Key points
Women diagnosed with early invasive cervical cancer can usually be cured with effective treatment.
It is important for health-care providers at all levels to be able to recognize and promptly manage common symptoms and signs of cervical cancer.
The definitive diagnosis of invasive cervical cancer is made by histopathological examination of a biopsy.
Women with invasive cervical cancer benefit from referral for treatment at tertiary-level cancer facilities.
Treatment options include surgery, radiotherapy and chemotherapy; these may be used in combination.
Patients should be made aware of the potential side-effects of treatment, such as infertility, menopause, discomfort or pain with intercourse and possible bowel or bladder changes.
Patients need to be informed that they will need long-term follow-up and contact with the cancer unit where they received their treatment.
Tertiary-level providers should send complete written records of the treatment and ongoing care plan to providers closest to the patient's home who will be charged with facilitating her follow-up care.
If left untreated, invasive cervical cancer is almost always fatal.
About this chapter
This chapter is based on the following WHO guidelines:
Surgical care at the district hospital. Geneva: WHO; 2003. (http://www.who.int/surgery/publications/en/SCDH.pdf).
Comprehensive cervical cancer prevention and control: a healthier future for girls and women: WHO guidance note. Geneva: WHO; 2013. (http://www.who.int/reproductivehealth/publications/cancers/9789241505147/en/).
Implementation tools: package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings. Geneva: WHO; 2014. (http://www.who.int/nmh/ncd-tools/en/).
The provider at first or second health care levels may have diagnosed invasive cancer in the patient and referred her to a tertiary-level facility. This provider is responsible for making a link between the tertiary care level (where the patient undergoes staging and treatment for invasive cancer) and the patient herself, her family and her community. This chapter is not primarily intended to be used by tertiary-level providers, but rather to help first- and second-level providers to understand how cervical cancer is managed, to explain it to the patient and her family, and to communicate with carers at tertiary and community levels. In addition, the providers will be responsible for identifying and managing side-effects and complications of treatment, and referring the patient back to the treatment facility when necessary.
The main purpose of this chapter is to help primary- and secondary-level providers understand how cervical cancer is diagnosed, how it may be managed, and how to explain the process to the patient and her family, as well as how best to communicate with tertiary-level and community-based health-care providers. This is covered in section 6.2, in addition to some suggestions for tertiary-level providers on how to talk with a patient in their care, in nontechnical language, when discussing the implications of a diagnosis of cervical cancer.
This chapter continues with an explanation of cervical cancer staging (section 6.3), and goes on to give an overview of issues surrounding cervical cancer treatment (section 6.4). Section 6.5 provides short descriptions of each type of treatment that may be available at tertiary-level facilities, in order to help providers explain these treatments to patients. Section 6.6 describes the special considerations when cervical cancer must be managed during pregnancy and in women living with HIV. Finally, if a point is reached when the treatment is determined to be ineffective and the patient's illness is not curable, section 6.7 of this chapter suggests how tertiary-level providers can discuss this with the patient and her chosen companions, including how to explain that it would be better for her to be cared for at home during the time she has left, by her family and community, with the support of providers at all levels, as needed.
The practice sheets for this chapter contain helpful, nontechnical language for providers at all levels to use when communicating with a patient (and those she chooses to be with her) about her illness and her treatment. The specific topics for discussion include: symptoms and diagnosis, possible treatments at the tertiary-care hospital and their side-effects, prognosis, needed medical follow-up and how the patient can care for herself at all stages with help from her family, the community and her primary care providers. There are also practice sheets on each of the main treatment methods: hysterectomy, pelvic teletherapy and brachytherapy.
Please note that Chapter 7 and its practice sheets provide detailed information on palliative care and should be consulted as needed in conjunction with the information in this chapter.
Betty's story
Betty, aged 42, has five children. She went to her primary care provider when, after some months of vaginal discharge, she started having heavy vaginal bleeding after intercourse. The nurse, who had previously seen Betty for other health problems, gave her some pills and asked her to return if they did not have any effect. The bleeding and discharge did not improve, and Betty returned with her partner to the clinic. All the nurse could do was to conduct a vaginal examination without a speculum; when she introduced a finger into Betty's vagina, she felt a hard, irregular mass at the top. Now, the nurse informed Betty and her partner that they needed to go to the secondary care hospital for a gynaecologic evaluation and that she would make an appointment for her as soon as possible.
At the hospital, Betty was examined by the intern, who noted a large cauliflower-like (fungating) mass at the top of the vagina; she immediately suspected cancer so she took a confirmatory biopsy and ordered other tests. The biopsy confirmed the intern's suspicion of cancer and the blood tests showed that Betty was quite anaemic. Betty received a blood transfusion and was urgently referred to the specialists at the tertiary care hospital.
