What are the treatment options for cervical cancer?

Treatment Options for Cervical Cancer

The treatment of cervical cancer depends primarily on disease stage, with surgery recommended for early stages (IA-IB1, IIA1) and concurrent chemoradiation for more advanced disease (IB2-IVA). 1

Treatment by Stage

Stage IA1 (Microinvasive)

• For stage IA1 without lymphovascular space invasion (LVSI):
  • Fertility-sparing: Cone biopsy with negative margins 1, 2
  • Non-fertility-sparing: Extrafascial hysterectomy 1
• For stage IA1 with LVSI:
  • Pelvic lymph node dissection is recommended in addition to the above treatments 1
  • Consider treatment according to stage IB1 guidelines if extensive LVSI is present 1

Stage IA2

• Fertility-sparing: Radical trachelectomy plus pelvic lymph node dissection 1, 2
• Non-fertility-sparing: Modified radical hysterectomy plus pelvic lymph node dissection 1
• Radiation therapy is an option for medically inoperable patients 1

Stages IB1 and IIA1 (Tumor ≤4 cm)

• Primary treatment options include:
  • Radical hysterectomy with pelvic lymphadenectomy ± para-aortic lymph node sampling 1
  • Pelvic radiation therapy plus brachytherapy (total point A dose: 80-85 Gy) ± concurrent cisplatin-containing chemotherapy 1
• The choice between surgery and radiation depends on patient factors and institutional expertise, with similar efficacy but different morbidity profiles 1, 3
• Young women often prefer surgery to preserve ovarian function and avoid radiation-induced vaginal stenosis 3, 4

Stages IB2 and IIA2 (Tumor >4 cm)

• Treatment options include:
  • Pelvic radiation therapy plus concurrent cisplatin-containing chemotherapy plus brachytherapy (total point A dose: 75-80 Gy) 1
  • Radical hysterectomy with pelvic lymphadenectomy ± para-aortic lymph node sampling 1
• Most oncologists now include patients with IB2 and IIA2 disease in the advanced disease category 1

Stages IIB-IVA (Locally Advanced)

• Concurrent chemoradiation is the standard treatment 1
• Radiation therapy should consist of:
  • Pelvic external beam radiation with high-energy photons
  • Intracavitary brachytherapy
  • High doses (>80-90 Gy) administered in a short time (<55 days) 1, 2
• Cisplatin-based chemotherapy (either cisplatin alone or cisplatin/5-FU) is given concurrently with external-beam radiation 1

Stage IVB (Metastatic)

• Platinum-based combination chemotherapy is the standard option 1
• For recurrent, persistent, or metastatic disease, the addition of bevacizumab to combination chemotherapy improves survival 4
• Topotecan in combination with cisplatin is an FDA-approved option for recurrent or metastatic disease 5

Special Considerations

Fertility Preservation

• Fertility-sparing options should be considered for young women with early-stage disease 1, 2
• Not recommended for small cell neuroendocrine tumors or minimal deviation adenocarcinoma 1
• After childbearing is complete, hysterectomy can be considered, especially with chronic persistent HPV infection or abnormal Pap tests 1

Minimally Invasive Surgery

• Recent studies have shown poorer oncologic outcomes with minimally invasive radical hysterectomy compared to open surgery 1
• Women should be carefully counseled about the oncologic risks and potential short-term benefits of different surgical approaches 1

Ovarian Preservation

• For premenopausal women undergoing hysterectomy for squamous cell carcinoma, ovarian preservation may be considered 1, 2
• Ovarian transposition may be considered before pelvic radiation therapy in women younger than 45 years 1

Common Pitfalls and Caveats

• Treatment must be completed within the recommended timeframe (<55 days) for optimal outcomes 1, 2
• Adjuvant chemoradiation should be considered after surgery if risk factors are present (LVSI, G3, positive resection margins, multiple positive nodes) 1
• Combined modality treatment (surgery followed by radiation) has higher complication rates than either modality alone 1
• Carboplatin or non-platinum chemoradiation regimens are options for patients who cannot tolerate cisplatin 1
• Topotecan requires careful monitoring for bone marrow suppression, with dose adjustments for neutropenia and thrombocytopenia 5
• For cervical cancer in pregnancy, treatment decisions should consider gestational age and patient preferences regarding pregnancy continuation 6

Follow-up After Treatment

• Regular follow-up with physical and gynecological examinations every 3-6 months for 2 years, every 6-12 months for 3-5 years, then annually 1
• Annual cervical/vaginal cytology as indicated 1
• Imaging (chest radiography, CT, PET, MRI) as indicated based on symptoms or examination findings suspicious for recurrence 1
• Recommend use of vaginal dilator after radiation therapy 1