Treatment:

Treatment of Pre-Invasive Cancer

Treatment of cervical intraepithelial neoplasia (CIN), including pre-invasive cancer, depends on the type and extent of abnormal changes. Some of the treatments for CIN are also used for early-stage cancer.

• CIN I often goes away on its own. Careful follow up is required to make certain that the Pap smear and colposcopic exam return to normal.
• CIN II or CIN III may turn into invasive cancer if the suspicious area is not removed. This is often done using an outpatient technique called loop electrosurgical excision procedure (LEEP). [See "Surgery" section.]
• If doctors cannot see extensive areas of CIN II or III with colposcopy or if these areas spread into the mucous membrane in the cervical canal, a more aggressive procedure called conization (cone biopsy) may be required. [See "Surgery" section.]

Treatment of Invasive Cervical Cancer

In contrast to cervical intraepithelial neoplasia, cervical cancer represents true invasion of cells beyond the epithelium into surrounding tissue. Cervical cancer may be detected in a biopsy performed during colposcopy for an abnormal Pap smear, or it may be visible to the naked eye when the doctor performs a speculum exam.

After making a diagnosis, the doctor will classify the stage of the cancer according to how far the disease has spread into the lining of the cervix, throughout the cervix, or beyond. Doctors use these classifications to determine treatment and prognosis.

Stages of Cervical Cancer

Stage 0. Stage 0 cancer is also called carcinoma in situ. It is equivalent to CIN III pre-invasive cancer. In stage 0, the cancer cells are confined to the first layer of cervical tissue (the epithelium) lining the cervix and have not yet spread further in the cervix.

Stage I. Stage I is invasive cancer, but the tumor is confined to the cervix. This stage is further categorized as IA and IB, which each have further subcategorizations based on the size of the tumor:

• In stage IA, the cancer cells can only be seen under a microscope. In stage IA1, there is minimal invasion (less than 3 mm and less than 7 mm wide) In stage IA2, there is deeper invasion of 3 - 5 mm) but the microscopic tumor is still less than 7 mm wide.
• In stage IB, the cancer is either visible without a microscope, or it is still microscopic but is more than 5 mm deep or 7 mm wide. Cancer that can be seen without a microscope is divided into Stage 1B1 and Stage 1B2. In stage 1B1, the cancer is smaller than 4 cm. In stage IB2, the cancer is larger than 4 cm.

Stage II. Stage II invasive cancer has spread beyond the cervix, but it has not spread to the pelvic side wall. This stage is further categorized as IIA and IIB.

• In stage IIA, the cancer has spread to the upper two-thirds of the vagina but not to the uterus.
• In stage IIB, the cancer has spread beyond the vagina into the tissues of the uterus.

Stage III. In stage III, the cancer has spread to the lower third of the vagina.

• In stage IIIA, the cancer has not spread to the pelvic wall.
• In stage IIIB, the cancer has spread to the pelvic wall. The tumor may have become large enough to block the ureters of the kidney, which can cause the kidney to stop functioning.

Stage IV. Stage IV is advanced (metastasized) cancer. The cancer has spread to other organs or parts of the body.

• In stage IVA, the cancer has spread to organs located near the cervix, such as the bladder or rectum.
• In stage IVB, the cancer has spread beyond the pelvic area to other parts of the body, such as the liver, intestinal tract, or lungs.

Treatment Options by Stage

Treatments for cervical cancer depend on the stage of the cancer. Clinical trials investigating new treatment approaches are available for all stages of cervical cancer.

