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 Specific...
...New Recom...
...ns may offer upfront pembrolizumab and chemotherap...
...he other 2016 options....
...ent Capacity Treatment Basic...
Diagnosis
...Diagnosis...
...Evaluation (Ta...
...Basic...
...and physical examination, CBC, cervical...
...ional in ≤ stage IB1 disease): chest x...
...sation and counseling; may offer HIV testing (I,...
...physical examination, CBC, cervical bio...
...tional in ≤ stage IB1): chest x-ray, CT...
...g cessation and counseling; may offer...
History and physical examination, CBC,...
...nal in ≤ stage IB1): chest x-ray, CT, o...
...cessation and counseling; may offer HIV testing...
...Maximal...
...physical examination, CBC, cervica...
...aging (optional in ≤ stage IB1):...
...n and counseling; may offer HIV testing...
...Bold indicates addition of a recommended ac...
Treatment
...Treatment...
...Recommendations for St...
...IA1, LVSI negative,...
...ic1A1 (negative margins): cone biopsya (with sca...
...tive margins): cone biopsy. Repeat co...
...ced1A1 (negative margins): cone biopsy. Repeat con...
...A1 (negative margins): cone biopsy. Re...
...IA1, LVSI positive...
BasicCone biopsy in selected cases, if follow-up...
...itedCone biopsy (I, CB, W)744...
...hanced
...iopsy plus PLND (see Discussion in full text Gu...
...trachelectomy plus PLND (I, EB/CB,...
Maxim...
...plus PLND (H, EB/CB, S)7442...
...achelectomy plus PLND (may offer ±SLN) (I, EB/C...
...IA1, non-FS (no LV...
...iopsy (if follow-up possible) OR extrafascial...
...e biopsy (if follow-up possible); observ...
...hancedCone biopsyc OR extrafascial hyster...
...syc OR extrafascial hysterectomyb (e...
...IA1, non-FS (with...
...icAs above (L, CB, W)7442...
...mitedStage IA1 (with LVSI) and stage IA2: mo...
...cedStage IA1 (with LVSI) and stage IA2: modified...
...malStage IA1 (with LVSI) and stage IA2: mo...
...IA2, FS...
...opsy (if follow-up possible) (L, CB,...
...itedCone biopsy (if follow-up possible) (...
...hanced...
...ne biopsy plus PLND ± para-aortic LN sampl...
...ectomy plus PLND (I, EB, M)7442...
...aximal...
...sy plus PLND ± para-aortic LN samplingc (L,...
...helectomy plus PLND (I, EB, M)7...
...IA2, non-FS...
...e biopsy (if follow-up possible) or extra...
...scial hysterectomy (L, EB, W)74...
...Limited...
...biopsy plus PLND ± para-aortic LN samplingc (L,...
...dical hysterectomy plus PLND ± para-aortic LN...
...Enhance...
...biopsy plus PLND ± para-aortic L...
...odified radical hysterectomy plus PLND ± pa...
...vic RT and brachytherapy (I, EB, M)7442
...odified radical hysterectomy plus PLN...
...pelvic RT and brachytherapy (I, EB, M...
...IB1, FS...
...No recommendation (, , )7442...
...edNo recommendation (, ,...
...dRadical trachelectomy plus PLND (if adding t...
...rachelectomy plus pelvic LN sampling; may offer...
...IB1, non-...
...Basic...
...hysterectomy (Insufficient Quality...
...f available, then extrafascial hysterec...
...Limited...
...ical hysterectomy plus PLND or radical hyster...
...by extrafascial or radical hysterectom...
...En...
...ical hysterectomy plus PLND (H,...
...elvic RT plus brachytherapy plus concurrent l...
...erectomy plus PLND; may offer SLN (H,...
SLN Option (L, EB, W)744...
...elvic RT plus brachytherapy plus conc...
Wherever radical hysterectomy with concurrent chem...
...IB2 and IIA2...
...Bas...
...f chemotherapy is available, use NAC...
...Limited...
...chemotherapy is available, NACT followed by...
...T is available, but not brachytherapy, then...
...if no EBRT is available, then brachytherapy and...
Radical hysterectomy plus PLND ± para-a...
...Enhanced
...lus concurrent low-dose platinum-based chemothera...
...s concurrent low-dose platinum-based chemot...
...cal hysterectomy plus PLND ± para-...
...Ma...
...concurrent low-dose platinum-based chem...
...s concurrent low-dose platinum-based chemothe...
...tomy plus PLND ± para-aortic LN sampling and...
...Note...
...risk factors on pathology specimen: adjuvant ch...
...th risk factors on pathology specimen: adj...
...nhancedWith risk factors on pathology specimen: ad...
...risk factors on pathology specimen:...
...IIA1See IB1...
...IIA...
...E. Bold indicates addition of a recom...
Table 3a. Combination of Three Risk Factors: C...
...Recomme...
...IIB and IIIA...
...Basic...
NACT followed by extrafascial hysterectom...
...hysterectomy when chemotherapy is not consist...
Palliative care (I, CB, S...
...Limited...
...T or RTa followed extrafascial or mo...
...ascial or modified hysterectomy plus...
...lvic RT plus concurrent low-dose plati...
...Maximal...
...T plus concurrent low-dose platinum-based...
...IIIB to IV...
...Basic...
...iative care (I, EB, S)744...
...y extrafascial hysterectomy (Quali...
...Limited...
...or RTa followed by extrafascial or radic...
...rent low-dose platinum-based chemotherapy...
...Enhanced...
...s brachytherapy plus concurrent low...
...herapy ± concurrent low-dose platinum-b...
...Maximal...
...brachytherapy plus concurrent low-dose...
...apy ± concurrent low-dose platinum-based c...
...No...
...radical hysterectomy with concurrent chemoR...
...ative care and chemotherapy (if available) (H,...
...ative care and/or chemotherapy ± individualized...
EnhancedChemotherapy ± individuali...
...alChemotherapy ± bevacizumab ± individualize...
Recurr...
...iative care (H, EB, S...
and/or central disease: chemotherapy...
...evious RT and either “no prior RT...
...Enhance...
Depending on previous RT and central v...
...RT plus central disease: pelvic exenteration OR...
...Maximal...
...previous RT and central vs. noncentral diseas...
...lus central disease: pelvic exenteration...
...Note...
...Basic...
...st managed with exenteration (type...
...Limi...
...r RT plus noncentral disease: chemotherapy or...
...Enhanced...
...noncentral disease: tumor-directed...
...fore palliative care alone, try options su...
...rior RT plus noncentral disease: tu...
...e after any of the above, then clinical t...
New Recommendation from 2021 Focused G...
Table Views
...Table View...
...Evaluation Basic Li...
...mmendations for Stage IA, IB, and...
...le 4. Recommendations for Stage IIB, III, IVA, an...