After examining Betty and doing additional tests, doctors explained to her and her partner that she had a cancer which had spread to the tissue around her cervix but had no involvement of other organs or distant metastases. They explained that they believed she had a good chance of being cured by five weeks of daily radiotherapy treatments on an outpatient basis. They explained how radiotherapy works and described the external and internal radiotherapy treatments they could provide. She was told that as a result of radiotherapy she would most likely enter her menopause, meaning that she would have no more menstrual periods, she would be unable to become pregnant (infertility), and she could expect to experience hot flushes. She and her partner might also find sexual intercourse uncomfortable. The doctors explained that they would help to relieve Betty's symptoms, and they responded to Betty's and her partner's questions and made sure Betty understood what they had explained. The doctors told her she could start treatments very soon, if she was ready, but they explained that before starting she needed to sign an informed consent form provided by the hospital. They reassured her that signing this form would not prevent her from changing her mind for any reason at any time before or during the treatments. She chose to start treatment and her partner supported her decision and promised to help her get through this time.
Betty rented a room near the hospital and her partner returned home to care for their children and paid frequent short visits. Betty was able to tolerate her treatments and after five weeks she was able to return home. Her partner and older children helped with household duties until she recovered.
The specialists sent a detailed report to the regional hospital doctor who was charged with providing follow-up care for Betty every three months, and more often if needed. Her doctor communicated with the treating specialist about emerging problems during follow-up and how to manage them. Betty's side-effects were just as expected and she received advice on how to manage them. Betty's cancer showed no signs of recurrence during two years' follow-up.
At the end of two years, Betty returned to the tertiary care hospital where she had been treated and saw the specialist for a thorough examination and discussion. Here it was confirmed that there was no recurrence and Betty was told that she only needed yearly examinations as long as she did not have any new symptoms. She was given a brochure with all this information and a detailed note to give to her primary care doctor.
6.1. Presentation and diagnosis of cervical cancer
Occasionally, a patient who attends a pre-cancer screening clinic will be noted to have a visible abnormality on her cervix. If a trained provider and necessary equipment and supplies are available at the clinic, a biopsy can be taken and sent to the laboratory for diagnosis. If this is not feasible, the patient will be referred to a secondary-level facility for biopsy and diagnosis (see Practice Sheet 5.9 on biopsy and endocervical curettage).
More often, a woman will present to her primary care provider with abnormal symptoms suspicious for cervical cancer. If the primary care provider is trained and has the needed equipment and supplies she may take a biopsy, but in most cases she will refer the patient to the secondary care hospital to be examined by a gynaecologist who will take the biopsy and send it to the laboratory for histopathological examination. If positive results are returned, the patient will be referred to a tertiary care hospital to see a specialist for further testing and treatment.1
Unfortunately, many women may remain asymptomatic until the disease is advanced, especially women who are not currently sexually active.
Presenting symptoms of invasive cervical cancer by level of severity (early and advanced) are listed in (see also section 6.3, including and , for more information on the FIGO staging system).
Symptoms of invasive cervical cancer.
Investigations for staging and treatment for cervical cancer.
Revised FIGO staging system (2009). Sources: Edge et al. (2010), Gold et al. (2008), Pecorelli (2009); see Further reading
For more information on managing a patient who has symptoms that may be due to cervical cancer, see Practice Sheet 6.1.
6.2. The role of the health-care provider
6.2.1. Provider roles at the primary and secondary levels
When a patient experiences any of the abnormal symptoms listed in , she may first discuss her situation with a community health worker or traditional healer. She may be given a remedy and, if symptoms continue, she will likely be advised to consult her primary care provider, often a nurse.
a. When a woman presents at the primary- or secondary-level facility with abnormal symptoms
If a provider at a primary-level facility is trained and has all the essential equipment and supplies, she may perform a pelvic examination and take a biopsy of any abnormality noted on the cervix. If the result of the biopsy is invasive cervical cancer, the primary care provider will probably refer the patient directly to the tertiary care hospital for further tests and management. However, many primary care centres do not have the necessary equipment or lack a trained provider to perform a pelvic examination. Therefore, most often a woman presenting with symptoms will be informed that she needs to see a gynaecologist at the closest secondary-level facility without delay. In rare cases, a patient may present at a primary care centre with severe vaginal haemorrhaging; these patients will probably be sent directly to a tertiary-level facility for evaluation and treatment.
At the secondary-level hospital, the provider who manages patients with abnormal symptoms is advised to first establish or reinforce a trusting relationship and rapport with the patient. The provider will take a full history and perform a thorough examination to determine if there are any cervical lesions and note the presence of any indurations, swellings and other abnormalities in the cervix and the surrounding tissues and organs (see Practice Sheet 5.2).
If appropriate for the patient, pregnancy and HIV tests will also be done before taking a biopsy of a cervical lesion at the secondary care facility. If both tests are negative and an experienced provider and needed equipment are available, a biopsy will be taken and sent to the laboratory for histopathological examination. If, on the other hand, the woman is pregnant and/or is living with HIV, it is advisable to send her to the tertiary-level hospital to have the biopsy taken and, depending on results, have her treatment planned.
