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

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==Overview==
==Overview==
If left untreated, 30-70% of patients with in situ cervical cancer may progress to develop, cervical cancer. Common complications of cervical cancer include vaginal bleeding,fistula and renal failure.  
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 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.
[[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==
==Natural history==
*Cervical cancer arises from  [[squamous-columnar]] junction.
* 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>
*The earliest microscopic change corresponding to Cervical intraepithelial neoplasia(CIN) is dysplasia of the epithelial or surface lining of the cervix,are associated with HPV infection, such as koilocytes, are also commonly seen in Cervical intraepithelial neoplasia (CIN).
* [[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.  
*However most CIN spontaneously regress. Left untreated, about 70% of CIN-1 will regress within one year, and 90% will regress within two years. About 50% of CIN 2 will regress within 2 years without treatment.
* 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>
*Progression to in situ cervical cancer in situ (CIS) occurs in approximately 11% of Cervical intraepithelial neoplasia(CIN1) and 22% of Cervical intraepithelial neoplasia(CIN2). Progression to invasive cancer occurs in approximately 1% of Cervical intraepithelial neoplasia (CIN1), 5% in Cervical intraepithelial neoplasia (CIN2) and at least 12% in Cervical intraepithelial neoplasia (CIN3).
* 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>
*. This process can be quite slow. Longitudinal studies have shown that in patients with untreated in situ cervical cancer, 30% to 70% will develop invasive carcinoma over a period of 10 to 12 years. However, in about 10% of patients, lesions can progress from in situ to invasive in a period of less than 1 year. As it becomes invasive, the tumor breaks through the basement membrane and invades the cervical stroma.<ref>https://en.wikipedia.org/wiki/Cervical_intraepithelial_neoplasia</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>
*Extension of the tumor in the cervix may ultimately manifest as ulceration, exophytic tumor, or extensive infiltration of underlying tissue, including the bladder or rectum.
*If the diseases advances and spreads to other organs, the patient may present with dyspnea, cough with blood-stained sputum, persistent pain or discomfort in the chest, swelling in hands/feet,
*Once the cancer spreads to the other organs, it is most likely fatal


==Complications==
==Complications==
* Vaginal bleeding
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>
* Pelvic pain
* [[Pain]]
* Renal failure
* Vaginal [[hemorrhage]]
* fistula
* Enterovaginal, [[Rectovaginal fistula|rectovaginal]], and vesico- or ureterovaginal [[fistula]]<nowiki/>s
* vaginal dischrage
* [[Renal failure]] and/or [[uremia]]
* DVT/Pulmonary embolism
* [[Malnutrition]]
* [[Anemia]]
* Mental [[depression]]
 
*  


==Prognosis==
==Prognosis==
The prognosis for patients with cervical cancer is markedly affected by the extent of disease at the time of diagnosis. More than 90% of cervical cancer cases can be detected early through the use of the Pap test and HPV testing.Pap and HPV testing are not performed on approximately 33% of eligible women, which results in a higher-than-expected death rate.<ref>http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#link/_285_toc</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.   
* Prognostic Factors
* Majority of cervical cancer cases can be detected early through the use of screening by [[Pap test]] and [[HPV]] [[DNA]] testing.  
:* Clinical stage
::* Clinical stage as a prognostic factor is supplemented by several gross and microscopic pathologic findings in surgically treated patients.
::* Gynecologic Oncology Group identified the following variables that were significant for progression-free interval and survival:
:::* Periaortic and pelvic lymph node status.
:::* Tumor size
:::* Patient age
:::* Performance status
:::* Bilateral disease
:::* Clinical stage
:* Other prognostic factors
::* Other prognostic factors that may affect outcome include the following:
::* 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.
::* Number of cells in S phase: The number of cells in S phase may also have prognostic significance in early cervical carcinoma.
::* HPV-18 DNA: HPV-18 DNA has been found to be an independent adverse molecular prognostic factor. Two studies have shown a worse outcome when HPV-18 was identified in cervical cancers of patients undergoing radical hysterectomy and pelvic lymphadenectomy.
::* A polymorphism in the Gamma-glutamyl hydrolase enzyme, which is related to folate metabolism, has been shown to decrease response to cisplatin, and as a result is associated with poorer outcomes.
 
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%.
===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>
* [[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>


* 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>
* 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]].


{| style="cellpadding=0; cellspacing= 0; width: 600px;"
==Refrences==
|-
{{Reflist|2}}
|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>
 
[[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]]
 
==References==
{{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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