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Cervical Cancer

 

The cervix is a female reproductive organ that forms the lower portion of the uterus or womb. The uterus and cervix lie in the pelvis, on top of the vagina, in between the rectum and bladder. The cervix forms the part of the birth canal that opens to the vagina.

 

How does cervical cancer form?

 

The surface layer of the cervix is mostly composed of squamous cells. The squamous cells of the cervix merge with the glandular cells lining the cervical canal of the uterus. The area of merging is called the squamo-columnar junction and the area on the cervix outside of this junction is called the transformation zone. Cervical cancer occurs when cervical cells grow out of control, typically in the transformation zone. When cells grow out of control, they spread and grow throughout the cervix and may invade and destroy neighboring organs or break away and spread through the bloodstream and lymphatic system to other parts of the body.

 

How to screen for cervical cancer?

 

Doctors who care for women routinely perform pelvic examinations and a Papanicolaou (Pap) smear to screen for cancer in the cells on the surface of the cervix. During a Pap smear, a sample of cells from the cervix is taken with a small wooden spatula or brush and examined under the microscope. Women may first become aware that they have cervical cancer when a suspicious area is identified during a pelvic examination or an abnormal Pap smear. If a suspicious or a precancerous lesion is found, additional tests will be recommended to determine whether a precancerous lesion or invasive cancer exists.

 

Cells taken from the surface of the cervix can appear abnormal, but may not be cancerous. These abnormal cells, however, may be the first step in a series of changes that lead to cancer. Doctors refer to the abnormal cells as "precancerous" and have used different terms to refer to them, such as squamous intraepithelial lesions, dysplasia, cervical intraepithelial neoplasia or carcinoma in situ. Precancerous disease involves only the surface of the cervix. When the abnormal cells begin to spread deeper into the cervix, they are referred to as invasive cancer of the cervix.

 

If physicians feel they need more information following an abnormal Pap smear, they may use a colposcope (lighted microscope) to better visualize the cervix or to perform a biopsy, which is the removal of a sample of tissue from the cervix in order to evaluate cervical cells under a microscope. If the doctor cannot determine whether the abnormal cells are only on the surface of the cervix, an endocervical curettage or conization may be recommended. During an endocervical curettage, a small spoon-shaped instrument called a curette is used to scrape cells away from inside the cervical opening. A conization or cone biopsy removes a cone-shaped sample of tissue from the cervical canal. Conization can also serve as the primary treatment of precancerous cervical cancer.

 

Infrequently, it may still remain unclear whether the abnormal cells are confined to the cervix or arise from inside the uterus. In this situation, a dilatation and curettage (D and C) may be recommended. During a D and C, the cervical opening is stretched (dilated) and a curette is inserted to remove cells from the lining of the uterus and cervical canal.

 

Stages of cervical cancer

 

Stage 0: Precancerous lesion involves only the cells on the surface of the cervix.

 

Stage I: Cancer is confined to the cervix, and may be evident only under microscopic evaluation (stage IA) or apparent by visible or physical examination (stage IB).

 

Stage II: Cancer has spread beyond the cervix to involve the tissues surrounding the cervix (parametria) or the upper portion of the vagina.

 

Stage III: Cancer spreads beyond the cervix to the lower vagina or to the sides of the pelvis, or causes a blockage of drainage from the kidney, a condition called hydronephrosis.

 

Stage IV: Cancer invades structures adjacent to the cervix such as the bladder or rectum or has spread to other parts of the body such as the liver or lungs.

 

Recurrent/Relapsed: Cervical cancer is still detected or has returned (recurred/relapsed) following an initial treatment with surgery, radiation therapy, and/or chemotherapy.

 

Recurring cervical Cancer

 

When cervical cancer has been detected or has returned following initial treatment with surgery, radiation therapy and/or chemotherapy, it is said to be recurrent or relapsed. The course of treatment for relapsed cervical cancer depends on what treatment a patient has previously received and where the recurrence is located. Some patients who have recurrence of cervical cancer within the pelvis can be treated with additional surgery or with radiation therapy, if no radiation therapy was given previously. Recurrence of cervical cancer outside the pelvis is difficult to treat.

 

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

 

The following is a general overview of the treatment of recurrent cervical cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

 

Treatment depends on many factors, including what treatment the patient had before, the location of the recurrence and the overall condition of the patient. If the patient had surgery to remove the cervix and the cancer comes back only in a small area near the operation, radiation therapy may be administered. If the patient already received radiation therapy to the pelvis, radiation therapy cannot be administered again to the same part of the body. Some patients with recurrent cervical cancer in the pelvis can undergo an extensive surgical procedure that removes the cancer and many pelvic organs. Other patients have recurrent cervical cancer outside the pelvis and may receive chemotherapy or radiation therapy to alleviate symptoms.

 

Recurrent Cervical Cancer After Surgery

 

A radical hysterectomy is a very effective therapy if the cancer has not spread beyond the cervix. At times, a small area of cancer has spread beyond the cervix and cancer cells may be present at the edge of the surgical specimen. Usually, this can be determined only after the surgery when the specimen is examined under the microscope. Other times, the region of the operation may be contaminated with microscopic cancer cells. The presence of microscopic areas of cancer cells can cause the cancer to return some time after the surgery. This situation occurs more frequently in patients with large stage IB or stage II cervical cancer.

 

Patients with a small amount of cancer recurrence in the area of previous surgery can be treated in an attempt to rid the cancer again. If the patient has not received radiation therapy to the pelvis, external beam radiation therapy to the area of the recurrence can kill cancer cells after the surgery. Patients who have received prior radiation therapy may be able to undergo a pelvic exenteration, which is an extensive surgical procedure that removes the cancer and many pelvic organs. A pelvic exenteration is only performed if cancer cannot be detected elsewhere in the body and all of the cancer can be removed by the surgery. Approximately one-third of patients with recurrent cancer will survive free of cancer after treatment with radiation therapy or pelvic exenteration.

 

Other patients already have small amounts of cancer that have spread outside the pelvis and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the pelvis are referred to as micrometastases. The presence of microscopic areas of cancer cells can cause the cancer to return outside the pelvis some time after the surgery. Please see the section below for more information.

 

Recurrent Cervical Cancer After Radiation Therapy

 

Depending on the features of the cervical cancer, some patients will experience a recurrence of the cervical cancer after radiation therapy. In these patients, cancer cells may have survived despite the radiation therapy. Other patients already have small amounts of cancer that have spread outside the pelvis and were not treated by the radiation. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the pelvis are referred to as micrometastases. The presence of these microscopic areas of cancer or surviving cancer cells can cause the relapses that follow treatment with radiation therapy.

 

Once a patient has received radiation therapy to the pelvis, more radiation therapy cannot safely be administered to the same area. Patients who have received prior radiation therapy may be able to undergo a pelvic exenteration, which is an extensive surgical procedure that removes the cancer and many pelvic organs. A pelvic exenteration is only performed if cancer cannot be detected elsewhere in the body and all of the cancer can be removed by the surgery. Approximately one-third of patients with recurrent cancer will survive free of cancer after treatment with radiation therapy or pelvic exenteration.

 

Recurrent Cervical Cancer Outside the Pelvis

 

Cervical cancer that has spread to distant organs and bones is difficult to treat. Historically, patients with metastatic cervical cancer have been considered incurable. Some patients are offered treatment with chemotherapy for the purpose of prolonging their duration of survival and alleviating symptoms from progressive cancer. Other patients are managed with efforts to reduce pain or bleeding, including local radiation therapy to affected parts of the body.

