these diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and x-ray examination of the lungs and skeleton, and cervical conization. however, the current system allows use of any imaging or pathological methods for staging. stage 1a cervical cancer stage 1b cervical cancer stage 2a cervical cancer stage 2b cervical cancer stage 3b cervical cancer stage 4a cervical cancer stage 4b cervical cancer prevention screening cervical screening test vehicle in taiwan negative visual inspection with acetic acid of the cervix positive visual inspection with acetic acid of the cervix for cin-1 main articles: cervical screening and pap test checking cervical cells with the papanicolaou test (pap test) for cervical pre-cancer has dramatically reduced the number of cases of, and mortality from, cervical cancer. liquid-based cytology may reduce the number of inadequate samples. pap test screening every three to five years with appropriate follow-up can reduce cervical cancer incidence up to 80%. abnormal results may suggest the presence of precancerous changes, allowing examination and possible preventive treatment, known as colposcopy. the treatment of low-grade lesions may adversely affect subsequent fertility and pregnancy. personal invitations encouraging women to get screened are effective at increasing the likelihood they will do so. educational materials also help increase the likelihood women will go for screening, but they are not as effective as invitations. according to the 2010 european guidelines, the age at which to start screening ranges between 20 and 30 years of age, but preferentially not before age 25 or 30 years, and depends on burden of the disease in the population and the available resources. in the united states, screening is recommended to begin at age 21, regardless of age at which a woman began having sex or other risk factors. pap tests should be done every three years between the ages of 21 and 65. in women over the age of 65, screening may be discontinued if no abnormal screening results were seen within the previous 10 years and no history of cin2 or higher exists. hpv vaccination status does not change screening rates. a number of recommended options exist for screening those 30 to 65. this includes cervical cytology every 3 years, hpv testing every 5 years, or hpv testing together with cytology every 5 years. screening is not beneficial before age 25, as the rate of disease is low. screening is not beneficial in women older than 60 years if they have a history of negative results. the american society of clinical oncology guideline has recommend for different levels of resource availability. pap tests have not been as effective in developing countries. this is in part because many of these countries have an impoverished health care infrastructure, too few trained and skilled professionals to obtain and interpret pap tests, uninformed women who get lost to follow-up, and a lengthy turn-around time to get results. visual inspection with acetic acid and hpv dna testing have been tried, though with mixed success. barrier protection barrier protection or spermicidal gel use during sexual intercourse decreases, but does not eliminate risk of transmitting the infection, though condoms may protect against genital warts. they also provide protection against other sexually transmitted infections, such as hiv and chlamydia, which are associated with greater risks of developing cervical cancer. vaccination three hpv vaccines (gardasil, gardasil 9, and cervarix) reduce the risk of cancerous or precancerous changes of the cervix and perineum by about 93% and 62%, respectively. the vaccines are between 92% and 100% effective against hpv 16 and 18 up to at least 8 years. hpv vaccines are typically given to age 9 to 26, as the vaccine is most effective if given before infection occurs. the best time to vaccinate girls is initially at the onset of the menses and then before the first sexual contact. the duration of effectiveness and whether a booster will be needed is unknown. the high cost of this vaccine has been a cause for concern. several countries have considered (or are considering) programs to fund hpv vaccination. the american society of clinical oncology guideline has recommendations for different levels of resource availability. since 2010, young women in japan have been eligible to receive the cervical cancer vaccination for free. in june 2013, the japanese ministry of health, labor and welfare mandated that, before administering the vaccine, medical institutions must inform women that the ministry does not recommend it. however, the vaccine is still available at no cost to japanese women who choose to accept the vaccination. nutrition vitamin a is associated with a lower risk as are vitamin b12, vitamin c, vitamin e, and beta-carotene. treatment cervical cryotherapy the treatment of cervical cancer varies worldwide, largely due to access to surgeons skilled in radical pelvic surgery, and the emergence of fertility-sparing therapy in developed nations. less advanced stages of cervical cancer typically have treatment options that allow fertility to be maintained, if the patient desires. because cervical cancers are radiosensitive, radiation may be used in all stages where surgical options do not exist. surgical intervention may have better outcomes than radiological approaches. in addition, chemotherapy can be used to treat cervical cancer, and has been found to be more effective than radiation alone. evidence suggests chemoradiotherapy may increase overall survival and reduce the risk of disease recurrence compared to radiotherapy alone. there is low-certainty evidence that peri-operative care approaches, such as 'fast-track surgery' or 'enhanced recovery programmes' may lower surgical stress and improve recovery after gynaecological cancer surgery. microinvasive cancer (stage ia) may be treated by hysterectomy (removal of the whole uterus including part of the vagina). for stage ia2, the lymph nodes are removed as well. alternatives include local surgical procedures such as a loop electrical excision procedure or cone biopsy. a systematic review concluded that more evidence is needed to inform decisions about different surgical techniques for women with cervical cancer at stage ia2. if a cone biopsy does not produce clear