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
...acility Specificatio...
...ecommendation from 2021 Focused Guideline...
...nicians may offer upfront pembrolizumab and chemot...
...he other 2016 options....
.... Treatment CapacityHaving trouble viewing table?...
Diagnosis
...iagnosis
...tion (Table 2)...
...asic...
...d physical examination, CBC, cervical biopsy, con...
...g (optional in ≤ stage IB1 disease): chest x-ra...
Smoking cessation and counseling; may...
...imited...
...ory and physical examination, CBC, cervical...
...ing (optional in ≤ stage IB1): chest x-ray, CT...
...moking cessation and counseling; may offer...
...hanced...
...tory and physical examination, CBC, cervi...
...g (optional in ≤ stage IB1): chest x-ray, C...
...g cessation and counseling; may offer HIV...
Maxima...
...ory and physical examination, CBC, cervical biop...
...ng (optional in ≤ stage IB1): chest x-ray, CT, o...
Smoking cessation and counseling; may offer HIV...
...old indicates addition of a recommend...
Treatment
...reatment...
...tions for Stage IA, IB, and IIA Di...
...A1, LVSI negative, FS (see Discussion i...
...gative margins): cone biopsya (with scalpel). Repe...
...d1A1 (negative margins): cone biopsy. Repeat c...
...nhanced1A1 (negative margins): cone biopsy. Repea...
...negative margins): cone biopsy. Repeat cone...
...A1, LVSI positive, FS
...biopsy in selected cases, if follow-...
...tedCone biopsy (I, CB, W)744...
Enhanc...
...plus PLND (see Discussion in full text...
...radical trachelectomy plus PLND (I, EB/CB, M)7...
...aximal
...e biopsy plus PLND (H, EB/CB...
...al trachelectomy plus PLND (may offer Â...
...on-FS (no LVSI)...
...icCone biopsy (if follow-up possible) OR ex...
...biopsy (if follow-up possible); observe (after...
...ncedCone biopsyc OR extrafascial hys...
...one biopsyc OR extrafascial hysterectomyb...
...non-FS (with LVSI)...
...s above (L, CB, W)7442...
...e IA1 (with LVSI) and stage IA2: modified...
...edStage IA1 (with LVSI) and stage IA2: modifi...
...ximalStage IA1 (with LVSI) and stage...
...A2, FS...
...y (if follow-up possible) (L, CB, W)7442...
...iopsy (if follow-up possible) (L, CB,...
Enhanced
...e biopsy plus PLND ± para-aortic LN sampl...
...rachelectomy plus PLND (I, EB, M)744...
...aximal
...s PLND ± para-aortic LN samplingc (L, EB,...
...dical trachelectomy plus PLND (I, EB, M...
..., non-FS
Basi...
...iopsy (if follow-up possible) or extr...
...l hysterectomy (L, EB, W)7442...
...mited...
...iopsy plus PLND ± para-aortic LN samplingc...
...dical hysterectomy plus PLND ± para-aor...
Enhanced
...iopsy plus PLND ± para-aortic LN sampl...
...dical hysterectomy plus PLND ± para-aortic LN sa...
...R pelvic RT and brachytherapy (...
...axima...
...ee above Modified radical hysterect...
...RT and brachytherapy (I, EB, M)7442...
...B1, FS...
...No recommendation (, , )7442...
...recommendation (, , )7442...
...dRadical trachelectomy plus PLND (...
...trachelectomy plus pelvic LN sampling; m...
IB1, non-F...
...asic...
...xtrafascial hysterectomy (Insufficient Quality o...
...available, then extrafascial hysterectomy (Insu...
...imited...
...ysterectomy plus PLND or radical hysterecto...
...ed by extrafascial or radical hystere...
...hanced...
...ical hysterectomy plus PLND (H, EB, S)...
...rachytherapy plus concurrent low-dose platinum-...
...axima...
...cal hysterectomy plus PLND; may offer SLN (H,...
...Option (L, EB, W)7442...
...c RT plus brachytherapy plus concurrent...
...ote
Wherever radical hysterectomy with concurrent chem...
IB2 and I...
Basic
...py is available, use NACT followed by...
Limited
...is available, NACT followed by radical hysterecto...
...vailable, but not brachytherapy, then chemoRT fo...
...RT is available, then brachytherapy a...
...al hysterectomy plus PLND ± para-aortic...
...nhanced
...us concurrent low-dose platinum-based chemo...
...s concurrent low-dose platinum-based ch...
...tomy plus PLND ± para-aortic LN samplingc...
Maximal
...lus concurrent low-dose platinum-based chem...
...c RT plus concurrent low-dose platinum-ba...
...dical hysterectomy plus PLND ± para-aortic LN s...
Not...
...h risk factors on pathology specimen:...
...risk factors on pathology specimen:...
...hancedWith risk factors on patholo...
...imalWith risk factors on pathology specime...
...S...
...2 See IB2...
...TE. Bold indicates addition of a recommended actio...
.... Combination of Three Risk Factors: CLS...
...mmendations for Stage IIB, III, IVA, an...
...B and IIIA...
Basic
...followed by extrafascial hysterect...
...afascial hysterectomy when chemotherapy is not c...
...ative care (I, CB, S)7442...
...imited...
...owed extrafascial or modified hysterecto...
Extrafascial or modified hysterectomy plus pel...
...hanced...
...us concurrent low-dose platinum-based chemo...
Maxim...
...elvic RT plus concurrent low-dose platinu...
...B to IVA...
...asic...
Palliative care (I, EB, S)7442
...CT followed by extrafascial hystere...
...imite...
...or RTa followed by extrafascial or...
...rrent low-dose platinum-based chemotherapy (may...
...nhance...
...us brachytherapy plus concurrent low-dose plati...
...hytherapy ± concurrent low-dose platinum-based...
...ximal
...RT plus brachytherapy plus concurrent low-dose...
...chytherapy ± concurrent low-dose platinu...
Note
...itedWherever radical hysterectomy with conc...
...VB...
...liative care and chemotherapy (if avail...
...iative care and/or chemotherapy ± individua...
...otherapy ± individualized RT and/or palliative...
...alChemotherapy ± bevacizumab ± individu...
...current...
...asic...
...iative care (H, EB, S)7442
...d/or central disease: chemotherapy (Quality o...
Limite...
...epending on previous RT and either “no prio...
...hanced...
...on previous RT and central vs. noncentral diseas...
...T plus central disease: pelvic exenteration...
...aximal
...ng on previous RT and central vs. noncentr...
Prior RT plus central disease: pelvic...
...ote
...asic...
...is best managed with exenteration...
...mited...
...plus noncentral disease: chemotherapy or...
...nhance...
...r RT plus noncentral disease: tumor-directed R...
...iative care alone, try options such as RT...
Maximal
...noncentral disease: tumor-directed RT ± ch...
...ter any of the above, then clinical...
...on from 2021 Focused Guideline Update (plus...
Table Views
Table Vie...
...ble 2. EvaluationHaving trouble view...
...3. Recommendations for Stage IA, IB, and IIA D...
...commendations for Stage IIB, III, IVA, and...