 

There is no good single chemotherapy approach that can improve the length of survival in patients with metastatic cervical cancer. Treatment with Platinol® can produce shrinkage in 15-25% of patients with metastatic cervical cancer. Many clinical trials have combined Platinol® with other chemotherapy drugs in hopes of improving cancer shrinkage and survival. Although these combination regimens can have more side effects, length of survival has not been improved over Platinol® alone. Unfortunately, these chemotherapies typically work for only a few months before the cervical cancer begins to grow again. Most patients ultimately succumb to cancer and better treatment strategies are clearly needed.

 

Strategies to Improve Treatment

 

The progress that has been made in the treatment of cervical cancer has resulted from development of better treatments in patients with more advanced stages of cancer and participation in clinical trials. While some progress has been made in the treatment of cervical cancer that has recurred outside the pelvis, nearly all patients still succumb to cancer and better treatment strategies are clearly needed. Future progress in the treatment of cervix cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of cervical cancer.

 

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed.

 

New Chemotherapy Regimens: Several new chemotherapy drugs show promising activity for the treatment of advanced or recurrent cervical cancer. Development of new multi-drug chemotherapy treatment regimens that incorporate new or additional anti-cancer therapies is an active area of clinical research.

 

One recent study demonstrated that the combination of Platinol® and Gemzar® appears to be an effective treatment option for recurrent cervical cancer. In this study, 17 women with advanced, resistant or recurrent cervical cancer received an average of 5 cycles of Platinol® plus Gemzar® in 21-day intervals. Following treatment, 41% of the women responded to treatment and one woman had a complete response of 14 months duration. The researchers concluded that the combination of Platinol® and Gemzar® demonstrated relatively high anti-cancer activity against cervical cancer.

 

Biological Therapy: Biologic therapies are naturally occurring or synthesized substances that direct, facilitate or enhance the body’s normal immune defenses. The goal of biologic therapy is to have the patient’s own immune defenses attack and destroy the cancer cells. Biologic therapies include interferons, interleukins, monoclonal antibodies and vaccines. In an attempt to improve survival rates, these and other agents are being tested alone or in combination with chemotherapy in clinical trials.

 

Cervical Cancer Screening/Prevention

 

Information about the prevention of cancer and the science of screening appropriate individuals at high-risk of developing cancer is gaining interest. Physicians and individuals alike recognize that the best “treatment” of cancer is preventing its occurrence in the first place or detecting it early when it may be most treatable. Each year in the United States, there are an estimated 12,000 new cases of cervical cancer and 4,000 deaths due to the disease.1 Widespread use of a screening test called the Pap smear has led to a decline in the number of deaths resulting from cervical cancer. Continued progress and education about screening may allow for earlier detection and higher cure rates.

 

The chance of an individual developing cancer depends on both genetic and non-genetic factors. A genetic factor is an inherited, unchangeable trait, while a non-genetic factor is a variable in a person´s environment, which can often be changed. Non-genetic factors may include diet, exercise, or exposure to other substances present in our surroundings. These non-genetic factors are often referred to as environmental factors. Some non-genetic factors play a role in facilitating the process of healthy cells turning cancerous (i.e. the correlation between smoking and lung cancer) while other cancers have no known environmental correlation but are known to have a genetic predisposition. A genetic predisposition means that a person may be at higher risk for a certain cancer if a family member has that type of cancer.

 

Precancerous Changes to the Cervix

 

A range of cervical abnormalities can be detected by screening. In some cases, the changes to the cervix are minimal or of uncertain significance. These cases may be managed with repeated screening, HPV testing, or colposcopy. In other cases, the changes are suggestive of potentially important precancerous or cancerous lesions. These cases are often further evaluated by colposcopy and, depending on the findings, may warrant treatment.

 

Many cervical abnormalities involve the squamous cells of the cervix and are referred to as cervical intraepithelial neoplasia (CIN). Depending on the extent of the changes, CIN is classified on a scale of 1 to 3. CIN 1 is considered “low-grade;” the condition requires follow-up but may not require treatment. CIN 2 and CIN 3, in contrast, are considered “high-grade” changes that typically require treatment. The goal of treatment is to prevent the development of invasive cervical cancer.

 

Cervical abnormalities may also involve the glandular cells of the cervix. Adenocarcinoma in situ (AIS) is a cervical cancer precursor that arises in glandular cells and generally requires treatment.

 

A variety of factors ultimately influence a patient’s decision to receive treatment. The purpose of receiving treatment may be to improve symptoms through local control of the condition, increase a patient’s chance of cure, or prolong a patient’s survival. In the case of precancerous changes to the cervix, the primary goal of treatment is to prevent invasive cervical cancer. The potential benefits of receiving treatment must be carefully balanced with the potential risks of receiving treatment.

 

The following is a general overview of the treatment of precancerous changes to the cervix. Circumstances unique to your situation and prognostic factors of your condition may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating physician.

 

Conservative Surgery for Precancerous Cervical Disease

 

Surgical procedures that preserve the uterus and may permit future childbearing include cryosurgery (freezing), laser surgery, loop electrosurgical excision procedure (LEEP) or cold-knife conization. Cryosurgery, laser surgery, and LEEP can be performed in the doctor’s office or short procedure facility, often with local anesthesia. A cold-knife conization is a more extensive operation that involves removal of part of the cervix under general anesthesia. Not all patients can be adequately treated with cryosurgery, laser surgery or LEEP. This decision depends on the extent and appearance of the disease upon examination.

 

Women treated with conservative surgery require lifelong visits to their doctor to ensure that recurrence of cervical disease can be detected in the precancerous state or early while the cancer is still curable.

 

Hysterectomy

 

If the precancerous disease is more extensive or involves adenocarcinoma in situ (AIS), and the woman has completed childbearing, a total hysterectomy may be recommended.[1] During a total hysterectomy, the entire uterus (including the cervix) is removed. In addition, doctors can perform a bilateral salpingo-oophorectomy, which is the removal of the ovaries and fallopian tubes. The decision to perform a bilateral salpingo-oophorectomy depends on the woman’s age and whether the ovaries are still functioning.

 

A total hysterectomy and/or a bilateral salpingo-oophorectomy are the most extensive surgical options used for precancerous disease and require general anesthesia and a hospital stay. Women undergoing a hysterectomy may experience lower abdominal pain and difficulty with urination after the operation. After a hysterectomy, women no longer menstruate and can no longer have children.

 

Stage I Cervical Cancer

 

Stage I cancer of the cervix is commonly detected from an abnormal Pap smear or pelvic examination. Following a staging evaluation, a stage I cancer is said to exist if the cancer is confined to the cervix. Stage I cervical cancer is curable for the majority of patients if surgery, radiation, and chemotherapy are appropriately used.

 

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

 

The following is a general overview of the treatment of stage I cervical cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

 

Patients diagnosed with stage I cervical cancer are divided into two groups. Patients with cancer that is visible only under the microscope have stage IA cancer. These patients are most often treated with surgery. Patients with larger cancers that can be seen or felt on examination have stage IB cancer. Patients with stage IB cervical cancer have historically been treated with multiple treatment modalities including surgery, radiation and chemotherapy.

