By Dr Ananya Mandal, MD
Cervical cancer, if detected early, is curable.
Who provides cervical cancer treatment?
Treatment is provided by a multidisciplinary team. The team usually consists of a gynaecologist, a surgeon, a clinical oncologist who specializes in chemotherapy and radiotherapy, a medical oncologist who specializes in chemotherapy, a pathologist, a radiologist or an imaging radiologist, a social worker, a psychologist and an oncology nurse.
The regimen and plan for therapy depends on numerous factors. Some of these include:
Stage of the disease
Patient’s age and wish for future child bearing
General condition of the patient
Personal preferences of the patient
Recommendations based on stages of cancer
In most cases the recommendations for various stages of cancer can be outlined as:
Stage 0 – this is a precancerous stage. Any abnormal cells that are detected are removed. This can be done by different methods, including using lasers to burn away the cells or a very cold instrument to freeze them (cryotherapy).
Stages 1 and early stages – surgery is the first choice. The cervix in its entirety with or without the part or all of the womb (uterus) is removed (hysterectomy). The prospect of a complete cure is usually good for stage one cervical cancer.
Stages 2 and advanced cancer – surgery is followed by radiotherapy to kill the remnant cancer cells after surgery. The prospect of cure is moderate for stage two cervical cancer.
Stages 3 and early Stage 4 cancer – radiotherapy is combined with chemotherapy. A complete cure is less likely for stage three cervical cancer
Stage 4 advanced cancer – here surgery is followed by both chemotherapy and radiotherapy. Cure is unlikely for stage four cervical cancer.
Palliative care – this is usually provided in advanced cancers to relieve symptoms as much as possible if there is very little chance of cure.
Methods of treatment
Removal of dysplastic or abnormal cells
This is a method applied to CIN or precancerous conditions. Laser therapy uses laser or special light rays to burn away the abnormal cells. Cryotherapy or cold coagulation freezes the abnormal cells and kills them. A cone biopsy removes the abnormal cells by a sham surgery. This is used for both diagnosis and therapeutic purposes.
There are three main types of cervical cancer surgery. One of them is radical trachelectomy where the cervix, surrounding tissue and the upper part of the vagina are removed but the uterus is left in place. This is usually only suitable for very early stage one cancer. It is usually offered to women who want to preserve their child-bearing potential. Lymph nodes from the pelvis may also be removed.
In radical hysterectomy both the cervix and the uterus are removed. If the cancer is advanced, then both the fallopian tubes and the ovaries may be removed. This is usually recommended for advanced stage one cervical cancer and early stage two cervical cancer. Surgery may be followed by a course of radiotherapy to help prevent the cancer coming back. The patient’s child bearing potential is lost and if the ovaries are removed she will achieve a premature menopause if the surgery is undertaken before actual menopause sets in.
The third and most extensive surgery is called pelvic exenteration in which the cervix, vagina, womb, bladder, ovaries, fallopian tubes and rectum are removed.
This is used alone in early stage one cancer and combined with surgery in stage 2 and with chemotherapy as well as surgery in stage 3 and 4 cervical cancer. Radiotherapy is not routinely combined with surgery because of the higher risk of side effects.
There are two ways that radiotherapy can be delivered. One is called the external radiation therapy where the patient has to routinely visit the hospital for sessions and is placed before a machine that is similar to an X ray machine with high energy waves directed to the pelvis killing off cancer cells.
The other method is by internal radiation where radioactive pellets of seeds are placed inside the patient’s vagina. These release radiation locally to kill the cancer cells.
A course of radiotherapy usually lasts for around five to eight weeks. Radiation therapy has several side effects as it also destroys surrounding healthy cells. Some of the side effects for radiation for cervical cancer include pain on urination, diarrhea, bleeding from vagina and/or rectum, fatigue, nausea, skin sores, narrowing of the vagina leading to painful intercourse, infertility, menopause and damage to bowel and bladder functions.
Chemotherapy can be combined with radiotherapy and surgery in stages 3 and 4 of cervical cancer. It helps to slow the progression of the cancer and relieve symptoms. Single anticancer drugs like cisplatin may be used or a combination with other drugs may be used. Side effects of most chemotherapy drugs include nausea, diarrhea, mouth sores, weakness, anemia, bleeding tendencies, propensity to get infections, bone marrow suppression, loss of appetite, hair loss etc.
Follow up after treatment
Once treatment is completed and the cancer has been removed the patient is asked to return regularly (every four months or so for the first 2 years and then every 6 months to 12 months for further 3 years) monitor the possible return of the cancer. If a suspicious lesion is seen, it is biopsied. In around 1 in 5 cases, cervical cancer can return. This usually occurs around 18 months after a course of treatment has been completed.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)