What are the treatment options for cervical cancer?

Cervical Cancer Treatment

Treatment for cervical cancer is determined by FIGO stage, with early-stage disease (IA-IB1) managed primarily by surgery, locally advanced disease (IB2-IVA) treated with concurrent chemoradiation using weekly cisplatin, and metastatic/recurrent disease requiring platinum-based chemotherapy with bevacizumab. 1, 2

Treatment by FIGO Stage

Stage IA1 (Microinvasive Disease)

• Without lymphovascular space invasion (LVSI): Conization with negative margins or simple hysterectomy based on patient age 3, 2
• With LVSI: Add pelvic lymphadenectomy to the above surgical approach 3, 2
• If pelvic nodes are positive: Proceed to adjuvant concurrent chemoradiation with weekly cisplatin 40 mg/m² 3, 1

Stage IA2

• Standard approach: Radical hysterectomy with mandatory pelvic lymphadenectomy 3, 4
• Fertility-sparing option: Conization or trachelectomy for young patients desiring fertility 3, 4
• If nodes are involved: Complementary concurrent chemoradiation 3, 1

Stage IB1 and IIA1

• Primary treatment options include: 2, 4
  • Radical hysterectomy with pelvic lymphadenectomy (preferred for younger women to preserve ovarian function and avoid vaginal stenosis) 5
  • External beam radiation plus brachytherapy 3, 2
  • Combined radio-surgery (preoperative brachytherapy followed 6-8 weeks later by surgery) 3
• Conservative surgery may be considered for tumors with excellent prognostic factors 3, 4
• Post-surgical adjuvant therapy: If high-risk pathologic features are found (positive nodes, positive margins, parametrial involvement), add concurrent chemoradiation with weekly cisplatin 40 mg/m² 1, 2

Stage IB2 and IIA2

• Primary treatment: Concurrent chemoradiation is preferred over surgery for tumors >4 cm 2, 5
• Chemoradiation regimen: Weekly cisplatin 40 mg/m² during external beam radiation therapy 1, 2
• Radiation dosing: High-dose radiation (80-90 Gy to target) delivered over <50-55 days, including external beam plus brachytherapy 1, 2

Stage IIB-IVA (Locally Advanced Disease)

• Standard treatment: Concurrent chemoradiation with weekly cisplatin 40 mg/m² 1, 2, 4
• This regimen provides: An absolute 5-year survival benefit of 8% for overall survival 1
• Radiation components: External beam radiation to cover gross disease, parametria, and nodal volumes at risk, plus brachytherapy as an essential component 4
• Treatment duration: Must be completed within 55 days for optimal outcomes 2
• Alternative for cisplatin-intolerant patients: Carboplatin or non-platinum chemoradiation regimens 2

Stage IVB and Metastatic/Recurrent Disease

• First-line regimen: Paclitaxel + cisplatin + bevacizumab 15 mg/kg every 3 weeks 1, 6
• This combination: Significantly improves survival compared to chemotherapy alone 1, 6
• Alternative options: Platinum-based combination chemotherapy without bevacizumab 4
• Selected cases: Pelvic exenteration surgery or radiotherapy may be considered for isolated locoregional recurrence 3

Special Considerations

Fertility Preservation

• Appropriate for: Young women with stage IA1-IB1 disease with tumors <2 cm and favorable histology 2, 4
• Options include: Cone biopsy with negative margins or trachelectomy 2, 4
• Contraindications: Small cell neuroendocrine tumors or minimal deviation adenocarcinoma 2

Ovarian Preservation

• May be considered: For premenopausal women with squamous cell carcinoma undergoing hysterectomy 2
• Ovarian transposition: Should be considered before pelvic radiation in women <45 years 2

Critical Pitfalls to Avoid

• Combined modality treatment (surgery followed by chemoradiation) has higher complication rates than either modality alone, so treatment planning must be coordinated upfront 2
• Treatment delays beyond 55 days significantly worsen outcomes in patients receiving radiation therapy 2
• For cervical cancer with cisplatin combination therapy: Only initiate in patients with serum creatinine ≤1.5 mg/dL, and discontinue cisplatin if creatinine rises >1.5 mg/dL 7
• Dose modifications for topotecan in cervical cancer: Reduce to 0.60 mg/m² for severe febrile neutropenia or platelet count <25,000 cells/mm³ 7

Follow-Up Protocol

• First 2 years: Clinical and gynecological examination with PAP smear every 3 months 3, 2
• Years 3-5: Every 6 months 3, 2
• After 5 years: Yearly 3, 2
• Additional monitoring: Annual cervical/vaginal cytology and imaging as indicated for symptoms or examination findings suspicious for recurrence 2