The histopathology of the biopsy specimen will confirm or rule out the diagnosis of cervical cancer, which is an essential step before more extensive examinations are done. If the biopsy is positive for cancer, the patient will again be referred, this time from the secondary- to the tertiary-level facility for further tests and investigations and determination of the most appropriate available treatment (see section 6.2.2 on the roles of tertiary-level providers).
Providers should keep in mind that the biopsy results may also identify a few other possible diagnoses for women with similar symptoms (this process is called differential diagnosis). Other possibilities include infectious diseases, such as herpes, which can change the appearance of the cervix and be confused with early cervical cancers, or metastatic cancer from other sites, including from the lining of the uterus (i.e. uterine or endometrial cancer).
b. When a woman is diagnosed with cervical cancer at the primary- or secondary-level facility
When a definitive diagnosis of cervical cancer is reported, the provider who performed the biopsy needs to gently explain the diagnosis to the woman, allowing time for her to reflect and understand the seriousness of her disease and ask questions. If she is not already at a tertiary care hospital, she will be referred to the closest specialist hospital, where cancer specialists and sophisticated equipment are available to provide treatment. See Practice Sheets 6.2 and 6.3 for further advice on communicating with patients at this stage.
c. When a woman is discharged from hospital after treatment
An additional role for primary and secondary care providers is to provide care and support to women who have been discharged from the hospital either because treatment was successful and she can begin her recovery, or because treatment was not effective and she is returning home for palliative care. The primary and secondary care providers, if possible, will maintain communication with the tertiary-level specialists and conduct prescribed periodic follow-up examinations, identify and manage side-effects and complications secondary to the disease and/or treatment, and, if needed and possible, refer the patient back to the treatment facility.
If the patient is receiving palliative care, the primary and secondary care providers are her main medical support, in consultation with the specialists at the tertiary care facility and, if desired, with traditional medicine providers. This medical support may include maintaining the patient free of pain and treating many of the common problems developed by patients who have been treated for cancer.
d. Other important roles
Primary- and secondary-level providers also have other important collaborative roles as members of the cervical cancer team. These may include:
educating and training communities;
training community health workers, including to dispense medicines for pain-relief (if this is permitted by the national regulations);
training staff who have recently joined the care team;
instructing the patient's close family and friends on how to provide special care to prevent serious symptoms and treat these if they occur;
establishing links between the patient and her family and faith-based or other assistance agencies that may provide broad nonmedical support, including donations of funds, food and nonmedical supplies;
aiding the patient and her family as much as possible during the terminal stages of disease;
doing home visits during severe or terminal phases of the disease, if feasible.
For further details on palliative care, see Chapter 7 and its practice sheets.
6.2.2. Understanding provider roles at the tertiary level
At the tertiary care hospital, there are cancer care and management specialists, and advanced testing and treatment options are available. This section is mainly intended to help primary- and secondary-level providers understand and explain what a patient can expect when she is referred to a tertiary-level facility.
Tertiary-level provider roles include the following:
Assess the stage of the woman's cancer using a complete physical examination and a series of tests; this will inform the best management for the patient including treatment and follow-up (see
section 6.3 for further information on cancer staging as well as comments on how tertiary care providers can talk about this with the patient).
Determine the best treatment(s) available for the patient at the facility, taking into account the availability of specialists and equipment.
Monitor the patient during and after treatments to determine the effect of the treatment on the cancer and to manage any side-effects.
If communication between local and tertiary care providers is possible, the specialist may assist the local providers in the patient's community to offer follow-up care after the patient is discharged from hospital. If needed, the specialist will provide advice on additional tests to be ordered and on management of side-effects and other emerging problems.
Provide continuity of support for follow-up care for patients discharged to receive home-based palliative care; this support may take place via telephone, email or other available channels with the primary- and/or secondary-level providers. In some cases, due to severe, intractable symptoms (e.g. pain, severe bleeding), the patient may be referred back to the hospital for additional palliative treatment (see
Chapter 7).
6.3. Cervical cancer staging
Cervical cancer staging is undertaken using one of the existing international staging systems to determine the extent of the cervical cancer invasion and the presence or absence of distant metastases. The stage of the patient's cancer is used by the specialists to select and plan the most appropriate available treatment for her (see Annex 10 on cervical cancer treatment by stage).
At some tertiary-level facilities, speculum, vaginal and rectal examinations and possibly tests to examine the urinary system (cystoscopy) and intestinal system (proctoscopy) may be the only available tools for staging. Based on this limited number of tests, an experienced specialist will know the location of the tumour, whether it is growing outwards or inwards from the tissues of the cervix, its size, its extension to the tissues next to the cervix and to the uterus and the ligaments holding the uterus in place, as well as to the pelvic walls. Involvement of the urinary bladder and rectum can also be determined.
