cervical%20cancer%20-%20treatment
CERVICAL CANCER - TREATMENT
Patients w/ abnormal Pap smear are referred for colonoscopy to screen for presence of cervical cancer.
Colposcopic exam should include inspection of the transformation zone, definition of the extent of the lesion & biopsy of the most abnormal area for tissue diagnosis.
The earliest stages of cervical carcinoma are generally asymptomatic.
Watery vaginal discharge & postcoital bleeding or intermittent spotting may be present & are usually unrecognized by the patient.

Radiotherapy

Stage IA1

  • Postoperative pelvic radiotherapy with or without Cisplatin-containing chemotherapy should be considered in patients with at least 2 high-risk factors (ie lymphovascular invasion, deep stromal invasion, large primary tumor)
  • Patients with positive surgical margins, parametrial involvement or pelvic node involvement should be treated with post-op pelvic external beam radiation with concurrent Cisplatin-containing chemotherapy with or without vaginal brachytherapy
    • Concomitant chemoradiation may utilize Cisplatin as single agent or Cisplatin with 5-Fluorouracil

Stage IA2

  • Brachytherapy + pelvic external beam radiotherapy (point A dose: 70-80 Gy)
    • Dose is based on summation of conventional external-beam fractionation and low-dose rate (40-70 cGy/hour) brachytherapy equivalents
    • Dose should be modified based on normal tissue tolerance
  • Brachytherapy is an important part of radiotherapy for cervical carcinomas
    • It treats mainly the primary tumor
    • The surrounding tissue can be relatively spared while high doses of radiation are delivered to the tumor
    • Delivery is through manual or remote after-loading techniques
    • If brachytherapy is not available in limited-resource settings, extrafascial hysterectomy or its modification may be performed in patients with residual tumor found 2-3 months after concurrent chemoradiotherapy and additional boost

Stage IB1 or Stage IIA1 

  • Patients with stage IB1 or stage IIA1 may be treated with pelvic EBRT plus brachytherapy (point A dose: 80-85 Gy)
    • Should be modified based on normal tissue tolerance
    • When using high dose-rate brachytherapy, define the doses according to biological equivalence
  • Combined radio-surgery, which represents a therapeutic option, consists of pre-op brachytherapy followed by surgery

Advanced Tumors

  • Concurrent chemoradiation represents the standard treatment  
    • Has been shown 30-50% decrease in the mortality risk compared to radiotherapy
  • In patients undergoing primary chemoradiation, the volume of radiotherapy is critical and is guided by assessment of nodal involvement in the pelvic and para-aortic nodes
  • Patients with advanced stage IB2-IIA/B may benefit more from chemoradiotherapy than patients with stage III and IVA
    • Based on trials done, it translated to a 5-year survival benefit of 10% for patients with stage IB-IIA, 7% for patients with stage IIB and 3% for patients with stage IIIB-IVA
  • Patients with locally advanced cancer may benefit from initial pelvic EBRT of 40-45 Gy to obtain tumor shrinkage for optimal intracavitary placements
    • With low-dose rate intracavitary systems, total doses from brachytherapy and external-beam radiation to point A of at least 80 Gy are recommended particularly for small tumors; whereas for larger tumors, doses of 85 Gy or higher is recommended
  • Inguinal lymph nodes should be treated in patients with lesions in the lower 1/3 of the vagina
    • Treatment of occult or macroscopic para-aortic lymph node disease using extended-field EBRT should be carefully planned so that adequate dose (45 Gy for microscopic disease) is given without exceeding bowel, spinal cord, or renal tolerances
  • Patients with positive para-aortic lymph nodes after surgical staging should undergo further screening with CT or PET scan
    • Once indicated, biopsy of suspected areas should be considered
    • If positive for distant metastases, they should be treated with chemotherapy and individualized radiotherapy  
  • In basic-resource settings, neoadjuvant chemotherapy may be given to patients with larger tumors or advanced cancer to shrink the tumor prior to hysterectomy

Relapse and Metastases

  • After radical surgery, factors that increase risk of early cervical cancer recurrence include high grade tumor, >4-cm tumor, non-squamous histology, lymphovascular space or deep stromal invasion, and involvement of lymph nodes, lower uterine segment, or parametrial or vaginal margin

Local or Regional Therapy

  • Determine whether radiotherapy or surgery may be utilized for patients with local recurrence after initial treatment
    • Survival rates of approximately 40% have been reported
    • Salvage pelvic radiotherapy may be offered to radiotherapy-naive patients with local recurrence
  • Individualized EBRT and chemotherapy with platinum-based agent(s), with or without brachytherapy, may be recommended in the following patients: With local or regional recurrence but without previous radiotherapy, and with recurrences outside of the previously treated radiotherapy field
    • Surgical resection may be considered

Central Recurrence

  • Patients with central recurrence after radiotherapy may benefit from pelvic exenteration, with or without intra-operative radiotherapy (IORT)
  • Patients will benefit from pelvic exenteration if rehabilitation programs dealing with psychosocial and psychosexual issues are available
    • Reconstructive procedures should also be available
  • Radical hysterectomy or brachytherapy may be an option in very few selected patients with small central lesions of <2 cm

Noncentral Recurrence

  • The following options may be utilized:
    • Resection with or without IORT for close or positive margins
    • Individualized EBRT with or without chemotherapy
    • Chemotherapy
    • Best supportive care
    • Participation in clinical trials
  • Patients who recur after 2nd-line therapy, such as radiotherapy or surgery, have a poor prognosis
    • Chemotherapy, supportive care, or participation in clinical trials are the treatment options for these patients
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