How is cervical cancer treated?

The options for treating each patient with cervical cancer depend on the stage of disease. The stage of a cancer describes its size, depth of invasion (how far it has grown into the cervix), and how far it has spread.

After establishing the stage of your cervical cancer, your cancer care team will recommend your treatment options. Think about your options without feeling rushed. If there is anything you do not understand, ask for an explanation. Although the choice of treatment depends largely on the stage of the disease at the time of diagnosis, other factors that may influence your options are your age, your general health, your individual circumstances, and your preferences. Be sure that you understand all the risks and side effects of the various treatments before making a decision.

It is often a good idea to get a second opinion, especially from doctors experienced in treating cervical cancer. A second opinion can give you more information and help you feel more confident about choosing a treatment plan.. Some insurance companies require a second opinion before they will agree to pay for certain treatments. Almost all will pay for a second opinion. Still, you might want to check your coverage first, so you’ll know if you will have to pay for it.

The 3 main methods of cancer treatment are surgery, radiation therapy, and chemotherapy. Sometimes the best treatment approach uses 2 or more of these methods. Your recovery is the goal of your cancer care team. If a cure is not possible, the goal may be to remove or destroy as much of the cancer as possible to help you live longer and feel better. Sometimes treatment is aimed at relieving symptoms. This is called palliative treatment.

Surgery

Cryosurgery

A metal probe cooled with liquid nitrogen is placed directly on the cervix. This kills the abnormal cells by freezing them. Cryosurgery is used to treat pre-invasive cervical cancer (stage 0), but not invasive cancer.

Laser surgery

A focused laser beam, directed through the vagina, is used to vaporize (burn off) abnormal cells or to remove a small piece of tissue for study. Laser surgery is used to treat pre-invasive cervical cancer (stage 0). It is not used to treat invasive cancer.

Conization

A cone-shaped piece of tissue is removed from the cervix. This is done using a surgical or laser knife (cold knife cone biopsy) or using a thin wire heated by electricity (the loop electrosurgical, LEEP or LEETZ procedure). (See the section, “Can cervical cancer be prevented?” for more information.) A cone biopsy may be used to diagnose the cancer before additional treatment with surgery or radiation. It can also be used as the only treatment in women with early (stage IA1) cancer who want to preserve their ability to have children (fertility). After the biopsy, the tissue removed (the cone) is examined under the microscope. If the margins (outer edges) of the cone contain cancer (or pre-cancer) cells, further treatment will be needed to make sure that all of the cancer is removed.

Hysterectomy

This is surgery to remove the uterus (both the body of the uterus and the cervix) but not the structures next to the uterus (parametria and uterosacral ligaments). The vagina and pelvic lymph nodes are not removed. The ovaries and fallopian tubes are usually left in place unless there is some other reason to remove them.

When the uterus is removed through a surgical incision in the front of the abdomen, it is called an abdominal hysterectomy. When the uterus is removed through the vagina, it is called a vaginal hysterectomy. When the uterus is removed using laparoscopy, it is called a laparoscopic hysterectomy. In some cases, laparoscopy is performed with special tools to help the surgeon see better and with instruments that are controlled by the surgeon. This is called robotic-assisted surgery.

General or epidural (regional) anesthesia is used for all of these operations. The recovery time and hospital stay tends to be shorter for a laparoscopic or vaginal hysterectomy than for an abdominal hysterectomy. For a laparoscopic or vaginal hysterectomy, the hospital stay is usually 1 to 2 days followed by a 2- to 3-week recovery period. A hospital stay of 3 to 5 days is common for an abdominal hysterectomy,, and complete recovery takes about 4 to 6 weeks. Any type of hysterectomy results in infertility (inability to have children). Complications are unusual but could include excessive bleeding, wound infection, or damage to the urinary or intestinal systems.

Hysterectomy is used to treat stage IA1 cervical cancers. It is also used for some stage 0 cancers (carcinoma in situ), if cancer cells were found at the edges of the cone biopsy (this is called positive margins) or for adenocarcinoma in situ. A hysterectomy is also used to treat some non-cancerous conditions. The most common of these is leiomyomas, a type of benign tumor commonly known as fibroids.

Radical hysterectomy and pelvic lymph node dissection

For this operation the surgeon removes more than just the uterus. Also removed are the tissues next to the uterus (parametria and uterosacral ligaments), the upper part (about 1 inch) of the vagina next to the cervix, and some pelvic lymph nodes (pea-sized collections of immune system tissue). The ovaries and fallopian tubes are not removed unless there is some other medical reason to do so. This surgery is usually performed through an abdominal incision.

