What are the treatment recommendations for cervical cancer?

From the Guidelines

Treatment for cervical cancer should be individualized based on the stage of disease, with options including surgery, radiation therapy, chemotherapy, or a combination approach, prioritizing definitive surgery with radical hysterectomy with lymph node sampling for smaller, locally confined invasive cervical cancers, and primary chemoradiotherapy for larger invasive cervical cancers. When considering treatment options, it is essential to assess the local tumor extension and determine the size and local extent of the tumor, as this information is critical in determining the treatment strategy used 1. For early-stage cervical cancer, surgical options like radical hysterectomy with lymph node dissection are typically recommended, while for locally advanced disease, concurrent chemoradiation is the standard of care 1. Some key points to consider when making treatment decisions include:

• Disease extent and stage
• Patient age and performance status
• Desire for fertility preservation
• Tumor size and location
• Presence of nodal or distant metastases Definitive surgery with radical hysterectomy with lymph node sampling is the treatment of choice for smaller (≤4 cm), locally confined invasive cervical cancers, while primary chemoradiotherapy is the treatment of choice for larger invasive cervical cancers (>4 cm) 1. Fertility-sparing procedures like trachelectomy may be options for select early-stage patients with stage IA2 or IB1 tumors who wish to maintain fertility, but tumor size and location are critical factors in assessing trachelectomy candidacy 1. Regular follow-up after treatment is essential for monitoring for recurrence and managing long-term complications, and side effect management is crucial throughout treatment, including addressing radiation-induced vaginal stenosis, lymphedema, and chemotherapy-related neuropathy. In terms of specific treatment approaches, concurrent chemoradiation typically consists of external beam radiation therapy with concurrent weekly cisplatin (40 mg/m²) for 5-6 weeks, followed by brachytherapy, while systemic therapy options for metastatic or recurrent disease include platinum-based chemotherapy combinations, immunotherapy with pembrolizumab for PD-L1 positive tumors, or bevacizumab added to chemotherapy 1.

From the FDA Drug Label

The recommended dose of Topotecan Injection is 0.75 mg/m2 by intravenous infusion over 30 minutes daily on days 1,2, and 3; followed by cisplatin 50 mg/m2 by intravenous infusion on day 1 repeated every 21 days (a 21-day course). Persistent, recurrent, or metastatic cervical cancer, in combination with paclitaxel and cisplatin, or paclitaxel and topotecan.

Treatment Recommendations for Cervical Cancer:

• Topotecan Injection in combination with cisplatin is recommended for the treatment of cervical cancer.
• The recommended dose of Topotecan Injection is 0.75 mg/m2 by intravenous infusion over 30 minutes daily on days 1,2, and 3; followed by cisplatin 50 mg/m2 by intravenous infusion on day 1 repeated every 21 days.
• Bevacizumab in combination with paclitaxel and cisplatin, or paclitaxel and topotecan is also recommended for the treatment of persistent, recurrent, or metastatic cervical cancer 2 3. Key Considerations:
• Dosage adjustments for subsequent courses of Topotecan Injection in combination with cisplatin are specific for each drug.
• Topotecan Injection in combination with cisplatin should only be initiated in patients with serum creatinine ≤1.5 mg/dL.

From the Research

Treatment Recommendations for Cervical Cancer

The treatment for cervical cancer depends on the stage of the disease, lymph node involvement, patient comorbidities, and risk factors for recurrence 4.

• For early-stage, microinvasive disease, surgery alone may be sufficient if margins are negative and there is no lymph node involvement 4.
• Adjuvant chemoradiation should be considered for other early-stage disease 4.
• Locally advanced disease is often treated with chemoradiation 4.
• The addition of bevacizumab, an antivascular endothelial growth factor monoclonal antibody, to combination chemotherapy improves survival among patients with recurrent, persistent, or metastatic cervical cancer 4.
• Disease stage and lymph node involvement are the most prognostic factors 4.
• Pregnancy status and desire to preserve fertility should be considered when developing a treatment strategy 4, 5, 6.

Fertility-Preserving Treatment Options

For women with early-stage cervical cancer who wish to preserve fertility, radical trachelectomy with pelvic lymphadenectomy is a viable option 7, 5.

• A study published in 1999 found that radical trachelectomy in combination with pelvic lymph node dissection had similar efficacy to radical hysterectomy for patients with stage IA-B carcinoma of the cervix who desire preservation of fertility 5.
• Another study published in 2020 found that neoadjuvant chemotherapy followed by vaginal radical trachelectomy was a promising fertility-sparing treatment option for patients with FIGO 2018 stage 1B2 cervical cancer 6.
• However, patients with poor response to neoadjuvant chemotherapy and those with adenocarcinoma and/or lymph vascular space invasion may be at risk for recurrence 6.

Conservative Surgical Options

Conservative surgical options, such as simple hysterectomy, simple trachelectomy, and cervical conization with or without sentinel lymph node biopsy and pelvic lymph node dissection, may be available for patients with low-risk early-stage cervical cancer 7.

• Criteria that define this low-risk group include: squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma, tumor size <2 cm, stromal invasion <10mm, and no lymph-vascular space invasion 7.