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
Facility Specification...
...w Recommendation from 2021 Focused Guideline U...
...may offer upfront pembrolizumab an...
a Plus the other 2016 opt...
...reatment CapacityHaving trouble viewing table? Exp...
Diagnosis
...gnosis...
...aluation (Table 2)...
...asic
...physical examination, CBC, cervical biops...
...tional in ≤ stage IB1 disease): chest x-ray (I...
...moking cessation and counseling; m...
Limit...
...nd physical examination, CBC, cervica...
...ptional in ≤ stage IB1): chest x-ray, CT (specif...
...cessation and counseling; may offer HIV testi...
...hanced
...d physical examination, CBC, cervical biopsy, pa...
...aging (optional in ≤ stage IB1): chest x-...
...g cessation and counseling; may off...
...aximal...
...ry and physical examination, CBC, cervical biopsy...
...ing (optional in ≤ stage IB1): ches...
...ssation and counseling; may offer HIV testing Opt...
...indicates addition of a recommended action o...
Treatment
Treatm...
...for Stage IA, IB, and IIA Disease (Table 3)...
...tive, FS (see Discussion in full text Guidelin...
...A1 (negative margins): cone biopsya (w...
Limited1A1 (negative margins): cone biopsy....
...nced1A1 (negative margins): cone biop...
...negative margins): cone biopsy. Re...
...LVSI positive, F...
...in selected cases, if follow-up possible (I, CB,...
...Cone biopsy (I, CB, W)744...
Enhanced
...sy plus PLND (see Discussion in full text Gu...
...achelectomy plus PLND (I, EB/CB, M)74...
Maxima...
...iopsy plus PLND (H, EB/CB, S)7442...
...radical trachelectomy plus PLND (may of...
...on-FS (no LVSI)...
...sy (if follow-up possible) OR extrafascia...
...sy (if follow-up possible); observe (af...
...cedCone biopsyc OR extrafascial hysterecto...
...lCone biopsyc OR extrafascial hysterecto...
...n-FS (with LVSI)
BasicAs above (L, CB, W)...
...Stage IA1 (with LVSI) and stage IA2: modifi...
...ge IA1 (with LVSI) and stage IA2: modified radical...
...tage IA1 (with LVSI) and stage IA2: mo...
...A2, FS
...one biopsy (if follow-up possible) (L, CB, W)744...
...itedCone biopsy (if follow-up possible) (L, CB, W)...
Enhance...
...s PLND ± para-aortic LN samplingc (L, E...
...lectomy plus PLND (I, EB, M)7442...
Maxim...
Cone biopsy plus PLND ± para-aortic L...
...adical trachelectomy plus PLND (I, EB,...
...A2, non-FS...
Basi...
...f follow-up possible) or extrafascial h...
...hysterectomy (L, EB, W)7442...
...imited
...one biopsy plus PLND ± para-aortic LN samplin...
...dical hysterectomy plus PLND ± pa...
...nhance...
Cone biopsy plus PLND ± para-aortic LN sam...
...ified radical hysterectomy plus PLND Â...
...lvic RT and brachytherapy (I, EB, M)7442...
...axima...
...e Modified radical hysterectomy plus PLND ± p...
...elvic RT and brachytherapy (I, EB, M)7442...
IB1, F...
BasicNo recommendation...
...imitedNo recommendation (, , )7442...
...trachelectomy plus PLND (if adding trachel...
...trachelectomy plus pelvic LN sampling; may offer...
..., non-FS
...asic...
...al hysterectomy (Insufficient Quality o...
NACT if available, then extrafascial hysterec...
Limited
...ectomy plus PLND or radical hysterectomy (s...
...by extrafascial or radical hysterectomy (see No...
...hanced
...rectomy plus PLND (H, EB, S)7442...
...s brachytherapy plus concurrent low-dose platinum-...
...ximal...
...ical hysterectomy plus PLND; may offer...
SLN Option (L, EB, W)7...
...ic RT plus brachytherapy plus concurre...
Note
...ever radical hysterectomy with concurrent ch...
...and IIA2
Basi...
...is available, use NACT followed by...
Limite...
...is available, NACT followed by radical hysterec...
...available, but not brachytherapy, then c...
...no EBRT is available, then brachythe...
...dical hysterectomy plus PLND ± para-...
...hanced...
...lus concurrent low-dose platinum-bas...
...lus concurrent low-dose platinum-based chemoth...
...erectomy plus PLND ± para-aortic...
...aximal...
...oncurrent low-dose platinum-based chemotherapy p...
...plus concurrent low-dose platinum-...
...hysterectomy plus PLND ± para-aortic...
Not...
...factors on pathology specimen: adju...
...isk factors on pathology specimen: adjuv...
...ith risk factors on pathology specimen: adjuvan...
...ith risk factors on pathology specimen: adj...
IIA1 S...
...See IB2...
...Bold indicates addition of a recommende...
...bination of Three Risk Factors: CLS,...
...s for Stage IIB, III, IVA, and IVB and Re...
...IB and IIIA
...asic
...CT followed by extrafascial hysterectomy (modif...
...sterectomy when chemotherapy is not consi...
...ative care (I, CB, S)7442...
Limite...
or RTa followed extrafascial or modified hystere...
...or modified hysterectomy plus pelvic LND ± para...
...hanced...
...lvic RT plus concurrent low-dose platinum...
...aximal
...oncurrent low-dose platinum-based chemotherapy pl...
...B to IVA...
...asic...
...alliative care (I, EB, S)7...
NACT followed by extrafascial hysterectomy (Q...
...mited...
...llowed by extrafascial or radical hy...
...± concurrent low-dose platinum-based che...
Enhanced
...RT plus brachytherapy plus concurrent low-...
...achytherapy ± concurrent low-dose...
Maximal
...plus brachytherapy plus concurrent low-dose pl...
RT + brachytherapy ± concurrent low-dose platinu...
Not...
...tedWherever radical hysterectomy wi...
...VB...
...e care and chemotherapy (if availa...
...tedPalliative care and/or chemothe...
...emotherapy ± individualized RT an...
MaximalChemotherapy ± bevacizumab Â...
...ecurre...
...asic...
...e care (H, EB, S)7442...
...disease: chemotherapy (Quality of...
...mited
...revious RT and either “no prior RT or fai...
...hanced...
...vious RT and central vs. noncentral disease: Centr...
Prior RT plus central disease: pelvic ex...
Maxima...
...on previous RT and central vs. noncentral di...
...ior RT plus central disease: pelvic exenteration...
Note
...asic...
...managed with exenteration (type of surg...
...mited...
...s noncentral disease: chemotherapy or best...
...hanced...
...rior RT plus noncentral disease: tumor-directed R...
...re palliative care alone, try options such as RT...
...aximal
...rior RT plus noncentral disease: tumor-directed RT...
...nce after any of the above, then clinical tri...
...tion from 2021 Focused Guideline Update (plus...
Table Views
...ble View...
...able 2. EvaluationHaving trouble viewin...
...endations for Stage IA, IB, and IIA...
...ndations for Stage IIB, III, IVA, and IVB a...