What is the treatment for carcinoma of the cervix (cervical cancer)?

Treatment of Carcinoma of the Cervix (Cervical Cancer)

The treatment of cervical cancer must be tailored according to disease stage, with surgery recommended for early stages (IA-IB1, IIA1) and concurrent chemoradiation for more advanced disease (IB2-IVA). 1

Treatment by Stage

Microinvasive Disease (Stage IA)

• For stage IA1 without lymphovascular space invasion (LVSI):

  • Fertility-sparing: Cone biopsy with negative margins 1
  • Non-fertility-sparing: Extrafascial hysterectomy (Piver type I) 2, 1

• For stage IA1 with LVSI or 1-3 mm invasion:

  • Standard surgery: Simple hysterectomy or total hysterectomy 2
  • External and interiliac lymphadenectomy is recommended 2
  • For fertility preservation: Complete excision by cone biopsy (if patient wishes to become pregnant) 2

• For stage IA2 (3-5 mm invasion):

  • Standard treatment: Hysterectomy with lymphadenectomy 2, 1
  • For fertility preservation: Radical trachelectomy with pelvic lymph node dissection 1

Early Invasive Disease (Stages IB1, IIA1)

• For tumors <4 cm, treatment options include:
  • Radical hysterectomy with pelvic lymphadenectomy 2, 1
  • Pelvic radiation therapy plus brachytherapy 2, 1
  • The choice between surgery and radiation depends on patient factors and institutional expertise 1

Locally Advanced Disease (Stages IB2-IIA2, IIB)

• For tumors ≥4 cm:
  • Standard treatment: Concurrent chemoradiation (external beam radiation + brachytherapy + cisplatin-based chemotherapy) 2, 1
  • Radiochemotherapy significantly improves local control and overall survival compared with radiotherapy alone 2
  • The chemotherapy usually involves cisplatin either alone or combined with 5-FU 2
  • For stage IIB proximal disease, options include primary surgery, radiotherapy and brachytherapy, or combination radiosurgery 2

Advanced Disease (Stages IIB distal, III, IVA)

• Standard treatment: Concurrent chemoradiation 2, 1

  • External beam radiation + brachytherapy + cisplatin-based chemotherapy 2
  • Para-aortic irradiation if para-aortic nodes are involved 2
  • Treatment should be completed within the recommended timeframe (<55 days) 1

• For stage IVA specifically:

  • Pelvic exenteration may be considered, especially when there is no parametral invasion, fixation to the pelvic wall, or para-aortic extension 2

Chemotherapy Regimens

• For concurrent chemoradiation:
  • Standard regimen: Cisplatin-based chemotherapy (40 mg/m² weekly or 50-75 mg/m² every 3-4 weeks) 2
  • For cervical cancer in combination with cisplatin: Topotecan 0.75 mg/m² by intravenous infusion over 30 minutes daily on days 1,2, and 3; followed by cisplatin 50 mg/m² on day 1, repeated every 21 days 3

Special Considerations

• Fertility preservation:

  • Should be considered for young women with early-stage disease 1
  • Not recommended for small cell neuroendocrine tumors or minimal deviation adenocarcinoma 1

• Pregnancy:

  • Stage IA disease can be followed until the end of pregnancy 2
  • For invasive cancers, priority should be given to treatment during the first trimester 2
  • After the second trimester, management varies based on tumor progression 2

• Lymphadenectomy:

  • Pelvic lymphadenectomy is standard for most stages of cervical cancer 4
  • Para-aortic lymphadenectomy should be considered for larger tumors and suspected pelvic nodal disease 4
  • In stage IIB disease, lymphadenectomy should extend to the renal artery level 4

Follow-up After Treatment

• Regular surveillance is recommended:

  • 3-4 times per year during the first 2 years
  • Every 6 months for the following 3 years
  • Once a year thereafter 2

• Follow-up should include:

  • History-taking and clinical examination 2
  • Assessment for treatment-related complications 2
  • Vaginal smears only if clinically indicated, not routinely 2

Common Pitfalls and Caveats

• Combined modality treatment (surgery + radiation) has higher complication rates than either modality alone 1
• Induction or neoadjuvant chemotherapy before radiotherapy increases radiotherapy-induced toxicity and the risk of treatment disruption 2
• For recurrent disease, management depends on previous treatment, site and extent of recurrence 5
• Toxicity of radiochemotherapy is predominantly hematological and intestinal and is greater than that of radiotherapy alone 2