Diagnosis of Cervical Cancer

Overview of Treatment Options for Cervical Cancer

The treatment of cervical cancer depends upon the stage of the disease, the woman's age and overall condition, her desire to bear children in the future, and in the advanced stages of the disease, her goals of care (aggressive treatment versus focus on comfort).

Ablative Modalities

Ablative modalities are procedures that destroy the affected tissue and are usually recommended only for women in whom invasive cervical cancer has been ruled our through a combination of colposcopy and cytology. These methods are not known to cause any complications with sex, becoming pregnant, or giving birth.

Ablative modalities for cervical cancer include:

• Cryotherapy - this is a method of destroying abnormal cells by freezing. The procedure can be performed in the doctor's office under a local anesthetic. Some cramping may be felt during the procedure. A light vaginal discharge may be present for a few days following the procedure. Some women will require a second treatment to ensure that all abnormal tissue has been destroyed.

• Electrocautery - this method burns off abnormal cells using an electric current; this procedure may cause more discomfort than newer procedures so is less frequently used now than in the past. It is, however, an effective method for treatment of CIN 1 and CIN 2.

• Laser Vaporization - this is a method of destroying abnormal cells with a laser.

• Cold Coagulation - unlike its name suggests, this is a method of destroying abnormal cells with a heated probe.

• Diathermy/Electrofulguration - this method uses an electric current to cut away the area of abnormal cells.

Excisional Modalities

These procedures remove the affected tissue by surgical excision:

• Loop Electrocautery Excision Procedure (LEEP) This procedure entails the removal of suspicious cervical tissue with a sharp wire loop and the site is cauterized (burned) to eliminate any remaining abnormal tissue.

• Conization - In this procedure, a small scalpel or laser is used to remove a cone-shaped section of the cervix. This procedure requires general anesthesia and usually is performed as outpatient surgery in the hospital.

Chemotherapy

Chemotherapy uses toxic drugs to destroy cancer cells. Chemotherapy is administered intravenously, through injection, or in pill form. Platinum-based drugs (Cisplatin/Platinol) and fluorouracil (Adrucil; Efudex) are the most commonly used drugs for cervical cancer and are often used in combination.

Side effects of chemotherapy may include:

• Nausea and vomiting
• Hair loss
• Diarrhea
• Leukopenia - low white blood cell count which can increase susceptibility to infection
• Anemia - low red blood cell count which can cause fatigue

Neoadjuvant chemotherapy is the use of chemotherapy prior to radiation or surgery to reduce the size of the tumor which needs to be irradiated or removed. Chemotherapy administered prior to surgery may shrink inoperable tumors (such as later Stage II and Stage III tumors) sufficiently so as to make them operable, as well as treat any disease that has spread (metastasized).

As tumors increase in size, they can exceed their blood supply which leads to inadequate oxygen supply to the cells. To maximize the effectiveness of radiation therapy and chemotherapy, it is important for the area to be treated to have adequate blood and oxygen supply. This can also be affected by issues such as anemia. Therefore, interventions such as medications to stimulate the bone marrow to make red blood cells or blood transfusions may be used to increase red blood cell (hemoglobin) levels.

Radiation Therapy

The goal of radiation therapy is to kill cancer cells with high-energy X-rays. Women with cervical cancer treated with radiation often get low-dose chemotherapy at the same time which can make the radiation therapy more effective. This is called radiosensitization or chemoradiation.

Radiation therapy may be offered for the purposes of cure, or for palliative reasons (to control symptoms). Radiation therapy is the primary management modality for locally advanced cervical cancer.

There are 2 ways methods for the delivery of radiation doses and they may be used in combination:

• External-beam Radiation - With external beam radiation, a machine is used to deliver high-powered X-rays that kill cancer cells. Treatments are generally given five days a week for about six to eight weeks on an outpatient basis. The initial appointment may take up to 2 hours to allow for treatment planning (simulation) and placement of markings where the radiation beam is to be directed. After that, each treatment appointment takes about 15 minutes.

