Invasive Cervical Cancer
Key Points
Key Points
- If follow-up is available, the Expert Panel recommends cone biopsy for women with stage IA2 disease in basic settings and cone biopsy plus pelvic lymphadenectomy in limited settings. In enhanced and maximal settings, radical trachelectomy is recommended for patients with stage IB1 cervical cancer with tumor size ≤2 cm who desire fertility-sparing surgery.
- In basic settings where patients cannot be treated with radiation therapy, extrafascial hysterectomy either alone or after chemotherapy may be an option for women with stage IA1 to IVA cervical cancer.
- In basic settings, for women with larger tumors or advanced-stage cervical cancer, neoadjuvant chemotherapy is recommended, whenever chemotherapy is available, for the purpose of shrinking the tumor before performing hysterectomy.
- Concurrent radiotherapy and chemotherapy is standard in enhanced and maximal settings for women with stage IB to IVA disease.
- The panel stresses the addition of low-dose chemotherapy during radiotherapy but not at the cost of delaying radiation therapy if chemotherapy is not available.
- In limited-resource settings where there is no brachytherapy, the ASCO Expert Panel recommends extrafascial hysterectomy or its modification for women who have residual tumor 2–3 months after concurrent chemoradiotherapy and additional boost.
- For patients with stage IV or recurrent cervical cancer, single-agent chemotherapy (carboplatin or cisplatin) is recommended in basic settings.
- If the resources are available and the patient cannot receive treatment with curative intent, palliative radiotherapy should be used to relieve symptoms of pain and bleeding.
- Where resources are constrained, single- or short-course radiotherapy schemes can be used with retreatments if feasible for persistent or recurrent symptoms.
- Palliative care and pain management are part of the treatment of cancers, including cervical cancer, to avoid unnecessary suffering during the final stages of disease. Pain control is a vital component of palliative care, a basic human right often neglected in cancer control programs.
Facility Specifications
...cility Specifica...
New Recommendation from 2021 Focused...
...ay offer upfront pembrolizumab and chemother...
...e other 2016 options....
...reatment CapacityHaving trouble viewing ta...
Diagnosis
...gnosis...
...uation (Table 2)
...asic
...and physical examination, CBC, cervical biopsy, co...
...ional in ≤ stage IB1 disease): c...
...moking cessation and counseling; may offer HIV tes...
Limited
...d physical examination, CBC, cervical biop...
...onal in ≤ stage IB1): chest x-ray, CT (specif...
...ing cessation and counseling; may offer HIV te...
Enhance...
...y and physical examination, CBC, cervical...
...tional in ≤ stage IB1): chest x-ray, C...
...on and counseling; may offer HIV tes...
Maxima...
History and physical examination, CBC, cervi...
...ptional in ≤ stage IB1): chest x-ray, CT,...
...ing cessation and counseling; may off...
...OTE. Bold indicates addition of a recommended acti...
Treatment
...eatment...
...tions for Stage IA, IB, and IIA Disease (Table...
...tive, FS (see Discussion in full text Guideline...
...1A1 (negative margins): cone biopsya (with scalp...
Limited1A1 (negative margins): cone biopsy....
...d1A1 (negative margins): cone biopsy. Repe...
...gative margins): cone biopsy. Repeat cone bi...
IA1, LVSI positive...
...one biopsy in selected cases, if follow-up possib...
...mitedCone biopsy (I, CB, W)7442...
...nhanced
...biopsy plus PLND (see Discussion in ful...
...trachelectomy plus PLND (I, EB/CB, M)7442...
...ximal...
...iopsy plus PLND (H, EB/CB, S)7442...
...al trachelectomy plus PLND (may offer ±SLN) (I, E...
...1, non-FS (no L...
...sicCone biopsy (if follow-up possible) OR extra...
...imitedCone biopsy (if follow-up possible)...
EnhancedCone biopsyc OR extrafasci...
...ne biopsyc OR extrafascial hysterec...
...A1, non-FS (with LVSI)...
...s above (L, CB, W)7442...
...A1 (with LVSI) and stage IA2: modified radical...
...nhancedStage IA1 (with LVSI) and stage IA2...
...ximalStage IA1 (with LVSI) and stage IA2:...
...2, FS
...cCone biopsy (if follow-up possible) (L, CB,...
...biopsy (if follow-up possible) (L, CB, W)7442...
...nhanced...
...sy plus PLND ± para-aortic LN samplingc (L...
...adical trachelectomy plus PLND (I,...
...axima...
...psy plus PLND ± para-aortic LN samplingc (L...