Another surgical approach is called laparoscopic-assisted radical vaginal hysterectomy. This operation combines a radical vaginal hysterectomy with a laparoscopic pelvic node dissection. Laparoscopy allows the inside of the abdomen and pelvis to be seen through a tube inserted into very small surgical incisions. Small instruments can be controlled through the tube, so the surgeon can remove lymph nodes through the tubes without making a large cut in the abdomen. The laparoscope can also make it easier for the doctor to remove the uterus, ovaries, and fallopian tubes through the vaginal incision.

Robot-assisted laparoscopic surgery is also sometimes used to perform radical hysterectomies. The advantages are lower blood loss and a shorter stay in the hospital after surgery. However, this way of treating cervical cancer is still relatively new, and its ultimate role in treatment is still being studied.

More tissue is removed in a radical hysterectomy than in a simple one, so the hospital stay can be longer, about 5 to 7 days. Because the uterus is removed, this surgery results in infertility. Complications are unusual but could include excessive bleeding, wound infection, or damage to the urinary and intestinal systems. A radical hysterectomy and pelvic lymph node dissection are the usual treatment for stages IA2, IB, and less commonly IIA cervical cancer, especially in young women.

Sexual impact of hysterectomy: Radical hysterectomy does not change a woman’s ability to feel sexual pleasure. Although the vagina is shortened, the area around the clitoris and the lining of the vagina remains as sensitive as before. A woman does not need a uterus or cervix to reach orgasm. When cancer has caused pain or bleeding with intercourse, the hysterectomy may actually improve a woman’s sex life by stopping these symptoms.

Trachelectomy

Most women with stage IA2 and stage IB are treated with hysterectomy. Another procedure, known as a radical trachelectomy, allows some of these young women to be treated without losing their ability to have children. This procedure removes the cervix and the upper part of the vagina and placing a “purse-string” stitch to act as an artificial internal opening of the cervix (the opening of the cervix inside the uterine cavity). The nearby lymph nodes are also removed using laparoscopy. The operation is done either through the vagina or the abdomen.

After trachelectomy, some women are able to carry a pregnancy to term and deliver a healthy baby by cesarean section. In one study, the pregnancy rate after 5 years was more than 50%, but the risk of miscarriage after this surgery was higher than what is seen in normal healthy women. The risk of the cancer coming back after this procedure is low.

Pelvic exenteration

This is a more extensive operation that may be used to treat recurrent cervical cancer. In this surgery, all of the organs and tissues are removed as in a radical hysterectomy with pelvic lymph node dissection. This operation may also remove the bladder, vagina, rectum, and part of the colon, depending on where the cancer has spread.

If the bladder is removed, a new way to store and eliminate urine will be needed. This usually means using a short segment of intestine to function as a new bladder. The new bladder may be connected to the abdominal wall so that urine is drained periodically when the patient places a catheter into a urostomy (a small opening). Or urine may drain continuously into a small plastic bag attached to the front of the abdomen.

If the rectum and part of the colon are removed, a new way to eliminate solid waste must be created. This is done by attaching the remaining intestine to the abdominal wall so that fecal material can pass through a colostomy (a small opening) into a small plastic bag worn on the front of the abdomen. It may be possible to remove the involved colon (next to the cervix) and reconnect the colon so that no bags or external appliances are needed. If the vagina is removed, a new vagina can be surgically created out of skin, intestinal tissue, or myocutaneous (muscle and skin) grafts.

Sexual impact of pelvic exenteration: Recovery from total pelvic exenteration takes a long time. Most women don’t begin to feel like their normal selves again for 6 months after surgery. Some say it takes a year or two to adjust completely.

Nevertheless, these women can lead happy and productive lives. With practice and determination, they can also have sexual desire, pleasure, and orgasms.

Radiation therapy

Radiation therapy uses high energy x-rays to kill cancer cells. These x-rays may be given externally in a procedure that is much like having a diagnostic x-ray. This is called external beam radiation therapy. This treatment usually takes 6 to 7 weeks to complete. For cervical cancer, this type of radiation therapy is often given along with low doses of chemotherapy with a drug called cisplatin.