 

Stage IA Cervical Cancer

 

Treatment of stage IA cervical cancer typically consists of surgical removal of the cancer. This can be accomplished with a hysterectomy or a conization procedure. A simple hysterectomy involves surgical removal of the uterus, including the cervix and a small amount of surrounding normal tissue. This can be performed through a low abdominal incision (below the belly button and above the pelvic bone) or through the vagina, which avoids an abdominal incision. A simple hysterectomy is very effective therapy for most stage IA cervical cancers.

 

Women with stage IA cervical cancer who wish to have children in the future may elect to undergo a procedure called a conization. In a conization procedure, the surgeon removes only a portion of the cervix in the operating room. If the cancer is completely removed, no additional surgery is necessary. If cancer is detected at the edge of the removed specimen, a complete hysterectomy is required. To learn more about surgical treatment and its side effects, go to Surgical Management of Cervical Cancer.

 

Some patients do not want to or cannot undergo an operation such as a hysterectomy because of co-existing medical conditions. For these patients, radiation therapy can be used to treat the cancer. The possible complications and the relative inconvenience usually determine whether surgery or radiation is the most appropriate treatment. For example, surgery is a one-time procedure, whereas external beam radiation therapy requires 3-6 weeks of daily treatments and implant radiation may require additional hospitalization time.

 

Implant radiation is a procedure that is performed in the operating room and involves the placement of radioactive material or seeds in or near the cancer. This process may be repeated depending on the necessary radiation dose. Radiation therapy appears to be as effective as surgery in curing stage IA cervical cancer. To learn more about radiation therapy and its side effects, go to Radiation Therapy for Cervical Cancer.

 

Approximately 95% of patients with stage IA cervical cancer survive without evidence of cancer recurrence 10 years after surgery or radiation therapy. Less than 5% of patients with stage IA cervical cancer experience recurrence.

 

Stage IB Cancer of the Cervix

 

Small stage IB cervical cancers can be successfully cured with hysterectomy or radiation therapy in approximately 90% of patients. Bulky stage IB cancers (greater than 4 centimeters in size) are only cured in 70-75% of patients when surgery or radiation therapy is administered alone. Bulky stage IB cancers are best treated with combined modality therapy using radiation, surgery and chemotherapy.

 

Before a hysterectomy is performed in a patient suspected of having a stage IB cancer, the doctor will often remove the lymph nodes in the pelvis to see if they contain cancer. This is called a pelvic lymph node dissection. If the lymph nodes contain cancer, the surgeon will not usually proceed with a hysterectomy because treatment over a larger area is necessary to destroy all the cancer cells. Radiation therapy and chemotherapy are generally recommended.

 

Even with surgical removal of all visible cancer, 10% of patients with small stage IB and 30-40% of patients with bulky stage IB cancers will experience a recurrence. This is because some patients already have small amounts of cancer that spread outside the cervix and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix are referred to as micrometastases. The presence of micrometastases or residual cancer causes the relapses that follow treatment with surgery alone.

 

In order to improve the cure rate of cervical cancer, it is important to develop strategies to cleanse the body of micrometastases and prevent recurrences. Adjuvant therapy is additional treatment that increases the effectiveness of a primary therapy. The goal of adjuvant treatment is to improve the chance of a cure, prevent cancer from recurring and/or to improve the duration of overall survival. Adjuvant therapy may consist of radiation, chemotherapy or other treatments. The role of adjuvant treatment for small stage IB cancers is not clear; however, patients with bulky stage IB cancers have improved survival if treated with adjuvant therapy.

 

A clinical study conducted by the Gynecologic Oncology Group demonstrated a reduction in cancer recurrence when radiation therapy was used after radical hysterectomy for patients with high-risk stage IB cancer of the cervix. Patients treated with external beam radiation therapy to the pelvis were directly compared with a group of patients who received no radiation therapy. The results indicated that patients treated with adjuvant radiation therapy after surgery experienced a cancer recurrence rate of 12%, compared to 21% in patients treated with surgery alone. The addition of adjuvant radiation therapy reduced the chance of cancer recurrence by almost 50% in this study.

 

Adjuvant therapy can also consist of combined treatment with external beam radiation therapy and chemotherapy. Patients with cancer cells in the pelvic lymph nodes or cancer at the edge of the surgical specimen may additionally benefit from treatment with combined radiation therapy and chemotherapy. Several chemotherapy drugs such as Platinol® and 5-fluorouracil have the ability to kill cancer cells directly and increase the effectiveness of radiation therapy in killing cancer cells.

 

In April of 1999, the New England Journal of Medicine published the results of a clinical study that compared adjuvant treatment with radiation only to treatment with radiation and concurrently administered Platinol® chemotherapy following surgical hysterectomy in patients with high-risk stage IB cancers. Patients treated with chemotherapy and radiation after surgery were more likely to survive without cancer recurrence. At 3 years from treatment, 80% of patients receiving combined radiation and chemotherapy were alive without recurrence, compared to only 63% of patients treated with radiation alone. Currently, the combination of surgery, radiation and Platinol® chemotherapy appears to produce the best results for treatment of patients with high-risk stage IB cervical cancer.

 

Strategies to Improve Treatment

 

The progress that has been made in the treatment of cervical cancer has resulted from improved development of treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of stage I cervical cancer.

 

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed.

 

Preservation of Reproductive Function: Generally, women who receive treatment for stage I cervical cancer have an excellent prognosis, with a cure rate of greater than 90% following a hysterectomy. However, some women of childbearing age would prefer a therapy that preserves their reproductive function. One procedure for preserving reproduction function is a radical trachelectomy, which only removes a portion of the uterus. In a recent clinical study, 32 patients with stage I cervical cancer measuring 2cm or less treated with radical trachelectomy experienced a 2-year survival rate of 95%, without any relapse of the cancer. Approximately 40% of women were able to conceive after treatment.

 

New Adjuvant Chemotherapy Regimens: Platinol® chemotherapy administered concurrently with radiation improves the survival of women with stage IB bulky cervical cancer. Evaluation of new chemotherapy drugs in addition to or in place of Platinol® that can kill cancer cells more effectively are now being tested as adjuvant therapies.

 

In one study, Ellence® was found to be an effective drug for the adjuvant treatment of cervical cancer when combined with radiation therapy. Ellence® was evaluated in 220 patients with bulky stage I-III cervical cancer receiving radiation therapy. The results indicated that 15% of patients treated with a combination of Ellence® and radiation relapsed, compared to 30% of patients treated with radiation therapy alone. Overall survival was 80% for patients treated with Ellence® and radiation therapy, compared to 70% for patients treated with radiation alone. The primary benefit of Ellence® was the prevention of distant relapses. Further improvements might result from combining Ellence® with Platinol® or other chemotherapy agents.

 

Neoadjuvant Therapy: The practice of administering treatment before surgery is referred to as neoadjuvant therapy. In theory, neoadjuvant chemotherapy can decrease the size of the cancer, making it easier to remove with surgery. With the development of new chemotherapy regimens and radiation therapy, clinical trials of neoadjuvant therapy performed in patients with cervical cancer are currently ongoing.

 

The use of radiation prior to a simple hysterectomy is being evaluated in clinical trials for patients with larger stage IB cervical cancers. This combination of treatment appears to reduce the chance of a cancer recurrence in the area of the cancer by removing cancer cells that may have survived through the radiation therapy.

 

Newer Radiation Techniques: External beam radiation therapy can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum.