Stage 0. Treatment options for stage 0 cancer are similar to those used for pre-invasive cancer. They include:

• Loop electrosurgical excision procedure (LEEP)
• Laser surgery
• Conization
• Cryosurgery
• Total hysterectomy (removal of uterus and cervix), for women who no longer want children
• Internal radiation therapy, for women who cannot have surgery

Stage IA1. Treatment options for stage IA1 may include:

• Conization
• Total hysterectomy, with or without bilateral salpino-oopherectomy (removal of fallopian tubes and both ovaries)
• Radical hysterectomy (removal of uterus, cervix, part of vagina, ovaries, fallopian tubes, and pelvic lymph nodes)
• Internal radiation therapy

Stage IA2. Treatment options for stage IA2 may include:

• Radical hysterectomy
• External beam radiation therapy plus brachytherapy (implantation of radioactive pellets)
• Radical trachelectomy (removal cervix) may be an option for some women who want to preserve fertility

Stage IB1. Treatment options for stage IB1 may include:

• Radical hysterectomy
• High-dose internal and external radiation therapy
• Radical trachelectomy

Stage IB2. Treatment options for stage 1B2 may include:

• Combination of chemotherapy and radiation therapy
• Radical hysterectomy, followed by radiation therapy (and possibly chemotherapy) if cancer cells are found.

Stage IIA. Treatment options for stage IIA may include:

• Internal and external radiation therapy
• Radiation therapy plus chemotherapy
• Radical hysterectomy followed by radiation therapy and chemotherapy

Stage IIB. Treatment options for stage IIB may include:

• Combined internal and external radiation therapy along with chemotherapy with cisplatin
• Other drugs may be given along with cisplatin

Stage III. Treatment options for stage IIIA and stage IIIB may include:

• Combined internal and external radiation therapy plus chemotherapy Stage IVA. Treatment options for stage IVA may include:
• Combined internal and external radiation therapy plus chemotherapy

Stage IVB. Stage IVB cancer is generally not considered curable. Treatment options may include:

• Radiation therapy to relieve symptoms and improve quality of life
• Chemotherapy with cisplatin or carboplatin in combination with another drug (paclitaxel, gemcitabine, topotecan, or vinorelbine)

Recurrent Cancer. Cervical cancer may recur locally in the lymph nodes near the cervix, it may spread to distant sites, such as the lung or bones, or it may appear both locally and in distant locations. Treatment options depend on where the cancer has recurred. They include:

• Pelvic exenteration if cancer has spread to only local areas. This involves surgical removal of the cervix, uterus, vagina, and perhaps the bladder, lower colon, or rectum.
• Chemotherapy or radiation if cancer has spread to distant area.

Treatment of Pregnant Women with Cervical Cancer

Cervical cancer is one of the most common cancers diagnosed during pregnancy. To diagnose the condition, a cervical biopsy, in which a small amount of tissue is removed for diagnosis, can be performed anytime during the pregnancy. However, a cone biopsy, which removes larger amounts of tissue, is typically delayed until after the first trimester to reduce the risk of causing an abortion. The loop electrosurgical excision procedure (LEEP/LLETZ) may be performed in centers equipped to handle it, but should be reserved only for patients in whom invasive disease is strongly suspected.

Treatment of cervical cancer depends in part on whether a patient wishes to continue the pregnancy, and her desire for future fertility. For pregnant women who want to continue the pregnancy, and preserve fertility when possible, treatment options may include::

• If the abnormality is diagnosed as dysplasia or pre-invasive cancer, treatment is usually delayed until after the mother gives birth. The baby is delivered vaginally. It is rare for cervical cancer to progress from pre-invasive to invasive within the space of 1 - 2 trimesters.
• For stage 1A1, a cesarean section is performed at term, or earlier if the fetus is viable. After delivery, LEEP/LLETZ or conization is performed.
• For stages IA2 and IB1, a cesarean section and radical hysterectomy is performed when the fetus is viable. After delivery, radiation and chemotherapy is given.
• For stages IB2 - IVA, a cesarean section is performed as soon as possible. Treatment should not be delayed beyond weeks 32 - 34. For patients who have a delayed cesarean, chemotherapy may be given. After delivery, the patient is treated with radiation and chemotherapy.
• For stage IVB, the pregnancy is terminated for pregnancies less than 20 weeks and the patient is treated with chemotherapy. For pregnancies more than 20 weeks, a cesarean may be delayed while the woman receives chemotherapy.