Dear Colleagues,

In this Special Issue, we would like to focus on selected patients suffering from forms of cervical cancer that are characterized by the dynamics of increased progression. Among cervical cancer patients, those with increased disease progression can be seen in everyday practice. Consequently, the cause of this dynamic progression has become a subject of interest for researchers. These individuals often do not receive adequate therapy, although recommendations for the treatment of cervical cancer patients are precise and widely accessible. Furthermore, such patients have a higher risk of early relapse and an overall worse prognosis.

When cervical cancer is diagnosed in an advanced stage, most often the late diagnosis is attributed to avoidance of gynecological appointments and screening programs. However, there is an increasing number of cervical cancer patients who participate regularly in screening programs but are nevertheless diagnosed with advanced disease. The diagnosis is not attributed to screening but to the appearance of such symptoms as vaginal bleeding. The aggressive phenotypes of cervical cancer usually affect younger women. Moreover, in such cases, the cancer is more often radioresistant and the prognosis worse compared to other cases of cervical cancer.

The exact causes of the development of an aggressive phenotype of cervical cancer are not yet known. There is possibly a link with changes in sexual behavior and early sexual initiation, which raises the question of whether the age of enrollment into cervical cancer screening programs should be based on the age of sexual initiation. Some reports suggest that cervical cancer is diagnosed at a more advanced stage in sexual abuse survivors. Aside from increasing the prevalence of cervical cancer risk factors, it is possible that a history of sexual abuse shortens the length of time from HPV infection to carcinogenesis. It has also been observed that the development of cancer in these patients is more dynamic and the prognosis often worse, as it is with immunosuppressed patients. A history of intrafamilial sexual abuse may alter immune tolerance in the cervical microenvironment, enabling cancer nest progression.

As diagnosis is usually made in an advanced stage of the disease, it is important to define the characteristics of the group of patients with an aggressive phenotype. Recent studies reveal that completion hysterectomy provides an additional benefit for patients treated with chemoradiation due to locally advanced cervical cancer. Such multimodal therapy may prolong overall survival. When cancer relapse occurs in the group of patients with the aggressive phenotype of the disease, exceptional treatment, including exenteration, may be necessary. In an increasing number of cases, exenteration due to palliative indications is usually performed because of a relapse of cervical cancer that was treated primarily by chemoradiation. The qualification criteria for this procedure have not yet been established. Surgery plays a key role in the treatment of cervical cancer relapse following radiotherapy, including complications, such as the fistula and hemorrhage, that negatively impact the patient's quality of life. This problem especially affects those patients who have the aggressive phenotype of cervical cancer. The benefits of extensive surgical treatment may include the prolongation of overall survival as well as the restoration of an acceptable quality of life.

In countries with screening programs that encompass most of the population, young women are the only group in whom an increase in cervical cancer incidence and mortality has been observed. This issue raises an important question regarding the liability of gynecologists, as the death from cervical cancer of a patient participating regularly in a screening program is often considered a medical error.

We would like to encourage research in this area. Additionally, we would like to create a platform to discuss the potential clinical implications of distinguishing groups of patients who exhibit different dynamics of cervical cancer progression.

Prof. Lukasz Wicherek
Guest Editor

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