Management of cervical cancer

HUGHES C. (2011) European Journal of Cancer Care 20 , 5
Management of cervical cancer This module provides an overview of cervical cancer which will help health professionals provide evidence‐based patient‐centred care.     

Management of locally advanced cervical cancer

PURPOSE OF REVIEW: Cervical cancer is a significant global public health problem. In underdeveloped countries where screening programs are not widely available and in underserved populations in developed countries, women commonly present with locally advanced disease that is not curable by any extent of radical hysterectomy. This review will critically evaluate the evidence supporting the available treatment modalities for locally advanced cancer of the uterine cervix. RECENT FINDINGS: Concurrent cisplatin-based chemotherapy and radiation have demonstrated significant survival improvement for patients with locally advanced cervical cancer. Advances in imaging and radiotherapy technologies, the inclusion of newer agents to the chemoradiation regimens, the use of new hypoxic cell radiosensitizers and monoclonal antibodies that inhibit cell growth, with consequent increase in malignant cell kill fractions, are some of the new therapeutic options that may be used to improve the survival of these patients. SUMMARY: Continued improvement in understanding the natural history of cervical cancer, the limitations of the current staging system, and these newer therapeutic options will increase the efficacy of chemoradiation and improved the survival of these patients.     

Management of cervical cancer in pregnancy

Carcinoma of the cervix is the most common gynecologic cancer found during pregnancy. Management and treatment of this condition depend on cancer stage, estimated gestational age, and ethical, religious, and personal desires. Review of the medical literature in English from 1965 to 1998 is presented with recommendations for management.     

Management of invasive cervical cancer in patients initially treated by simple hysterectomy.

This study includes 15 patients with invasive cervical cancer found at the time of standard hysterectomy for benign conditions. All patients underwent laparotomy and were subjected to peritoneal cytology, radical parametriectomy, bilateral pelvic and para-aortic lymphadenectomy. Residual disease was found in 10 of the 15 patients (66.7%). The 3-year survival of patients with and without residual disease were 80% and 100%, respectively. Following secondary radical surgery, five patients without evidence of residual disease were identified and spared the risks of radiation therapy. Furthermore, two patients with para-aortic lymph node metastases, who would otherwise have been overlooked, were thus treated completely. One patient died of complications of secondary surgical procedure.     

Efficacy of cervical cancer screening.

The earlier optimistic predictions that invasive carcinoma of the uterine cervix could be totally eradicated by means of Pap screening have failed. Experiences from different countries give evidence, however, that a considerable reduction of incidence and mortality can be gained with this type of secondary prevention. Improved knowledge of the epidemiology of carcinoma of the uterine cervix and of its natural history could be anticipated to give a better basis for the planning of preventive measures. Maintenance of a high laboratory standard, a good technique for taking of smears, and improved communications between laboratories and the doctor or nurse taking the smear and the doctor or clinic performing the treatment and an adequate reaction to the report from the laboratory with adequate treatment of the precancerous stages is supposed to improve the effect of the screening programmes.     

Management of occult invasive cervical cancer found after simple hysterectomy

Background: To estimate safety and efficacy of radical parametrectomy (RP) and radiation therapy (RT) or concurrent chemoradiation therapy (CCRT) for patients with occult invasive cervical cancer found after simple hysterectomy.Materials and methods: We retrospectively evaluated outcomes in 147 patients with occult invasive cervical cancer.Results: Forty-eight patients with IA1 lesions (IA1 group) did not receive further treatment. Of the 99 patients with IA2–IIA lesions, 26 received no definitive treatment (observation group), 44 received RT or CCRT (RT/CCRT group), and 29 underwent RP (RP group). After a median follow-up of 116 months (range 3–235 months), recurrent disease was observed in 0%, 34.6%, 6.8%, and 0% of patients in the IA1, observation, RT/CCRT, and RP groups, respectively. In the RT/CCRT group, treatment was delayed due to severe diarrhea in 4 patients (9%) and 12 patients (27%) had late complications related to RT requiring further management (including two surgical interventions). Five patients in the RP group (17%) experienced perioperative complications which were easily managed, intraoperatively or conservatively. Late complications were not observed in the RP group.Conclusion: Although RP and RT/CCRT had similar therapeutic efficacy, the lower rate of late complications observed with RP makes it preferable to RT/CCRT.     

