Treatment Options for Cervical Cancer

Once a diagnosis of cervical cancer is made, your doctor will explain your prognosis and treatment options. Your prognosis is what the doctor thinks will happen with your cancer – your chance of recovery, the expected course of the cancer or the length of time you will be sick.

Your prognosis will depend on the following:

• The stage of the cancer. (The stage tells whether the tumor has spread to nearby tissues and other parts of the body.)
• The type of cervical cancer (squamous cell or adenocarcinomas).
• The size of the tumor.
• Lymph node involvement.

Treatment options will depend on the following:

• The stage of the cancer.
• The size of the tumor.
• The patient’s desire to have children.
• The patient’s age and overall health, along with other risk factors.

Treatment of cervical cancer during pregnancy depends on the stage of the cancer and the stage of the pregnancy. If cervical cancer is detected before it has spread or found in the last trimester of pregnancy, treatment may be delayed until after the baby is born.

Staging Cervical Cancer

If the biopsy shows you have cancer, your doctor will do a pelvic exam and may biopsy additional tissue to learn the stage of your disease. Staging may also include other tests, such as a chest Xray and cystoscopy or proctoscopy. The stage tells whether the tumor has spread to nearby tissues and other parts of the body.

The stages of cervical cancer are:

• Stage 0 – The cancer is found only in the top layer of cells lining the cervix and has not invaded deeper tissues of the cervix.
• Stage I – The cancer has invaded the cervix beneath the top layer of cells. It is found only in the cervix.
• Stage II – The cancer has spread beyond the cervix but not to the pelvic wall (the tissues that line the part of the body between the hips) or to the lower third of the vagina.
• Stage III – The cancer has spread to the lower part of the vagina and may have spread to the pelvic wall and nearby lymph nodes. The cancer may also be pressing on the ureter, the tube that carries urine from the kidney to the bladder.
• Stage IV – The cancer has spread to the bladder, rectum or other parts of the body.

Recurrent cervical cancer is cancer that comes back after it has been treated. The cancer may appear again in the cervix or in other parts of the body. The cancer’s stage never changes even if your cancer recurs.

Precancerous Lesions

Treatment for a precancerous lesion of the cervix depends on whether it is low or high grade, whether the woman wants to have children in the future and the woman’s age and general health. A woman with a low-grade lesion may not need further treatment, especially if the abnormal area was completely removed during biopsy. When a precancerous lesion requires treatment, the doctor may use cryosurgery (freezing) or laser surgery to destroy the abnormal area without harming nearby healthy tissue. More often, the doctor will remove the abnormal tissue by LEEP or conization. In some precancerous cases, a woman may have a hysterectomy (removal of the uterus, including the cervix), particularly if abnormal cells are found inside the opening of the cervix.

Precancerous lesions are usually curable if caught early. However, a woman should continue with regular Pap tests and pelvic exams, especially if she has HPV.

Surgery for Small Cancers

Surgery for small cancers and precancerous lesions that have not spread beyond the cervix include:

• Cryosurgery (Cryotherapy) – This surgical procedure uses an instrument to freeze and destroy precancerous tissue. This is not used on invasive cancer.
• LEEP (Loop Electrosurgical Excision Procedure) – This procedure uses electrical current passed through a thin, wire hook. The hook removes the tissue. This is primarily used on precancerous lesions under local anesthesia.
• Cone – A gynecologist uses the same procedure as a cone biopsy to remove all of the cancerous tissue. This procedure can be used in a woman who has a very small cervical cancer and who wishes to preserve the ability to have children.
• Hysterectomy – This procedure removes the uterus and the cervix. If a woman has a hysterectomy, she will no longer be able to have children. This kind of hysterectomy is used only on women with very small cervical cancers of less than three millimeters in depth.
• Bilateral Salpingo-Oophorectomy – In this procedure, the fallopian tubes and ovaries are removed at the same time as the hysterectomy. If a woman is close to the age of menopause, her doctor may discuss removing her ovaries and fallopian tubes to reduce the chance that the cancer will recur in one of those organs.

Surgery for Larger Cancers

The following surgical procedures may be used for larger lesions (usually up to four to five centimeters in width), but only if the cancer is all within the cervical tissue. If the cancer has spread beyond the cervix, doctors will usually recommend chemotherapy in combination with radiation therapy.

• Trachelectomy – This procedure removes the cervix and surrounding tissue but not the uterus. It is used in special circumstances for women who have a larger cancer but wish to preserve the ability to have children.
• Radical Hysterectomy – The surgeon removes the cervix, uterus, part of the vagina and the tissues surrounding the cervix called the parametria. At the same time, the surgeon also removes nearby lymph nodes.
• Laparoscopic Surgery – In some cases, these procedures can be done without open surgery, with the help of a small telescope called a laparoscope. The laparoscope is inserted through small incisions in the abdomen so the surgeon can see the area around the uterus. At the same time, surgical instruments can be inserted through another incision. Laparoscopy allows the surgeon to inspect the abdominal cavity for spread of cervical cancer and scar tissue without making a large incision.
• Robotic-Assisted Surgery – By using robotics, surgeons are able to perform surgeries in a precise and controlled manner using clear 3-D views of the abdominal cavity.

You should discuss your surgical options with your doctor.

Radiation Therapy

Radiation therapy is used for cancers that have spread beyond the cervix (Stages II, III or IV) or very large lesions (larger than five centimeters).

Radiation therapy uses high energy X-rays or other types of radiation to kill cancer cells or shrink the tumor. Radiation therapy is used instead of surgery in most cases. However, it is sometimes necessary after surgery if it is discovered the cancer has spread outside the cervix or to reduce the risk that a cancer will come back after surgery.

There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cervical cancer. The type of radiation used depends on the stage of the cervical cancer. A radiation oncologist, a doctor who specializes in radiation therapy, will give you your treatments. The length of your radiation treatment will be determined by your radiation oncologist.
• Internal radiation therapy may follow external radiation therapy. Internal radiation therapy delivers high dose rate radiation (HDR) through a plastic sleeve sewn into your cervix. The sleeve is removed once treatments are complete.

Chemotherapy

Chemotherapy uses drugs to stop the growth of cancer cells either by killing them or stopping them from dividing. Chemotherapy can be given by mouth or delivered directly into the bloodstream. In most cases, it is given to a patient during an outpatient visit. The drugs enter the bloodstream to reach cancer cells throughout the body. This is called systemic chemotherapy. When chemotherapy is placed directly into an organ or a body cavity, such as the abdomen, the drugs mainly affect cancer cells in that area. This is called regional chemotherapy.

How chemotherapy is given depends on the stage of the cervical cancer.

Recurrent Cervical Cancer

If cervical cancer recurs, the treatment depends on where the cancer is located and how it was treated before. If radiation has not already been given, it may be the treatment of choice for the recurrence. If radiation was already given and the cervical cancer has spread to the lower colon, rectum and bladder, a surgeon may be able to remove these organs, but this surgery is not always possible. If the cancer has spread to multiple areas, chemotherapy is usually the treatment of choice.

Treatment Follow-Up

For the first three years after treatment, you should have follow-up visits every three to six months to ensure any changes in your health are monitored and problems are treated early. Your follow-up visits will include physical exams, pelvic exams and possibly urine tests, blood tests and X-rays. A Pap test may also be done to look for cancer cells in the vagina. If the cancer does not return within three to five years, visits can be scheduled less often.