Another type of radiation therapy is called brachytherapy, or internal radiation therapy. For cervical cancer, the radioactive material is placed in a cylinder in the vagina. For some cancers, radioactive material may be placed in thin needles that are inserted directly in the tumor. Low-dose brachytherapy is completed in just a few days. During that time, the patient remains in the hospital with instruments holding the radioactive material in place. High-dose rate brachytherapy is done as an outpatient over several treatments. For each treatment, the radioactive material is inserted for a few minutes and then removed. The advantage of high-dose rate is that you do not have to stay still for long periods of time.

Common side effects of radiation therapy include tiredness, upset stomach, or loose bowels. Some people have problems with nausea and vomiting. These side effects tend to be worse when chemotherapy is given with radiation. Radiation can also lead to low blood counts, causing anemia (low red blood cells) and leukopenia (low white blood cells). The blood counts usually return to normal after radiation is stopped. Skin changes are also common, with the skin in the treated area looking and feeling sunburned.

Pelvic radiation therapy may cause scar tissue to form in the vagina. The scar tissue can make the vagina more narrow (called vaginal stenosis) or even shorter, which makes sex (vaginal intercourse) painful. A woman can help prevent this problem by stretching the walls of her vagina several times a week. This can be done by engaging in sexual intercourse 3 to 4 times per week or by using a vaginal dilator (a plastic or rubber tube used to stretch out the vagina). Vaginal dryness and painful intercourse can be long-term side effects from radiation. Pelvic radiation can damage the ovaries, causing premature menopause. Radiation can irritate the bladder and problems with urination may occur. Vaginal (local) estrogens may also be used to help with vaginal dryness and atrophy.

Radiation to the pelvis can also weaken the bones, leading to fractures. Hip fractures are the most common, and may occur 2 to 4 years after radiation. Bone density studies are recommended.

Treating lymph nodes with radiation can lead to problems with drainage of fluid from the leg. This can cause severe swelling in the leg, a condition called lymphedema.

If you are having side effects from radiation, discuss them with your cancer care team.

It is important to know that smoking increases the side effects from radiation. If you smoke, you should stop.

Chemotherapy

Systemic chemotherapy uses anti-cancer drugs that are injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment potentially useful for cancers that have spread to distant organs (metastasized).

Drugs most often used to treat cervical cancer include cisplatin, paclitaxel (Taxol®), topotecan, ifosfamide, and fluorouracil (5-FU). If chemotherapy is chosen, you may receive a combination of drugs. Chemotherapy drugs kill cancer cells but also damage some normal cells, which can lead to side effects.

Chemotherapy side effects depend on the type of drugs, the amount taken, and the length of time you are treated. Temporary side effects of chemotherapy might include:

• nausea and vomiting

• loss of appetite

• loss of hair

• mouth sores

Because chemotherapy can damage the blood-producing cells of the bone marrow, the blood cell counts might become low. This can result in:

• an increased chance of infection (from a shortage of white blood cells)

• bleeding or bruising after minor cuts or injuries (because of a shortage of blood platelets)

• shortness of breath (due to low red blood cell counts)

Fatigue is also quite common and may be caused by low red blood cell counts, by other reasons related to the chemotherapy, or by the cancer itself.

Most side effects of chemotherapy (except premature menopause and infertility) disappear once treatment is stopped. Hair will grow back after treatment ends. Premature menopause can be treated with hormones.

If you have problems with side effects, talk with your cancer care team. There are remedies for many of the temporary side effects of chemotherapy. For example, there are very good drugs that can prevent or reduce nausea and vomiting. Other drugs can be given to boost blood cell production.

For some stages of cervical cancer, chemotherapy is given to help the radiation work better. When chemotherapy and radiation therapy are given together, it is called concurrent chemoradiation. One option is to give a dose of cisplatin every week during radiation. This drug is given into a vein (IV) about 4 hours before the radiation appointment. Another choice is to give cisplatin along with fluorouracil (5-FU) every 4 weeks during radiation. Other drug combinations are also used. Giving chemotherapy with radiation can improve the patient’s outlook, but giving the 2 together also tends to have worse side effects. The nausea and fatigue are often worse. Diarrhea can also be a problem if chemotherapy is given at the same time as radiation. Problems with low blood counts can also be worse. Your health care team will watch for side effects and can give you medicines to help you feel better.

Clinical trials

You may have had to make a lot of decisions since you’ve been told you have cancer. One of the most important decisions you will make is choosing which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.

Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures.

