Basic Medical SciencesGeneral SurgeryHealth A-ZOB / GYNOncologyPathologyUrology

Cervical Cancer: Stages, Types of Treatments

Stages of Cervical Cancer, Surgery, Radiation Therapy, Chemotherapy, Targeted Therapy, Immunotherapy, Metastatic Cervical Cancer and Recurrence

Stages of Cervical Cancer

Cervical cancer staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests and physical examination to find out the cancer’s stage, so staging may not be complete until all of the tests are finished.

Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

For cervical cancer, the staging system developed by the International Federation of Obstetrics and Gynecology (Federation Internationale de Gynecologie et d’Obstetrique, or FIGO) is used.

FIGO Stages for Cervical Cancer

Doctors assign the stage of the cancer by evaluating the tumor and whether the cancer has spread to other parts of the body.

Staging is based on the results of a physical exam, imaging scans, and biopsies.

  • Stage I: The cancer has spread from the cervix lining into the deeper tissue but is still just found in the uterus. It has not spread to other parts of the body. This stage may be divided into smaller groups to describe the cancer in more detail.
    • Stage IA: The cancer is diagnosed only by viewing cervical tissue or cells under a microscope. Imaging tests or evaluations of tissue samples can also be used to determine tumor size.
      • Stage IA1: There is a cancerous area of less than 3 millimeters (mm) in depth.
      • Stage IA2: There is a cancerous area 3 mm to less than 5 mm in depth.
    • Stage IB: In this stage, the tumor is larger but still only confined to the cervix. There is no distant spread.
      • Stage IB1: The tumor is 5 mm or more in depth and less than 2 centimeters (cm) wide. A centimeter is roughly equal to the width of a standard pen or pencil.
      • Stage IB2: The tumor is 2 cm or more in depth and less than 4 cm wide.
      • Stage IB3: The tumor is 4 cm or more in width.
    • Stage II: The cancer has spread beyond the uterus to nearby areas, such as the vagina or tissue near the cervix, but it is still inside the pelvic area. It has not spread to other parts of the body. This stage may be divided into smaller groups to describe the cancer in more detail (see below).
      • Stage IIA: The tumor is limited to the upper two-thirds of the vagina. It has not spread to the tissue next to the cervix, which is called the parametrial area.
        • Stage IIA1: The tumor is less than 4 cm wide.
        • Stage IIA2: The tumor is 4 cm or more in width.
      • Stage IIB: The tumor has spread to the parametrial area. The tumor does not reach the pelvic wall.
    • Stage III: The tumor involves the lower third of the vagina and/or: has spread to the pelvic wall; causes swelling of the kidney, called hydronephrosis; stops a kidney from functioning; and/or involves regional lymph nodes. Lymph nodes are small, bean-shaped organs that help fight infection. There is no distant spread.
      • Stage IIIA: The tumor involves the lower third of the vagina, but it has not grown into the pelvic wall.
      • Stage IIIB: The tumor has grown into the pelvic wall and/or affects a kidney.
      • Stage IIIC: The tumor involves regional lymph nodes. This can be detected using imaging tests or pathology. Adding a lowercase “r” indicates imaging tests were used to confirm lymph node involvement. A lowercase “p” indicates pathology results were used to determine the stage.
        • Stage IIIC1: The cancer has spread to lymph nodes in the pelvis.
        • Stage IIIC2: The cancer has spread to para-aortic lymph nodes. These lymph nodes are found in the abdomen near the base of the spine and near the aorta, a major artery that runs from the heart to the abdomen.
      • Stage IVA: The cancer has spread to the bladder or rectum, but it has not spread to other parts of the body.
      • Stage IVB: The cancer has spread to other parts of the body.

Recurrent: Recurrent cancer is cancer that has come back after treatment. Cervical cancer can come back either in the pelvis where it began or spread to other areas throughout the body, such as the lungs, lymph nodes, and bones.

If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Types of Treatment for Cervical Cancer

This section explains the types of treatments that are the standard of care for cervical cancer. “Standard of care” means the best treatments known.

Clinical trials may also be an option for you, which is something you can discuss with your doctor. A clinical trial is a research study that tests a new approach to treatment.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the common types of treatments used for cervical cancer are listed below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

The treatment of cervical cancer depends on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear.

Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.”

Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for cervical cancer because there are different treatment options. Learn more about making treatment decisions.

A diagnosis of cervical cancer can bring concerns about if or how treatment may affect sexual function and ability to have children, called fertility. These topics should be discussed with the health care team before treatment begins.

A woman who is pregnant should talk with their doctor about how treatments could affect both them and the unborn child. Treatment may be able to be delayed until after the baby is born.

1. Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. A gynecologic oncologist is a doctor who specializes in treating gynecologic cancer using surgery. For cervical cancer that has not spread beyond the cervix, these procedures are often used:

  • The use of the same procedure as a cone biopsy to remove all of the abnormal tissue. It can be used to remove cervical cancer that can only be seen with a microscope, called microinvasive cancer.
  • The use of an electrical current passed through a thin wire hook. The hook removes the tissue. It can be used to remove microinvasive cervical cancer.
  • The removal of the uterus and cervix. Hysterectomy can be either simple or radical. A simple hysterectomy is the removal of the uterus and cervix. A radical hysterectomy is the removal of the uterus, cervix, upper vagina, and the tissue around the cervix. A radical hysterectomy also includes an extensive pelvic lymph node dissection, which means lymph nodes are removed. This procedure can be done using a large cut in the abdomen, called laparotomy, or smaller cuts, called laparoscopy.
  • Bilateral salpingo-oophorectomy. If needed, this surgery is the removal of both fallopian tubes and both ovaries. It is done at the same time as a hysterectomy.
  • Radical trachelectomy. A surgical procedure in which the cervix is removed, but the uterus is left intact. It includes pelvic lymph node dissection (see above). This surgery may be used for young patients who want to preserve their fertility. This procedure has become an acceptable alternative to a hysterectomy for some patients.
  • The removal of the uterus, vagina, lower colon, rectum, or bladder if cervical cancer has spread to these organs after radiation therapy. Exenteration is rarely recommended. It is most often used for some people whose cancer has come back after radiation treatment.

