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 Specifi...
...New Recommendation f...
...inicians may offer upfront pembrolizumab...
...the other 2016 optio...
...Treatment CapacityHaving trouble viewing...
Diagnosis
...Diagnosis...
...Evaluation (Table 2)...
...B...
...physical examination, CBC, cervical biopsy, con...
...tional in ≤ stage IB1 disease): chest x-ra...
...ssation and counseling; may offer HIV testi...
...ysical examination, CBC, cervical bio...
...ional in ≤ stage IB1): chest x-ray, C...
...ion and counseling; may offer HIV testing (H, EB,...
...Enhanced...
...ysical examination, CBC, cervical biopsy, pa...
...ging (optional in ≤ stage IB1): chest x-ray,...
...king cessation and counseling; may offer HIV...
...Ma...
History and physical examination, CBC, cervical b...
...ng (optional in ≤ stage IB1): ches...
...cessation and counseling; may offer HIV testin...
NOTE. Bold indicates addition of a recommended act...
Treatment
...Treatment...
...Recommendat...
...IA1, LVSI...
...egative margins): cone biopsya (with scalpel)....
...1 (negative margins): cone biopsy. Repeat cone bio...
...(negative margins): cone biopsy. Repeat cone b...
...1A1 (negative margins): cone biopsy. Repeat cone...
...IA1, LVSI p...
...biopsy in selected cases, if foll...
...itedCone biopsy (I, CB...
...hanced
...ne biopsy plus PLND (see Discussion...
...l trachelectomy plus PLND (I, EB/CB,...
Maxima...
...psy plus PLND (H, EB/CB, S)7442...
...achelectomy plus PLND (may offer ±SLN) (I, EB/C...
...IA1, non-FS...
...ne biopsy (if follow-up possible) OR extrafascia...
...edCone biopsy (if follow-up possible); obs...
...ancedCone biopsyc OR extrafascial hys...
...ne biopsyc OR extrafascial hysterectomyb (ex...
...s above (L, CB, W)7442...
...1 (with LVSI) and stage IA2: modif...
...cedStage IA1 (with LVSI) and stage IA2: modified...
...imalStage IA1 (with LVSI) and stage...
...IA2, FS...
...one biopsy (if follow-up possible) (L...
...edCone biopsy (if follow-up possib...
...hanced
...s PLND ± para-aortic LN samplingc (L, E...
...dical trachelectomy plus PLND (I, EB...
Maxima...
...y plus PLND ± para-aortic LN samplin...
...adical trachelectomy plus PLND (I, EB, M)7...
I...
...y (if follow-up possible) or extra...
...hysterectomy (L, EB, W)7442...
...Limited...
...plus PLND ± para-aortic LN samplingc (L, EB,...
...cal hysterectomy plus PLND ± para-aortic LN...
...Enhanced...
...PLND ± para-aortic LN samplingc (L, EB, W)74...
...hysterectomy plus PLND ± para-aor...
...d brachytherapy (I, EB, M)7442...
...e Modified radical hysterectomy plus PLND ± p...
...RT and brachytherapy (I, EB, M)7...
...IB1, FS
...ommendation (, , )7442...
...itedNo recommendation (, ,...
...dical trachelectomy plus PLND (if adding trachel...
...al trachelectomy plus pelvic LN sampling;...
...IB1, non-FS...
...Basic...
...trafascial hysterectomy (Insufficient Qual...
...ailable, then extrafascial hysterectomy (Insuf...
...tomy plus PLND or radical hysterec...
...d by extrafascial or radical hysterectomy (see Not...
...Enhanced...
Radical hysterectomy plus PLND (H, EB,...
...rachytherapy plus concurrent low-dose...
...Maximal
...ical hysterectomy plus PLND; may offer SLN...
SLN Option (L, EB, W)744...
Pelvic RT plus brachytherapy plus concurrent...
...Note...
...ever radical hysterectomy with concurrent chemo...
...IB2 a...
...Basic
...erapy is available, use NACT followed by ex...
...motherapy is available, NACT followed b...
...available, but not brachytherapy, then ch...
...R if no EBRT is available, then brachythe...
...rectomy plus PLND ± para-aortic LN s...
...lvic RT plus concurrent low-dose platinum-ba...
...c RT plus concurrent low-dose platinum-ba...
...hysterectomy plus PLND ± para-aortic LN sampl...
...Maxim...
...elvic RT plus concurrent low-dose platinum-bas...
...plus concurrent low-dose platinum-based ch...
...dical hysterectomy plus PLND ± para...
...Note...
...factors on pathology specimen: adjuvan...
...With risk factors on pathology specimen: adj...
...cedWith risk factors on pathology...
MaximalWith risk factors on pathology specime...
...II...
...IIA2See I...
...icates addition of a recommended action ove...
...ation of Three Risk Factors: CLS, Strom...
...IIB and IIIA...
...Basic...
...CT followed by extrafascial hyster...
...al hysterectomy when chemotherapy is not...
...tive care (I, CB, S)744...
...Limited...
...ollowed extrafascial or modified hystere...
...trafascial or modified hysterectomy plus pelvi...
...Enhan...
...plus concurrent low-dose platinum-based...
...Maximal...
...s concurrent low-dose platinum-based chemotherapy...
IIIB...
Basi...
...liative care (I, EB,...
...extrafascial hysterectomy (Quality o...
...Limit...
...ed by extrafascial or radical hysterectomy (see N...
...rrent low-dose platinum-based chemot...
...E...
...brachytherapy plus concurrent low-dose platinum-ba...
...ytherapy ± concurrent low-dose platinum-base...
...Ma...
...RT plus brachytherapy plus concurrent low-dose pla...
...achytherapy ± concurrent low-dose platin...
...No...
...herever radical hysterectomy with concurrent...
...IVB...
...ve care and chemotherapy (if available) (H, EB,...
...imitedPalliative care and/or chemotherapy ± ind...
...hemotherapy ± individualized RT and/...
...emotherapy ± bevacizumab ± individualized RT...
...Recurrent...
...Basic...
...ve care (H, EB, S)74...
...nd/or central disease: chemotherapy (Qual...
...Limite...
Depending on previous RT and either “no prior R...
...Enhanced...
...ing on previous RT and central vs. noncen...
...RT plus central disease: pelvic exentera...
...Maxi...
...ing on previous RT and central vs. noncentral...
...rior RT plus central disease: pelv...
...No...
...Basic...
...his is best managed with exenteration (t...
...L...
...noncentral disease: chemotherapy or best...
...Enhanced...
...RT plus noncentral disease: tumor-directed RT...
...lliative care alone, try options such a...
...Maximal...
...plus noncentral disease: tumor-direc...
...after any of the above, then clinical tr...
...tion from 2021 Focused Guideline Upda...
Table Views
...Table Views...
Table 2. EvaluationHaving trouble viewing table...
...mendations for Stage IA, IB, and IIA DiseaseHavin...
...4. Recommendations for Stage IIB, III, IVA, and IV...