Online Quiz
Test Your Knowledge: Ten Questions
about Cervical Cancer
This quiz is related to the Perspective in the May issue of PLoS Medicine (DOI: 10.1371/journal.
pmed.0030164).
Gavin Yamey
Question 1. Which is the most common type of cervical
cancer?

Adenocarcinoma

Squamous cell carcinoma

Adenosquamous carcinoma
Question 2. Which one of the following is true about
the epidemiology of cervical cancer?

Most cases occur in the developing world

Worldwide it is the most common malignancy in women

It is most commonly diagnosed in the third decade of life
Question 3. Which one of the following is not a risk
factor for cervical cancer?

Smoking

History of genital warts

High socioeconomic status

Micronutrient deficiency

HIV infection
Question 4. Which one of the following is true about
HPV infection in women?

Peak prevalence is in women aged 20–30 years

Infection is usually persistent

HPV DNA is found in about half of squamous cervical
cancers
Question 5. The FIGO (Federation of Gynecology and
Obstetrics) staging of cervical cancer, which is the
internationally accepted classification, is based on
which of the following?

Clinical examination with cystoscopy and proctoscopy

Radiological examination with computed tomography
(CT) and magnetic resonance imaging (MRI)

Surgical examination
Question 6. Which of the following best reflects the
evidence on conisation of the cervix (removing the
abnormal portion using a diathermy loop or scalpel)
for treating microinvasive carcinoma (stage Ia1)?

Several randomized controlled trials (RCTs) have
shown that conisation of the cervix is superior to simple
hysterectomy (removal of the cervix and uterus)
PLoS Medicine | www.plosmedicine.org

Consensus opinion, based on observational studies,
is that conisation of the cervix is effective for treating
microinvasive carcinoma (stage Ia1)

Conisation of the cervix is not suitable for women who wish
to preserve their fertility
Question 7. Which of the following best reflects the
evidence on radical trachelectomy (removal of the
cervix and parametrium) plus lymph node removal for
treating early-stage cervical cancer?

Several RCTs have shown that the rate of recurrence
free survival is lower with this treatment than with radical
hysterectomy (removal of the cervix, uterus, vaginal cuff,
pelvic lymph nodes, obturator lymph nodes, paracervical
tissue, and parametrial tissue)

The rate of operative complications is the same as with
radical hysterectomy

Unlike radical hysterectomy, radical trachelectomy plus
lymph node removal can preserve fertility
Question 8. Which of the following best reflects the
evidence on radiotherapy versus surgery (i.e. radical
hysterectomy plus lymph node removal) for early-
stage cervical cancer?

There is overwhelming evidence that surgery is associated
with higher rates of overall survival and disease-free survival

There is overwhelming evidence that radiotherapy is
associated with higher rates of overall survival and disease-
free survival

One RCT found no significant difference in overall
survival or disease-free survival and consensus regards both
treatments as likely to be beneficial
Citation: Yamey G (2006) Test your knowledge: Ten questions about cervical
cancer. PLoS Med 3(5): e275.
DOI: 10.1371/journal.pmed.0030275
Copyright: © 2006 Gavin Yamey. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author
and source are credited.
Gavin Yamey is Magazine Editor at PLoS Medicine. E-mail: gyamey@plos.org
0001 May 2006 | Volume 3 | Issue 5 | e275
Question 9. Which of the following best reflects the
evidence on chemoradiotherapy (chemotherapy
and radiotherapy given simultaneously for a short
duration of time) for treating bulky early-stage
cervical cancer?

There is no evidence of any survival benefit from adding
chemotherapy to radiotherapy alone

Several RCTs have found that chemoradiotherapy
improves overall survival and progression-free survival
compared with radiotherapy, when used either with or
after hysterectomy

Several RCTs have found that chemoradiotherapy
improves progression-free survival but not overall survival
compared with radiotherapy, when used either with or
after hysterectomy
Question 10. Approximately what proportion of
women with stage IVb disease will survive for over two
years?

