Types of treatment for Cervical Cancer

Executive Summary

The different types of standard treatments for cervical cancer are explained in detail. Standard treatments are used along with the integration of effective treatment planning. Clinical trials are used as an innovative treatment approach that combines different therapies and drugs for treating cervical cancer. The common treatments for cervical cancer include surgery (Conization, LEEP, Hysterectomy, Bilateral salpingo-oophorectomy, exenteration, Radical trachelectomy), radiation therapy, chemotherapy, targeted therapy, and immunotherapy. Palliative care is provided to the patients to cope with mental, physical or financial issues while involving medication, nutritional changes, emotional and spiritual support and other relaxation therapies.

Cervical cancer treatment options by Stage are also integrated, involving the radiation therapy alone or surgery in case of the early-stage tumor. Chemoradiation is generally used for women with a giant and advanced-stage tumor found only in the pelvis or if the lymph nodes have cancer cells. The treatment plan for metastatic cervical cancer includes surgery, targeted therapy, radiation therapy, and immunotherapy, which is a treatment created to boost the body’s natural defenses to fight the tumor. Remission and chance of recurrence of cervical cancer include surgery, chemotherapy, radiation therapy, and targeted therapy. 

Treatment of Cervical Cancer

“Standard to care” refers to the best-known treatment. In cancer care, different doctors work together to bring out an overall treatment plan for the cervical cancer patient. This is called a multidisciplinary team.

Treatments for Cervical Cancer recommendations depend on many factors:

• The size, grade and type of tumor
• Whether the tumor is applying pressure on vital parts of the brain
• If the tumor has increased to other parts of the CNS or body
• Possible side effects
• The patient’s preferences and overall health

Details of the common types of treatments used for cervical cancer are mentioned below:

Surgery 

Surgery is the removal of a tumor and nearby healthy tissue during an operation ^​1​. 

A doctor specializing in treating gynecologic cancer using surgery is called a gynecologic oncologist. The following procedures are used for cervical cancer that has not spread beyond the cervix:

• Conization: The use of the same procedure as a cone biopsy to remove all abnormal tissue. It can remove cervical cancer that can only be seen with a microscope, called micro-invasive cancer.
• LEEP:  The use of an electrical current passed through a thin wire hook. The hook removes the tissue. It is used to remove micro-invasive cervical cancer.
• Hysterectomy: The removal of the uterus and cervix is called hysterectomy. Hysterectomy can be simple or radical. A simple hysterectomy removes the cervix and uterus, while a radical hysterectomy removes the uterus, cervix, and tissue around the cervix and upper vagina ^​2​. A radical hysterectomy also consists of an extensive pelvic lymph node dissection, which means lymph nodes are removed. This procedure can be done using a significant cut in the abdomen, called laparotomy, or smaller cuts, called laparoscopy.
• Bilateral salpingo-oophorectomy: If needed, this surgery removes both fallopian tubes and ovaries. It is performed at the same time as a hysterectomy.
• Exenteration: The removal of the vagina, uterus, rectum, lower colon, or bladder if cervical cancer spreads to these organs after radiation therapy. Exenteration is rarely recommended. It is most often used for people whose cancer has returned after radiation treatment.
• Radical trachelectomy: A surgical procedure in which the cervix is removed, but the uterus is left intact. It includes pelvic lymph node dissection. This surgery can be used for young patients wanting to preserve their fertility. This procedure has become an alternative to a hysterectomy for some patients.

Complications from surgery vary depending on the extent of the procedure. Sometimes, patients experience significant bleeding, infection, or damage to the urinary and intestinal systems. As these surgical procedures affect sexual health, patients should talk to the doctor about their symptoms and concerns in detail before surgery. The doctor may help lessen the side effects of surgery. Other surgical procedures can make an artificial vagina if extensive surgical procedures have affected sexual function.

Radiation therapy 

Radiation therapy uses high-energy X-rays or particles to destroy cancer cells. The most common radiation treatment type is external-beam radiation therapy, in which radiation is given from the machine outside the body. Internal radiation therapy or brachytherapy is when radiation treatment is given using implants. A radiation therapy schedule consists typically of a specific number of treatments offered over a set period.

A combination of low-dose weekly chemotherapy and radiation therapy for early-stage cervical cancer is often used. Radiation therapy combined with chemotherapy aims to increase the effectiveness of radiation treatment. This combination controls cancer in the pelvis to cure cancer without surgery. It may also be given to kill microscopic cancer that might have remained after surgery.

Side effects from radiation therapy can include fatigue, upset stomach, mild skin reactions, and loose bowel movements. Side effects of internal radiation therapy may consist of abdominal pain and bowel obstruction, although it is uncommon. Most side effects go away after treatment for cervical cancer is completed. After radiation therapy, the vaginal area can lose elasticity, so women may want to use a vaginal dilator, a plastic or rubber cylinder inserted into the vagina to avoid narrowing. Women who receive external-beam radiation therapy will lose the ability to be pregnant, and unless the ovaries are surgically moved out of the pelvis, premenopausal women will enter menopause.

Occasionally, doctors suggest their patients not to have sexual intercourse during radiation therapy. Regular sexual activity can restart within a few weeks after cervical cancer treatment if the patient feels ready.