If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. You can also get a list of current clinical trials by calling the National Cancer Institute’s Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI clinical trials Web site at www.cancer.gov.

There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.

Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number (1-800-227-2345) and have it sent to you.

Complementary and alternative therapies

When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn’t mentioned. Everyone from friends and family to Internet groups and Web sites offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

What exactly are complementary and alternative therapies?

Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment.

Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few have even been found harmful.

Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.

Finding out more

It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.

As you consider your options, here are 3 important steps you can take:

• Look for “red flags” that suggest fraud. Does the method promise to cure all or most cancers? Are you told not to have regular medical treatments? Is the treatment a “secret” that requires you to visit certain providers or travel to another country?

• Talk to your doctor or nurse about any method you are thinking about using

• Contact us at 1-800-ACS-2345 to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at.

The choice is yours

Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.

Treatment options for cervical cancer by stage

The stage of a cervical cancer is the most important factor in choosing treatment. However, other factors that affect this decision include the exact location of the cancer within the cervix, the type of cancer (squamous cell or adenocarcinoma), your age, your overall physical condition, and whether you want to have children.

Stage 0 (carcinoma in situ)

Although the staging system classifies carcinoma in situ (CIS) as the earliest form of cancer, doctors often think of it as a pre-cancer. That is because the cancer cells in CIS are only in the surface layer of the cervix — they have not grown into deeper layers of cells. Treatment options for squamous cell carcinoma in situ are the same as for other pre-cancers (dysplasia or cervical intraepithelial neoplasia [CIN]). Options include cryosurgery, laser surgery, loop electrosurgical excision procedure (LEEP/LEETZ), and cold knife conization. For adenocarcinoma in situ, hysterectomy is usually recommended. For those who wish to have children, treatment with a cone biopsy may be an option. No cancer cells must be found at the edges of the cone, and the patient must be closely watched as long as the cervix remains in place. After the woman has finished having children, a hysterectomy is recommended.

A simple hysterectomy is also an option for treatment of squamous cell carcinoma in situ, and may be done if it returns following other treatments. All cases of CIS can be cured with appropriate treatment. However, pre-cancerous changes can recur (come back) in the cervix or vagina, so it is very important for your doctor to watch you closely. This includes follow-up with regular Pap smears and in some instances with colposcopy.

Stage IA is divided into stage IA1 and stage IA2

Stage IA1: For this stage you have 3 options

• If you still want to be able to have children, first the cancer is removed with a cone biopsy, and then you are watched closely to see if the cancer comes back.

• If the cone biopsy doesn’t remove all of the cancer (or if you are done having children), the uterus will be removed (hysterectomy).

• If the cancer has invaded the blood vessels or lymph vessels, you might need a radical hysterectomy along with removal of the pelvic lymph nodes.

Stage IA2: There are 3 treatment options

• radical hysterectomy along with removal of lymph nodes in the pelvis

• external beam radiation therapy plus brachytherapy

• radical trachelectomy with removal of pelvic lymph nodes can be done if you still wants to be able to have children

If you have surgery, the tissue removed will be examined in the laboratory to see if the cancer has spread further than expected. If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, radiation therapy is usually recommended. Often chemotherapy will be given with the radiation therapy. If the pathology report says that the tumor had positive margins, this means that some cancer may have been left behind. This is also treated with pelvic radiation (given with cisplatin chemotherapy). The doctor may advise brachytherapy, as well.

Stage IB is divided into stage IB1 and stage IB2

Stage IB1: There are 3 options available:

• The standard treatment is a radical hysterectomy with removal of lymph nodes in the pelvis. Some lymph nodes from higher up in the abdomen (called para-aortic lymph nodes) are also removed to see if the cancer has spread there. If cancer cells are found in the edges of the tissues removed (positive margins) or if cancer cells are found in lymph nodes during this operation, radiation therapy may be given, possibly with chemotherapy, after surgery.

• The second treatment option is high-dose internal and external radiation therapy.

• Radical trachelectomy with removal of pelvic (and some para-aortic) lymph nodes is an option if the patient still wants to be able to have children

Stage IB2: There are 3 options available

• The standard treatment is the combination of chemotherapy with cisplatin and radiation therapy to the pelvis plus brachytherapy.

• Another choice is radical hysterectomy with removal of pelvic (and some para-aortic) lymph nodes. If cancer cells are found in the lymph nodes removed, or in the margins, radiation therapy may be given, possibly with chemotherapy, after surgery.

