204 and was confirmed in the phase III innovaTV 301 trial, which showed superior overall survival over chemotherapy in the second- or third-line setting (Vergote et al., innovaTV 301, NEJM 2024). Other active agents used in later lines in Indian practice include topotecan, gemcitabine, vinorelbine, ifosfamide and combination regimens selected based on prior exposure and performance status. Clinical trial enrolment at leading cancer centres in the region is considered for women who have exhausted standard options. Supportive care across all stages includes nutrition support, vaginal dilator counselling after pelvic radiation, hormone replacement for premenopausal women rendered menopausal by treatment, lymphoedema management, and structured survivorship follow-up with three-monthly visits for two years and then six-monthly visits up to five years.
Cost of Cervical Cancer Care Across Delhi, Gurgaon and Noida
Cervical cancer pricing in the National Capital Region varies widely between government tertiary centres, trust hospitals and private corporate chains. The indicative bands below reflect 2025 rack rates and negotiated packages at a tertiary cancer centre Delhi, leading cancer centres (a tertiary cancer centre) Rohini, a leading cancer centre Rajendra Place, a leading cancer centre Shalimar Bagh and Gurgaon, a leading cancer centre Saket and Shalimar Bagh, a leading cancer centre Gurgaon, a leading cancer centre Gurgaon, a leading cancer centre Gurgaon, a leading cancer centre Indraprastha and Noida, a leading cancer centre Dwarka, a leading cancer centre Noida and Felix Hospital Noida. Initial workup covering a gynaecological examination, VIA or colposcopy, cervical biopsy, HPV DNA testing, MRI pelvis 3T and PET-CT for stage IB3 and above runs from about 18,000 rupees at a tertiary cancer centre through 45,000 to 70,000 rupees at leading cancer centres in the region, and up to 95,000 to 1.25 lakh rupees at leading cancer centres in the region when imaging and molecular add-ons are bundled. A cone biopsy or LEEP under anaesthesia costs 12,000 to 20,000 rupees at government and trust centres and 55,000 to 95,000 rupees at private units. A radical hysterectomy with pelvic lymphadenectomy for stage IB or IIA is packaged at 45,000 to 70,000 rupees at a tertiary cancer centre and a tertiary cancer centre, 1.6 to 2.4 lakh rupees at a tertiary cancer centre and a leading cancer centre, and 3.5 to 6.2 lakh rupees at leading cancer centres in the region, with robotic assistance adding 1.2 to 2 lakh rupees when offered for non-LACC indications.
A full definitive chemoradiation course covering 25 to 28 fractions of IMRT or VMAT external beam radiotherapy, five cycles of weekly cisplatin and an image-guided HDR brachytherapy boost of three to four insertions costs approximately 55,000 to 90,000 rupees at a tertiary cancer centre and a tertiary cancer centre under subsidised slabs, 2.2 to 3.2 lakh rupees at a tertiary cancer centre, 3.8 to 5.5 lakh rupees at a leading cancer centre and a leading cancer centre, and 5 to 7.5 lakh rupees at leading cancer centres in the region, with brachytherapy alone billed at 18,000 to 35,000 rupees per insertion in the public sector and 55,000 to 1.1 lakh rupees per insertion in private centres. For metastatic and recurrent cervical cancer, a single cycle of carboplatin, paclitaxel and bevacizumab costs 32,000 to 55,000 rupees at public hospitals using biosimilar bevacizumab and 85,000 to 1.4 lakh rupees per cycle in private units. Pembrolizumab 200 mg runs at 1.6 to 2.1 lakh rupees per cycle at most NCR corporate centres. Cemiplimab costs 2 to 2.6 lakh rupees per cycle, and tisotumab vedotin imported on a named-patient basis can exceed 5 lakh rupees per cycle. Financial assistance is available through PMJAY for eligible families, CGHS and DGEHS empanelment at most private NCR centres, the Delhi Arogya Kosh, Haryana Swasthya Bima Yojana, the Health Minister Cancer Patient Fund at a tertiary cancer centre, Tata Trusts, Cipla Access programmes, Dr Reddy patient support, Natco and Roche programmes, and NGO support from CanSupport, Indian Cancer Society and Ugam (PMJAY Health Benefit Package 2022).
