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
...ity Specification...
...Recommendation from 2021 Focused Guideline...
...offer upfront pembrolizumab and chemot...
...the other 2016 options....
...1. Treatment CapacityHaving trouble viewi...
Diagnosis
...gnosis
Evaluation (Table 2...
...asic...
...story and physical examination, CBC, ce...
...al in ≤ stage IB1 disease): chest x-ray...
...n and counseling; may offer HIV testing (I,...
...mited...
...hysical examination, CBC, cervical biopsy, pat...
...ing (optional in ≤ stage IB1): chest x-ray...
...ion and counseling; may offer HIV testing (H, EB,...
...nhanced
...y and physical examination, CBC, cervic...
...ing (optional in ≤ stage IB1): ches...
...on and counseling; may offer HIV te...
...aximal
...istory and physical examination, CBC, cer...
...(optional in ≤ stage IB1): chest x-ray...
...cessation and counseling; may offer HI...
...ld indicates addition of a recommen...
Treatment
...reatment
...ndations for Stage IA, IB, and IIA Disease (Table...
...negative, FS (see Discussion in full tex...
...ative margins): cone biopsya (with scalp...
...d1A1 (negative margins): cone biopsy. Repeat c...
...(negative margins): cone biopsy. Repeat cone...
...al1A1 (negative margins): cone biopsy. Rep...
...SI positive, FS...
...one biopsy in selected cases, if follow-up possib...
LimitedCone biopsy (I, C...
...nhance...
...biopsy plus PLND (see Discussion in full...
OR radical trachelectomy plus PLND...
...aximal
...ne biopsy plus PLND (H, EB/CB,...
...radical trachelectomy plus PLND (ma...
...on-FS (no LVSI...
...(if follow-up possible) OR extrafas...
...biopsy (if follow-up possible); observe (after co...
...biopsyc OR extrafascial hysterectomyb (ext...
...iopsyc OR extrafascial hysterectomyb (...
IA1, non-FS (with...
...asicAs above (L, CB, W)7442...
...tedStage IA1 (with LVSI) and stage IA2:...
...tage IA1 (with LVSI) and stage IA2...
...imalStage IA1 (with LVSI) and stage IA2: modifi...
IA2, F...
...ne biopsy (if follow-up possible) (L, CB, W)74...
LimitedCone biopsy (if follow-up possible) (L, C...
...hanced...
...s PLND ± para-aortic LN samplingc...
...cal trachelectomy plus PLND (I, EB...
...axima...
...sy plus PLND ± para-aortic LN samplingc (...
...cal trachelectomy plus PLND (I, E...
...A2, non-FS
Basic
...iopsy (if follow-up possible) or extrafascial hy...
...hysterectomy (L, EB, W)7442...
...mited
...plus PLND ± para-aortic LN samplingc (L, EB,...
...al hysterectomy plus PLND ± para-aortic L...
...hanced
...us PLND ± para-aortic LN samplingc (L...
Modified radical hysterectomy plus...
...nd brachytherapy (I, EB, M)7442...
Maximal
...above Modified radical hysterectomy plus...
...RT and brachytherapy (I, EB, M)7442...
IB1, F...
...ecommendation (, , )7442...
...No recommendation (, , )7...
...edRadical trachelectomy plus PLND (if...
...imalRadical trachelectomy plus pelvic LN sa...
...1, non-F...
Basic
...al hysterectomy (Insufficient Qualit...
...le, then extrafascial hysterectomy (I...
...imite...
...ctomy plus PLND or radical hysterectom...
...ed by extrafascial or radical hysterectomy (see...
...hanced...
...rectomy plus PLND (H, EB, S)7442...
...ic RT plus brachytherapy plus concurrent low-dos...
...ximal...
...l hysterectomy plus PLND; may offer SLN (H, E...
...ion (L, EB, W)7442...
...us brachytherapy plus concurrent low-dose pl...
...ote
...erever radical hysterectomy with co...
...and IIA2...
Basi...
...chemotherapy is available, use NACT followed by e...
Limite...
...motherapy is available, NACT followe...
...f EBRT is available, but not brachytherapy,...
...BRT is available, then brachytherapy a...
...tomy plus PLND ± para-aortic LN sampling (L,...
...hanced
...plus concurrent low-dose platinum-based chemot...
Pelvic RT plus concurrent low-dose platinum-ba...
...ectomy plus PLND ± para-aortic LN samplingc...
...axima...
Pelvic RT plus concurrent low-dose platinum-...
...RT plus concurrent low-dose platinum-based che...
...l hysterectomy plus PLND ± para-ao...
...ote...
...factors on pathology specimen: adjuvant...
...sk factors on pathology specimen: adjuvant...
...ncedWith risk factors on pathology specime...
...h risk factors on pathology specimen: adjuva...
IIA1 S...
...See IB2...
...old indicates addition of a recommende...
...bination of Three Risk Factors: CLS, Stroma...
...ndations for Stage IIB, III, IVA, and IVB...
...IB and I...
...asic...
...ollowed by extrafascial hysterectomy (mod...
...ascial hysterectomy when chemotherapy is not consi...
...ve care (I, CB, S)7442...
Limite...
...owed extrafascial or modified hyst...
...rafascial or modified hysterectomy plus pelvi...
Enhanc...
...elvic RT plus concurrent low-dose platinum...
...ximal
...lus concurrent low-dose platinum-based chemother...
...B to IVA...
...asic...
...ve care (I, EB, S)7442...
...owed by extrafascial hysterectomy (Q...
Limited
...lowed by extrafascial or radical hys...
...nt low-dose platinum-based chemotherapy (may offer...
...nhanced...
...plus brachytherapy plus concurrent low-do...
RT + brachytherapy ± concurrent low-d...
...aximal...
...RT plus brachytherapy plus concurrent low-do...
...T + brachytherapy ± concurrent low-dose platinum-...
...ote...
...rever radical hysterectomy with concurr...
IV...
...lliative care and chemotherapy (if available)...
...ve care and/or chemotherapy ± individual...
...hemotherapy ± individualized RT an...
...aximalChemotherapy ± bevacizumab ±...
...ecurrent
...asic
...liative care (H, EB, S)7442...
.../or central disease: chemotherapy (Quality of Evid...
...imited
...revious RT and either “no prior RT or failu...
...hanced...
...revious RT and central vs. noncentral disease...
...RT plus central disease: pelvic exenteration...
...aximal...
...n previous RT and central vs. noncentr...
...entral disease: pelvic exenteration ±...
Note
...asic
...managed with exenteration (type of surgery that...
...mited
...or RT plus noncentral disease: chemothera...
Enhanced
...RT plus noncentral disease: tumor-dire...
...ative care alone, try options such as RT boost, sa...
Maximal
...noncentral disease: tumor-directed RT ± ch...
...urrence after any of the above, then clinical tr...
...dation from 2021 Focused Guideline...
Table Views
...able Vie...
...tionHaving trouble viewing table? Expan...
...able 3. Recommendations for Stage IA, IB, and II...
...mmendations for Stage IIB, III, IVA...