• Some doctors advise radiation given with chemotherapy (first option) followed by a hysterectomy.

Stage II is divided into stage IIA and stage IIB

Stage IIA: Treatment for this stage depends on the size of the tumor.

• One choice for treatment is brachytherapy and external radiation therapy. This is most often recommended if the tumor is larger than 4 cm (about 1½ inches). Chemotherapy with cisplatin will be given along with the radiation.

• Some experts recommend removing the uterus after the radiation therapy is done.

• If the cancer is not larger than 4 cm, it may be treated with a radical hysterectomy and removal of lymph nodes in the pelvis (and some in the para-aortic area). If the tissue removed at surgery shows cancer cells in the margins or cancer in the lymph nodes, radiation treatments to the pelvis will be given with chemotherapy. Brachytherapy may be given as well.

Stage IIB: Combined internal and external radiation therapy is the usual treatment. The radiation is given with the chemotherapy drug cisplatin. Sometimes other chemo drugs may be given along with cisplatin.

Stage III and IVA

Combined internal and external radiation therapy given with cisplatin is the recommended treatment.

If cancer has spread to the lymph nodes (especially those in the upper part of the abdomen) it can be a sign that the cancer has spread to other areas in the body. Some experts recommend checking the lymph nodes for cancer before giving radiation. One way to do this is by surgery. Another way is to do a CT or MRI scan to see how big the lymph nodes are. Lymph nodes that are bigger than usual are more likely to have cancer. Those lymph nodes can be biopsied to see if they contain cancer. If lymph nodes in the upper part of the abdomen (the para-aortic lymph nodes) are cancerous, doctors may want to do other tests to see if the cancer has spread to other parts of the body.

Stage IVB

At this stage, the cancer has spread out of the pelvis to other areas of the body. Stage IVB cervical cancer is not usually considered curable. Treatment options include radiation therapy to relieve the symptoms of cancer that has spread locally (near the cervix) or distant metastases. Chemotherapy is often recommended. Most standard regimens use a platinum compound (such as cisplatin or carboplatin) along with another drug such as paclitaxel, gemcitabine, topotecan, or vinorelbine. Clinical trials are testing other combinations of chemotherapy drugs, as well as some other experimental treatments.

Recurrent cervical cancer

Cancer that comes backs after treatment is called recurrent cancer. Cancer can come back locally (in the pelvic organs near the cervix) or come back in distant areas (spread through the lymphatic system and/or the bloodstream to organs such as the lungs or bone).

If the cancer has recurred in the pelvis only, extensive surgery (by pelvic exenteration) may be an option for some patients. This operation may successfully treat 40% to 50% of patients. (See the discussion under Surgery in the section, “How is cervical cancer treated?”) Sometimes radiation or chemotherapy may be used for palliative treatment (treatment to relieve symptoms but not expected to cure).

If your cancer has recurred in a distant area, chemotherapy or radiation therapy may be used to treat and relieve specific symptoms. If chemotherapy is used, you should understand the goals and limitations of this therapy. Sometimes chemotherapy can improve your quality of life, and other times it can diminish it. You need to discuss this with your doctors. Fifteen percent to 25% of patients may respond at least temporarily to chemotherapy.

New treatments that may benefit patients with distant recurrence of cervical cancer are being evaluated in clinical trials. You may want to think about participating in a clinical trial.

Cervical cancer in pregnancy

A small number of cervical cancers are found in pregnant women. If your cancer is a very early cancer, such as stage IA, then most doctors believe that it is safe to continue the pregnancy to term. Several weeks after delivery, a hysterectomy or a cone biopsy is recommended (the cone biopsy is suggested only for substage IA1).

If the cancer is stage IB, then you and your doctor must decide whether to continue the pregnancy. If not, treatment would be radical hysterectomy and/or radiation. If you decide to continue the pregnancy, the baby should be delivered by cesarean section as soon as it is able to survive outside the womb. More advanced cancers, should be treated immediately.

Financial help

In 2000, the Breast and Cervical Cancer Treatment Act was signed into law. This act provides funds to treat breast and cervical cancer for some low-income women. States must adopt the program in order to receive matching federal funds. For more information, you can contact the CDC at 1-888-842-6355 or on the Internet at www.cdc.gov/cancer.

Disclaimer

This information represents the views of the doctors and nurses serving on the American Cancer Society’s Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options. The following information is provided by the American Cancer Society.