20%

50%

70%
Answer 1. Squamous cell carcinoma
About 80% of cervical cancers are of the squamous type [1].
Reference
1. Waggoner SE (2003) Cervical cancer. Lancet 361: 2217–2225.
Answer 2. Most cases occur in the developing world
Almost 80% of cases occur in the developing world [1],
which may partly be explained by the lack of screening
programs in many developing countries [2].
Worldwide, cervical cancer is the second most common
malignancy in women, after breast cancer [3].
Cervical cancer is most often diagnosed in the fifth decade
[1].
References
1. Waggoner SE (2003) Cervical cancer. Lancet 361: 2217–2225.
2. Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–
2292.
3. Stewart BW, Kleihues P, editors (2003) World cancer report. Lyon (France):
IARC Press. 351 p.
Answer 3. High socioeconomic status
Risk factors for cervical cancer include smoking, history
of genital warts, low socioeconomic status, micronutrient
deficiency, HIV infection, immunosuppressive therapy, early
age of sexual activity, a high total number of sexual partners,
and persistent infection with oncogenic strains of human
papilloma virus (HPV) [1,2].
References
1. Waggoner SE (2003) Cervical cancer. Lancet 361: 2217–2225.
2. Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–
2292.
Answer 4. Peak prevalence is in women aged 20–30 years
HPV is acquired mainly through sexual intercourse and has
a peak prevalence (of 20%–30%) in women aged 20–30 years
[1]. In most cases (80%) the infection is transient, resolving
within 12–18 months [2]. HPV DNA is found in over 90% of
squamous cervical cancers [3].
PLoS Medicine | www.plosmedicine.org
References
1. Sellors JW, Mahony JB, Kaczorowski J, Lytwyn A, Bangura H, et al. (2000)
Prevalence and predictors of human papillomavirus infection in women in
Ontario, Canada. Survey of HPV in Ontario Women (SHOW) Group. CMAJ
163: 503–508.
2. Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–2292.
3. Waggoner SE (2003) Cervical cancer. Lancet 361: 2217–2225.
Answer 5. Clinical examination with cystoscopy and
proctoscopy
As most cases of cervical cancer occur in the developing
world, staging is based on clinical examination, although
improved imaging with MRI has allowed greater prediction
of parametrial and pelvic lymph node involvement. However,
there are no randomized controlled trials showing that
the use of imaging (with CT, MRI, or positron-emission
tomography) leads to better survival for women with cervical
cancer [1].
Reference
1. Waggoner SE (2003) Cervical cancer. Lancet 361: 2217–2225.
Answer 6. Consensus opinion, based on observational
studies, is that conisation of the cervix is effective for
treating microinvasive carcinoma (stage Ia1)
A systematic review of the clinical evidence found no RCTs
of conisation of the cervix versus simple hysterectomy,
but concluded that that there is a consensus (based on
observational studies) that conisation is effective for
treating microinvasive carcinoma (stage Ia1) [1]. Unlike
hysterectomy, conisation of the cervix does preserve fertility.
Reference
1. Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–2292.
Answer 7. Unlike radical hysterectomy, radical trachelectomy
plus lymph node removal can preserve fertility
A systematic review of the clinical evidence found no RCTs
of radical trachelectomy plus lymph node removal versus
radical hysterectomy [1], but it did find a retrospective
observational study comparing these two treatments [2].
The study included women with stage Ia2 or Ib tumors 2
cm or smaller without pelvic lymph node metastasis. Thirty-
two women had received radical trachelectomy plus lymph
node removal and this group was compared with two groups
of women who had undergone radical hysterectomy: one
unmatched control group (556 women) and one control
group matched for age and tumor characteristics (30
women). There was no significant difference between the
treatments in recurrence-free survival. The study found a
significantly higher rate of intraoperative complications
with radical trachelectomy plus lymphadenectomy than with
radical hysterectomy in unmatched controls. The conception
rate in women who underwent radical trachelectomy plus
lymph node removal was 37% at one year.
References
1. Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–
2292.
2. Covens A, Shaw P, Murphy J, DePetrillo D, Lickrish G, et al. (1999) Is
radical trachelectomy a safe alternative to radical hysterectomy for patients
with stage IA–B carcinoma of the cervix? Cancer 86: 2273–2279.
Answer 8. One RCT found no significant difference in overall
survival or disease-free survival and consensus regards both
treatments as likely to be beneficial
One RCT, involving 343 women with stage Ib-IIa disease,
found no significant difference between surgery and
0002 May 2006 | Volume 3 | Issue 5 | e275
radiotherapy in 5-year survival or disease-free survival rates
[1]. Consensus opinion is that both surgery and radiotherapy
are likely to be beneficial [2,3].
References
1. Landoni F, Maneo A, Colombo A, Placa F, Milani R, et al.(1997)
Randomised study of radical surgery versus radiotherapy for stage Ib–IIa
cervical cancer. Lancet 350: 535–540.
2. Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–
2292.
3. Waggoner SE (2003) Cervical cancer. Lancet 361: 2217–2225.
Answer 9. Several RCTs have found that chemoradiotherapy
improves overall survival and progression-free survival
compared with radiotherapy, when used either with or after
hysterectomy
One systematic review identified two RCTs comparing
chemoradiotherapy versus radiotherapy alone for women
with bulky early-stage cancer (in the first RCT, women
had stage Ib2 tumors [1]; in the second RCT, women had
stage Ia2, Ib, and IIa tumors [2]). These trials found that
chemoradiotherapy improves overall survival and progression-
free survival compared with radiotherapy, when used either
with or after hysterectomy.
References
1. Keys HM, Bundy BN, Stehman FB, Muderspach LI, Chafe WE, et al. (1999)
Cisplatin, radiation, and adjuvant hysterectomy compared with radiation
and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J
Med 340: 1154–1161.
2. Peters WA III, Liu PY, Barrett RJ II, Stock RJ, Monk BJ, et al. (2000)
Concurrent chemotherapy and pelvic radiation therapy compared with
pelvic radiation therapy alone as adjuvant therapy after radical surgery in
high-risk early-stage cancer of the cervix. J Clin Oncol 18: 1606–1613.
PLoS Medicine | www.plosmedicine.org
Answer 10. 20%
Roughly 20% of women with stage IVb disease will survive
for over two years [1].
Reference
1. Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–
2292.
References
Covens A, Shaw P, Murphy J, DePetrillo D, Lickrish G, et al. (1999) Is radical
trachelectomy a safe alternative to radical hysterectomy for patients with
stage IA–B carcinoma of the cervix? Cancer 86: 2273–2279.
Keys HM, Bundy BN, Stehman FB, Muderspach LI, Chafe WE, et al. (1999)
Cisplatin, radiation, and adjuvant hysterectomy compared with radiation
and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J
Med 340: 1154–1161.
Landoni F, Maneo A, Colombo A, Placa F, Milani R, et al.(1997) Randomised
study of radical surgery versus radiotherapy for stage Ib–IIa cervical cancer.
Lancet 350: 535–540.
Peters WA III, Liu PY, Barrett RJ II, Stock RJ, Monk BJ, et al. (2000) Concurrent
chemotherapy and pelvic radiation therapy compared with pelvic radiation
therapy alone as adjuvant therapy after radical surgery in high-risk early-
stage cancer of the cervix. J Clin Oncol 18: 1606–1613.
Sardi JE, Giaroli A, Sananes C, Ferreira M, Soderini A (1997) Long-term follow-
up of the first randomized trial using neoadjuvant chemotherapy in stage
Ib squamous carcinoma of the cervix: The final results. Gynecol Oncol 67:
61–69.
Sellors JW, Mahony JB, Kaczorowski J, Lytwyn A, Bangura H, et al. (2000)
Prevalence and predictors of human papillomavirus infection in women in
Ontario, Canada. Survey of HPV in Ontario Women (SHOW) Group. CMAJ
163: 503–508.
Stewart BW, Kleihues P, editors (2003) World cancer report. Lyon (France):
IARC Press. 351 p.
Sundar S, Horne A, Kehoe S (2005) Cervical cancer. Clin Evid 13: 2285–2292.
Tierney JF, Stewart LA, Parmar MK (1999) Can the published data tell us about
the effectiveness of neoadjuvant chemotherapy for locally advanced cancer
of the uterine cervix? Eur J Cancer 35: 406–409.
Waggoner SE (2003) Cervical cancer. Lancet 361: 2217–2225.
0003 May 2006 | Volume 3 | Issue 5 | e275