Overview of approach to cervical cancer survivors

INTRODUCTION — While cervical cancer is the fourth most common cancer of females in the world, the number of cases has continuously declined in regions where screening programs have been implemented. However, in resource-limited areas, where screening programs are not well established, incidence and mortality rates remain disproportionately high [1]. Cervical cancer is the leading cause of cancer death in 42 countries, the majority of which are in sub-Saharan Africa and Southeastern Asia. The highest regional incidence and mortality rates are seen in Africa.

Compared with other gynecologic cancers, cervical cancer most often affects younger individuals, with a mean age at diagnosis of 50 years [2]. Many of these patients with early-stage disease will be cured and have significant additional life expectancy following completion of treatment. Consequently, they will face years of potential treatment-related side effects. They may also have concerns regarding fertility preservation, and, given their younger age, may have more family and work responsibilities than those with other gynecologic cancers, which will impact their survivorship [3]. Patients with locally advanced cervical cancer (LACC) are treated with combination chemotherapy and radiation (chemoRT). While this treatment might be curative, these patients will then live years with significant treatment sequelae and will also lose their fertility as well as ovarian function as a result of treatment.

This topic will review the approach to cervical cancer survivors.

OVERVIEW OF PRIMARY TREATMENT — Following a diagnosis of cervical cancer, all patients undergo a pretreatment staging evaluation to help determine the approach, which can then be stratified on whether the disease is early or locally advanced at presentation. The overwhelming majority of long-term cervical cancer survivors were originally treated for early-stage or locally advanced cervical cancer. In contrast, the median survival of patients diagnosed with metastatic or recurrent cervical cancer is generally less than two years. Therefore, this section will review the treatment of patients with early-stage or locally advanced cervical cancer.

Early-stage cervical cancer — Early-stage cervical cancer is defined as disease confined to the cervix measuring ≤4 cm in size (stage IA to IB2 (table 1 and table 2)). These patients may be appropriately treated with either radical surgery (which may require adjuvant radiation depending on risk factors) or concomitant chemoradiation, which is usually based on the volume of disease, patient characteristics, and surgical judgment [4]. (See "Management of early-stage cervical cancer".)

Primary treatment — Various procedures are performed for the management of early-stage cervical cancer that range from fertility-sparing options to hysterectomy. For most of these patients, a radical hysterectomy will have been performed, which entails removal of the parametrial and paravaginal tissue to include a 2 cm margin of normal tissue around the tumor, and excision of the upper one-third of the vagina. In addition to the hysterectomy, most will have undergone removal of the regional retroperitoneal lymph nodes, which may lead to subsequent issues with lymphedema, among other issues (see 'Lymphedema' below). The utilization of sentinel node dissection in cervical cancer has been prospectively shown to decrease lymphedema morbidity [5].

For select patients, an alternative approach to modified radical hysterectomy may have been performed (see "Fertility-sparing surgery for cervical cancer"):

●A cone biopsy may have been sufficient treatment for patients with microscopically identified cervical cancer (stage IA1).

●A radical trachelectomy (removal of the cervix only) may have been performed, particularly if patients were of reproductive age at the time of diagnosis, and desired fertility preservation.

In addition, nonsurgical management with radiation therapy (RT) with or without concomitant chemotherapy may have been performed if patients were not surgical candidates for whatever reason at the time of diagnosis. (See "Management of early-stage cervical cancer", section on 'Alternatives in select populations'.)

Adjuvant therapy — For patients who were treated with primary surgery, risk criteria are often employed to determine appropriate candidates for adjuvant therapy, which usually consists of RT with or without chemotherapy. Therefore, cervical cancer survivors may report additional therapy after surgery consisting of the following:

●Adjuvant RT – RT is usually administered to patients if intermediate risk factors were identified at final pathologic analysis of the uterine specimen. Risk is based on the presence of lymphovascular space invasion, depth of cervical stromal involvement, and tumor size [6]. (See "Management of early-stage cervical cancer", section on 'Intermediate-risk disease'.)