At most tertiary-level facilities, more advanced tests are also available and will be used to obtain a more detailed description of the disease, which will assist in determining the best treatments available for the patient (see ). The assessment can be done under general anaesthesia if the investigations for the full diagnosis and staging are too uncomfortable and/or painful.
In addition to the tests suggested by the International Federation of Gynaecology and Obstetrics (FIGO) in , the specialist(s) at the hospital may conduct additional tests to further investigate the extent of the cancer. These may include:
blood tests, including full blood count and haemoglobin levels (to assess the presence of anaemia caused by blood loss, which, if present, can impact the effectiveness of radiotherapy), in addition to pregnancy and HIV tests when appropriate;
kidney and liver function tests;
computerized tomography (CT) scan or, better yet, magnetic resonance imaging (MRI) of the abdomen and pelvis (to help plan radiotherapy); however, treatment can be planned in the absence of these procedures if they are not available, affordable or feasible.
All investigations undertaken for the purpose of staging, and their results, must be carefully documented in the case record. A descriptive diagram can be included and provided to all health-care providers who will be involved in the patient's care.
a. FIGO staging system
A number of systems are used for cervical cancer staging. FIGO's staging system, based on tumour size and the extent of spread of the disease within the pelvis and to distant organs, is the most commonly used system (see ).
The FIGO staging system (2009 revision) describes four progressively more advanced stages of cervical cancer, from stage I to stage IV.
Summary of the FIGO stages and substages (as shown in ):
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| Stage I: | The disease is confined to the cervix (includes substages IA1, IA2, IB1 and IB2). |
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| Stage II: | Cancer has spread outside the cervix into the upper vagina or to the tissue beside the cervix (parametrium), but not to the sidewall(s) of the pelvis (includes substages IIA1, IIA2 and IIB). |
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| Stage III: | Cancer has spread to the lower part of the vagina or all the way through the parametrium to the sidewall(s) of the pelvis (includes substages IIIA and IIIB). |
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| Stage IV: | Cancer has spread to surrounding organs or distant tissue, such as the lungs and distant lymph nodes (includes substages IVA and IVB). |
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b. Suggestions for tertiary care providers on how to talk with the patient about the importance of staging before it is conducted and after tests results are available
These conversations can be very emotional and may need more than one session. The utmost sensitivity and respect for the woman's clear understanding and reactions are essential. The patient should be offered the option of having with her one or more close family members or friends for support during this conversation. During this session, stop frequently and encourage the patient and her companions to ask questions. From time to time, assure yourself that she understands what you are saying and correct any misunderstandings, using different words.
In all conversations regarding cervical cancer, be mindful of cultural aspects of the patient's community.
See Box 6.1 on factors that influence prognosis and survival rates, and see Practice Sheet 6.4 for more specific suggestions for cancer specialists who need to speak with patients about their cancer and treatment.
Factors influencing cervical cancer prognosis or five-year survival rates for women after completing the best treatment. The single most important predictor of long-term survival is the clinical stage of the disease when first diagnosed. The following (more...)
6.4. Treatment of invasive cervical cancer: overview
6.4.1. The principles of treatment
Each country or region has referral plans in place for women diagnosed with invasive cervical cancer to be seen and treated at tertiary-level institutions.
The therapeutic options offered to a patient should draw on international, national or institutional guidelines, based on the availability of qualified health-care professionals (i.e. surgeons, medical oncologists and/or radiotherapists/medical physicists) as well as the availability and condition of needed equipment. As described later, in section 6.6, there are some special treatment considerations for women who are pregnant or living with HIV.
In all cases, health-care providers should ensure that the chosen treatment, while reducing the extent of the cancer, will also probably reduce the patient's pain and suffering. If the treatment and/or its side-effects carry greater risks than the disease (i.e. more likely than the disease to shorten the patient's life, or likely to worsen the quality of her entire remaining life), then that treatment should not be considered.
Treatment should be individualized for the patient. The treatment plan is best decided by a team composed of gynaecologists, oncologists and radiotherapy specialists. Once this team is in place, they will consider the best interests and preferences of the patient and use this information to plan her treatment, selecting the best option or options based on the extent of her disease and her overall state of health. This treatment plan then needs to be discussed with the patient and conveyed to her primary and secondary care providers using language appropriate for that patient (so that the providers can also reinforce the contents of the conversation using the same language) (see Practice Sheet 6.3).
Not all treatment options described in this chapter (section 6.5) are available at all tertiary-level facilities; the necessary equipment may not be in an acceptable condition, supplies may be lacking, or the providers' qualifications may not be up-to-date for provision of a particular treatment. Based on the availability and quality of services, the health-care provider charged with management of the patient will be able to explain the best option or options to her. If there is a choice between two treatment options with similar outcomes, or a choice between a single treatment and a combination of treatments, the patient and her support circle should be given details of each option as a basis for making an informed decision.
