Cervical cancer

Diagnostic and Staging Work up

Diagnostic and staging work up should include history and

physical examination, complete blood count, as well as liver function and renal function studies.

Good practice statement

We recommend cervical cytology or Papanicolaou (Pap) smears and cervical biopsies for diagnosis.

Strong recommendation

We recommend cone biopsy (i.e., conization) if the cervical biopsy is inadequate to define invasiveness or if accurate assessment of microinvasive disease is required.

Strong recommendation

Recommended radiologic imaging includes pelvic MRI, and FDG-PET/CT.

Strong recommendation

Consider examination under anesthesia (EUA) cystoscopy/proctoscopy for cases having ≥ stage IB.

Good practice statement

Consider options for fertility sparing or referral to reproductive endocrinology and infertility.

Conditional recommendation

Staging and risk assessment.

Tumor risk assessment should include tumor size, stage, depth of tumor invasion, lymph node status, LVSI and histological subtype.

Strong recommendation

Management of local/locoregional disease,

Surgery

Surgical therapy in cervical cancer should be adapted to the stage of disease according to FIGO and TNM classification (Appendix).

Good practice statement

Surgery should only be considered in patients with earlier stages of cervical cancer (up to FIGO IIA) without risk factors necessitating adjuvant therapy, which results in a multimodal therapy without improvement of survival but increased toxicity.

Strong recommendation

Microinvasive cervical cancer (stage IA1) without LVSI should be managed with conisation or simple trachelectomy to preserve fertility, and simple hysterectomy is recommended if the patient does not wish to preserve fertility.

Strong recommendation

In stage IA1 with LVSI, surgical assessment of pelvic lymph nodes is recommended.

Strong recommendation

In patients with FIGO stage IA2, IB and IIA, radical hysterectomy with bilateral lymph node dissection (with or without SLN) is standard treatment, if the patient does not wish to preserve fertility.

Strong recommendation

Adjuvant/neoadjuvant treatment

Consider NACT with surgery as this may reduce the need for adjuvant RT.

Conditional recommendation

Intermediate-risk surgicopathologic findings, frequently referred to as Sedlis criteria, are defined by a combination of lymphovascular space involvement, depth of stromal invasion, and tumor size (Table 5, appendix), and they should be treated by whole pelvic RT delivered to a total dose of 4500 to 5040 cGy, in 180 Gy per fraction or 4000 to 4400 Gy in 200 Gy per fraction.

Strong recommendation

Adjuvant CRT is recommended in high-risk patients (one or more negative prognostic factors such as positive or close surgical margins, positive lymph nodes or microscopic parametrial involvement). For these patients, whole pelvic RT should be delivered to a total dose of 4500 to 5040 cGy, in   180 cGy fractions, with concurrent weekly cisplatin (40mg/m2).

Strong recommendation

Chemoradiotherapy in locally advanced cervical cancer

We recommend CRT  for patients with bulky IB2–IVA disease, and the most commonly used regimen is weekly cisplatin 40 mg/m2.

Strong recommendation

Patients not eligible to cisplatin may receive carboplatin or gemcitabine.

Strong recommendation

Brachytherapy is needed to obtain a sufficiently high dose to ensure a high rate of local control in advanced cases.

Good practice statement

Management of advanced/metastatic disease

Palliative chemotherapy with the aim of relieving symptoms and improving quality of life is recommended if the patient has a PS< 2 and no formal contraindications.

Strong recommendation

Cisplatin-based doublets with paclitaxel or topotecan have demonstrated superiority to cisplatin monotherapy in terms of response rate and PFS.

Strong recommendation

Paclitaxel and cisplatin combined with bevacizumab is recommended as the preferred first-line regimen in metastatic or recurrent cervical cancer based on the balance between efficacy and toxicity profile.

Strong recommendation

The combination of paclitaxel and carboplatin is recommended as an alternative for patients that are not candidates for cisplatin.

Strong recommendation

Some patients develop small lung metastases only, which do not rapidly progress and can be managed with stereotactic RT and/or a watchful waiting policy, frequently delaying systemic chemotherapy for a significant period of time.

Conditional recommendation

Local recurrence of cervical cancer following radical surgery

Higher doses of RT can be delivered with brachytherapy and increase the likelihood of local control for patients with small volume central recurrences.

Strong recommendation

Clinical indicators  

Follow-up visits with a complete physical examination including a pelvic–rectal exam and a patient history should be conducted by a physician experienced in the surveillance of cancer patients.

Good practice statement

CT or PET/CT scan should be carried out as clinically indicated. A reasonable follow-up schedule involves follow-up visits every 3–6 months in the first 2 years and every 6–12 months in years 3–5.

Good practice statement

Patients should return to annual population-based general physical and pelvic examinations after 5 years of recurrence-free follow-up.

Good practice statement