●Adjuvant chemoradiation – Concomitant chemotherapy plus RT is usually administered to patients following primary surgery if there is evidence of positive surgical margins, pathologic involvement of the pelvic lymph nodes, or invasion into the parametrial tissue. (See "Management of early-stage cervical cancer", section on 'High-risk disease'.)

Oophoropexy — In an effort to preserve ovarian function, patients who underwent RT may have undergone ovarian transposition outside of the RT field. This is discussed in detail separately. (See "Ovarian transposition before pelvic radiation".)

Locally advanced cervical cancer — This category includes patients with cervical tumors >4 cm (stage IB3) and patients with disease that has locally spread outside of the true pelvis and/or invades the bladder or rectum (stage II to IVA (table 1 and table 2)). For these patients, primary treatment consists of definitive chemoradiation with weekly doses of cisplatin, which is used to increase tissue sensitivity to the effects of RT. Although not commonly administered, some patients may have received a second agent (eg, fluorouracil or gemcitabine) during RT. These patients are treated with combination RT (both external beam and brachytherapy) as well as radiosensitizing cisplatin. (See "Management of locally advanced cervical cancer".)

Adjuvant chemotherapy — We do not administer systemic chemotherapy for patients completing primary chemoradiation, as there is limited evidence of benefit to justify the additional toxicity risks. (See "Management of locally advanced cervical cancer", section on 'No role for systemic chemotherapy after chemoradiation'.)

Adjuvant hysterectomy — Some patients may have undergone a hysterectomy following chemoradiation, particularly if they had disease features suggesting they were at a higher risk of relapse (eg, initially large cervical lesion >7 cm, lower uterine segment involvement, or those with post-treatment residual disease). However, this is not uniformly performed because there are no prospective data to show that doing so improves survival outcomes. (See "Management of locally advanced cervical cancer", section on 'Role of hysterectomy after chemoradiation'.)

POST-TREATMENT SURVEILLANCE — Surveillance after primary curative therapy for cervical cancer is uniformly recommended, although its effectiveness is not well studied. The main goal of surveillance is early detection of those recurrences that might be amenable to potentially curative salvage therapy. This is only considered in patients who have an isolated central pelvic recurrence. While there is no consensus approach to surveillance, a reasonable strategy takes into account the patient's risk for recurrence (see "Invasive cervical cancer: Patterns of recurrence and post-treatment surveillance", section on 'Surveillance strategies'):

●Patients with high-risk disease (advanced stage, treated with primary chemotherapy/radiation therapy (RT) or surgery plus adjuvant therapy) should be followed every three months for the first two years, every six months for years 3 through 5, and then annually.

●Patients with low-risk disease (early stage, treated with surgery alone, no adjuvant therapy) can be followed every six months for the first two years, and then annually.

Components of follow-up — A careful clinical examination (including review of systems and comprehensive physical examination) is the most important component of the evaluation. The role of annual cervicovaginal cytology after the first two years of surveillance is controversial [7]. (See "Invasive cervical cancer: Patterns of recurrence and post-treatment surveillance", section on 'Cervicovaginal cytology'.)

Role of imaging — Imaging has a limited role in the follow-up of asymptomatic cervical cancer survivors. Therefore, no imaging should be performed as part of routine surveillance. In patients with locally advanced cervical cancer, a positron emission tomography scan is typically performed at 12 weeks postcompletion of combination chemotherapy and radiation to assess response. While this scan has been shown to be prognostic, routine surveillance scanning is not recommended [8]. We reserve radiologic examination for the work-up of the patient suspected of recurrent or metastatic disease. (See "Invasive cervical cancer: Patterns of recurrence and post-treatment surveillance".)

PATTERNS OF RECURRENCE — Cervical cancer survivors are at risk for both local (eg, vaginal or pelvic) and distant recurrences, with most recurrences detected within the first two years of follow-up. This topic is discussed in more detail separately. (See "Invasive cervical cancer: Patterns of recurrence and post-treatment surveillance".)