Intensity Modulated Radiation Therapy (IMRT) is a high-precision mode of radiotherapy that utilizes computer-controlled X-ray accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. The radiation dose is designed to conform to the three-dimensional (3-D) shape of the tumor by controlling the intensity of the radiation beam to focus a higher radiation dose to the tumor while minimizing radiation exposure to surrounding normal tissues. Treatment is carefully planned by using 3-D computed tomography (CT) images in conjunction with computerized dose calculations to determine the dose intensity pattern that will best conform to the tumor shape. Because the ratio of normal tissue dose to tumor dose is reduced to a minimum with the IMRT approach, higher and more effective radiation doses can safely be delivered to tumors with fewer side effects compared with conventional radiotherapy techniques. IMRT has the capability of sparing intestinal, rectal, and bladder tissues from receiving toxic doses of radiation.

• Intracavity Brachytherapy (ICBT) - This is a form of internal radiation which entails the placement of radioactive material inside the body either directly into, or near the tumor to deliver a therapeutic dose of radiation to the cervix, surrounding tissues, and pelvic lymph nodes. Recent advancements in this technique allow for more specific tailoring of dose (low dose or high dose) and area to be treated, while allowing reduced time required for treatment.

Radiation is very effective in destroying cancerous cells at the treated area, however, it can also damage adjacent healthy tissue. Side effects of radiation therapy may include:

• Fatigue
• Urinary frequency and incontinence
• Rectal inflammation and diarrhea
• Changes in the vagina that can make sexual intercourse uncomfortable
• Infertility
• Skin changes and loss of pubic hair

Late effects of radiation therapy may also include development of a fistula which is an abnormal connection between the rectum or bladder and the vagina. At times, surgery may be necessary for repair of fistulas or other radiation injuries.

Surgery

Surgery plays a major role in the treatment of cervical cancer, particularly in women with early-stage disease.

• Hysterectomy - This is an operation to remove a woman's uterus, and in some cases, the ovaries and fallopian tubes as well. It may be offered to women with earlier stage invasive cancer who do not desire future childbearing. Depending on the specific situation, the surgery may be performed as an open procedure (through an incision in the lower abdomen) or, if the cancer is small and in an early stage, laparoscopically ("minimally invasive surgery", which requires several very small incisions). There are several types of hysterectomies:

  • Complete or total hysterectomy - removes the cervix as well as the uterus (this is the most common type of hysterectomy.)
  • Partial or subtotal hysterectomy - removes the upper part of the uterus and leaves the cervix in place (not used in the case of cervical cancer).
  • Radical hysterectomy - removes the uterus, the cervix, the upper part of the vagina, lymph nodes and supporting tissues.

• Radical trachelectomy - In some very early cervical cancers, when the woman wishes to preserve fertility, it may be possible to remove most of the cervix but leave enough to preserve fertility. Radical trachelectomy involves removal all of the cancer, but spares the internal opening of the cervix which is then secured with placement of a stitch to support a pregnancy until the baby can be born by Caesarean section. Unfortunately, however, the premature delivery rate remains high. It may still be necessary to perform a hysterectomy if the cancer cells are found upon microscopic evaluation during surgery to have spread beyond the area. Because there is a small risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, your surgeon may also need to remove some lymph nodes in the area. This is usually done with a laparoscope via several small incisions in the abdomen. Hospital stays for this procedure are usually only 2-3 days. Most women recover quickly and complications are uncommon.

• Pelvic Exenteration - This is a type of surgery that involves a radical hysterectomy (removal of the cervix, uterus, fallopian tubes, ovaries) in addition to removal of the urethra, vagina, rectum, anus, and in some cases, the vulva. The procedure requires placement of a permanent colostomy, where stool empties into a bag on the left side of the abdominal wall. The bladder is reconstructed from bowel to provide a reservoir which empties into a pouch on the abdomen. Pelvic exenteration is most commonly used in cases of advanced or recurrent cervical cancer, vaginal cancer, and vulvar cancer when more conservative surgical options are not technically possible or would not be able to remove the extent of the tumor.

Complications of Surgical Treatment

• Urinary tract injury - may result in incontinence or bladder retention (the inability to fully empty the bladder).

• Lymphocysts - These are benign cystic masses that may develop in the early days to weeks following radical pelvic surgery. When lymphocysts develop many months after surgery, it is important to differentiate between the usual benign cyst and the presence of recurrent tumor. This is accomplished by surgical removal of the cyst so that it can be evaluated microscopically.