Cervical cancer medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Nima Nasiri, M.D.[2]Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

The optimal therapy for cervical cancer depends on the stage at diagnosis, treatment of cervical neoplasia is mainly combination of radiation therapy and use of chemotherapeutic agents.

Medical Therapy

Treatment options are variable depending upon the individual stages according to the International Federation of Gynecology and Obstetrics (FIGO).[1][2]

In situ carcinoma of the cervix:

Treatment options for squamous cell carcinoma in situ include:

Treatment options for adenocarcinoma in situ include:

Stage IA cervical cancer

Stages IB, IIA cervical cancer

Stages IIB, III, and IVA cervical cancer

Stage IVB cervical cancer

Recurrent cervical cancer

Radiation therapy

In Situ Cervical Cancer[3]

  • Internal radiation therapy can be used for patients can't go under surgery, in this technique a single intracavitary insertion with tandem and ovoid can be used with dosage of 5,000 mg hours (80 Gy vaginal surface dose)

Stage IA Cervical Cancer[4]

  • Intracavitary radiation therapy is a treatment option for women who are not surgical candidate and if the depth of invasion is less than 3 mm and no capillary lymphatic space invasion is noted, and the frequency of lymph node involvement is low. In these patients one or two insertions with tandem and ovoids for 6,500 mg to 8,000 mg hours (100–125 Gy vaginal surface dose) are recommended.

Stages IB and IIA Cervical Cancer

  • Radiation therapy with concomitant chemotherapy[5][6][7]
  • cisplatin-based chemotherapy with radiation therapy is the standard of care for women who require radiation therapy. Radiation therapy protocols for patients with cervical cancer have historically used dosing at two anatomical points, termed point A and point B, to standardize the doses received. Point A is defined as 2 cm from the external os, and 2 cm lateral, relative to the endocervical canal. Point B is also 2 cm from the external os, and 5 cm lateral from the patient midline, relative to the bony pelvis. In general, for smaller tumors, the curative-intent dose for point A is around 70 Gy, whereas for larger tumors, the point A dose may approach 90 Gy.
  • Brachytherapy
  • brachytherapy after external-beam radiation therapy (EBRT) is the standard of care for women with cervical cancer. The use of high-dose rate (HDR) brachytherapy provides the advantage of the following:
    • Eliminating radiation exposure to medical personnel
    • Shorter treatment time
    • Patient convenience
    • Improved outpatient management.
  • The radiation therapy included EBRT and one Cs-137 LDR insertion, with a total dose to point A from 70 to 90 Gy (median 76 Gy)
  • Other Treatment Options:
  • Adjuvant radiation therapy post surgery
  • External-beam pelvic radiation therapy combined with two or more intracavitary brachytherapy applications is appropriate therapy for patients with stage IA2 and IB1 lesions. For patients with stage IB2 and larger lesions, radiosensitizing chemotherapy is indicated. The role of radiosensitizing chemotherapy in patients with stage IA2 and IB1 lesions is untested. However, it may prove beneficial in certain cases.
  • Intensity-modulated radiation therapy (IMRT) which is 3D conformal radiotherapy, a technique that allows for focusing radiation beams on targeted cancer tissue precisely, while sparing adjacent organs. It is shown in studies that it decreases radiation therapy toxicity but it may decrease its efficacy. [8]

Stages IIB, III, and IVA Cervical Cancer

  • Radiation therapy with concomitant chemotherapy
  • Interstitial brachytherapy
  • For patients who complete EBRT and have bulky cervical disease such that standard brachytherapy cannot be placed anatomically, interstitial brachytherapy has been used to deliver adequate tumoricidal doses with an acceptable toxicity profile.

Stage IVB Cervical Cancer

  • Palliative radiation therapy
  • Radiation therapy may be used to palliate central disease or distant metastases

Recurrent Cervical Cancer

Chemotherapy

Stages IB and IIA Cervical Cancer[9]

  • Concurrent, cisplatin-based chemotherapy with radiation therapy is the standard of care for women who require radiation therapy for treatment of cervical cancer

Stages IIB, III, and IVA Cervical Cancer

  • Strong consideration should be given to the use of intracavitary radiation therapy and external-beam radiation therapy (EBRT) to the pelvis combined with cisplatin or cisplatin/fluorouracil (5FU)

Stage IVB Cervical Cancer[10]

Drugs used in stage IVB cervical cancer treatment are shown in table below[11]

Drug Name Response Rate
Cisplatin 15%–25%
Ifosfamide 31%
Paclitaxel 17%
Ifosfamide/cisplatin 31%
Irinotecan 21% in patients previously treated with chemotherapy
Paclitaxel/cisplatin 46%
Cisplatin/gemcitabine 41%
Cisplatin/topotecan 27%

Recurrent Cervical Cancer[12]

Drugs used in Recurrent Cervical Cancer treatment are shown in table below[13]

Drug Name Response Rate
Cisplatin 15%–25%
Ifosfamide 31%
Paclitaxel 17%
Ifosfamide/cisplatin 31%
Irinotecan 21% in patients previously treated with chemotherapy
Paclitaxel/cisplatin 46%
Cisplatin/gemcitabine 41%
Cisplatin/topotecan 27%
Cisplatin/vinorelbine 30%
Bevacizumab 11%; 24% survived progression free for at least 6 months, as seen in GOG-0227C(NCT00025233)

References

  1. http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq/#section/_85
  2. Hazell, Sarah Z.; Stone, Rebecca L.; Lin, Jeffrey Y.; Viswanathan, Akila N. (2018). "Adjuvant therapy after radical trachelectomy for stage I cervical cancer". Gynecologic Oncology Reports. 25: 15–18. doi:10.1016/j.gore.2018.05.001. ISSN 2352-5789.
  3. http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_93
  4. Creasman WT, Fetter BF, Clarke-Pearson DL, Kaufmann L, Parker RT (September 1985). "Management of stage IA carcinoma of the cervix". Am. J. Obstet. Gynecol. 153 (2): 164–72. PMID 4037011.
  5. Eifel, Patricia J (2006). "Concurrent chemotherapy and radiation therapy as the standard of care for cervical cancer". Nature Clinical Practice Oncology. 3 (5): 248–255. doi:10.1038/ncponc0486. ISSN 1743-4254.
  6. Kamrava, Mitchell; Banerjee, Robyn (2014). "Brachytherapy in the treatment of cervical cancer: a review". International Journal of Women's Health: 555. doi:10.2147/IJWH.S46247. ISSN 1179-1411.
  7. Kamrava, Mitchell; Banerjee, Robyn (2014). "Brachytherapy in the treatment of cervical cancer: a review". International Journal of Women's Health: 555. doi:10.2147/IJWH.S46247. ISSN 1179-1411.
  8. Lin, Yanzhu; Chen, Kai; Lu, Zhiyuan; Zhao, Lei; Tao, Yalan; Ouyang, Yi; Cao, Xinping (2018). "Intensity-modulated radiation therapy for definitive treatment of cervical cancer: a meta-analysis". Radiation Oncology. 13 (1). doi:10.1186/s13014-018-1126-7. ISSN 1748-717X.
  9. http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_110
  10. http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_141
  11. http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_141
  12. http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_147
  13. http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_147

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