Once conversations and exchange of information about the extent of the disease and the treatment plan have taken place (see Practice Sheet 6.4), the provider will explain and review all the contents of the informed consent form used in the hospital and make certain that the patient understands what her signature means. Reassure her that she has the power to change what she has consented to if she wishes to do so for any reason. After this, the patient is asked if she is ready to sign and have witness signatures added (see Practice Sheet 5.1 on obtaining informed consent).
6.4.2. Choosing whether to treat and when to start treatment: the patient's own decision
The patient, once fully informed, is the person who has the power to choose whether to be treated, which treatment she prefers (if she is given a choice), and when to start. To do this, she will probably need to take into account:
her personal and family situation
her commitments at home
the time needed for treatment
expected treatment effectiveness and side-effects
whether the treatment is included in her health insurance
any out-of-pocket costs for her and her family if not covered by health insurance
the consequences of no treatment.
In this process, the patient may also wish to consider the advice of people who are close to her.
6.4.3. Patient barriers to care
Treatment is often only available at tertiary care hospitals, which may be far from the woman's home, necessitating long periods away from home. The costs to the woman and her family and the disruption associated with treatment may be considerable and may even cause some women to refuse or stop treatment. If this is a possibility, providers at all levels of care can help by mobilizing support from the patient's family and community, and from the government and nongovernmental organizations. Some countries offer disability grants for women undergoing cancer treatment, while others offer accommodation close to regional cancer treatment centres; in other countries there is no support available. In some countries, that have no facilities for cancer treatment, women are referred to neighbouring countries for treatment and this may cause further hardship for her and her family. All of these issues need in-depth exploration in order to find solutions that will enable each woman to have the treatments that may cure her cancer or prolong and improve her life.
6.5. Treatment options
Cervical cancer treatment options include surgery, radiotherapy and chemotherapy, and these may be used in combination. Each option will be discussed in this section in sufficient detail to assist providers at all levels of the health system in keeping patients informed, always paying attention to use of appropriate nontechnical language. The terminology used here is intended to assist the provider in describing these therapies to a patient.
Depending on the stage of the cancer, the general health of the woman, and the availability of facilities and expertise, the primary therapy may be surgery or radiotherapy, with or without chemotherapy. Primary therapy (also called first-line therapy or primary treatment) is the first treatment for invasive cancer, usually with the objective of curing the disease. Adjunctive therapy is another treatment used with the primary treatment to assist the primary treatment. Secondary therapy refers to a treatment that can be given after another (primary) treatment has been used.
6.5.1. Surgery
Surgery consists of removal of varying amounts of tissue from the area involved with cancer and its surroundings. It can be done via the vagina or through an opening in the abdomen.
Surgery can be used as primary therapy as well as secondary therapy, after another treatment has been used.
The first two surgical procedures described here (cone biopsy and simple hysterectomy) remove less tissue while the third (radical hysterectomy) removes more tissue.
a. Surgery as primary therapy
Surgery as primary therapy for cervical cancer consists of the removal of a varying amount of tissue based on the extent of the cancer spread within the pelvis and other individual case characteristics.
Cone biopsy is the removal of a wide circle of tissue that surrounds the opening of the uterus and includes the lower portion of the cervical canal (see ). Microinvasive cancers (those that are entirely contained within the cervical epithelium) can be treated with cone biopsy, particularly if retaining fertility is an issue.
Cone biopsy – removal of a cone-shaped area of the cervix.
Simple hysterectomy is the surgical removal of the entire uterus, including the cervix, either through an incision in the lower abdomen or through the vagina with or without using laparoscopy (see ). The tubes and ovaries are not routinely removed, but they may be in postmenopausal women or if they appear abnormal. Simple hysterectomy is indicated for the treatment of early microinvasive cervical cancers in postmenopausal women and younger women who are not interested in preserving fertility.
Removal of the uterus by simple hysterectomy.
Radical hysterectomy is the most common surgery for early invasive cancers. This surgery removes tissue to the side of the uterus and often lymph nodes in the pelvis and around the aorta (see ). The tubes and ovaries are not routinely removed unless they appear abnormal. See Annex 14 for information on how to process and record a radical hysterectomy specimen, including a sample pathology report form (Sample Form 14.1).
Radical and modified radical hysterectomy.
b. Surgery as secondary therapy
Salvage surgery can still have the objective of curing the patient. It consists of radical hysterectomy including removal of a portion of the upper vagina to decrease chances of recurrence of the cancer. It is performed when:
the patient has had primary surgery, but microscopic examination of the removed tissue shows that the margin of normal tissue around the cancer is too thin; or
the patient has undergone radiotherapy and/or chemotherapy, but early recurrences or incomplete destruction of the cancer are noted on follow-up.
