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
...ty Specifications...
...mmendation from 2021 Focused Guideline Updatea...
...ans may offer upfront pembrolizumab and chemother...
...the other 2016 options...
...able 1. Treatment CapacityHaving tr...
Diagnosis
...agnosi...
...tion (Table 2)
Basi...
...ical examination, CBC, cervical bio...
...g (optional in ≤ stage IB1 disease): c...
...on and counseling; may offer HIV testing (I, EB,...
...mited...
...physical examination, CBC, cervical biopsy, patho...
...aging (optional in ≤ stage IB1): chest x-...
...ing cessation and counseling; may offer HI...
...nhance...
...story and physical examination, CBC, cervic...
...(optional in ≤ stage IB1): chest x-ray...
...cessation and counseling; may offer HIV testi...
Maxima...
...and physical examination, CBC, cervical...
...optional in ≤ stage IB1): chest x-r...
...n and counseling; may offer HIV tes...
...old indicates addition of a recommended action...
Treatment
Treatm...
...commendations for Stage IA, IB, and IIA Disea...
...VSI negative, FS (see Discussion in full text Guid...
...(negative margins): cone biopsya (with scalp...
...(negative margins): cone biopsy. Repeat...
...1A1 (negative margins): cone biopsy....
...al1A1 (negative margins): cone biopsy. Repeat c...
...SI positive, FS...
...Cone biopsy in selected cases, if fo...
...ne biopsy (I, CB, W)7442...
...hanced...
...one biopsy plus PLND (see Discussion in ful...
...helectomy plus PLND (I, EB/CB, M)7442...
...ximal...
Cone biopsy plus PLND (H, EB/...
...achelectomy plus PLND (may offer ±SLN) (I, EB/...
..., non-FS (no LVSI)...
BasicCone biopsy (if follow-up possi...
...tedCone biopsy (if follow-up possible)...
...opsyc OR extrafascial hysterectomyb (extrafascial...
...ximalCone biopsyc OR extrafascial hyste...
...non-FS (with LV...
...above (L, CB, W)7442
...(with LVSI) and stage IA2: modified radical hyst...
...hancedStage IA1 (with LVSI) and stage IA2: mo...
...imalStage IA1 (with LVSI) and stage IA2:...
IA2, FS
...asicCone biopsy (if follow-up possible) (L, CB, W)...
...biopsy (if follow-up possible) (L, CB, W)...
Enhanc...
...plus PLND ± para-aortic LN sampl...
...electomy plus PLND (I, EB, M)7442
...ximal...
...s PLND ± para-aortic LN samplingc (L, EB,...
...ical trachelectomy plus PLND (I,...
..., non-FS
...asic...
...psy (if follow-up possible) or extrafascia...
...trafascial hysterectomy (L, EB, W)744...
...mited
...plus PLND ± para-aortic LN samplingc (L,...
...ed radical hysterectomy plus PLND ± para-a...
...hanced...
...PLND ± para-aortic LN samplingc (...
...hysterectomy plus PLND ± para-aortic...
...pelvic RT and brachytherapy (...
...aximal
...above Modified radical hysterectomy plus PLND...
...vic RT and brachytherapy (I, EB, M)7442...
...1, FS
...recommendation (, , )7442...
...imitedNo recommendation (, , )74...
...nhancedRadical trachelectomy plus PLND (if a...
...adical trachelectomy plus pelvic LN s...
...1, non-F...
...asic...
...al hysterectomy (Insufficient Quality of Evid...
...available, then extrafascial hyst...
Limited
...hysterectomy plus PLND or radical hysterectom...
...followed by extrafascial or radical hysterectomy...
Enhanc...
...terectomy plus PLND (H, EB, S)7442...
...lvic RT plus brachytherapy plus concurrent low-do...
...ximal...
...ical hysterectomy plus PLND; may offer SLN (H...
...ption (L, EB, W)74...
...us brachytherapy plus concurrent low-dose...
...ote
...al hysterectomy with concurrent chemoR...
...B2 and IIA...
...asic...
...y is available, use NACT followed b...
...mited...
...y is available, NACT followed by radical hyst...
...ailable, but not brachytherapy, then ch...
...T is available, then brachytherapy and concu...
Radical hysterectomy plus PLND ± par...
...hanced...
...oncurrent low-dose platinum-based chemotherapy p...
...lus concurrent low-dose platinum-based chemotherap...
...dical hysterectomy plus PLND ± para-aortic LN sa...
Maxim...
...concurrent low-dose platinum-based chemot...
...elvic RT plus concurrent low-dose platinum-base...
...rectomy plus PLND ± para-aortic LN s...
...ote...
...risk factors on pathology specimen:...
...With risk factors on pathology specimen: adj...
...cedWith risk factors on pathology speci...
...sk factors on pathology specimen: ad...
...See I...
...See IB2...
...old indicates addition of a recomme...
...nation of Three Risk Factors: CLS, St...
Recommendations for Stage IIB, III, IVA,...
...and IIIA...
...asic
...d by extrafascial hysterectomy (mod...
...afascial hysterectomy when chemotherapy is not...
...e care (I, CB, S)7442...
...mited...
...or RTa followed extrafascial or modified hyst...
...cial or modified hysterectomy plus pelvic LND...
Enhanced
Pelvic RT plus concurrent low-dose platinum-based...
...ximal...
...ic RT plus concurrent low-dose platinum-based c...
...IB to IVA...
Basi...
...iative care (I, EB, S)7442...
...by extrafascial hysterectomy (Quality of Ev...
...mited...
...RTa followed by extrafascial or radical hys...
...t low-dose platinum-based chemotherap...
Enhanc...
...us brachytherapy plus concurrent low-dose p...
...erapy ± concurrent low-dose platinum-ba...
...aximal
...us brachytherapy plus concurrent l...
...brachytherapy ± concurrent low-dose platinu...
Not...
...Wherever radical hysterectomy with...
...VB
...care and chemotherapy (if available...
...itedPalliative care and/or chemotherapy ± i...
...motherapy ± individualized RT and/or p...
...herapy ± bevacizumab ± individualize...
...current...
Basi...
...lliative care (H, EB, S)...
...ral disease: chemotherapy (Quality of Evidenc...
...mited...
...previous RT and either “no prior R...
...nhanced...
...vious RT and central vs. noncentral dis...
...ntral disease: pelvic exenteration OR radical hyst...
Maxima...
...epending on previous RT and central vs. nonce...
...rior RT plus central disease: pelvic...
...ote
Basic
...is is best managed with exenteration (type...
...imited
...oncentral disease: chemotherapy or best p...
Enhanced
...plus noncentral disease: tumor-directe...
...alliative care alone, try options such as RT...
Maximal
...noncentral disease: tumor-directed RT ± chemo...
...nce after any of the above, then clin...
...Recommendation from 2021 Focused Guideline Up...
Table Views
...ble Views
...tionHaving trouble viewing table? Expan...
...le 3. Recommendations for Stage IA, IB,...
...Recommendations for Stage IIB, III, IVA, and...