Chemotherapy 

Chemotherapy uses medicine to kill or stop the growth of cancerous cells. Depending upon the stage, different chemotherapy is given. The point that makes a difference is how the chemotherapy enters the body and which cells it affects.

A chemotherapy schedule usually consists of a certain number of cycles over a fixed period. A patient can be given one drug at a time or a combination of different drugs given simultaneously.

Although chemotherapy can be given orally, all the drugs used to treat cervical cancer are intravenously (IV). IV chemotherapy is delivered directly into a vein or through a thin tube called a catheter; a tube is temporarily put into a large vein to make injections easier.

The side effects of chemotherapy depend on the patient and the dose used. Still, they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhoea. The side effects typically go away after cervical cancer treatment is completed.

Rarely, certain drugs can cause some hearing loss. Others may cause kidney damage; hence patients may be given extra fluid intravenously to protect their kidneys. 

Targeted therapy

Targeted therapy aims at any factor contributing to the growth and development of cancer cells. It can be a specific protein, gene or tissue environment. These treatments are typical and do not harm surrounding cells like those in chemotherapy or Radiotherapy.

All tumours do not have the same target; doctors may recommend testing to understand better changes in the individual tumour’s genes and proteins. 

When cervical cancer comes back after treatment, it is called recurrent cancer, and if cervical cancer has spread beyond the pelvis, it is called metastatic disease; it can be treated with platinum-based chemotherapy combined with the targeted therapy bevacizumab (Avastin). The FDA has two drugs similar to bevacizumab, called bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev), which has been approved to treat advanced cervical cancer ^​3​.

Additionally, in 2021, the FDA granted accelerated approval to the targeted therapy tisotumab vedotin (HuMax-TF) to treat recurrent or metastatic cervical cancer that has progressed during or after chemotherapy. Tisotumab vedotin is a targeted therapy called an antibody-drug conjugate that works by attaching to targets on cancer cells and then releasing a small quantity of the anticancer drug directly into the tumour cell.

Immunotherapy 

Immunotherapy, also known as biologic therapy, is formed to boost the body’s natural defences to fight against cancer. It uses materials created by the body or in a laboratory to improve, target, or restore the functioning of the immune system.

The immune checkpoint inhibitor pembrolizumab (Keytruda) is used to treat cervical cancer that has recurred or spread to other parts of the body during or after chemotherapy. It may also be combined with chemotherapy with or without bevacizumab in people with recurrent or metastatic cervical cancer whose tumors express PD-L1 ^​4​. Some cancer cells express the PD-L1 protein, which binds to the PD-1 protein located on T cells. T cells are the cells of the immune system that kill specific other cells, such as cancer cells. When the PD-1 and PD-L1 proteins bind, the T cell does not attack the cancer cell. Pembrolizumab is a PD-1 inhibitor, so it blocks the binding between PD-1 and PD-L1, which allows the T cells to find and attack the cancer cells. 

Different immunotherapy can cause various side effects. Common side effects include skin reactions, diarrhoea, flu-like symptoms, and weight changes. Talk with your doctor about the possible side effects of the immunotherapy recommended for you.

Palliative Care 

Cervical cancer and its treatment have side effects that can be mental, physical or financial and managing the effects are palliative or supportive care.

Palliative care includes medication, nutritional changes, emotional and spiritual support and other relaxation therapies. 

Palliative care focuses on alleviating how you feel during cervical cancer treatment by managing symptoms and supporting patients and their families with other non-medical needs. Regardless of type and stage of Cancer age, any person may receive this type of care.

Cervical cancer treatment options by Stage

Radiation therapy alone or surgery is often used for an early-stage tumour. These treatments are shown to be equally effective for treating early-stage cervical cancer. Chemoradiation is generally used for women with a larger tumour, an advanced-stage tumour found only in the pelvis, or if the lymph nodes have cancer cells. Radiation therapy and chemotherapy are commonly used after surgery if there is a high risk of cancer coming back or if cancer has spread.

Metastatic Cervical cancer

When cancer starts spreading to other parts of the body, it is called metastatic cancer. Doctors can have different opinions regarding the best standard treatment plan. Clinical trials might also be an option. For many people, the diagnosis of metastatic cancer is very stressful and challenging. It is usually helpful to talk with other patients through support groups or peer support programs. The treatment plan can include a combination of surgery, targeted therapy, radiation therapy, and immunotherapy, which is a treatment created to boost the body’s natural defenses to fight the tumour.

Remission and chance of recurrence

When cancer can’t be detected in the body and there are no symptoms, this is known as remission. This may also be called having ‘no evidence of disease’ or ‘NED.’

A remission can be temporary or permanent. Many people worry about the recurrence of cancer. The doctor performs another round of tests to know the extent of the recurrence.

Mainly the cervical cancer treatment plan includes the treatments explained above, like surgery, chemotherapy, radiation therapy, and targeted therapy. 

If treatment doesn’t work

If cancer can’t be treated or controlled, it leads to advanced or terminal cancer. It is vital to have straightforward conversations with your health care team to express your feelings, preferences, and concerns. The health care team has unique skills, knowledge, and experience to assist patients and their families. Ensuring that a person is physically comfortable, free from pain, and emotionally supported is extremely important. 

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