BEST PRACTICE GUIDELINES - Management of Cervical Cancer

 

SUMMARY OF MAJOR RECOMMENDATIONS BASED ON SIGN GUIDELINE NO 99 (JANUARY 2008)
http://www.sign.ac.uk/pdf/qrg99.pdf


INTRODUCTION
 
Cervical cytology detects precancerous changes of the cervix known as cervical intraepithelial neoplasia (CIN). Population screening has been known to reduce the incidence of cervical cancer and reduce the proportion of women presenting with advanced disease. Only 30% of cervical cancers are screen detected and the majority of cases occur in women who have never had a smear or have not been regularly screened. Any woman who is sexually active is at risk of infection with Human Papilloma Virus (HPV). Over 100 subtypes of HPV are known, of which, subtypes 16 and 18 cause 70% of cervical cancer cases worldwide. Two HPV vaccines have been developed:


1) Cervarix a bivalent vaccine active against types 16 and 18


2) Gardasil a quadrivalent vaccine active against subtypes 6,11,16, 18.


Both are prophylactic vaccines that have been shown to be effective in young women who have not had HPV exposure.
 
This guideline covers presentation, referral, diagnosis, staging and treatment. The management of small cell and large cell neuroendocrine tumors is not included. The aim of this guideline is to ensure optimal management by a multidisciplinary team to minimize the huge burden experienced by women with the disease.
 
SUMMARY OF MAJOR RECOMMENDATIONS
 
PRESENTATION
 
· Intermenstrual Bleeding (IMB)


· Postcoital Bleeding (PCB)


· Post menopausal bleeding (PMB)


· Abnormal appearance of the cervix


· Vaginal Discharge


· Pelvic Pain
 
DIAGNOSIS AND SYMPTOMS


Pathology reports of cervical tumours should include the following histological features: D


· Tumor type


· Tumor size


· Extent of tumor (e.g. involvement of the vaginal wall or parametrium)


· Depth of invasion


· Pattern of invasion (infiltrative or cohesive invasive front)


· Lymphovascular space invasion (LVSI)


· Status of resection margins (presence of tumor and distance from margin)


· Status of lymph nodes (including site and number of nodes involved)


· Presence of pre-invasive disease.


GOOD PRACTICE GUIDELINE
 
· Pathological assessment should be quality assured and standardized, with readily accessible specialist review available if required, following discussion by the multidisciplinary team
 
RADIOLOGICAL STAGING

  • All patients with visible, biopsy proven cervical carcinoma (except those with FIGO IV disease) should have an MRI scan. B

  • The MRI scan should include: thin section T2 weighted images perpendicular to the cervix, and
    sequences to include urinary tract and para-aortic nodal areas. C

  • Post contrast spiral CT should be considered as an alternative to MRI in patients who cannot have MRI. Women who have clinically apparent FIGO stage IV disease should have post contrast spiral or multislice CT scans of chest abdomen and pelvis. B

  • Patients not suitable for surgery should be considered for a PET scan. C

  • If imaging cannot exclude bladder or bowel involvement, cystoscopy and sigmoidoscopy should be used for staging C
     

SURGERY

  • Radical surgery is recommended for FIGO IB1 disease if there are no contraindications to surgery. B

  • Removal of pelvic lymph nodes is not recommended during treatment for FIGO IA1 disease. D

  • Pelvic lymph nodes should be removed if FIGO IA2 disease is present. D

  • Women requesting fertility conservation should be offered radical trachelectomy and pelvic lymph node dissection, providing the tumor diameter is less than 2 cm and no lymphatic-vascular space invasion is present. C

  • Women with early stage disease and no LVSI (FIGO IA2 and microscopic IB1) requesting fertility conservation may be offered cold knife conisation or large loop excision of the transformation zone combined with pelvic lymph node dissection. D

  • Laparoscopic-vaginal radical hysterectomy should not be offered to patients with tumor diameter greater than 2 cm. D
     

TREATMENT DURING PREGNANCY

  • For pregnant women with cervical cancer, the choice of therapeutic modality should be decided in the same manner as for non-pregnant patients. C

  • For pregnant women diagnosed with cervical cancer before 16 weeks of gestation, immediate treatment is recommended. C

