Invasive Cervical Cancer

Publication Date: February 15, 2022

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 Specificat...

...ion from 2021 Focused Guideline Updat...

...offer upfront pembrolizumab and chemotherapy...

...lus the other 2016 op...


...ble 1. Treatment CapacityHaving trouble viewing...


Diagnosis

...agnosis...

...aluation (Tabl...

...asic...

...story and physical examination, CBC, cervical bio...

...tional in ≤ stage IB1 disease): ches...

...tion and counseling; may offer HIV testing (I, EB...

...mited...

...sical examination, CBC, cervical biopsy...

...nal in ≤ stage IB1): chest x-ray, CT (spec...

...on and counseling; may offer HIV tes...

...hanced

History and physical examination, CBC, cervical...

...ng (optional in ≤ stage IB1): chest x-...

...g cessation and counseling; may offer...

...axima...

...and physical examination, CBC, cervical biopsy...

...optional in ≤ stage IB1): chest x-ray, CT, o...

...ing cessation and counseling; may offer HIV test...

...cates addition of a recommended action o...


Treatment

...eatment

...endations for Stage IA, IB, and IIA Dis...

...egative, FS (see Discussion in full text...

...ative margins): cone biopsya (with scalpel). Repea...

...mited1A1 (negative margins): cone biopsy. Repe...

...d1A1 (negative margins): cone biopsy. Repeat cone...

...l1A1 (negative margins): cone biopsy....

...A1, LVSI positive, FS

...biopsy in selected cases, if follow-up poss...

...one biopsy (I, CB, W)744...

Enhance...

...biopsy plus PLND (see Discussion in f...

...achelectomy plus PLND (I, EB/CB, M)7442...

...ximal

...plus PLND (H, EB/CB, S)7442...

...cal trachelectomy plus PLND (may offer ±SLN...

...on-FS (no LVSI...

...iopsy (if follow-up possible) OR extrafasc...

...iopsy (if follow-up possible); observe...

...hancedCone biopsyc OR extrafascial hysterecto...

...biopsyc OR extrafascial hysterectomy...

...n-FS (with LVSI)...

...cAs above (L, CB, W)7442...

...IA1 (with LVSI) and stage IA2: modified radic...

...ge IA1 (with LVSI) and stage IA2: modi...

...ximalStage IA1 (with LVSI) and stage IA2:...

IA2, F...

...biopsy (if follow-up possible) (L, CB, W)7442...

...sy (if follow-up possible) (L, CB, W)7442...

...hanced

...psy plus PLND ± para-aortic LN samplingc (L,...

...cal trachelectomy plus PLND (I, EB, M)7442...

...ximal...

...lus PLND ± para-aortic LN sampling...

...ectomy plus PLND (I, EB, M)7442...

..., non-FS...

...asic...

...psy (if follow-up possible) or extrafascial hy...

...scial hysterectomy (L, EB, W)74...

...imite...

...biopsy plus PLND ± para-aortic LN sampling...

...adical hysterectomy plus PLND ± par...

Enhanced

...e biopsy plus PLND ± para-aortic LN...

...l hysterectomy plus PLND ± para-aortic L...

...ic RT and brachytherapy (I, EB, M)7442...

...ximal

...ee above Modified radical hysterectomy p...

...T and brachytherapy (I, EB, M)7442...

IB1,...

...icNo recommendation (, ,...

...dNo recommendation (, , )7...

EnhancedRadical trachelectomy plus PLND (if addin...

...dical trachelectomy plus pelvic LN sampli...

...B1, non-...

...asic

Extrafascial hysterectomy (Insufficient Qualit...

...ACT if available, then extrafascial hysterectomy...

Limite...

...cal hysterectomy plus PLND or radical hys...

...wed by extrafascial or radical hysterectomy (s...

...hanced...

...cal hysterectomy plus PLND (H, EB, S)7442...

...rachytherapy plus concurrent low-dos...

...aximal...

...hysterectomy plus PLND; may offer SL...

...Option (L, EB, W)...

Pelvic RT plus brachytherapy plus concurrent low-...

Not...

Wherever radical hysterectomy with concurrent c...

...and IIA2...

...asic...

...is available, use NACT followed by extra...

Limited

...apy is available, NACT followed by radical hyst...

...available, but not brachytherapy, then chemoR...

...if no EBRT is available, then brachytherap...

...dical hysterectomy plus PLND ± para-aorti...

...nhanced

...c RT plus concurrent low-dose plat...

...elvic RT plus concurrent low-dose platinum-based...

...hysterectomy plus PLND ± para-aortic LN sampl...

...ximal...

...lus concurrent low-dose platinum-based chemotherap...

...T plus concurrent low-dose platinum-ba...

...adical hysterectomy plus PLND ± para-aortic...

Note

...risk factors on pathology specimen: adjuva...

...k factors on pathology specimen: adjuvant RT ± ch...

...risk factors on pathology specimen: ad...

MaximalWith risk factors on pathology speci...

...See IB2...

...icates addition of a recommended act...


...3a. Combination of Three Risk Factors: CLS, S...


...mmendations for Stage IIB, III, IVA, an...

...B and IIIA...

...asic...

...by extrafascial hysterectomy (modificatio...

...terectomy when chemotherapy is not consiste...

...ive care (I, CB, S)744...

Limite...

...followed extrafascial or modified hys...

...r modified hysterectomy plus pelvic...

Enhanc...

...plus concurrent low-dose platinum-...

Maxim...

...RT plus concurrent low-dose platinum-bas...

...IB to IVA

Basi...

...lliative care (I, EB, S)7...

...ACT followed by extrafascial hysterectomy...

...imited...

...lowed by extrafascial or radical hysterectomy...

RT ± concurrent low-dose platinum-base...

Enhanced

...rachytherapy plus concurrent low-do...

...apy ± concurrent low-dose platinum-based ch...

...aximal...

...brachytherapy plus concurrent low-dose platinum-b...

...T + brachytherapy ± concurrent low-dose platin...

...ote...

...r radical hysterectomy with concurrent chemoRT...

IVB

...cPalliative care and chemotherapy (if available)...

...tive care and/or chemotherapy ± individu...

...erapy ± individualized RT and/or palliati...

...herapy ± bevacizumab ± individualiz...

Recurre...

Basic

...ive care (H, EB, S)7442

...l disease: chemotherapy (Quality of E...

Limit...

...on previous RT and either “no prio...

...nhance...

...nding on previous RT and central vs. noncentra...

...rior RT plus central disease: pelvic exenteration...

...ximal...

...on previous RT and central vs. nonce...

...s central disease: pelvic exenteration...

...ote

...asic...

...best managed with exenteration (type o...

...mited...

...RT plus noncentral disease: chemoth...

Enhanced

Prior RT plus noncentral disease: tumor-...

...iative care alone, try options such as RT...

Maxima...

...us noncentral disease: tumor-directed RT ...

...recurrence after any of the above, then cli...

...tion from 2021 Focused Guideline Update (pl...


Table Views

...able Vie...

...le 2. EvaluationHaving trouble viewing table? E...


.... Recommendations for Stage IA, IB, and IIA D...


...endations for Stage IIB, III, IVA, and...