 

Biological Therapy: Biologic therapies are naturally occurring or synthesized substances that direct, facilitate, or enhance your body’s normal immune defenses. The goal is to have the patient’s own immune defenses attack and destroy the cancer cells. Biologic therapies include interferons, interleukins, monoclonal antibodies and vaccines. In an attempt to improve the chance of cure, biologic therapies are being tested alone or in combination with chemotherapy in clinical trials.

 

Stage II Cervical Cancer

 

Cervical cancer diagnosed as stage II disease is commonly detected from an abnormal Pap smear or pelvic examination. Following a staging evaluation of cervical cancer, a stage II cancer is said to exist if the cancer has extended beyond the cervix to the upper portion of the vagina (stage IIA) or to the tissues next to the cervix, called the parametria (stage IIB). Patients with stage II cervical cancer are generally treated with a combination of radiation therapy and chemotherapy. Some patients with stage IIA disease can undergo a radical hysterectomy, sometimes followed by a course of radiation therapy.

 

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

 

The following is a general overview of the treatment of stage II cervical cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

 

Stage II cervical cancer is currently best managed by a combination of radiation therapy and chemotherapy. Radiation therapy is treatment with high energy x-rays that have the ability to kill cancer cells. Radiation therapy can be administered via a machine that aims x-rays at the body (external beam radiation) and/or by placing small capsules of radioactive material directly into and near the cervix (internal or implant radiation). Most patients will receive both types of radiation therapy during their course of treatment. External beam radiation therapy (EBRT) for cervical cancer is administered on an outpatient basis for approximately 4 to 6 weeks.

 

During or immediately following the external beam portion of radiation therapy, patients may also undergo an implant radiation procedure. Placing the radiation within the cervix allows a high dose of radiation to be delivered to the cancer, while reducing the radiation to the surrounding normal tissues and organs. During a procedure in the operating room, a small device is placed into the cervix and vagina and later is “loaded” with radioactive material. The radioactive material is left in place while the patient stays in the hospital for 1-3 days. This process may be performed once or twice during the course of treatment.

 

Prior to the 1990s, the standard treatment of stage II cervical cancer had utilized external beam and internal radiation therapy and no significant progress in the treatment of cervical cancer occurred for many years. Approximately 60% of patients with stage II cervical cancer survived 5 years from treatment with radiation therapy alone. More recently, however, the addition of chemotherapy (anti-cancer drugs) has improved long-term outcomes in patients with this disease.

 

Chemotherapy, such as Platinol®, 5-fluorouracil and other drugs, has the ability to kill cancer cells and make radiation therapy more effective at killing cancer cells. The strategy of administering chemotherapy concurrently with radiation treatment is appealing because chemotherapy and radiation therapy may act together to increase the killing of cancer cells. Chemotherapy may also destroy cells independently of radiation therapy. Several clinical studies performed in patients with locally advanced cervical cancer utilizing concurrent chemotherapy and radiation therapy have suggested that this strategy may improve remission rates and prolong survival. In order to definitively determine whether radiation therapy administered with concurrent chemotherapy is superior to radiation therapy alone, several clinical studies were designed to directly compare the two treatments in patients with locally advanced cervical cancer.

 

One recent pivotal clinical trial conducted by various oncology groups in the United States has shown that radiation therapy combined with chemotherapy for locally advanced cervical cancer is superior to treatment with radiation therapy alone. In this study, 403 patients were treated with radiation therapy alone or radiation therapy plus concomitant 5-fluorouracil and Platinol® chemotherapy. The 5-year survival rate of patients with stage IB, IIA, or IIB cervical cancer was 77% for patients treated with concurrent radiation therapy and chemotherapy, compared to only 50% for patients treated with radiation therapy alone. Concurrent chemotherapy and radiation therapy were well tolerated except for minor gastrointestinal and hematologic side effects, which were reversible.

 

In summary, the combination Platinol® chemotherapy administered concurrently with radiation produces superior overall survival and a decreased risk of cancer recurrence compared to treatment with radiation therapy alone. Continued research is ongoing to determine whether additional chemotherapy drugs or doses of radiation may improve the outcome of patients with locally advanced cervical cancer. At least four other clinical studies have confirmed that treatment of locally advanced cervical cancer with concurrent Platinol®-based chemotherapy and radiation therapy is superior to radiation therapy alone.

 

Even with combination chemotherapy and radiation treatment, approximately 20-40% of patients with stage II cervical cancer experience recurrence of their cancer. In some patients, cancer cells may have survived near the cancer despite the radiation therapy. Other patients with stage II disease already have small amounts of cancer that have spread outside the cervix and were not treated by the chemotherapy. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix gland are referred to as micrometastases. The presence of these microscopic areas of cancer or surviving cancer cells can cause the relapses that follow treatment.

 

Strategies to Improve Treatment

 

The progress that has been made in the treatment of cervical cancer has resulted from improved development of treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of stage II cervical cancer.

 

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed.

 

New Adjuvant Chemotherapy Regimens: Platinol® chemotherapy administered concurrently with radiation improves the survival of women with stage IB bulky cervical cancer. Evaluation of new chemotherapy drugs in addition to or in place of Platinol® that can kill cancer cells more effectively are now being tested as adjuvant therapies.

 

In one study, Ellence® was found to be an effective drug for the treatment of cervical cancer when combined with radiation therapy. Ellence® was evaluated in 220 patients with bulky stage I-III cervical cancer receiving radiation therapy. The results indicated that 15% of patients treated with Ellence® and radiation therapy relapsed, compared to 30% of patients treated with radiation therapy alone. Overall survival was 80% for patients treated with Ellence® and radiation therapy, compared to 70% for patients treated with radiation alone. The primary benefit of Ellence® was the prevention of distant relapses. Further improvements might result from combining Ellence® with Platinol® or chemotherapy agents.

 

Biological Therapy: Biologic therapies are naturally occurring or synthesized substances that direct, facilitate or enhance the body’s normal immune defenses. The goal of biologic therapies is to have the patient’s own immune defenses attack and destroy the cancer cells. Biologic therapies include interferons, interleukins, monoclonal antibodies and vaccines. In an attempt to improve survival rates, these and other agents are being tested alone or in combination with chemotherapy in clinical trials.

 

Newer Radiation Techniques: External beam radiation therapy can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum.

 

Newer Imaging Techniques: The ability of current imaging technology to detect small areas of cancer within and around the cervix and elsewhere in the body is limited. Magnetic resonance imaging, or MRI, provides better images of the cervix and locates growths of cancer in the pelvis. The MRI can be used to guide radiation therapy.

 

Stage III Cervical Cancer

 

Cervical cancer diagnosed as stage III disease is commonly detected from an abnormal Pap smear or pelvic examination or from symptoms caused by the cancer. Following a staging evaluation, a stage III cancer is said to exist if the cancer has extended beyond the cervix to the lower portion of the vagina (stage IIIA), has extended to one or both sides of the pelvis (stage IIIB), or causes a blockage of drainage from the kidneys (stage IIIB). Patients with stage III cervical cancer are generally treated with radiation therapy and chemotherapy.

 

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

 

The following is a general overview of the treatment of stage III cervical cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

 

Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.

 

Stage III cervical cancer is currently best managed by a combination of radiation therapy and chemotherapy. Radiation therapy is treatment with high energy x-rays that have the ability to kill cancer cells. Radiation therapy can be administered by a machine that aims x-rays at the body (external beam radiation) or by placing small capsules of radioactive material directly into or near the cervix (internal or implant radiation). Most patients will receive both kinds of radiation therapy during their course of treatment. External beam radiation therapy for cervical cancer is administered on an outpatient basis for approximately 4 to 6 weeks.