margins (findings on biopsy showing that the tumor is surrounded by cancer free tissue, suggesting all of the tumor is removed), one more possible treatment option for women who want to preserve their fertility is a trachelectomy. this attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. it is a viable option for those in stage i cervical cancer which has not spread; however, it is not yet considered a standard of care, as few doctors are skilled in this procedure. even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown. if the surgeon is not able to microscopically confirm clear margins of cervical tissue once the woman is under general anesthesia in the operating room, a hysterectomy may still be needed. this can only be done during the same operation if the woman has given prior consent. due to the possible risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the uterus for pathologic evaluation. a radical trachelectomy can be performed abdominally or vaginally and opinions are conflicting as to which is better. a radical abdominal trachelectomy with lymphadenectomy usually only requires a two- to three-day hospital stay, and most women recover very quickly (about six weeks). complications are uncommon, although women who are able to conceive after surgery are susceptible to preterm labor and possible late miscarriage. a wait of at least one year is generally recommended before attempting to become pregnant after surgery. recurrence in the residual cervix is very rare if the cancer has been cleared with the trachelectomy. yet, women are recommended to practice vigilant prevention and follow-up care including pap screenings/colposcopy, with biopsies of the remaining lower uterine segment as needed (every 3–4 months for at least 5 years) to monitor for any recurrence in addition to minimizing any new exposures to hpv through safe sex practices until one is actively trying to conceive. early stages (ib1 and iia less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. radiation therapy is given as external beam radiotherapy to the pelvis and brachytherapy (internal radiation). women treated with surgery who have high-risk features found on pathologic examination are given radiation therapy with or without chemotherapy to reduce the risk of relapse. a cochrane review has found moderate-certainty evidence that radiation decreases the risk of disease progression in people with stage ib cervical cancer, when compared to no further treatment. however, little evidence was found on its effects on overall survival. brachytherapy for cervical cancer larger early-stage tumors (ib2 and iia more than 4 cm) may be treated with radiation therapy and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvant radiation therapy), or cisplatin chemotherapy followed by hysterectomy. when cisplatin is present, it is thought to be the most active single agent in periodic diseases. such addition of platinum-based chemotherapy to chemoradiation seems not only to improve survival but also reduces risk of recurrence in women with early stage cervical cancer (ia2–iia). a cochrane review found a lack of evidence on the benefits and harms of primary hysterectomy compared to primary chemoradiotherapy for cervical cancer in stage ib2. advanced-stage tumors (iib-iva) are treated with radiation therapy and cisplatin-based chemotherapy. on 15 june 2006, the us food and drug administration approved the use of a combination of two chemotherapy drugs, hycamtin and cisplatin, for women with late-stage (ivb) cervical cancer treatment. combination treatment has significant risk of neutropenia, anemia, and thrombocytopenia side effects. there is insufficient evidence whether anticancer drugs after standard care help women with locally advanced cervical cancer to live longer. for surgery to be curative, the entire cancer must be removed with no cancer found at the margins of the removed tissue on examination under a microscope. this procedure is known as exenteration. no evidence is available to suggest that any form of follow‐up approach is better or worse in terms of prolonging survival, improving quality of life or guiding the management of problems that can arise because of the treatment and that in the case of radiotherapy treatment worsen with time. a 2019 review found no controlled trials regarding the efficacy and safety of interventions for vaginal bleeding in women with advanced cervical cancer. tisotumab vedotin (tivdak) was approved for medical use in the united states in september 2021. diagram showing the area removed with a posterior surgery diagram showing the area removed with a total operation diagram showing the area removed with an anterior operation prognosis stage prognosis depends on the stage of the cancer. for intraepithelial cervical neoplasmas the prognosis is good. with treatment, the five-year relative survival rate for the earliest stage of invasive cervical cancer is 92%, and the overall (all stages combined) five-year survival rate is about 66%. these statistics may be improved when applied to women newly diagnosed, bearing in mind that these outcomes may be partly based on the state of treatment five years ago when the women studied were first diagnosed. with treatment, 80–90% of women with stage i cancer and 60–75% of those with stage ii cancer are alive 5 years after diagnosis. survival rates decrease to 58% for women with stage iii cancer and 17% or fewer of those with stage iv cancer five years after diagnosis. recurrent cervical cancer detected at its earliest stages might be successfully treated with surgery, radiation, chemotherapy, or a combination of the three. about 35% of women with invasive cervical cancer have persistent or recurrent disease after treatment. by country five-year survival in the united states for white women is 69% and for black women is 57%. regular screening has meant that precancerous changes and early-stage cervical cancers have been detected and treated early. figures suggest that cervical screening is saving 5,000 lives each year in the uk by preventing cervical cancer. about 1,000 women per year die of cervical cancer in the uk. all of the nordic countries have cervical cancer-screening programs in place. the pap test was integrated into clinical practice in the nordic countries in the 1960s. in