...trachelectomy plus PLND (I, EB, M)7442...
..., non-FS
...asic...
...f follow-up possible) or extrafascial hyste...
...rafascial hysterectomy (L, EB, W)7442
...imited
...us PLND ± para-aortic LN samplingc (L, EB...
...dified radical hysterectomy plus PLND ±...
...hanced
...one biopsy plus PLND ± para-aortic LN...
...radical hysterectomy plus PLND ± para-ao...
...vic RT and brachytherapy (I, EB, M)7442
Maxima...
...above Modified radical hysterectomy plus P...
...pelvic RT and brachytherapy (I, EB, M...
...B1, F...
...asicNo recommendation (, , )7442...
...recommendation (, , )7442...
...nhancedRadical trachelectomy plus PLND...
...malRadical trachelectomy plus pelvic LN samp...
IB1, non-F...
...asic...
...terectomy (Insufficient Quality of...
...able, then extrafascial hysterectomy (I...
...mited...
...adical hysterectomy plus PLND or radical hyster...
...followed by extrafascial or radical...
...hanced
...cal hysterectomy plus PLND (H, EB, S)7442
...brachytherapy plus concurrent low-dose platinum...
Maxim...
...ctomy plus PLND; may offer SLN (H, EB, S)7442...
...on (L, EB, W)7442...
...brachytherapy plus concurrent low-dose platinum...
...ote...
...ever radical hysterectomy with concurrent chemoRT...
...and IIA...
Basic
...erapy is available, use NACT followed b...
...imite...
...y is available, NACT followed by radi...
...is available, but not brachytherapy, then che...
...available, then brachytherapy and concurrent...
...dical hysterectomy plus PLND ± para-a...
...hanced
...lvic RT plus concurrent low-dose plat...
...concurrent low-dose platinum-based chem...
Radical hysterectomy plus PLND ± para...
Maxim...
...RT plus concurrent low-dose platinum-based che...
...lus concurrent low-dose platinum-based chemoth...
...ectomy plus PLND ± para-aortic LN sampl...
...ote...
...factors on pathology specimen: adjuvan...
...k factors on pathology specimen: adjuva...
...th risk factors on pathology specimen: adjuv...
...lWith risk factors on pathology specimen:...
...See IB1...
...See IB2...
...indicates addition of a recommended action over...
...able 3a. Combination of Three Risk Fa...
...ecommendations for Stage IIB, III, IVA, and IVB...
IIB and IIIA
Basi...
...followed by extrafascial hysterect...
...afascial hysterectomy when chemotherapy is not co...
...lliative care (I, CB, S...
Limited
...ollowed extrafascial or modified hysterectomy ±...
...al or modified hysterectomy plus pelvic...
...nhance...
...c RT plus concurrent low-dose platinum-bas...
Maximal
...elvic RT plus concurrent low-dose platinum-based c...
...IB to IVA...
...asic
...tive care (I, EB, S)7442...
NACT followed by extrafascial hysterectomy (Qua...
...imite...
...a followed by extrafascial or radi...
...concurrent low-dose platinum-base...
...nhanced
Pelvic RT plus brachytherapy plus concur...
...apy ± concurrent low-dose platinum-b...
...ximal
...brachytherapy plus concurrent low-dose platinu...
...+ brachytherapy ± concurrent low-dose platin...
...ote...
...herever radical hysterectomy with concurren...
IVB
...sicPalliative care and chemotherapy...
...ative care and/or chemotherapy ± in...
...otherapy ± individualized RT and/or pa...
...ximalChemotherapy ± bevacizumab ±...
...urrent...
Basic
...tive care (H, EB, S)...
...tral disease: chemotherapy (Quality...
...imited
...on previous RT and either “no p...
...nhanced
...epending on previous RT and central vs. nonc...
...entral disease: pelvic exenteration OR...
Maxima...
...ng on previous RT and central vs. noncentral...
...central disease: pelvic exenteration ± intraop...
Note
...asic...
...best managed with exenteration (type of surger...
Limited
...r RT plus noncentral disease: chemothera...
...hanced...
Prior RT plus noncentral disease: tumor-directe...
...palliative care alone, try options such as RT b...
...aximal...
...plus noncentral disease: tumor-directed...
...recurrence after any of the above, then clinic...
...ndation from 2021 Focused Guideline...
Table Views
...ble View...
...EvaluationHaving trouble viewing ta...
...able 3. Recommendations for Stage IA, IB, and...
...commendations for Stage IIB, III, IVA,...