Cervical Cancer FAQs for NCR Patients and Families
How is cervical cancer different from cervical dysplasia or a positive HPV test? Dysplasia (CIN) and a positive HPV test are precancerous signals that can be watched with repeat screening or treated with a local procedure such as LEEP or cryotherapy. Cervical cancer is an invasive tumour that has crossed the basement membrane of the cervical epithelium and requires stage-directed treatment with surgery, radiotherapy, chemotherapy or a combination.
Can the HPV vaccine cure an existing cervical cancer? No. The HPV vaccine prevents new HPV infection in uninfected individuals. Women already diagnosed with cervical cancer need stage-directed treatment. The vaccine can still be offered to younger women in the family to protect against the HPV types that cause cervical cancer.
Is fertility preservation possible after a cervical cancer diagnosis? Yes, for selected women with stage IA1 to IB1 disease where the tumour is under 2 cm and lymph nodes are negative. A cone biopsy with clear margins or a radical trachelectomy with pelvic node dissection can preserve the uterus and the option of future pregnancy. Ovarian transposition or oocyte cryopreservation should be discussed before pelvic radiation.
Is robotic or laparoscopic surgery an option for early-stage cervical cancer? The LACC trial showed worse disease-free and overall survival with minimally invasive radical hysterectomy compared with open surgery for early-stage cervical cancer. Most NCR centres now offer open radical hysterectomy as the standard for stage IB and IIA cervical cancer.
Why do some women with cervical cancer receive chemoradiation instead of surgery? Cervical tumours larger than 4 cm (stage IB3 and above), tumours with parametrial, vaginal or nodal involvement, and disease extending to the pelvic wall respond to concurrent chemoradiation with brachytherapy with lower morbidity than surgery followed by radiation. Giving both surgery and full-dose radiation in sequence increases complications without improving cure rates.
What is brachytherapy and why is it essential in cervical cancer treatment? Brachytherapy places a radioactive iridium-192 source inside the cervix and vagina through an intracavitary applicator, delivering a very high radiation dose to the residual tumour with a steep dose fall-off that spares the bladder and rectum. Omitting brachytherapy from the treatment of locally advanced cervical cancer is associated with a clear drop in local control and cure rates, so it is a required component of definitive chemoradiation.
How often should I have follow-up visits after cervical cancer treatment? The standard follow-up schedule is three-monthly clinic visits for the first two years, six-monthly through year five, and annually after that. Each visit includes a pelvic examination, symptom review and selective imaging based on clinical findings. Routine PET-CT is not recommended for asymptomatic women in remission.
Can cervical cancer recur after treatment? Yes. Recurrence is most common in the first two years after treatment and can occur locally in the vaginal vault or central pelvis, regionally in pelvic or paraaortic lymph nodes, or as distant metastases in the lungs, liver or bone. Treatment of recurrent cervical cancer depends on the site and extent of recurrence and prior treatment history.
Is immunotherapy available in Delhi NCR for cervical cancer? Yes. Pembrolizumab is available for PD-L1-positive metastatic or recurrent cervical cancer (KEYNOTE-826) and for high-risk locally advanced cervical cancer alongside chemoradiation (KEYNOTE-A18) at leading cancer centres in the region. Cemiplimab is available as a second-line option (EMPOWER-Cervical 1). The Health Minister Cancer Patient Fund at a tertiary cancer centre and manufacturer patient assistance programmes help reduce cost for eligible patients.
How do I access financial support for cervical cancer treatment in Delhi NCR? PMJAY covers eligible families below the poverty line up to 5 lakh rupees per year for cancer treatment. a tertiary cancer centre runs the Health Minister Cancer Patient Fund. Private centres in Delhi, Gurgaon and Noida accept CGHS, DGEHS and corporate insurance empanelment. Patient support programmes from Dr Reddy, Cipla, Natco and Roche provide targeted and immunotherapy drugs at reduced cost. NGO support from CanSupport, Indian Cancer Society and Ugam assists with non-medical expenses (a tertiary cancer centre evidence-based cervical cancer management, ESMO cervical cancer clinical practice guideline 2023).
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