Treatment Guideline Chart
Patients with abnormal Pap smear are referred for colposcopy to screen for presence of cervical cancer.
Colposcopic exam should include inspection of the transformation zone, definition of the extent of the lesion and biopsy of the most abnormal area for tissue diagnosis.
The earliest stages of cervical carcinoma are generally asymptomatic.
Watery vaginal discharge, postcoital or postmenopausal bleeding, intermittent spotting, or abdominal pain may be present and is usually unrecognized by the patient.

Cervical%20cancer%20-%20treatment Treatment


Stage IA2

  • For poor surgical risk patients
  • Brachytherapy + pelvic EBRT (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, fractionation and size of target volume
    • In patients with lymphovascular invasion, concurrent platinum-containing chemotherapy may be added to pelvic EBRT
    • Brachytherapy/internal radiation therapy treats mainly the primary 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, IB2 or IIA1 

  • Patients with stage IB1, IB2 or stage IIA1 may be treated with pelvic EBRT plus brachytherapy (point A dose: 80-85 Gy) with concurrent platinum-containing chemotherapy
    • Should be modified based on normal tissue tolerance, fractionation and size of target volume
    • Cisplatin is the preferred radiosensitizing agent and Carboplatin may be used for Cisplatin-intolerant patients
      • Other recommended radiosensitizing regimen are the Cisplatin/5-FU and Paclitaxel-Cisplatin combinations
    • When using high dose-rate brachytherapy, define the doses according to biological equivalence

Advanced Tumors

  • Concurrent chemoradiation represents the standard treatment for stages IB3 to IVA 
    • Concurrent chemoradiation with platinum-based chemotherapy (single-agent Cisplatin [preferred]) for stages IB3, II, III and IVA
      • Single-agent Carboplatin is the preferred radiosensitizing agent for patients intolerant to Cisplatin or with impaired renal function
    • Has been shown 30-50% decrease in the mortality risk compared to radiotherapy alone
    • Chemotherapy should be administered together with EBRT
  • 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
  • Adjuvant hysterectomy after chemoradiation for stage IB3 and IIA2 tumors may be considered in patients after protracted chemoradiation with residual tumor after treatment
  • Treatment of 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 and pelvic lymph nodes should undergo extended-field EBRT with concurrent platinum-containing chemotherapy and brachytherapy after imaging work-up for metastatic disease
    • If positive for distant metastases, they should be treated with systemic therapy and with or without 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 radical hysterectomy

Locoregional Therapy for Relapse and Metastases

  • Determine whether radiotherapy and/or systemic therapy or surgery may be utilized for patients with local recurrence after initial treatment
    • Survival rates of approximately 40% have been reported
    • Tumor-directed EBRT with or without systemic therapy and/or brachytherapy may be offered to patients with recurrence outside of the previously treated radiotherapy field or radiotherapy-naive patients with local recurrence
      • Patients with relapse soon after completion of initial chemoradiation with Cisplatin or Carboplatin should be given 5-FU, Bevacizumab, Carboplatin, Docetaxel, Entrectinib (for patients with neurotrophic tyrosine receptor kinase [NTRK] gene fusion-positive tumors), Gemcitabine, Irinotecan, Larotrectinib (for patients with NTRK gene fusion-positive tumors), Nivolumab (for patients with PD-L1-positive tumors), Paclitaxel, albumin-bound Paclitaxel, Pembrolizumab (for patients with PD-L1-positive, MSI-H/dMMR or tumor mutational burden-high [TMB-H] tumors), Pemetrexed, Selpercatinib (for rearranged during transfection [RET] gene fusion-positive tumors), Tisotumab vedotin-tftv, Topotecan, and Vinorelbine
    •  Surgical resection may be considered for highly select localized lesions

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 concurrent chemotherapy
    • Systemic therapy
    • Participation in clinical trials
  • Patients who recur after 2nd-line therapy, such as radiotherapy or surgery, have a poor prognosis
    • Systemic therapy (eg Cisplatin, Carboplatin, Bevacizumab, Carboplatin, Docetaxel, Entrectinib, 5-FU, Gemcitabine, Irinotecan, Larotrectinib, Nivolumab, Paclitaxel, albumin-bound Paclitaxel, Pembrolizumab, Pemetrexed, Selpercatinib, Tisotumab vedotin-tftv, Topotecan, and Vinorelbine), supportive care, or participation in clinical trials are the treatment options for these patients
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