Management of recurrent cervical cancer: a review of the literature

ObjectiveThe aim of this narrative review is to update the current knowledge on the treatment of recurrent cervical cancer based on a literature review.Material and methodsA web based search in Medline and CancerLit databases has been carried out on recurrent cervical cancer management and treatment. All relevant information has been collected and analyzed, prioritizing randomized clinical trials.ResultsCervical cancer still represents a significant problem for public health with an annual incidence of about half a million new cases worldwide. Percentages of pelvic recurrences fluctuate from 10% to 74% depending on different risk factors. Accordingly to the literature, it is suggested that chemoradiation treatment (containing cisplatin and/or taxanes) could represent the treatment of choice for locoregional recurrences of cervical cancer after radical surgery. Pelvic exenteration is usually indicated for selected cases of central recurrence of cervical cancer after primary or adjuvant radiation and chemotherapy with bladder and/or rectum infiltration neither extended to the pelvic side walls nor showing any signs of extrapelvic spread of disease. Laterally extended endopelvic resection (LEER) for the treatment of those patients with a locally advanced disease or with a recurrence affecting the pelvic wall has been described.ConclusionsThe treatment of recurrences of cervical carcinoma consists of surgery, and of radiation and chemotherapy, or the combination of different modalities taking into consideration the type of primary therapy, the site of recurrence, the disease-free interval, the patient symptoms, performance status, and the degree to which any given treatment might be beneficial.     

Management and clinical outcomes of pregnant patients with invasive cervical cancer

Background: The objective of this study was to evaluate theclinical outcomes and to discuss the management of women presentingwith an invasive cervical cancer during pregnancy. Patients and methods: We retrospectively reviewed patients treatedfor an invasive cervical cancer diagnosed during pregnancy between1985 and 2000 in our institution. Results: Twenty-one pregnant patients among a total of 487 womenwere treated. Thirteen, five, two and one, respectively, werediagnosed during the first, second and third pregnancy trimesterand post-partum. The FIGO stage was IB in 15 cases, IIB in fivecases and IVA in one case. Mean follow-up was 64 months (range2–165). Overall and disease-free survival at 5 years were82% and 79%, respectively. All five patients diagnosed in thesecond trimester were alive. Two of the 13 patients and oneof the two patients diagnosed during the first trimester andthe third trimester, respectively, died of their disease. Nodifference was observed between the nine patients whose treatmentwas delayed or not. Conclusions: Invasive cervical cancer during pregnancy is rarebut is a dilemma for women and their physicians. The presentstudy and review of the literature suggest that pregnancy doesnot seem to influence the prognosis of cervical cancer. Delayedtreatment could be proposed to selected patients diagnosed atthe end of the second trimester or at the beginning of the thirdtrimester, with a small tumor (<2 cm) and negative nodes,after a multidisciplinary approach. Key words: cervical cancer, conservative management, pregnancy     

Management of advanced or recurrent cervical cancer: chemotherapy and beyond

Metastatic or recurrent cervical cancer has a survival duration of approximately 12 months. Thus, we review the outcomes of chemotherapy and/or novel agents for women who present in this situation. Included were studies in women with advanced or recurrent cervical cancer where at least response rate, survival or toxicity were reported. Platinum alone chemotherapy at 50 mg/m² is superior to other single-agent platinum or nonplatinum regimens in terms of efficacy and toxicity profile. Platinum with either paclitaxel, gemcitibine, topotecan or vinorelbine has equivalent efficacy but differ with respect to toxicity profile and convenience of treatment regimen. Bevacizumab in addition to combination chemotherapy provides a duration of survival that is 3.7 months longer than that provided by combination chemotherapy alone. EGF receptor (EGFR) tyrosine kinase inhibitor agents did not provide promising efficacy. Bevacizumab in addition to combination chemotherapy provides superior efficacy with acceptable toxicity. Evaluation of other novel targeted antiangiogenic agents, either alone or in combination with chemotherapy is ongoing.     

Trends in cervical cancer incidence--Indian scenario.