 

During or immediately following the external beam portion of radiation therapy, patients may also undergo an implant radiation procedure. Placing the radiation within the cervix allows a high dose of radiation to be delivered to the cancer, while reducing the radiation to the surrounding normal tissues and organs. During a procedure in the operating room, a small device is placed into the cervix and vagina and later is “loaded” with radioactive material. The radioactive material is left in place while the patient stays in the hospital for 1-3 days. This process may be performed once or twice during the course of treatment.

 

Prior to the 1990s, the standard treatment of locally advanced cervical cancer had utilized external beam and internal radiation therapy and no significant progress in the treatment of cervical cancer occurred for many years. Approximately 60% of patients with stage III cervical cancer survived 5 years from treatment with radiation therapy alone. More recently, however, the addition of chemotherapy (anti-cancer drugs) has improved long-term outcomes in patients with this disease.

 

Chemotherapy, such as Platinol®, 5-fluorouracil and other drugs, has the ability to kill cancer cells and make radiation therapy more effective at killing cancer cells. The strategy of administering chemotherapy concurrently with radiation treatment is appealing because chemotherapy and radiation therapy may act together to increase the killing of cancer cells. Chemotherapy may also destroy cells independently of radiation therapy. Several clinical studies performed in patients with locally advanced cervical cancer utilizing concurrent chemotherapy and radiation therapy have suggested that this strategy may improve remission rates and prolong survival. In order to definitively determine whether radiation therapy administered with concurrent chemotherapy is superior to radiation therapy alone, several clinical studies were designed to directly compare the two treatments in patients with locally advanced cervical cancer.

 

One recent pivotal clinical trial conducted by various oncology groups in the United States has shown that radiation therapy combined with chemotherapy for locally advanced cervical cancer is superior to treatment with radiation therapy alone. In this study, 403 patients were treated with radiation therapy alone or radiation therapy plus concomitant 5-fluorouracil and Platinol® chemotherapy. Patients with stage III or IVA cervical cancer experienced a 5-year survival rate of 63% compared to 57% for patients treated with radiation therapy alone. The chance of cancer recurrence was 42% for patients treated with chemotherapy and radiation therapy compared to 62% for those treated with radiation therapy alone. Concurrent chemotherapy and radiation therapy were well tolerated except for minor gastrointestinal and hematologic side effects, which were reversible.

 

In summary, the combination Platinol® chemotherapy administered concurrently with radiation produces superior overall survival and a decreased risk of cancer recurrence compared to treatment with radiation therapy alone. Continued research is ongoing to determine whether additional chemotherapy drugs or doses of radiation may improve the outcome of patients with locally advanced cervical cancer. At least four other clinical studies have confirmed that treatment of locally advanced cervical cancer with concurrent Platinol®-based chemotherapy and radiation therapy is superior to radiation therapy alone.

 

Even with combination chemotherapy and radiation treatment, approximately 20-40% of patients with stage III cervical cancer experience recurrence of their cancer. In some patients, cancer cells may have survived near the cancer despite the radiation therapy. Other patients with stage III cervical cancer already have small amounts of cancer that have spread outside the cervix and were not treated by the chemotherapy. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix gland are referred to as micrometastases. The presence of these microscopic areas of cancer or surviving cancer cells can cause the relapses that follow treatment.

 

Strategies to Improve Treatment

 

The progress that has been made in the treatment of cervical cancer has resulted from improved development of treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of stage III cervical cancer.

 

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed.

 

New Adjuvant Chemotherapy Regimens: Platinol® chemotherapy administered concurrently with radiation improves the survival of women with stage IB bulky cervical cancer. Evaluation of new chemotherapy drugs in addition to or in place of Platinol® that can kill cancer cells more effectively are now being tested as adjuvant therapies.

 

In one study, Ellence® was found to be an effective drug for the treatment of cervical cancer when combined with radiation therapy. Ellence® was evaluated in 220 patients with bulky stage I-III cervical cancer receiving radiation therapy. The results indicated that 15% of patients treated with Ellence® and radiation therapy relapsed, compared to 30% of patients treated with radiation therapy alone. Overall survival was 80% for patients treated with Ellence® and radiation therapy, compared to 70% for patients treated with radiation alone. The primary benefit of Ellence® was the prevention of distant relapses. Further improvements might result from combining Ellence® with Platinol® or chemotherapy agents.

 

Biological Therapy: Biologic therapies are naturally occurring or synthesized substances that direct, facilitate or enhance the body’s normal immune defenses. The goal of biologic therapy is to have the patient’s own immune defenses attack and destroy the cancer cells. Biologic therapies include interferons, interleukins, monoclonal antibodies and vaccines. In an attempt to improve survival rates, these and other agents are being tested alone or in combination with chemotherapy in clinical trials.

 

Newer Radiation Techniques: External beam radiation therapy can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum.

 

Newer Imaging Techniques: The ability of current imaging technology to detect small areas of cancer within and around the cervix and elsewhere in the body is limited. Magnetic resonance imaging, or MRI, provides better images of the cervix and locates growths of cancer in the pelvis. The MRI can be used to guide radiation therapy.

 

Stage IV Cervical Cancer

 

Cervical cancer diagnosed as stage IV disease is commonly detected from an abnormal pelvic examination or symptoms produced by the patient’s cancer. Following a staging evaluation of cervical cancer, a stage IV cancer is said to exist if the cancer has extended beyond the cervix into adjacent organs, such as the rectum or bladder (stage IVA), or the cancer has spread to distant locations in the body which may include the bones, lungs or liver (stage IVB). Cervical cancer diagnosed in this stage is often difficult to treat, and a small minority of patients are cured of disease.

 

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

 

The following is a general overview of the treatment of stage IV cervical cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

 

Patients diagnosed with stage IV cervical cancer can be broadly divided into two groups. Patients with disease that is locally confined, but involves adjacent organs in the pelvis, such as the rectum and bladder, have localized stage IVA cervical cancer. Other patients have disease that has spread to distant organs, most commonly the bones, lungs or liver, and have metastatic stage IVB cervical cancer. Management of patients with metastatic stage IVB disease is aimed at control of symptoms and pain. After undergoing treatment for cervical cancer, your doctor will continue to follow you to check to see that the cancer has not returned or is not progressing.

 

Treatment of Localized Stage IVA Cervical Cancer

 

Stage IVA cervical cancer is currently best managed by a combination of radiation therapy and chemotherapy. Radiation therapy is treatment with high energy x-rays that have the ability to kill cancer cells. Radiation therapy can be administered by a machine that aims x-rays at the body (external beam radiation) or by placing small capsules of radioactive material directly near the cervix (internal or implant radiation). Most patients will receive both kinds of radiation therapy during their course of treatment. External beam radiation therapy for cervical cancer is administered on an outpatient basis for approximately 4 to 6 weeks.

 

During or immediately following the external beam portion of radiation therapy, patients may also undergo an implant radiation procedure. Placing the radiation within the cervix allows a high dose of radiation to be delivered to the cancer while reducing the radiation to the surrounding normal tissues and organs. During a procedure in the operating room, a small device is placed into the cervix and vagina and later is “loaded” with radioactive material. The radioactive material is left in place while the patient stays in the hospital for 1-3 days. This process may be performed once or twice during the course of treatment.