  • For pregnant women with early stage disease (FIGO IA1, IA2, IB) diagnosed after 16 weeks of gestation, treatment may be delayed to allow fetal maturity to occur. C

  • For pregnant women with advanced disease (FIGO 1B2 or greater) diagnosed after 16 weeks of gestation, consideration for delay must be based on gestational age at time of diagnosis C

 
CHEMOTHERAPY/RADIOTHERAPY
 

  •  Any patient with cervical cancer considered suitable for radical radiotherapy treatment should have concurrent chemoradiotherapy with a platinum based chemotherapy, if fit enough. A

  • Patients who have undergone surgery for cervical carcinoma and have positive nodes should be considered for adjuvant treatment with concurrent chemoradiotherapy with platinum based chemotherapy. B

  • Patients who have undergone surgery for cervical carcinoma, have negative nodes and any two of the following risk factors should be considered for adjuvant treatment with radiotherapy, if fit enough:

1. greater than a third stromal invasion
2. Lymphovascular space invasion
3. tumor diameter of >4 cm. B

  •  Concurrent chemoradiation should be considered in preference to radiation alone. D

  •  Brachytherapy should be considered an essential component of radical radiotherapy or chemoradiotherapy. D

  •  Patients with cervical carcinoma undergoing radiotherapy or chemoradiotherapy should have their hemoglobin level monitored and corrected if it falls below 12 g/dl. D

  •  Rectal or oral sucralfate is not recommended to reduce acute radiation induced proctitis. B

  •  Rectal sucralfate may be considered to reduce late radiation induced proctitis. D

  •  HRT is recommended for women who have lost ovarian function as a result of treatment for cervical cancer. C

  •  Sexual morbidity: Women should be offered a vaginal stent or dilator to prevent post-radiotherapy vaginal complications. C

LYMPHOEDEMA

  •  Patients with symptoms suggestive of lymphoedema should be referred early for assessment by a designated lymphoedema practitioner. D

  •  Patients with severe or poorly controlled lymphoedema should be offered decongestive lymphatic therapy with a specialist lymphoedema practitioner. D

 
FOLLOW-UP
 
GOOD PRACTICE GUIDELINE:

  •  Patients should be followed up every four months for at least two years.

  •  History taking and clinical examination should be carried out during follow up of patients with cervical cancer to detect symptomatic and asymptomatic recurrence. D

  •  Cervical cytology or vault smears are not indicated to detect asymptomatic recurrence of cervical cancer D.

Management of Minor Hemorrhage
 
Treatment for minor hemorrhage may include:

 

  •  Oral tranexamic acid or aminocaproic acid

 Tranexamic acid applied topically to superficial fungating wound tranexamic acid by rectal or bladder instillation a single fraction of radiotherapy D
 
DETECTION OF RECURRENT DISEASE 

  •  MRI or CT should be considered initially to assess potential clinical recurrence in symptomatic patients. C

  •  A whole body PET scan or PET-CT should be performed on all patients in whom recurrent or persistent disease has been demonstrated on MRI or CT and in whom salvage therapy (either pelvic exenteration or radiotherapy) is being considered. B

GOOD PRACTICE GUIDELINE

  •  A PET-CT scan at nine months of follow up is recommended in women who have had chemoradiotherapy

MANAGEMENT OF RECURRENT DISEASE

  •  Pelvic exenteration should be reserved as salvage surgery for women with recurrent cervical cancer in the central pelvis whose chemoradiotherapy has failed. D

 Palliative chemotherapy should be offered to women with FIGO stage IVB or recurrent cervical carcinoma, after discussion of the relative benefits and risks, with either cisplatin 50 mg/m2 on day 1 plus topotecan 0.75 mg/m2 on days 1 to 3 every 3 weeks, or cisplatin 50 mg/m2 on day 1 plus paclitaxel 135 mg/m2 every 3 weeks.
  
SUPPORTIVE MANAGEMENT

  •  Patients with cervical cancer should be offered psychological support at the time of diagnosis and at intervals throughout their management. B

  •  Information about local support services should be made available to patients. D

  •  Careers, families and dependants should be made aware of support available including local and national organizations. D

  
     

 
         
     

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