Cancer of the uterine cervix is the second most common cancer among women in the world after breast cancer. It is the most common cancer among Indian women. The present communication reports the trends in the incidence rate of cervical cancer for the Indian population. The data published in Cancer Incidence in Five Continents for various Indian registries for different periods and/or publication by the individual registry served as the source material. During the years 1990-1997, the age-adjusted incidence rates (AAR) for cervical cancer varied from 10.9 to 65.4 amongst various registries. The highest incidence was noted in the Ambillikai registry. The age-specific incidence rates (ASIR) for cervical cancer revealed that the disease increases from 35 years and reaches a peak between the ages 55 to 64 years. The trend analysis by period showed a decreasing trend in the incidence rate of cervical cancer in all the registries. However, the decrease was very small. The mean annual percentage decrease in the AAR ranged from 0.9 to 2.6% amongst various registries. Analysis of the data by ASIR revealed that the mean annual percentage decrease was higher for women in earlier age groups in most of the registries. For women beyond 64 years, the disease incidence showed an increasing trend or minimal decrease. It was also noted that most of the cervical cancer cases were detected with regional spread of the disease and a very small proportion were diagnosed at a localized stage. In India, an organized mass-screening programme with Pap smear for early detection of cervical cancer is not in practice. The data suggest an urgent need for initiation of community screening and educational programmes for the control and prevention of cervical cancer.     

Management of endometrial cancer.

AIM: To review broadly the diagnosis and treatment of endometrial cancer, concentrating on the evidence base. METHODS: The peer reviewed literature has been cited selectively to support the principal themes of the review. RESULTS: A rising incidence of endometrial cancer will continue to present challenges to improve survival particularly for high-risk and advanced disease. Lymphadenectomy and adjuvant radiotherapy are and will be used more rationally as evidence for their effectiveness accumulates. CONCLUSIONS: The area of greatest need in endometrial cancer is now to improve outcomes for women with advanced/recurrent disease.     

Management of cervical metastasis

Cervical metastasis from head and neck cancer is a common occurrence. Despite improvements in diagnostic modalities and treatment options, survival in this group of patients has not changed appreciably over the past few decades. Cervical metastasis portends a poor prognosis and also presents a diagnostic and treatment dilemma for the head and neck oncologist. This article reviews the current state of the art in the diagnosis and treatment of this difficult group of patients and the literature on the topic.     

Cell-mediated immunity in patients with cervical cancer.

In 16 patients with cervical carcinoma (stages II and III) tumor-specific and general immune reactivity was investigated. Cancer patients' skin reactivity was different from that of controls insofar as there was a decreased response to streptokinase-streptodornase as well as to DNCB. Absence of DNCB sensitization was mainly in stage III patients. Cell-mediated immunity to autologous and/or allogeneic tumor-associated antigens (TAA) was demonstrated in vivo and in vitro. 3 of 8 patients had positive skin reactions to autologous TAA and 8 of 14 reacted to allogeneic TAA. In the lymphocyte migration inhibition test, 8 of 14 patients reacted to autologous tumor membrane preparations and 3 of 10 to allogeneic pooled preparations. In addition, there was some indication of cross-reaction with antigens from a human squamous cell carcinoma of the lung. There was no reaction in vitro to normal cervical tissue and no association between tumor-specific reactions and herpes simplex virus type II antibodies could be demonstrated. Patients with DNCB sensitization and in vivo as well as in vitro lymphocyte reactivity to TAA had a better prognosis than nonreacting patients, indicating the value of combined immunological tests.     

Ages and frequencies for cervical cancer screening.

A simple method of calculating the best ages for carrying out cervical cytology screening procedures is proposed. The argument is graphical, the outcomes are readily understood by visual and intuitive methods, but a computer program for assisting the calculations is constructed. Use of the method indicates that relatively high rates of screening should be employed in women over 45, and that routine screening in women under 30 years of age is likely to be ineffective in reducing mortality. The method predicts that, if we assume a negative error rate for the test of 0-2, and a natural history with a mean interval between detectability and incurability of about 6 years, a series of 10 tests deployed between 35 and 80 years in England and Wales should give a yield of 0-67 deaths saved per 1000 tests performed, and should be capable of saving about 77% of all deaths from cervical cancer in women who conform with the recommendation.