Latest Guidelines for Managing Cervical Cancer
The latest guidelines for managing cervical cancer recommend a stage-specific approach with multidisciplinary team involvement, utilizing appropriate imaging modalities for accurate staging, and treatment options including surgery, radiotherapy, or chemoradiation based on disease stage and patient factors. 1
Diagnosis and Workup
- Complete history and physical examination, with special attention to symptoms such as intermenstrual bleeding, post-coital bleeding, and post-menopausal bleeding 1
- Cervical biopsy with pathologic review; cone biopsy if needed to define invasiveness or assess microinvasive disease 1
- Complete blood count, liver and renal function tests 1
- Imaging studies:
- MRI is recommended for patients with visible cervical carcinoma (except FIGO stage IV) to determine tumor size, stromal penetration, vaginal/corpus extension 1
- CT for patients with FIGO stage IV disease or those unsuitable for MRI 1
- PET/CT for detection of lymph node involvement and distant metastases, particularly valuable in locally advanced disease 1
Treatment by Stage
Stage IA1
- Without lymphovascular space invasion (LVSI):
- With LVSI:
Stage IA2
- Fertility-sparing: Radical trachelectomy and pelvic lymph node dissection (SLN mapping can be considered) 1
- Non-fertility-sparing: Radical hysterectomy and bilateral pelvic lymph node dissection 1
- Brachytherapy for patients with surgical contraindications 1
Stages IB1 and IIA1
- Radical hysterectomy with pelvic lymphadenectomy OR radiotherapy (both approaches have similar efficacy but different morbidity profiles) 1
- Fertility-sparing (for select IB1 patients): Radical trachelectomy and pelvic lymph node dissection, typically only for tumors ≤2 cm 1
- No evidence supporting concurrent chemoradiation for early cervical cancer (stages IB1 and IIA <4 cm) 1
Locally Advanced Cervical Cancer (Stages IB2-IVA/IB3-IVA)
- Concurrent chemoradiation is the standard treatment 2, 3
- Definitive radiation therapy should include:
- Pelvic external beam radiation with high-energy photons
- Intracavitary brachytherapy
- High doses (>80-90 Gy) administered in a short time (<55 days) 1
- Neoadjuvant chemotherapy followed by radical surgery yields inferior disease-free survival compared to definitive concurrent chemoradiation 3
Recent Advances in Treatment
- Minimally invasive surgical approaches (laparoscopic, robotic) are now being cautioned against based on recent evidence 3, 4
- Sentinel lymph node mapping is increasingly being incorporated into surgical management 1
- Nerve-sparing radical hysterectomy techniques reduce postoperative bladder morbidity 4
- Immunotherapy has emerged as an important treatment option for advanced and recurrent disease:
Special Considerations
- Sexual function should be assessed before treatment, and women should be offered information, training, and support for sexual concerns before and after treatment 1
- Young women (<45 years) with early-stage squamous cell carcinoma who opt for hysterectomy may consider ovarian preservation as the rate of ovarian metastases is low 1
- Smoking cessation should be advised for all patients 1
Common Pitfalls and Caveats
- Cervical cytologic screening methods are less useful for diagnosing adenocarcinoma compared to squamous cell carcinoma 1
- Treatment must be completed within the recommended timeframe (<55 days) for optimal outcomes 1
- Unscheduled cervical smears are not recommended outside the screening program 1
- Small cell neuroendocrine histology and adenoma malignum are not suitable for fertility-sparing procedures 1