SPECIFIC ISSUES — There are more data about cervical cancer survivors compared with what has been published about survivors of other gynecologic cancers. These data suggest that the modalities used in definitive treatment can result in significant symptoms experienced by the long-term survivor [9]. What follows are discussions of specific issues addressed in the literature that relate to this population. More general information on cancer survivorship is discussed elsewhere. (See "Overview of cancer survivorship care for primary care and oncology providers".)

Sequelae specific to radical surgery — The anatomic dissection encompassed by a radical hysterectomy is directly related to multiple long-term side effects that differ from those of an extrafascial hysterectomy, which is the procedure of choice when the surgical indication is for benign disease or corpus-confined endometrial cancer, because a radical hysterectomy disrupts the autonomic nervous system in the pelvis. The sympathetic and parasympathetic nerves to the bladder and rectum are often disrupted during the radical hysterectomy because they run in the inferior portion of the cardinal and uterosacral ligaments and are most often divided during the division of the parametrium and uterosacral ligaments. As a result, patients may experience bowel and/or bladder dysfunction [10,11] (see 'Bladder dysfunction' below and 'Bowel dysfunction' below). Sympathetic denervation can lead to bowel and bladder symptoms, including urinary urgency and incontinence, constipation, and incomplete stool evacuation or fecal incontinence. These symptoms can be divided into acute (in the immediate postoperative period) and long-term effects. The pelvic lymphadenectomy performed as part of the standard surgery can lead to lymphedema, and the resection of the upper vagina included in the radical surgery may lead to sexual dysfunction as a result of a shortened vagina. Finally, division of the utero-ovarian ligaments may result in premature ovarian failure due to disruption of the ovarian blood supply.

Techniques to decrease the postoperative sequelae of radical hysterectomy include the so-called "nerve-sparing" radical hysterectomy, and sentinel node dissection rather than full pelvic lymphadenectomy [12-14]. (See "Invasive cervical cancer: Staging and evaluation of lymph nodes", section on 'Surgical evaluation of lymph nodes'.)

Sequelae associated with chemoradiotherapy — As in the case of radical surgery, there are acute (self-limited) and long-term side effects of combination chemotherapy and radiation (chemoRT). While the acute side effects are short-lived and manageable, the cervical cancer survivor may suffer from lifelong side effects that significantly impact quality of life. Similar to radical surgery, these symptoms are most often related to bowel or bladder function, vaginal function, and loss of ovarian function.

One study that included mostly patients with stage I disease (73 percent) reported that patients who received radiation with or without chemotherapy had significantly worse quality of life (QOL) when adjusting for other covariates than patients who had surgery alone. The radiated patients also reported higher perceived stress, depression, and anxiety as well as more frequent gynecologic problems [15].

Bladder dysfunction — Bladder dysfunction is a common long-term concern for cervical cancer survivors, particularly those treated with chemoradiation rather than radical hysterectomy [16]. The incidence varies, but over 20 percent appear to be impacted. As an example, in one study, approximately 25 percent of patients reported treatment-related symptoms such as frequent voiding two years after radiotherapy [17]. The types of symptoms vary, but may include [18-20]:

●Urinary frequency

●Urgency

●Dysuria

●Hematuria

Signs of radiation therapy (RT)-related toxicity include [18-20]:

●Detrusor instability

●Bladder ulceration

●Incontinence due to vesicovaginal fistula

It is noteworthy that the prevalence of bladder morbidity related to RT flattens out after two to three years [21]. However, some reports suggest that 20 to 50 percent of patients may have treatment-induced bladder symptoms that have a significant effect on QOL over a 20-year period [22].

While radical hysterectomy commonly results in bladder symptoms in the postoperative recovery course (including bladder hypertonicity and decreased sensation to bladder filling) as a result of the disruption of autonomic nerve fibers that innervate the bladder, it is not clear that these issues persist in long-term survivors. In one study, 30 to 75 percent of patients reported bladder symptoms, including urinary leakage and urgency, frequent urinary tract infections, and overall urinary dysfunction [16]. However, another study suggested that urinary symptoms decrease with time and may no longer be distressing two years postoperatively [23].

