What is the recommended management plan for a patient with grade 3B (grade 3, stage B) cervical (Ca cervix) cancer?

Management of Cervical Cancer Stage IIIB

The standard treatment for stage IIIB cervical cancer is concurrent chemoradiation consisting of external beam radiation therapy plus brachytherapy with weekly cisplatin 40 mg/m² for 6 weeks during external radiation. 1

Primary Treatment Approach

Concurrent Chemoradiation (Standard)

• Radiotherapy combined with cisplatin-based chemotherapy is the definitive standard treatment for stage IIIB disease, demonstrating an absolute benefit of 8% in 5-year survival, 9% in locoregional disease-free survival, and 7% in metastasis-free survival compared to radiation alone 1

• The chemotherapy regimen consists of weekly cisplatin at 40 mg/m² administered during external radiation therapy, with level I evidence supporting this approach 1, 2

• Although the benefit is less marked for stage III disease compared to earlier stages, concurrent chemoradiation remains the standard of care and must be offered 2

Radiation Therapy Components

External Beam Radiation:

• Deliver a minimum of 55 Gy to the pelvis with the possibility of a boost up to 65-70 Gy to limited areas for locally advanced disease with distal parametrial invasion 2
• The central pelvic dose should reach 60 Gy as specified by the reference isodose 2
• Complete the entire treatment (external beam plus brachytherapy) within 8 weeks to optimize outcomes, ideally within 50-55 days 2, 1

Brachytherapy:

• Brachytherapy is an essential component of definitive treatment with level I evidence supporting its mandatory inclusion 1
• The combination of external radiation and brachytherapy should achieve a high total dose of 80-90 Gy to the target 1

Para-aortic Lymph Node Management

• If para-aortic lymph nodes are involved (confirmed by imaging or surgical staging), para-aortic irradiation at 45 Gy is standard treatment 2
• Prophylactic para-aortic radiotherapy in the absence of proven nodal involvement remains optional, as the benefit is not clearly established and carries significantly increased risk of bowel complications 2

Alternative Chemotherapy Regimens

• For patients who cannot tolerate cisplatin, alternative regimens with carboplatin or non-platinum schemes can be considered, though cisplatin remains superior 1
• Avoid the combination of cisplatin, 5-FU, and hydroxyurea, as this regimen demonstrates greater toxicity than cisplatin alone with no greater efficacy 2
• Cisplatin alone is preferred over cisplatin plus 5-FU, as the combination does not appear to provide better results 2

Emerging Evidence: Adjuvant Chemotherapy

• Recent level II evidence suggests a potential benefit with adjuvant chemotherapy (cisplatin-gemcitabine) after concurrent chemoradiation for locally advanced disease, showing improved progression-free and overall survival 1
• This strategy requires further research before becoming standard treatment and should be considered investigational at present 1

Surgery in Stage IIIB

• Surgery for stage IIIB disease, with or without preoperative radiotherapy, is NOT recommended outside prospective therapeutic trials 2
• Pelvic exenteration is reserved only for stage IVA disease and is not appropriate for stage IIIB 2

Follow-up Protocol

• Clinical and gynecological examination every 3 months for the first 2 years, then every 6 months for the next 3 years, then annually thereafter 2, 1
• Include cervical cytology (PAP smear) at each visit, though be aware of radiation-induced changes that may complicate interpretation 2, 1
• SCC antigen monitoring can be useful if initially elevated in squamous cell carcinomas 1
• Routine surveillance is justified to detect treatable pelvic or vaginal recurrence 2

Critical Pitfalls to Avoid

• Do not delay treatment: The entire radiation course must be completed within 8 weeks to maintain efficacy 2
• Do not use radiation alone: Concurrent chemotherapy significantly improves survival and local control compared to radiation monotherapy 2, 1
• Do not attempt primary surgical management: Stage IIIB disease is not surgically resectable and requires definitive chemoradiation 2
• Anticipate increased acute toxicity: Concurrent chemoradiation increases gastrointestinal and hematological side effects, requiring close monitoring 1

Expected Outcomes

• Complete response rates of approximately 83% can be achieved with standard concurrent chemoradiation 3
• Overall 5-year survival rates improve significantly with the addition of chemotherapy to radiation 1
• The majority of patients (67%) can complete the planned six courses of weekly cisplatin 3