 

Prior to the 1990s, the standard treatment of locally advanced cervical cancer had utilized external beam and internal radiation therapy and no significant progress in the treatment of cervical cancer occurred for many years. More recently, however, the addition of chemotherapy (anti-cancer drugs) has improved long-term outcomes in patients with this disease.

 

Chemotherapy, such as Platinol®, 5-fluorouracil and other drugs, has the ability to kill cancer cells and make radiation therapy more effective at killing cancer cells. The strategy of administering chemotherapy concurrently with radiation treatment is appealing because chemotherapy and radiation therapy may act together to increase the killing of cancer cells. Chemotherapy may also destroy cells independently of radiation therapy. Several clinical studies performed in patients with locally advanced cervical cancer utilizing concurrent chemotherapy and radiation therapy have suggested that this strategy may improve remission rates and prolong survival. In order to definitively determine whether radiation therapy administered with concurrent chemotherapy is superior to radiation therapy alone, several clinical studies were designed to directly compare the two treatments in patients with locally advanced cervical cancer.

 

One recent pivotal clinical trial conducted by various oncology groups in the United States has shown that radiation therapy combined with chemotherapy for locally advanced cervical cancer is superior to treatment with radiation therapy alone. In this study, 403 patients were treated with radiation therapy alone or radiation therapy plus concomitant 5-fluorouracil and Platinol® chemotherapy. Patients with stage III or IVA cervical cancer experienced a 5-year survival rate of 63% compared to 57% for patients treated with radiation therapy alone. The chance of cancer recurrence was 42% for patients treated with chemotherapy and radiation therapy compared to 62% for those treated with radiation therapy alone. Concurrent chemotherapy and radiation therapy were well tolerated except for minor gastrointestinal and hematologic side effects, which were reversible.

 

In summary, the combination Platinol® chemotherapy administered concurrently with radiation produces superior overall survival and a decreased risk of cancer recurrence compared to treatment with radiation therapy alone. Continued research is ongoing to determine whether additional chemotherapy drugs or doses of radiation may improve the outcome of patients with locally advanced cervical cancer. At least four other clinical studies have confirmed that treatment of locally advanced cervical cancer with concurrent Platinol®-based chemotherapy and radiation therapy is superior to radiation therapy alone.

 

Even with combination chemotherapy and radiation treatment, approximately 20-40% of patients with stage IV cervical cancer experience recurrence of their cancer. In some patients, cancer cells may have survived near the cancer despite the radiation therapy. Other patients with stage IV disease already have small amounts of cancer that have spread outside the cervix and were not treated by the chemotherapy. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix gland are referred to as micrometastases. The presence of these microscopic areas of cancer or surviving cancer cells can cause the relapses that follow treatment.

 

Treatment of Metastatic Stage IVB Cervical Cancer

 

Cervical cancer that has spread to distant organs and bones is difficult to treat. Historically, patients with metastatic cervical cancer have been considered incurable and rarely survive more than a year or two. Some patients are offered treatment with chemotherapy for the purpose of prolonging their duration of survival and alleviating symptoms from progressive cancer. Other patients are managed with efforts to reduce pain or bleeding, including local radiation therapy to affected parts of the body.

 

There is no good single chemotherapy approach that can improve the length of survival in patients with metastatic cervical cancer. Treatment with Platinol® can produce shrinkage in 15-25% of patients with metastatic cervical cancer. Many clinical trials have combined Platinol® with other chemotherapy drugs in hopes of improving cancer shrinkage and survival. Although these combination regimens can have more side effects, length of survival has not been improved over Platinol® alone. Unfortunately, these chemotherapies typically work for only a few months before the cervical cancer begins to grow again. Most patients still succumb to cancer and better treatment strategies are clearly needed.

 

Strategies to Improve Treatment

 

The progress that has been made in the treatment of cervical cancer has resulted from development of better treatments in patients with more advanced stages of cancer and participation in clinical trials. While some progress has been made in the treatment of metastatic cervical cancer, the majority of patients still succumb to cancer and better treatment strategies are clearly needed. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of cervical cancer.

 

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed.

 

New Chemotherapy Regimens: Several newer chemotherapeutic drugs have demonstrated ability to kill cervical cancer cells in patients with advanced cancer. One area of active investigation is the development and exploration of single or multi-agent chemotherapy regimens as a treatment approach for patients with widespread cervical cancer. In particular, drugs such as paclitaxel, ifosfamide, Taxotere®, Navelbine® and Camptosar® appear to have promising activity against cervical cancer cells and are being tested alone or in combination with radiation and other anticancer agents in clinical trials.

 

Newer Radiation Techniques: External beam radiation therapy can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum.

 

Biological Therapy: Biologic therapies are naturally occurring or synthesized substances that direct, facilitate or enhance the body’s normal immune defenses. The goal of biologic therapy is to have the patient’s own immune defenses attack and destroy the cancer cells. Biologic therapies include interferons, interleukins, monoclonal antibodies and vaccines. In an attempt to improve survival rates, these and other agents are being tested alone or in combination with chemotherapy in clinical trials.

 

Surgery for Cervical Cancer

 

Surgery is a local therapy to remove precancerous tissue or cancer in or near the cervix. A surgeon who specializes in treatment of disorders of the female reproductive tract is known as a gynecologist. Some gynecologists have special training in treatment of cancers of the female reproductive tract, and are known as gynecologic oncologists. Gynecologic oncologists have developed expertise in performing surgical treatment of cancer of the cervix.

 

Cervical Biopsy

 

If a pelvic examination or Pap smear result suggests that cervical cancer may be present, the patient will need to have a biopsy. A biopsy is the only way to know for sure whether a patient has cancer. During a biopsy, an instrument is used to remove small pieces of cervical tissue. The pieces of cervical tissue are then examined under the microscope to determine whether cancer cells are present. A cervical biopsy can be performed in the office using a special microscope called a colposcope, or occasionally in the operating room during a more thorough examination while the patient is asleep.

 

Conservative Surgery for Precancerous Cervical Disease

 

Surgery is a standard treatment of precancerous cervical disease. The type of operation used to remove the precancerous disease depends on how abnormal the cells appear to be under the microscope, the patient’s general medical condition and whether the patient wishes to have children in the future. A number of surgical procedures are effective in treating precancerous cervical disease. Most procedures do not involve removal of the uterus and can permit future childbearing if desired by the patient.

 

Surgical procedures that preserve the uterus and may permit future childbearing include cryosurgery (freezing), laser surgery, loop electrosurgical excision procedure (LEEP) or cold-knife conization. Cryosurgery, laser surgery and LEEP can be performed in the doctor’s office or outpatient short procedure center, often with local anesthesia. A cold-knife conization is a more extensive operation that involves removal of part of the cervix under general anesthesia. Not all patients can be adequately treated with cryosurgery, laser surgery or LEEP. This decision depends on the extent and appearance of the disease on examination.

 

Women who undergo one of these surgical procedures may experience cramping or pain in the pelvis, infection, bleeding or watery discharge. Watery discharge can persist for several weeks following cryosurgery. Women who undergo a cold-knife conization may have difficulty with cervical function during a future pregnancy.