Complications or side effects from surgery vary depending on the extent of the procedure. Occasionally, patients experience significant bleeding, infection, or damage to the urinary and intestinal systems.

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have.

Because these surgical procedures affect sexual health, patients should talk with their doctor about their symptoms and concerns in detail before the surgery.

The doctor may be able to help reduce the side effects of surgery and provide support resources on coping with any changes. If extensive surgical procedures have affected sexual function, other surgical procedures can be used to make an artificial vagina.

2. Radiation Therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Radiation therapy may be given alone, before surgery, or instead of surgery to shrink the tumor.

The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy.

A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time that combines external and internal radiation treatments. This combined approach is the most effective to reduce the chances the cancer will come back, called a recurrence.

For early stages of cervical cancer, a combination of radiation therapy and low-dose weekly chemotherapy is often used. The goal of radiation therapy combined with chemotherapy is to increase the effectiveness of the radiation treatment.

This combination is given to control the cancer in the pelvis with the goal of curing the cancer without surgery. It may also be given to destroy microscopic cancer that might remain after surgery.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Side effects of internal radiation therapy may include abdominal pain and bowel obstruction, although it is uncommon.

Most side effects usually go away after treatment is finished. After radiation therapy, the vaginal area may lose elasticity, so some women may also want to use a vaginal dilator, which is a plastic or rubber cylinder that is inserted into the vagina to prevent narrowing.

Women who have received external-beam radiation therapy will lose the ability to become pregnant, and unless the ovaries have been surgically moved out of the pelvis, premenopausal women will enter menopause.

Sometimes, doctors advise their patients not to have sexual intercourse during radiation therapy. Normal sexual activity can restart within a few weeks after treatment if the patient feels ready.

3. Therapies Using Medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies for cervical cancer are given by a gynecologic oncologist or medical oncologist, doctors who specialize in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for cervical cancer include:

  • Chemotherapy
  • Targeted therapy
  • Immunotherapy

Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.

It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications.

a. Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. For women with cervical cancer, chemotherapy is often given in combination with radiation therapy (see above).

Although chemotherapy can be given orally (by mouth), all the drugs used to treat cervical cancer are given intravenously (IV). IV chemotherapy is either injected directly into a vein or given through a thin tube called a catheter, which is a tube temporarily put into a large vein to make injections easier.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished.

Rarely, specific drugs may cause some hearing loss. Others may cause kidney damage. Patients may be given extra fluid intravenously to protect their kidneys. Talk with your doctor about the possible short-term and long-term side effects based on the drugs and dosages you will be receiving.

b. Targeted Therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.

Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor.

This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.

When cervical cancer has come back after treatment, called recurrent cancer, or if cervical cancer has spread beyond the pelvis, called metastatic disease, it can be treated with a platinum-based chemotherapy combined with the targeted therapy bevacizumab (Avastin).

There are 2 drugs similar to bevacizumab, called bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev), that have been approved by the FDA to treat advanced cervical cancer. These are called biosimilars.

c. Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

The immune checkpoint inhibitor pembrolizumab (Keytruda) is used to treat cervical cancer that has recurred or spread to other parts of the body during or after treatment with chemotherapy.

Some cancer cells express the PD-L1 protein, which binds to the PD-1 protein on T cells. T cells are immune system cells that kill certain other cells, like cancer cells. When the PD-1 and PD-L1 proteins bind, the T cell does not attack the cancer cell. Pembrolizumab is a PD-1 inhibitor, so it blocks the binding between PD-1 and PD-L1, which allows the T cells to find and attack the cancer cells.

Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you.

Physical, Emotional, and Social Effects Of Cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs.

Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis.

People who receive palliative care along with treatment for the cancer often have less severe symptoms, a better quality of life, and report that they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies.

You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem.

This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Treatment Options By Stage

Radiation therapy alone or surgery is generally used for an early-stage tumor. These treatments are equally effective at treating early-stage cervical cancer.

Chemoradiation (a combination of chemotherapy and radiation therapy) is generally used for women with a larger tumor, an advanced-stage tumor found only in the pelvis, or if the lymph nodes have cancer cells.

Commonly, radiation therapy and chemotherapy are used after surgery if there is a high risk for the cancer coming back or if the cancer has spread.

Metastatic Cervical Cancer

If cancer spreads to another part of the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it.

Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Chemotherapy, immunotherapy, and surgery may be used to treat or remove newly affected areas in both the pelvic area and other parts of the body. Palliative care will also be important to help relieve symptoms and side effects, especially to relieve pain and other side effects from radiation therapy.

For most people, a diagnosis of metastatic cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the Chance of Recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning.

An important part of follow-up care is watching for recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.

If the cancer returns after the original treatment, it is called recurrent cancer. Recurrent cancer may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options.

Often the treatment plan will include the treatments described above, such as surgery, systemic therapy, and radiation therapy, but they may be used in a different combination or given at a different pace.

Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope.

If Treatment Does Not Work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called incurable, distant metastatic, or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns.

The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life.

You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations.

Nursing care and special equipment can make staying at home a workable option for many families. After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

References:

  1. Bhatla N, et al. Revised FIGO staging for carcinoma of the cervix uteri. Int J Gynecol Obstet 2019; 1–7.

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