Palliative surgery is sometimes done in advanced cancer to relieve obstruction of the bowel, or to treat fistulae (abnormal channels between the vagina and the urinary organs or rectum) that result from radiation or extension of the primary disease.
c. Possible side-effects and complications of cervical cancer surgery
Possible side-effects and complications apply to all surgical interventions; the risks are generally small and mostly manageable. They include:
a small risk of infection in the area of the surgery;
bleeding;
damage to the organs around the surgery (e.g. the bowel or bladder);
a risk of clots in the deep veins of the legs if the patient is kept in bed and relatively immobile for days after surgery; this must be detected and treated early to prevent the clots from dislodging and travelling to the lungs.
In addition to the above general complications, surgery for cervical cancer has the following risks:
Cone biopsy is associated with an increased risk of preterm labour and/or miscarriage when performed in pregnant patients.
Hysterectomy results in infertility.
Radical hysterectomy results in infertility and is also associated with bladder and/or bowel dysfunction.
For more information on hysterectomy as a treatment for cervical cancer, see Practice Sheet 6.5.
6.5.2. Radiotherapy
Radiotherapy (or radiation therapy) uses sophisticated equipment to produce invisible rays – similar to a ray of light but with higher energy – that are beamed onto the cancer and the surrounding affected areas. The rays penetrate the body and destroy cancer cells so that the cancer is fully or partially eliminated. Destroyed cancer cells are eliminated from the body.
Radiation itself is not painful but it may cause significant side-effects (refer to the end of this section).
a. Radiation as primary therapy
Primary radiotherapy, with or without chemotherapy, is used with curative intent, for women with cancer at stage IIA2 or greater (see ). It may be offered to women with cancers greater than 4 cm in diameter confined to the cervix, and for cancers that have spread beyond the cervix. Primary radiotherapy, intended to cure earlier cancers, is provided with daily treatments for 5–6 weeks using two modes of delivery:
External-beam radiotherapy, or teletherapy, uses radiation originating from a machine located outside the body (see
Practice Sheet 6.6).
Internal radiotherapy, also called brachytherapy, uses radiation originating from radioactive material placed inside the vagina, close to the cancer (see
Practice Sheet 6.7).
b. Radiation as adjunctive therapy
Radiotherapy, with or without chemotherapy, may be given as adjunctive therapy in combination with primary surgery for the following indications:
if, during primary surgery, the surgeon discovers that the cancer has spread beyond the cervix to the parametria (tissues between the uterus and the pelvic wall) or to other pelvic organs;
after hysterectomy, if the pathology report indicates less than 5 mm of disease-free tissue around the cancer;
if, during primary surgery, involvement of lymph nodes with cancer was found.
c. Radiation as secondary therapy
Radiotherapy, with or without chemotherapy, may be given as secondary therapy for the following indications:
d. Radiation as palliative therapy
Palliative radiotherapy, usually without chemotherapy, may be used in a variety of settings (see also Chapter 7):
as the only therapy in women with very advanced cancer;
to control severe symptoms, such as bleeding, offensive discharge and/or pain;
to assist a patient who is too ill to tolerate full-dose chemotherapy or radiotherapy (e.g. severe renal failure secondary to ureteric obstruction, liver failure, etc.);
for treatment of isolated metastases (e.g. to vertebrae or lymph nodes without evidence of widespread metastases).
e. Side-effects of radiation for cervical cancer
Radiotherapy also affects multiple systems but only those directly exposed to radiation; in the case of cervical cancer this is usually the lower abdomen, including the urinary bladder, rectum and regional bone marrow. Other possible side-effects include menopause, infertility, discomfort or pain with intercourse, and possible bowel or bladder changes. Fistula is a rare side-effect.
6.5.3. Chemotherapy
Chemotherapy is the administration of repeated treatments with toxic drugs. A series of several treatments with one or more chemicals is given intravenously to kill rapidly dividing cells (a hallmark of all cancers).
a. Chemotherapy as primary therapy
Chemotherapy is rarely used alone as the primary treatment for cervical cancer; rather, it is used in combination with radiotherapy and less often with surgery.
b. Chemotherapy as primary therapy combined with radiotherapy
Chemotherapy is used first in women with very large and bulky tumours, to reduce the cancer size, and then followed by radiotherapy. Treatment is done in this sequence because cancer is shown to respond better to radiation when the tumour is less bulky.
c. Chemotherapy as palliative care
Palliative chemotherapy is sometimes used, after careful consideration of the expected benefits versus the adverse side-effects, to relieve symptoms in women with widespread metastases to liver, lung and bone.
d. Side-effects of combination therapy (chemotherapy and radiotherapy)
The side effects of combination therapy may be additive: those caused by the chemotherapy and the radiation. Because the toxic chemotherapy drugs circulate with the blood around the entire body, side-effects of chemotherapy will be widespread in the body. On the other hand, those caused by radiation will be limited to the pelvic area (see section 6.5.2 on radiotherapy).
Chemotherapy treatments affect not only cancer cells but also rapidly dividing cells in systems of the entire body: bone marrow, digestive system, urinary system, skin and other organs lined by epithelia. This means that there is a risk of anaemia, low white blood cell counts and infections, or bleeding from low platelet counts. Chemotherapy can also cause nausea and diarrhoea or allergic reactions to the drug. These are usually very short-lived and do not imply increased risks.