 

Even with surgical treatment of precancerous cervical disease, some patients may experience recurrence of precancerous disease or invasive cancer. Treatment of stage 0 cervical cancer with cryosurgery, laser surgery or LEEP cures 85-90% of women. Approximately 10-15% may experience a recurrence of precancerous cervical disease and approximately 2% will develop invasive cancer following treatment with these procedures. Women treated with conservative surgery require lifelong visits to their doctor to ensure that recurrence of cervical disease can be detected in the precancerous state or early while the cancer is still curable.

 

Simple Hysterectomy

 

A hysterectomy is a common treatment of stage I cancer and precancerous disease of the cervix. The type of hysterectomy used to remove the cervical cancer depends upon the extent of the cancer.

 

If the precancerous disease is more extensive and the patient desires no further children, a simple hysterectomy can be performed. During a simple hysterectomy, the entire uterus, including the cervix with the precancerous disease and an area of normal tissue around it, is removed through a low abdominal incision or the vagina. A simple hysterectomy is very effective therapy if the cancer has not invaded beyond the surface cell layer of the cervix. In addition, doctors can perform a bilateral salpingo-oophorectomy, which is the removal of the ovaries and fallopian tubes. The decision to perform a bilateral salpingo-oophorectomy depends on the woman’s age and whether the ovaries are still functioning.

 

A simple hysterectomy and/or a bilateral salpingo-oophorectomy are the most extensive surgical options used for precancerous disease and require general anesthesia and a hospital stay. Women undergoing a hysterectomy may experience lower abdominal pain and difficulty with urination after the operation. After a hysterectomy, women no longer menstruate and can no longer have children.

 

Radical Hysterectomy

 

A radical hysterectomy is more extensive surgery that involves the removal of the entire uterus, including the cervix, with the cancer and an area of normal tissue through a low abdominal incision. This area of normal tissue also includes a portion of the upper vagina and may result in vaginal shortening after the operation, but rarely causes sexual problems. As with a simple hysterectomy, doctors might opt to perform a bilateral salpingo-oophorectomy, which is the removal of the ovaries and fallopian tubes. The decision to perform a bilateral salpingo-oophorectomy depends on the woman’s age and whether the ovaries are still functioning.

 

Women undergoing a radical hysterectomy may experience lower abdominal incisional pain, bleeding or infection after the operation. In addition, some women may experience difficulty with urination or problems with bladder control. Less commonly, some women may have injury to the rectum, ureters (tubes that drain the kidneys) or bladder. One type of injury may be in the form of a “fistula” or abnormal connection to the vagina. After a hysterectomy, women no longer menstruate and can no longer have children. With radical hysterectomy and pelvic lymph node dissection alone or, more commonly, when it is combined with radiation therapy, women are at higher risk for bowel complications and chronic swelling in the legs, known as lymphedema. In-hospital death occurs after radical hysterectomy in less than 1% of cases.

 

Hysterectomy and Pelvic Lymph Node Dissection

 

A radical hysterectomy is most effective if the exploration during surgery shows that the cancer has not spread beyond the cervix. Some patients will have cancer that has spread outside the cervix into the lymph nodes in the pelvis. Before performing a hysterectomy, the doctor will sometimes perform a pelvic lymph node dissection, which is surgery to remove lymph nodes to see if they contain cancer. If the lymph nodes contain cancer, usually the surgeon will not proceed with a radical hysterectomy. Another form of treatment, usually radiation therapy and chemotherapy, is generally recommended.

 

Even after surgical removal of cervical cancer, some patients may experience recurrence of their cancer. Cancer recurrence occurs more commonly with bulky stage IB or stage II cervical cancer. It is important to realize that some patients with cervical cancer already have small amounts of cancer that have spread outside the cervix and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix are referred to as micrometastases. The presence of these micrometastases causes recurrence following the initial treatment. External beam radiation therapy with or without implant radiation and chemotherapy are often recommended to cleanse the body of micrometastases in order to improve the cure rate achieved with surgical removal of the cancer.

 

Retroperitoneal Lymph Node Dissection and Scalene Lymph Node Biopsy

 

Patients who cannot undergo surgery to remove the cancer or who have advanced stage cervical cancers will often receive radiation therapy usually combined with chemotherapy. Before radiation therapy is delivered, it is helpful to know if the lymph nodes in the abdomen and pelvis have small deposits of cancer in them. This is determined by an operation called a retroperitoneal lymph node dissection. During this operation, a small incision is made in the middle abdomen and the surgeon removes the lymph nodes, which lie behind the abdominal contents. Most patients are able to leave the hospital after a day or two and begin treatment with radiation therapy shortly afterwards. If the sampled lymph nodes contain cancer, the radiation oncologist may modify treatment to include these areas of microscopic disease.

 

Some patients have advanced cervical cancer when they are diagnosed. In these patients, it is important to know whether disease has spread outside the pelvis to distant parts of the body. One method is to perform a small operation to dissect the lymph nodes at the base of the left neck. This operation is called a scalene lymph node biopsy, and can be performed on an outpatient basis. Subsequent treatment may depend on the results of this biopsy.

 

Strategies to Improve Treatment

 

The progress that has been made in the treatment of cervical cancer has resulted from improved development of treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently there are several areas of active exploration aimed at improving the treatment of cervical cancer.

 

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed.

 

Preservation of Reproductive Function: Generally, women who receive treatment for stage I cervical cancer have an excellent prognosis, with a cure rate of greater than 90% following a hysterectomy. However, some women of childbearing age would prefer a therapy that preserves their reproductive function. One such procedure for preserving reproduction function is a radical trachelectomy, which only removes a portion of the uterus. In a recent clinical study, 32 patients with stage I cervical cancer measuring 2cm or less who were treated with radical trachelectomy experienced a 2-year survival rate of 95%, without any relapse of the cancer. Approximately 40% of women were able to conceive after treatment.

 

Ovarian Transplantation Into Forearm: A new procedure that involves the permanent placement of a section (cortical strip) from a patient’s ovaries into her forearm may preserve fertility and normal ovarian function in pre-menopausal women who are treated with radiation to the pelvic area or undergo the removal of their ovaries.

 

Researchers evaluated the surgical procedure in two women, a 35-year-old with advanced cervical cancer who was to undergo pelvic radiation and a 37-year-old with benign cysts on her ovaries who was to undergo an oophorectomy. Both patients had cortical strips removed from their ovaries and permanently transplanted to the forearm. The first patient received her transplant prior to radiation and the second patient received her transplant during the oophorectomy. Ten weeks following surgery, the transplant tissue in both patient’s forearms had resumed the production of ovarian hormones and the development of follicles (eggs). One patient has actually ovulated and the other patient is producing cyclical hormone levels indicative of ovulation. Besides normal hormonal function, the other end goal of this procedure is to be able to harvest eggs from the transplanted ovarian strips so that pre-menopausal patients having to undergo treatment that normally causes sterility can bear children.

 

Radiation Therapy for Cervical Cancer

 

Radiation therapy, or radiotherapy, is a common way to treat cervical cancer. Doctors who specialize in treating cancers with radiation are known as radiation oncologists. During radiation therapy, high-energy x-rays are used to kill cancer cells. Radiation therapy can be administered by a machine that aims x-rays at the body (external beam radiation) or by placing small capsules of radioactive material directly into the cervix (internal or implant radiation or brachytherapy). Many patients receive both kinds of radiation therapy. In stage I cervical cancer, radiation therapy may be used instead of surgery, or it may be used after surgery to destroy remaining cancer cells. In stage IB-IVA cervical cancer, radiation therapy is administered concurrently with chemotherapy.