In one study, comparative lower urinary tract toxicities associated with RT or radical hysterectomy in 70 patients previously treated for cervical cancer were evaluated using multichannel urodynamic tests. Most patients included in the study were initially diagnosed with advanced disease and were at least three years post-treatment completion without evidence of recurrent disease [16]. Predictably, more advanced-stage patients were in the RT group and more early-stage patients were in the radical hysterectomy group. While RT and surgery resulted in similar rates of lower urinary tract symptoms (77 versus 71 percent, respectively), the incidence and type of specific toxicities appeared to differ:

●For patients treated with radical hysterectomy, a significantly higher proportion complained of straining symptoms compared with those treated with RT (31 versus 9 percent). In addition, a higher proportion of patients complained of voiding symptoms (42.9 versus 25.7 percent), although this difference was not statistically significant.

●For patients treated with RT, a lower incidence of bladder compliance was reported compared with surgery (9 versus 31 percent, respectively). In addition, patients treated with RT also experienced increased bladder sensation (45.7 versus 11.4 percent).

While there are no specific guidelines on management, the therapeutic approach depends on the symptoms present and is discussed elsewhere:

●Urinary retention – (See "Acute urinary retention".)

●Urinary incontinence – (See "Female urinary incontinence: Treatment".)

●Interstitial cystitis or bladder pain – (See "Chemotherapy and radiation-related hemorrhagic cystitis in cancer patients" and "Interstitial cystitis/bladder pain syndrome: Management".)

Bowel dysfunction — Bowel dysfunction is common, a major source of distress, and appears to be a bigger problem for patients treated with RT rather than surgery [24], although more than 60 percent of patients who received RT after radical surgery report that these symptoms are the most common cause of distress of any degree [25]. As with bladder symptoms due to RT, the symptoms of bowel dysfunction appear to flatten out after two to three years [21]. However, up to 50 percent of patients report bowel symptoms that negatively impact QOL over a 20-year period [22]. The symptoms of RT-related bowel dysfunction include diarrhea, nausea, and emesis [24,26,27]. Fecal urgency and leakage due to pelvic RT impacts from 10 [21] to 27 percent [28] of patients and can be present five years after pelvic RT [28]. Its presence is associated with social isolation and a negative impact on QOL [21].

Methods to reduce bowel toxicity from radiation therapy include the use of intensity-modulated radiation therapy (IMRT). IMRT allows minimization of the volume of radiated small intestine. One study reported results following treatment of 71 patients with RT; 46 were treated with IMRT and 25 with conformal RT. After a median follow-up of 18 months, 31 percent of patients had grade 2 bowel toxicity and 12.6 percent had grade 3 or higher bowel toxicity. The authors concluded that restricting small and large bowel dose volume can reduce the incidence of severe late bowel toxicity to less than 5 percent [29]. Another study prospectively considered 60 patients treated with IMRT compared with 62 treated with conventional RT [30]. The IMRT patients experienced lower acute (proctitis, enteritis, cystitis, myelosuppression, and dermatitis) and chronic (enterocolitis and cystitis) toxicities than did those treated with conventional RT. There were no significant differences in overall survival between groups. A small prospective randomized trial of 44 patients has confirmed these results for gastrointestinal toxicity and overall survival [31].

Patients who underwent a radical hysterectomy are also at risk for bowel symptoms, including constipation, incomplete emptying, and fecal incontinence, which may be due to partial denervation of the bowel [32]. However, while bowel symptoms can be very distressing following surgery [25], some studies suggest that they improve with time and may resolve within two years after surgery [11,23]. The management of gastrointestinal toxicities related to treatment is discussed elsewhere:

●Radiation-related toxicity – (See "Overview of gastrointestinal toxicity of radiation therapy".)

●Nausea and vomiting – (See "Approach to the adult with nausea and vomiting", section on 'Treatment'.)

●Fecal urgency and/or incontinence – (See "Fecal incontinence in adults: Management".)

●Constipation – (See "Management of chronic constipation in adults".)

