Management

Once the diagnosis of invasive cervical cancer is established confidently by histology, the disease is clinically staged (Table 3), which involves assessment of the degree of dissemination.
This assessment allows for consideration of the appropriate

treatment options. Pretreatment evaluation includes taking a thorough history and conducting a physical examination. Particular emphasis should be placed on the pelvic examination, because cervical cancer is often locally destructive before it is metastatic.

A rectovaginal examination is important to identify nodules or masses that indicate the possibility of locally invasive disease.

Selective use of chest radiography, intravenous pyelography, cystoscopy, gastrointestinal endoscopy (i.e., flexible sigmoidoscopy), lymphangiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the pelvis and abdomen may be useful in appraising the degree of metastatic disease. (Table 4). Assessment of renal function is vital to the staging of cervical cancer. The presence of unilateral or bilateral ureteral obstruction with azotemia often heralds metastatic disease and heralds a poorer prognosis.
Stage Ia Tumors
Stage Ia tumors are first diagnosed microscopically by colposcopic-directed biopsy and are always confirmed by cone biopsy. Because these early invasive tumors have a low risk of nodal metastases, the prognosis is good. Five-year survival exceeds 95 percent with appropriate treatment. Recommended therapy is simple hysterectomy without pelvic lymph node dissection. Adequate cone biopsy with close follow-up is an option in women who wish to preserve their fertility and understand the potential risk of progression.
Stage Ib and IIa Tumors
Stage Ib and IIa tumors are diagnosed clinically (Table 4) and can be treated surgically or with radiotherapy. Both treatments produce similar results, with a five-year survival rate of 80 to 90 percent. Surgery includes a radical hysterectomy, which involves removal of the parametria, uterosacral ligaments and a 2- to 3-cm cuff of the vagina, and dissection of pelvic lymph nodes. Oophorectomy is not necessary in premenopausal women.
Radiotherapy involves intracavitary (placement in the vaginal fornices and uterine cavity) and external beam radiation for the treatment of pelvic nodes. Pelvic radiotherapy may also be used when a tumor is found at the margins of the radical hysterectomy specimen or in the pelvic lymph nodes, because it can decrease local recurrence. The presence of lymph node metastasis dramatically decreases survival.
Bulky stage Ib tumors, which are 4 cm or more in diameter, carry a poorer prognosis than smaller stage I tumors. The Gynecologic Oncology Group recently completed a study that compared radiotherapy alone with a combination of radiotherapy and cisplatin (Platinol), taken weekly for up to six doses, followed by adjuvant hysterectomy in all patients. The addition of cisplatin therapy halved the risk of disease progression and death.
Stage IIb, III and IV Tumors
Once the tumor extends to or invades local organs, radiation therapy becomes the mainstay of treatment. This therapy provides five-year survival rates of 65, 40 and less than 20 percent for stages IIb, III and IV, respectively. Patients with distant metastases (stage IVb) also require chemotherapy to control systemic disease.
Research to improve the rate of survival in advanced-stage cervical neoplasia has been ongoing.
Two recent randomized trials compared radiotherapy alone with concurrent cisplatin-based chemotherapy, alone or with fluorouracil One study included hydroxyurea.
Researchers found that concurrent chemotherapy with cisplatin alone or with fluorouracil significantly improved the rates of survival and progression-free survival among women with stages IIb through IVa cervical cancer. Chemotherapy increased hematologic toxicity, but this effect was reversible, and the rates of late-onset side effects were similar among the radiotherapy groups when compared with those in the concurrent chemotherapy groups in both studies.