What are the treatment options for a patient with cervical (Ca) cancer?

Treatment of Cervical Cancer

Treatment for cervical cancer is determined by FIGO stage, with early-stage disease (IA1-IB1) managed primarily by surgery, locally advanced disease (IB2-IVA) treated with concurrent chemoradiation using weekly cisplatin, and metastatic/recurrent disease (IVB) requiring platinum-based chemotherapy with bevacizumab. 1

Initial Diagnostic Workup

Before treatment planning, accurate staging requires:

• MRI is superior to CT for tumor extension assessment and should be preferred for pelvic and abdominal imaging 2, 3
• Thoracic CT scan for metastasis assessment 2
• PET imaging is useful for nodal assessment, particularly in advanced disease 3
• Clinical examination remains fundamental for FIGO staging 3

Treatment Algorithm by FIGO Stage

Stage IA1 (Microinvasive Disease)

Without lymphovascular space invasion (LVSI):

• Conization with negative margins or simple hysterectomy based on patient age 2, 1, 3

With LVSI:

• Add pelvic lymphadenectomy to the above surgical approach 2, 1, 3
• If pelvic nodes are positive, proceed to complementary concurrent chemoradiation 2, 3

Stage IA2

Standard surgical approach:

• Radical hysterectomy with mandatory pelvic lymphadenectomy 2, 1
• For young patients desiring fertility: conization or trachelectomy with pelvic lymphadenectomy 1, 3
• If pelvic nodes are positive, add complementary concurrent chemoradiation 2, 3

Stage IB1 and IIA1

Multiple equally effective treatment options exist:

• Radical hysterectomy with pelvic lymphadenectomy 2, 1, 3
• External beam radiation plus brachytherapy 1, 3
• Combined radio-surgery (preoperative brachytherapy followed 6-8 weeks later by surgery) 2
• Conservative surgery may be considered only for tumors with excellent prognostic factors 2, 1

If upfront surgery reveals pelvic node involvement, proceed to complementary concurrent chemoradiation 2, 3

Stage IB2 and IIA2 (Tumors >4 cm)

Concurrent chemoradiation is preferred over surgery:

• Weekly cisplatin 40 mg/m² during external beam radiation therapy 1
• This provides an absolute 5-year survival benefit of 8% for overall survival 1, 3

Stage IIB-IVA (Locally Advanced Disease)

Standard treatment is concurrent chemoradiation:

• Weekly cisplatin 40 mg/m² during external beam radiation therapy 1, 3
• External beam radiation to cover gross disease, parametria, and nodal volumes at risk 3
• Brachytherapy is an essential component and must be included 3
• The entire course of external beam and brachytherapy must be completed within 8 weeks, as treatment duration >8 weeks is associated with worse outcomes 3
• Total dose to target should be 80-90 Gy 3

Stage IVB (Metastatic Disease)

Platinum-based combination chemotherapy with bevacizumab:

• Bevacizumab 15 mg/kg every 3 weeks with paclitaxel and cisplatin, or paclitaxel and topotecan 4
• This is palliative treatment, not curative 5, 6
• Do not delay systemic chemotherapy to pursue surgical staging or debulking in patients with confirmed distant metastases 5

Recurrent Disease Management

For locoregional recurrence:

• Radiotherapy-naïve patients: salvage chemoradiation with curative intent 6
• Previously irradiated patients: pelvic exenteration in highly selected cases 2, 5, 6
• Most patients require palliative chemotherapy 2, 5

For distant metastatic recurrence:

• Platinum-based combination chemotherapy is standard 5, 6
• Bevacizumab may be added to chemotherapy 6

Special Considerations for Fertility Preservation

For young women with stage IA1-IB1 disease:

• Cone biopsy with negative margins or trachelectomy are options 1, 3
• Ovarian preservation may be considered for premenopausal women with squamous cell carcinoma 1
• Ovarian transposition is recommended before pelvic radiation in women <45 years 1

Critical Surgical Considerations

Perioperative timing:

• Withhold bevacizumab for at least 28 days prior to elective surgery 4
• Do not administer bevacizumab for 28 days following major surgery and until adequate wound healing 4
• Discontinue bevacizumab for wound healing complications of necrotizing fasciitis 4

Follow-Up Protocol

Surveillance schedule:

• Every 3 months for the first 2 years 2, 1
• Every 6 months for years 3-5 2, 1
• Yearly after 5 years 2, 1
• Each visit includes clinical and gynecological examination with PAP smear 2, 1
• Annual cervical/vaginal cytology and imaging as indicated 1

Common Pitfalls to Avoid

• Do not attempt curative-intent extended-field chemoradiation for patients with paraaortic lymph node involvement AND distant metastases 5
• Do not exceed 8 weeks total treatment time for chemoradiation, as this significantly worsens outcomes 3
• Monitor for bevacizumab-related complications including gastrointestinal perforations, hemorrhage, arterial thromboembolic events, hypertension, and proteinuria 4
• Discontinue bevacizumab for Grade 3-4 hemorrhage, severe arterial thromboembolic events, Grade 4 venous thromboembolic events, hypertensive crisis, posterior reversible encephalopathy syndrome, or nephrotic syndrome 4