Sexual dysfunction — Treatment for cervical cancer results in significant adverse effects on sexual health in multiple ways:

●A radical hysterectomy can result in several anatomic changes, including:

•Vaginal shortening and reduced lubrication can both result in pain with attempts at penetrative intercourse (dyspareunia). This can be complicated by fibrosis around the vaginal cuff as a result of surgery [23,33]. In one study, 25 percent of patients reported distressing symptoms, including decreased lubrication and short vaginal length [34]. These symptoms may not dissipate with time and in one study, persisted at two years and longer [35].

•Damage to the autonomic nerves, resulting in difficulties in achieving sexual arousal and orgasm [36]. In another study, 23 and 17 percent of patients reported reduced orgasm frequency and overall intercourse disruption, respectively [25].

Of note, estrogen therapy is not contraindicated in cervical cancer patients; therefore, those sexual side effects related to menopause may be safely treated with systemic or vaginal estrogen treatment or both. However, patients who still have their uterus (locally advanced cervical cancer treated with chemoRT) should not be treated with estrogen alone [37].

●Pelvic radiation also causes significant sexual dysfunction [24,34,35,38-40], including hot flashes, vaginal dryness, greater difficulty achieving sexual arousal, vaginal lubrication, and reduced overall sexual satisfaction [41]. Patients treated with radiotherapy report stronger negative effect on sexual activity and sexual/vaginal functioning than patients treated without irradiation [15,42,43].

Whether the impact of RT on sexual health differs for patients treated for early-stage rather than locally advanced cervical cancer is not clear. In one study, patients with early-stage versus locally advanced cervical cancer who were two years out from the end of treatment were compared [44]. Lower levels of sexual activity were reported by patients treated for locally advanced disease, but the interpretation of this finding is confounded by the older age of this subgroup, which was also characterized by a higher proportion of postmenopausal patients.

The management of sexual issues in these patients depends on the symptoms present. Further discussion of the approach and management of sexual dysfunction is covered separately. (See "Overview of sexual dysfunction in females: Management".)

Lymphedema — Lymphedema of the lower extremities can be a significant issue, and at least one study reported it was the most disabling complication of treatment among cervical cancer survivors [45]. Lymphedema can follow both radical hysterectomy, especially if a pelvic node dissection was performed, and RT-containing treatment [45]. Multiple studies demonstrate that up to 25 percent of patients reported lymphedema to be moderately or very distressful five years after radical hysterectomy [3,23,25,46]. Lymphedema also may not improve over time, even after extended follow-up [24]. Sentinel lymph node dissection in cervical cancer may provide an opportunity to avoid postoperative lymphedema [5,47,48]; prospective trials regarding its safety and accuracy are ongoing. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema" and "Surgical treatment of primary and secondary lymphedema".)

Fatigue — Although not well delineated, up to 33 percent of patients treated for cervical cancer complain of fatigue two years and longer after treatment for cervical cancer [21,49,50]. Unfortunately, providers often underestimate the physical symptoms that their patients are experiencing [3,21]. Much of this underestimation is due to a failure to ask on the part of the provider and a reluctance to report on the part of the patient. Future study needs to focus on accurately measuring QOL physical effects on patients following chemoradiation for locally advanced cervical cancer. Future work is necessary to better characterize and increase awareness of fatigue as a long-term consequence of cervical cancer treatment. (See "Cancer-related fatigue: Prevalence, screening, and clinical assessment" and "Cancer-related fatigue: Treatment".)

Psychosocial issues — Cervical cancer patients report more anxiety, depression, and stress than other gynecologic cancer survivors. Supportive interventions addressing distress in the survivorship period may be helpful in improving QOL. Psychosocial issues that may affect the long-term cervical cancer survivor are discussed briefly below:

●Mood disturbances – Cervical cancer survivors have reported more mood disturbances, specifically anxiety, dysphoria, anger, and confusion, when compared with patients with other gynecologic cancers and patients without cancer [51-54]. Estimates vary based on the study design and questionnaires used, but in one, up to 50 percent of long-term survivors admitted to experiencing psychosocial issues related to their cancer of sufficient severity to warrant an interest in counseling [55].