 

External Beam Radiation Therapy

 

External beam radiation therapy (EBRT) for cervical cancer is administered on an outpatient basis, 5 days a week for several weeks. EBRT begins with a planning session, or simulation, where marks are placed on the body and measurements are taken in order to line up the radiation beam in the correct position for each treatment. A program of daily treatments is then begun where the patient lies on a couch and is treated with radiation from multiple directions to the pelvis. External beam radiation therapy for cervical cancer is administered on an outpatient basis for approximately 4 to 6 weeks.

 

A combination of external beam radiation therapy and implant radiation is used to increase the dose of radiation administered to the cancer. Implant or internal radiation is further described in the section below. When these two methods are combined, the external beam radiation therapy is given for 4-6 weeks, and the final “boost” of radiation to the cervix is given with the implant radiation.

 

Although patients do not feel anything while receiving radiation treatment, the effects of radiation gradually build up over time. Many patients become tired as treatment continues. It is also common for patients to experience loose stools or diarrhea. Urination may become more frequent or uncomfortable. Some patients may experience loss of pubic hair or irritation of the skin. After the radiation therapy is completed, the vagina can become narrower and less flexible. This can make sexual relations painful and make future pelvic examinations difficult. Patients are often taught how to use a dilator to maintain the pliability of the vagina. Finally, radiation therapy to the pelvis can stop the ovaries from functioning, thereby causing younger women to enter menopause early.

 

Implant Radiation Therapy

 

Implant radiation, sometimes referred to as brachytherapy, refers to treatment where radioactive material is placed directly into the cervix. Placing the radiation in this manner allows a high radiation dose to be delivered directly to the cancer, while reducing radiation to surrounding normal organs, such as the rectum and bladder. During a procedure in the operating room, a small device is placed into the cervix and vagina. This device is later “loaded” with the radiation capsules while the patient is in a lead-shielded hospital room. The radioactive material is left in place for 1-3 days. This procedure may be performed once or twice during the course of treatment. The patient is discharged from the hospital once the device is removed from the cervix.

 

Many centers are administering the implant radiation on an outpatient basis using a slightly different technique called “high-dose rate (HDR) brachytherapy.” With this procedure, a device is inserted into the cervix and vagina in the radiation therapy department and the patient remains with the radiation for only 30 minutes to one hour. This procedure is generally repeated weekly, approximately 3 to 5 times during the course of treatment. HDR brachytherapy is a newer technique and is not yet widely available. The results from early experience demonstrate that HDR brachytherapy appears to be just as effective as traditional implant radiation, but avoids a hospital stay.

 

A less commonly used method of brachytherapy is interstitial (into the tissue) implant. With this method, the patient is placed under general anesthesia and fine tube like needles are placed into the cancer and immediate tissue around it in a manner to fit the shape of the cancer. The tube-like needles are later “loaded” with the radioactive seeds and the remaining steps are similar to what is done with implants.

 

In implant radiation therapy, the positioning of the device is critical to the effectiveness and safety of the treatment. Although the cervical cancer receives the highest radiation dose, the surrounding organs, such as the rectum and bladder, are also exposed to some radiation. Radiation injury to the rectum, bladder or bowel can occur and may cause pain or bleeding with urination or passage of stools. Less commonly, some patients will develop a fistula, which is an abnormal connection between the rectum or bladder and the vagina. At times, additional surgery may be necessary for repair of fistulas or other radiation injury.

 

Strategies to Improve Treatment

 

The progress that has been made in the treatment of cervical cancer has resulted from improved development of radiation treatments concurrent with chemotherapy and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving radiation treatment of cervical cancer.

 

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed.

 

Newer Radiation Techniques: EBRT can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum. Since 3D-CRT can better target the area of cancer, radiation oncologists are evaluating whether higher doses of radiation can be given safely and improve the chance of cure.

 

Newer Radiation Machines: Most EBRT uses high energy x-rays to kill cancer cells. Some radiation oncology centers use different types of radiation that require special machines to generate. These different types of radiation, such as protons or neutrons, appear to kill more cancer cells with the same dose. Combining protons or neutrons with conventional x-rays is one method of radiation therapy being evaluated in clinical trials.

 

Preservation of Ovarian Function: A new procedure that involves the permanent placement of a section (cortical strip) from a patient’s ovaries into her forearm may preserve fertility and normal ovarian function in pre-menopausal women who are treated with radiation to the pelvic area or undergo the removal of their ovaries.

 

Researchers evaluated the surgical procedure in two women, a 35-year-old with advanced cervical cancer who was to undergo pelvic radiation and a 37-year-old with benign cysts on her ovaries who was to undergo an oophorectomy. Both patients had cortical strips removed from their ovaries and permanently transplanted to the forearm. The first patient received her transplant prior to radiation and the second patient received her transplant during the oophorectomy. Ten weeks following surgery, the transplant tissue in both patient’s forearms had resumed the production of ovarian hormones and the development of follicles (eggs). One patient has actually ovulated and the other patient is producing cyclical hormone levels indicative of ovulation. Besides normal hormonal function, the other end goal of this procedure is to be able to harvest eggs from the transplanted ovarian strips so that pre-menopausal patients having to undergo treatment that normally causes sterility can bear children.

 

Women and Cancer: Cervical, Ovarian, and Uterine

 

The National Foundation for Cancer Research is spreading the word about cancers that specifically affect women. Cervical cancer, ovarian cancer and uterine cancer are three types of cancer that women in particular should be aware of and take steps towards preventing and detecting early.

 

Cervical Cancer

 

In most cases, cervical cancer is caused by the Human Papillomavirus (HPV), which is sexually transmitted. There are now two HPV vaccines, Gardasil and Cervarix, which block two strains of HPV that usually lead to cervical cancer. To activate a young girl's immune system before she is likely to encounter HPV, girls as young as 10 can get the vaccine, and it is recommended for all women age 26 and under. Getting the vaccine is a tangible, easy way to significantly decrease your chances of getting cervical cancer. Finally, women should make sure they are getting routine pap smears during their yearly checkups, as these can screen for cervical cancer.

 

Ovarian Cancer

 

It is unclear as to what usually causes ovarian cancer, but symptoms include pressure or pain in the abdomen, pelvis, back or legs; a swollen or bloated abdomen; and nausea, indigestion, diarrhea, gas or constipation. Because these symptoms are ambiguous and the cancer is deep within, ovarian cancer is difficult to detect early. Therefore, women should receive regular examinations from a physician both to detect the disease when possible and to prevent spreading to other nearby organs. A pelvic exam performed by a physician during a yearly checkup is necessary each year to determine whether or not a woman has ovarian cancer. Other possible diagnostic tests include biopsies, ultrasounds and blood tests, and NFCR recommends that women talk with their doctor to see if one might be right for you.

 

Uterine Cancer

 

Uterine cancer commonly begins in the lining of the uterus (endometrium), but its cause is uncertain as well. It is thought that an imbalance between the two main female hormones, estrogen and progesterone is a related factor. Higher levels of estrogen can cause too much growth of endometrial cells, resulting in tumors. Women at a higher risk of getting uterine cancer include those with higher levels of estrogen, such as obese women and women who take large doses of estrogen over a long period of time. A pelvic examination may indicate that a woman has uterine cancer and other tests including a biopsy or an ultrasound may be used.

 

Source: http://www.medicinenet.com