Treatment options for cervical cancer by stage

The stage of a cervical cancer is the most important factor in choosing treatment. However, other factors that affect this decision include the exact location of the cancer within the cervix, the type of cancer (squamous cell or adenocarcinoma), your age, your overall physical condition, and whether you want to have children.
Stage 0 (carcinoma in situ)
Although the AJCC staging system classifies carcinoma in situ (CIS) as the earliest form of cancer, doctors often think of it as a pre-cancer. That is because the cancer cells in CIS are only in the surface layer of the cervix -- they have not grown into deeper layers of cells. Treatment options for squamous cell carcinoma in situ are the same as for other pre-cancers (dysplasia or cervical intraepithelial neoplasia [CIN]). Options include cryosurgery, laser surgery, loop electrosurgical excision procedure (LEEP/LEETZ), and cold knife conization. For adenocarcinoma in situ, hysterectomy is usually recommended. For those who wish to have children, treatment with a cone biopsy may be an option. The cone specimen must have no cancer cells at the edges, and the patient must be closely watched. After the woman has finished having children, a hysterectomy is recommended.
A simple hysterectomy is also an option for treatment of squamous cell carcinoma in situ, and may be done if it returns following other treatments. All cases of CIS can be cured with appropriate treatment. However, pre-cancerous changes can recur (come back) in the cervix or vagina, so it is very important for your doctor to watch you closely. This includes follow-up with regular Pap smears and in some instances with colposcopy.
Stage IA is divided into stage IA1 and stage IA2
Stage IA1: For this stage you have 3 options
• If you still want to be able to have children, first the cancer is removed with a cone biopsy, and then you are watched closely to see if the cancer comes back.
• If the cone biopsy doesn't remove all of the cancer (or if you are done having children), the uterus will be removed (hysterectomy).
• If the cancer has invaded the blood vessels or lymph vessels, you might need a radical hysterectomy along with removal of the pelvic lymph nodes.
Stage IA2: There are 3 treatment options
• Radical hysterectomy along with removal of lymph nodes in the pelvis
• External beam radiation therapy plus brachytherapy
• Radical trachelectomy with removal of pelvic lymph nodes can be done if you still wants to be able to have children
If you have surgery, the tissue removed will be examined in the laboratory to see if the cancer has spread further than expected. If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, radiation therapy is usually recommended. Often chemotherapy will be given with the radiation therapy. If the pathology report says that the tumor had positive margins, this means that some cancer may have been left behind. This is also treated with pelvic radiation (given with cisplatin chemotherapy). The doctor may advise brachytherapy, as well.
Stage IB is divided into stage IB1 and stage IB2
Stage IB1: There are 3 options available:
• The standard treatment is a radical hysterectomy with removal of lymph nodes in the pelvis. Some lymph nodes from higher up in the abdomen (called para-aortic lymph nodes) are also removed to see if the cancer has spread there. If cancer cells are found in the edges of the tissues removed (positive margins) or if cancer cells are found in lymph nodes during this operation, radiation therapy may be given, possibly with chemotherapy, after surgery.
• The second treatment option is high-dose internal and external radiation therapy.
• Radical trachelectomy with removal of pelvic (and some para-aortic) lymph nodes is an option if the patient still wants to be able to have children
Stage IB2: There are 3 options available
• The standard treatment is the combination of chemotherapy with cisplatin and radiation therapy to the pelvis plus brachytherapy.
• Another choice is radical hysterectomy with removal of pelvic (and some para-aortic) lymph nodes. If cancer cells are found in the lymph nodes removed, or in the margins, radiation therapy may be given, possibly with chemotherapy, after surgery.
• Some doctors advise radiation given with chemotherapy (first option) followed by a hysterectomy.
Stage II is divided into stage IIA and stage IIB
Stage IIA: Treatment for this stage depends on the size of the tumor.
• One choice for treatment is brachytherapy and external radiation therapy. This is most often recommended if the tumor is larger than 4 cm (about 1½ inches). Chemotherapy with cisplatin will be given along with the radiation.
• Some experts recommend removing the uterus after the radiation therapy is done.
• If the cancer is not larger than 4 cm, it may be treated with a radical hysterectomy and removal of lymph nodes in the pelvis (and some in the para-aortic area). If the tissue removed at surgery shows cancer cells in the margins or cancer in the lymph nodes, radiation treatments to the pelvis will be given with chemotherapy. Brachytherapy may be given as well.
Stage IIB: Combined internal and external radiation therapy is the usual treatment. The radiation is given with the chemotherapy drug cisplatin. Sometimes other chemo drugs may be given along with cisplatin.
Stage III and IVA
Combined internal and external radiation therapy given with cisplatin is the recommended treatment.
If cancer has spread to the lymph nodes (especially those in the upper part of the abdomen) it can be a sign that the cancer has spread to other areas in the body. Some experts recommend checking the lymph nodes for cancer before giving radiation. One way to do this is by surgery. Another way is to do a CT or MRI scan to see how big the lymph nodes are. Lymph nodes that are bigger than usual are more likely to have cancer. Those lymph nodes can be biopsied to see if they contain cancer. If lymph nodes in the upper part of the abdomen (the para-aortic lymph nodes) are cancerous, doctors may want to do other tests to see if the cancer has spread to other parts of the body.
Stage IVB
At this stage, the cancer has spread out of the pelvis to other areas of the body. Stage IVB cervical cancer is not usually considered curable. Treatment options include radiation therapy to relieve the symptoms of cancer that has spread to the areas near the cervix or to distant sites (such as the lungs or bone). Chemotherapy is often recommended. Most standard regimens use a platinum compound (such as cisplatin or carboplatin) along with another drug such as paclitaxel (Taxol), gemcitabine (Gemzar), topotecan, or vinorelbine (Navelbine). Clinical trials are testing other combinations of chemotherapy drugs, as well as some other experimental treatments.
Recurrent cervical cancer
Cancer that comes backs after treatment is called recurrent cancer. Cancer can come back locally (in the pelvic organs near the cervix) or come back in distant areas (spread through the lymphatic system and/or the bloodstream to organs such as the lungs or bone).
If the cancer has recurred in the pelvis only, extensive surgery (by pelvic exenteration) may be an option for some patients. This operation may successfully treat 40% to 50% of patients. (See the discussion under Surgery in the section, "How are cervical cancers and pre-cancers treated?") Sometimes radiation or chemotherapy may be used for palliative treatment (treatment to relieve symptoms but not expected to cure).
If your cancer has recurred in a distant area, chemotherapy or radiation therapy may be used to treat and relieve specific symptoms. If chemotherapy is used, you should understand the goals and limitations of this therapy. Sometimes chemotherapy can improve your quality of life, and other times it can diminish it. You need to discuss this with your doctors. Fifteen percent to 25% of patients may respond at least temporarily to chemotherapy.
New treatments that may benefit patients with distant recurrence of cervical cancer are being evaluated in clinical trials. You may want to think about participating in a clinical trial.
Cervical cancer in pregnancy
A small number of cervical cancers are found in pregnant women. If your cancer is a very early cancer, such as stage IA, then most doctors believe that it is safe to continue the pregnancy to term. Several weeks after delivery, a hysterectomy or a cone biopsy is recommended (the cone biopsy is suggested only for substage IA1).
If the cancer is stage IB or higher, then you and your doctor must decide whether to continue the pregnancy. If not, treatment would be radical hysterectomy and/or radiation. If you decide to continue the pregnancy, the baby should be delivered by cesarean section as soon as it is able to survive outside the womb. More advanced cancers, should be treated immediately.