One study evaluated the changes in anxiety over time among cervical cancer survivors [44]. While 20 to 25 percent of patients reported baseline severe anxiety, there was a significant improvement in the severity of symptoms at three months and a subsequently documented plateau in symptom severity over the following two years. However, 10 to 15 percent of patients continued to report severe anxiety at two years.

In contrast, depressive symptoms appear to be a lesser issue than anxiety in long-term survivors [54]. Despite this, cervical cancer survivors may be more likely to display negative mood states, even at five years post-diagnosis [54]. The etiology is unclear, though it may be due to lifestyle factors (eg, smoking, employment, and relationship status).

Risk factors for a mood disorder among cervical cancer survivors include [55,56]:

•Lower educational levels

•Unemployment

•The presence of medical comorbidities

•Age >50 years

•Lack of social support

●Fear of recurrence – Fear that a cancer may return contributes to a survivor's feeling of loss of control and unpredictability and can impact not only the patient but also her family and social network [49]. In one study, up to 91 percent of patients with cervical cancer admitted to worry about the risk of recurrence [49]. The presence of this fear may aggravate anxiety, as patients worry about symptoms such as vaginal bleeding, discharge, and pain as representing recurrence of cancer [51].

●Body image issues – Lower self-esteem and a poor body image have been reported in several studies [17,25,35,57-60]. This can be a problem particularly for patients who were of reproductive age at the time of diagnosis and for whom childbearing was important [24,57,58]. For such patients, a loss of femininity as a direct result of hysterectomy has been reported.

Secondary malignancies — Cervical cancer survivors are at risk for other human papillomavirus (HPV)-related malignancies. (See "Virology of human papillomavirus infections and the link to cancer".)

A population-based cohort study including over 21,000 survivors of cervical squamous cell carcinoma observed increased risks for oropharyngeal cancer (standardized incidence ratio 4.36, 95% CI 1.19-11.15) and anal cancer (standardized incidence ratio 2.20, 95% CI 1.28-3.52), and the increased risk persisted >10 years after initial diagnosis of cervical cancer [61]. The estimated number needed to screen for oropharyngeal cancer (282) and anal cancer (1272) was less than the number needed to screen for cervical cancer.

There are no formal guidelines regarding screening for oropharyngeal cancer in cervical cancer survivors. We recommend a careful review of oral symptoms and examination of the oral cavity by the clinicians following these patients. The review of systems includes questions about difficulty swallowing, unexplained ear or oropharyngeal pain, oral lesions or lumps, hoarseness, or a feeling of a lump in the throat. In all adults, the American Dental Association good practice statement recommends that dentists review the medical, social, and dental history and perform conventional visual and tactile examination intraorally and extraorally at dental visits [62]. The US Food and Drug Administration has not approved any HPV test for detecting HPV in the mouth.

It is also appropriate to discuss the risk of anal cancer. Patients should be informed about the types of symptoms (eg, anorectal bleeding, pain, or growths) that warrant assessment by a clinician. No formal screening guidelines are available for following asymptomatic patients and variation exists among approaches (eg, frequency of digital anorectal examination, whether to perform anal cytology) [63-65]. (See "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Screening for anal SIL'.)

HPV vaccination is recommended for individuals within the recommended age range, including those who have evidence of prior HPV infection, as vaccination can still provide protection against infection with HPV vaccine types not already acquired. (See "Human papillomavirus vaccination", section on 'Pre-existing HPV-associated disease'.)

Uterine sarcomas can arise in the radiated field after definitive treatment for cervical cancer. These sarcomas generally occur more than 10 years after radiation therapy and are rare (<1 percent of cases) [66].

COORDINATION OF CARE — Practice patterns vary according to whether follow-up is provided by an oncologist or another clinician [67]. In our practice, an oncologist follows patients for three to five years, after which they may transition back to a general gynecologist or primary care clinician. Patients may also choose to alternate follow-up visits with their gynecologist and gynecologic oncologist to limit travel time and cost where appropriate. (See "Overview of cancer survivorship care for primary care and oncology providers", section on 'Coordination of care'.)