6.6. Special situations: cervical cancer in pregnancy and in women living with HIV
6.6.1. Managing cervical cancer in pregnant women
Although rare, cancer of the cervix is sometimes diagnosed in pregnant women. Cervical cancer does not cross the placenta, so the fetus is only affected by the direct spread of a very large cervical tumour or by complications from the methods used for the evaluation and treatment of the cancer.
Counselling a pregnant woman with cervical cancer requires particular skill and sensitivity. The issues are a great deal more complex and include helping her decide if she wishes to attempt to preserve her pregnancy. It is helpful to involve a multidisciplinary team of health-care providers and the woman's support circle in order to create a management plan that meets all needs and takes into account the complexities of decision-making in this context. It is often a heartbreaking set of choices for a couple and support may be required for both partners before, during and after treatment.
a. If the patient wishes to maintain the pregnancy
If the patient and her partner (if she wishes him to be involved in this decision) express hope to maintain the pregnancy, then most treatments will occur after delivery. Patients should be informed in advance that to avoid delivery complications caused by cervical dilation (such as haemorrhage), her delivery will be by planned caesarean before her labour initiates.
However, it is still important to perform a confirmatory biopsy of the lesion without delay. Performing a biopsy of the cervix in pregnancy is not contraindicated, but heavier bleeding than usual should be anticipated. For this reason it is advised that the biopsy be performed at the tertiary-level facility. Patients should be counselled that although biopsies are generally safe in pregnancy, as with any procedure during pregnancy, a biopsy has a small risk of being associated with a miscarriage.
b. If the patient does not wish to maintain the pregnancy
In this case, treatment is determined based on the stage of the cancer, in exactly the same manner described for nonpregnant women. If the patient's condition is suitable for simple or radical hysterectomy and disease is confined to the cervix, surgical options may be considered depending on the gestational age. Primary radiotherapy (with or without chemotherapy) may be another option; in this case, the patient needs to be informed that treatment will cause loss of the fetus.
6.6.2. Managing cervical cancer in women living with HIV
Because there are no well-designed or longitudinal studies on the treatment of cervical cancer in women living with HIV, there are no evidence-based guidelines on this subject to include in this guide. In their absence, this section presents some practices that are commonly used in the international and national arenas.
It is best for women living with HIV who have cervical cancer to be fully diagnosed, staged and treated at a tertiary-level institution with the appropriate expertise. Most institutions treating women living with HIV use multidisciplinary teams; each woman will be evaluated individually and an assessment made of her overall health and the existence of other chronic illnesses that may further compromise her immune system and her ability to tolerate immunosuppressive anti-cancer therapy (e.g. tuberculosis).
Both radiotherapy and chemotherapy are immunosuppressive therapies and surgery requires women to be relatively healthy in order to avoid complications such as postoperative sepsis, bleeding or wound problems. Therefore, a baseline CD4 count is a key element of care for women living with HIV and should be one of the initial evaluative tests obtained, regardless of the extent of the cancer. CD4 counts will also be needed to monitor the patient's immune status throughout treatment. If the CD4 count is or becomes low during therapy, she may be started on antiretroviral therapy, which may delay treatment to allow for recovery of her immune system.
6.7. Patient support and follow-up
6.7.1. Patient support during treatment
At all stages of disease diagnosis and treatment, it is important to assess and adequately treat pain and other symptoms. Additionally, women undergoing radiotherapy and/or chemotherapy will require regular blood counts and renal and liver function tests to identify and, if possible prevent, risks for infection.
Many cancer patients suffer from moderate to severe blood loss and chronic malnutrition, which may be improved by a healthy diet and provision of iron and folate supplements. Treating anaemia is also important because anaemia diminishes the effectiveness of radiotherapy.
Gentle vaginal douching and antibiotics such as metronidazole may reduce or eliminate the foul-smelling discharge often associated with treatment of advanced disease.
See Chapter 7 and its practice sheets on palliative care for more advice on managing common problems found in advanced cancer.
6.7.2. Patient follow-up
When a woman has completed treatment for cervical cancer, she is discharged from the hospital or outpatient unit. Before discharge, follow-up care is usually discussed at a meeting of all those who have been and will be involved in the patient's care; this discussion should include input from the woman herself and her family. Although follow-up would be best conducted at the tertiary-level cancer treatment centre, in reality most of these centres are tertiary-level hospitals located in major cities; if this is too far from the woman's home then the distance may prevent her from attending due to lack of time, transportation or money, or other personal constraints. Many women will thus chose to have follow-up at a facility closer to home. If this is the case, it would be beneficial for the gynaecologist from the secondary-level (regional) hospital to be present and participate in this important meeting about follow-up care.
