Cervical Cancer Clinical Practice Guidelines (2019)

National Comprehensive Cancer Network

Reviewed and summarized by Medscape editors

February 05, 2019

The guidelines on cervical cancer were released in January 2019 by the National Comprehensive Cancer Network.[1]

Diagnosis and Workup

Cervical cytology or Papanicolaou (Pap) smears and cervical biopsies can usually result in an accurate diagnosis. Cone biopsy (ie, conization) is recommended if the cervical biopsy is inadequate to define invasiveness or if accurate assessment of microinvasive disease is required.

Workup for patients with suspicious symptoms includes history and physical examination, complete blood count (CBC; including platelets), and liver and renal function tests. Recommended radiologic imaging includes chest radiograph, CT, or combined PET/CT, and MRI as indicated (eg, to rule out disease high in the endocervix).

Cystoscopy and proctoscopy are recommended only if bladder or rectal extension is suspected.

Principles of Staging and Surgery

Clinical staging is based on primary tumor characteristics (ie, diameter in greatest dimension, cervical stromal invasion, locoregional spread) and distant metastasis.

Although not a part of formal staging, the use of imaging studies may aid in treatment planning: magnetic resonance imaging (MRI) is useful to delineate disease extent and to guide decisions regarding fertility-sparing versus non–fertility-sparing treatment approaches, while PET/CT may be useful to detect and/or rule out metastasis.

For surgical staging, primary tumor evaluation include tumor site; primary tumor volume in multiple dimensions); histologic type and grade; stromal invasion; surgical margin status; and the presence of lymphovascular invasion. When resected, the number of lymph nodes with isolated tumor cells, micrometastases, and macrometastases should be recorded. When sentinel lymph node (SLN) mapping is performed, SLNs should undergo ultrastaging for detection of low-volume metastasis; non-sentinel nodes do not require ultrastaging.

Primary Treatment

The primary treatment of early-stage cervical cancer is either surgery or radiation therapy (RT). Surgery is typically reserved for early-stage disease, fertility preservation, and smaller lesions (eg, stage IA, IB1, and selected IIA1 cases).

Fertility-sparing approaches (cone biopsy with or without pelvic lymph node dissection) may be considered in highly selected patients who have been thoroughly counseled regarding disease risk as well as prenatal and perinatal issues.

Recent studies have reported poorer oncologic outcomes and survival with radical hysterectomy performed using minimally invasive laparoscopic techniques compared with open laparotomy. Patients should be carefully counseled about the oncologic risks and potential short-term benefits of the different surgical approaches.

Non–fertility-sparing treatment

Stage IB1 and stage IIA1: Radical hysterectomy + pelvic lymph node dissection ± para-aortic lymph node dissection or pelvic external beam radiation therapy (EBRT) + brachytherapy (total point A dose: 80–85 Gy) ± concurrent platinum-containing chemotherapy.

Stage IB2 and stage IIA2: Definitive pelvic EBRT+ concurrent platinum-containing chemotherapy+ brachytherapy (total point A dose ≥85 Gy) or radical hysterectomy + pelvic lymph node dissection ± para-aortic lymph node dissection or pelvic EBRT + concurrent platinum-containing chemotherapy + brachytherapy + adjuvant hysterectomy.

Adjuvant Treatment

Observation is appropriate for patients with stage IA2, IB1, or IIA1 disease who have negative nodes, negative margins, negative parametria, and no cervical risk factors after radical hysterectomy (Sedlis criteria).

Pelvic EBRT is recommended with (or without) concurrent platinum-containing chemotherapy for patients with stage IA2, IB1, or IIA1 disease who have negative lymph nodes after surgery but have large primary tumors, deep stromal invasion, and/or lymphovascular space invasion (LVSI). Recommended radiosensitizing regimens include cisplatin (preferred), carboplatin (preferred if the patient is cisplatin intolerant), or cisplatin/fluorouracil.

Postoperative pelvic EBRT with concurrent platinum-containing chemotherapy with (or without) vaginal brachytherapy is recommended for high-risk patients (ie, those with positive pelvic nodes, positive surgical margin, and/or positive parametrium).

Use of neoadjuvant chemotherapy is not recommended outside of a clinical trial.

For more information, see Cervical Cancer, Cervical Cancer Staging, Cervical Cancer Imaging, Sentinel Node Biopsy for Vulvar/ Cervical Cancer, and Cervical Cancer Treatment Protocols.

For more Clinical Practice Guidelines, please go to Guidelines.

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