What are the treatment options for cervical cancer?

Treatment Options for Cervical Cancer

The treatment of cervical cancer is primarily determined by the FIGO stage of disease, with surgery recommended for early stages and concurrent cisplatin-based chemoradiation for locally advanced stages. 1

Staging and Assessment

Before determining treatment, proper staging is essential:

• MRI is superior to CT scan for tumor extension assessment and should be preferred for pelvic and abdominal imaging 2
• Blood counts, renal and liver function tests are required
• Thoracic CT scan may be included for metastasis assessment
• The FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) classification is the most widely used staging system 2

Treatment by Stage

Early Stage Disease (FIGO IA1)

• Standard treatment consists of conization with free margins or simple hysterectomy (choice depends on patient age and fertility desires) 2
• For patients with lymphovascular space involvement, pelvic lymphadenectomy is recommended 2
• If pelvic node involvement is found, complementary concomitant chemoradiation should be added 2

FIGO Stage IA2

• Surgery is the standard approach
• Options include:
  • For fertility preservation: Conization or trachelectomy in young patients 2, 1
  • For non-fertility preservation: Simple or radical hysterectomy 2
• Pelvic lymphadenectomy is required in all cases 2
• Complementary chemoradiation is needed if pelvic nodes are involved 2

FIGO Stage IB1

• Multiple treatment options exist:
  • Radical surgery (radical hysterectomy with pelvic lymphadenectomy)
  • External radiation plus brachytherapy
  • Combined radio-surgery (preoperative brachytherapy followed by surgery) 2
• For patients with excellent prognostic factors, conservative surgery may be considered 2
• Complementary chemoradiation is recommended for patients with positive pelvic nodes 2

Locally Advanced Disease

• Concurrent cisplatin-based chemoradiation plus brachytherapy is the standard treatment 1
• The chemotherapy regimen typically consists of cisplatin 50 mg/m² IV on day 1 of a 21-day course 1
• Radiation therapy should be administered in high doses (>80-90 Gy) and in a short time (<55 days) 1

Metastatic or Recurrent Disease (FIGO Stage IVB)

• Platinum-based combination chemotherapy is recommended 2
• For persistent, recurrent, or metastatic cervical cancer, bevacizumab may be added to chemotherapy regimens 3
• Topotecan in combination with cisplatin is FDA-approved for cervical cancer at a dose of 0.75 mg/m² IV on days 1-3, followed by cisplatin 50 mg/m² on day 1, repeated every 21 days 4
• Palliative chemotherapy is the standard for most patients with recurrent disease 2
• In selected cases, pelvic surgery (exenteration) or radiotherapy may be options 2

Treatment Outcomes

• The addition of concurrent chemotherapy to radiation results in a 30-50% decrease in the risk of death compared to radiation therapy alone 1
• Chemoradiotherapy leads to a 6% improvement in 5-year survival (hazard ratio, 0.81) 1
• For stage IB-IIA disease, surgery and radiation therapy have similar 5-year overall and disease-free survival rates (83% and 74%, respectively) 1
• The combination of surgery and radiation therapy significantly increases morbidity (28% vs 12% with radiation therapy alone) 1

Follow-up

• Clinical and gynecological examination including PAP smear should be performed:
  • Every 3 months for the first 2 years
  • Every 6 months for the next 3 years
  • Annually thereafter 2, 1

Important Considerations and Caveats

• Multidisciplinary treatment planning is mandatory for all patients 2
• Fertility preservation should only be considered in very early stages (IA1, IA2, small IB1) 1
• Fertility preservation is not recommended for neuroendocrine tumors or adenocarcinoma of minimal deviation 1
• When using topotecan, monitor for bone marrow suppression, particularly neutropenia and thrombocytopenia 4
• For patients receiving bevacizumab, be aware that it's indicated for persistent, recurrent, or metastatic cervical cancer in combination with paclitaxel and cisplatin, or paclitaxel and topotecan 3
• Immunotherapy options are emerging, with pembrolizumab approved for relapsed or metastatic PD-L1 positive cervical cancer after frontline chemotherapy 5

Treatment Algorithm

1. Determine FIGO stage through clinical examination and imaging
2. For early-stage disease (IA1-IB1):
   • Consider fertility desires
   • Evaluate for lymphovascular invasion
   • Choose between surgical options or radiation-based approaches
3. For locally advanced disease:
   • Concurrent cisplatin-based chemoradiation plus brachytherapy
4. For metastatic/recurrent disease:
   • Platinum-based combination chemotherapy
   • Consider addition of bevacizumab
   • Evaluate for surgical options in selected cases