When follow-up will take place at a distance from the treatment centre, a primary or secondary care physician with the skills to detect and manage problems or recurrence of cancer (often a gynaecologist) will have received a comprehensive report detailing the cancer stage, treatment administered and prognosis, as well as information about common problems that may occur and how to prevent or treat them. It is best to always include contact information (phone, fax, email, address) of the treatment centre in this report, to encourage those who are charged with the patient's follow-up care to provide regular feedback and seek advice from cancer experts if the patient presents with unexpected symptoms.
a. Follow-up for women treated with primary surgery and/or radiotherapy, with or without chemotherapy
It is advisable for women who have had any of these treatments to be seen and examined every three months post-treatment for a period of at least two years, which is the period during which most persistence or recurrence of disease will present or be detected. In addition, this is the period during which side-effects of treatment are most acute and need management.
During the follow-up consultations, the following activities need to be undertaken and fully documented in the patient's record:
a thorough history to elicit and discuss all physical symptoms experienced by the patient;
an assessment of her social, psychological/emotional and economic situation, and the impact of her illness and treatment on all of these factors;
a full examination, including general systems and abdominal examination plus palpation of lymph nodes, with particular attention to the neck and groin;
a speculum examination and visualization of the vaginal vault;
an annual cytological smear of the vaginal vault for women who have only been treated with surgery (the role of VIA or HPV testing in this setting is unknown and has not been examined in clinical trials) – if the patient was treated with radiotherapy (with or without chemotherapy), then cytology will not add value to the post-treatment examination;
2bimanual vaginal and rectal examination to palpate for recurrence of disease in the pelvis;
other investigations will be determined by the patient's symptoms and the clinical findings, as well as the availability of resources.
Persistent or recurrent disease in women who have been treated with surgery alone may be treated (and potentially cured) using secondary treatment with radiation, with or without chemotherapy. However, if a woman had received primary radiotherapy, repeating it needs to be carefully planned to ensure that the area previously treated will not be exposed to more than the maximum allowable dose, which would cause serious damage and future complications.
6.7.3. Making a choice to stop treatment
For women undergoing chemotherapy and/or radiotherapy, it is very important to constantly monitor their response to the treatment. When it becomes clear that there is progression of disease or no relief of pain and other symptoms, then treatment focused on the disease is stopped. Maximal attention to providing control of pain and other symptoms remains the major focus of palliative treatment once the patient returns home. See Practice Sheet 7.1 on the evaluation of pain and Practice Sheet 7.2 on the management of symptoms.
Ensuring pain control and management is a prime goal both in and out of the hospital, when disease is curable and when it is not. It is discussed in great detail in Chapter 7.
When treatment is stopped, this is the time for the specialist provider(s) to contact local health-care providers and other caregivers who will be charged with the patient's palliative care. A report needs to be sent and should include contact information (phone, fax, email, address) of the treatment centre. Advice will be provided about how to provide the follow-up care for the patient and the treatment centre will request regular feedback on the patient's status. The local caregivers may need additional training and, once trained, should be allowed to provide palliative support, pain control and care for patients in the local setting as the cancer progresses. Finally, the tertiary care providers should encourage the local caregivers to contact them to discuss any concerns, including for advice if the patient presents with any unexpected symptoms or if symptoms do not improve with specific treatment.
Further reading
Barakat RR, Berchuck A, Markman M, Randall ME. Principles and practice of gynecologic oncology. 6th edition. Philadelphia (PA): Wolters Kluwer/Lippincott Williams & Wilkins; 2013.
Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC Cancer Staging Manual. 7th edition. New York (NY): Springer; 2010. pp. 395–402.
Gold MA, Tian C, Whitney CW, Rose PG, Lanciano R. Surgical versus radiographic determination of para-aortic lymph node metastases before chemoradiation for locally advanced cervical carcinoma: a Gynecologic Oncology Group Study.
Cancer. 2008;112(9):1954–63. [
PubMed: 18338811] [
CrossRef]
Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium.
Int J Gynaecol Obstet. 2009;105(2):103–4. [
PubMed: 19367689]
Rimel BJ, Ferda A, Erwin J, Dewdney SB, Seamon L, Gao F, et al. Cervicovaginal cytology in the detection of recurrence after cervical cancer treatment.
Obstet Gynecol. 2011;118(3):548–53. [
PubMed: 21860282]
Wiebe E, Denny L, Thomas G. Cancer of the cervix uteri.
Int J Gynaecol Obstet. 2012;119(Suppl 2):S100–9. [
PubMed: 22999501] [
CrossRef]
Zanagnolo V, Ming L, Gadducci A, Maggino T, Sartori E, Zola P, et al. Surveillance procedures for patients with cervical carcinoma: a review of the literature.
Int J Gynecol Cancer. 2009;19:194–201. [
PubMed: 19395993]
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Please also refer to WHO's 2014 publication Implementation tools: package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings, available at: http://www.who.int/nmh/ncd-tools/en/
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