Regardless of who is seeing the patient, post-treatment surveillance is critical. Symptoms such as vaginal bleeding or post-coital bleeding, pelvic pressure, or change in bowel or bladder habits should be carefully investigated to rule out recurrent disease. (See 'Post-treatment surveillance' above.)

In addition, age-appropriate cancer prevention and health maintenance strategies should be offered to these patients. Given the excellent prognosis of the majority of these patients, it is likely that the responsibility of subsequent care will require greater coordination among disciplines than with female survivors of other gynecologic cancers.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Treatment of cervical cancer".)

SUMMARY AND RECOMMENDATIONS

●Introduction – While cervical cancer is the fourth most common cancer of females in the world, the number of cases has continuously declined in regions where screening programs have been implemented. However, in resource-limited areas, where screening programs are not well established and human papillomavirus vaccination rates may be low, incidence and mortality rates remain disproportionately high. (See 'Introduction' above.)

●Post-treatment surveillance – Surveillance after primary curative therapy for cervical cancer is uniformly recommended. The main objective is the early detection of those recurrences that might be amenable to potentially curative salvage therapy. (See 'Post-treatment surveillance' above.)

•For patients with high-risk disease (advanced stage, treated with primary chemotherapy/radiation therapy (RT) or surgery plus adjuvant therapy), clinical evaluations can be performed every three months for the first two years, every six months for years 3 through 5, and then annually.

•For patients with low-risk disease (early stage, treated with surgery alone, no adjuvant therapy), clinical evaluations can be performed every six months for the first two years, and then annually.

●Role of imaging – Imaging has a limited role in the follow-up of asymptomatic cervical cancer survivors. We reserve radiologic examination for the work-up of the patient suspected of recurrent or metastatic disease. (See 'Role of imaging' above.)

●Patterns of recurrence – Cervical cancer survivors are at risk for both local (eg, vaginal or pelvic) and distant recurrences, with most recurrences detected within the first two years of follow-up. (See "Invasive cervical cancer: Patterns of recurrence and post-treatment surveillance".)

●Bladder dysfunction – Bladder dysfunction is a common long-term concern for cervical cancer survivors, and over 20 percent of survivors report symptoms, especially after treatment with chemoradiation. The types of symptoms vary, but may include urinary frequency, urgency, dysuria, or hematuria. (See 'Bladder dysfunction' above.)

●Bowel dysfunction – Bowel dysfunction is common in survivors after cervical cancer. It is also a major source of distress and appears to be a bigger problem for patients treated with RT rather than surgery. Over 60 percent of patients who received RT after radical surgery report that these symptoms are the most common cause of distress of any degree. (See 'Bowel dysfunction' above.)

●Sexual dysfunction – Treatment for cervical cancer can result in issues involving sexual health, including vaginal shortening, reduction in lubrication, reduced orgasm frequency, intercourse disruption, and overall reduced sexual satisfaction. Patients treated with RT report stronger negative effect on sexual activity and sexual/vaginal functioning than patients treated without irradiation. (See 'Sexual dysfunction' above.)

●Lymphedema – Lymphedema can follow both radical hysterectomy and RT-containing treatment, with up to 25 percent of patients reporting this as a moderately or very distressful issue five years after treatment. (See 'Lymphedema' above.)

●Fatigue – Although not well delineated, up to 33 percent of patients treated for cervical cancer complain of fatigue two years and longer after treatment for cervical cancer. (See 'Fatigue' above.)

●Psychosocial issues – Cervical cancer patients report more anxiety, depression, and stress than other gynecologic cancer survivors. Supportive interventions addressing distress in the survivorship period may be helpful in improving quality of life. (See 'Psychosocial issues' above.)

●Coordination of care – Given the excellent prognosis of the majority of these patients, it is likely that the responsibility of subsequent care will require greater coordination among primary care, gynecologic oncology, and other disciplines than with female survivors of other gynecologic cancers. (See 'Coordination of care' above.)