Stage IVA Cervical Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
The size of the primary tumor is an important prognostic factor and should be carefully evaluated in choosing optimal therapy.[1] After surgical staging, patients found to have small volume para-aortic nodal disease and controllable pelvic disease may be cured with pelvic and para-aortic radiation therapy.
Screening Benefit According to Age
Cervical cancer mortality, usually occurring among unscreened women, increases with age, with the maximum mortality for white women between the ages of 45 and 70 years and for black women in the 70s.[1,2] (Also available online.) Mortality among women with negative Papanicolaou (Pap) screening is low at all ages. Screening by Pap testing with associated diagnostic testing and treatment is effective in reducing the incidence of all histologies and stages of invasive cervical cancer.[3] The benefit...
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Five randomized phase III trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy, [2,3,4,5,6,7,8] while one trial examining this regimen demonstrated no benefit.[9] The patient populations in these studies included women with Federation Internationale de Gynecologie et d'Obstetrique ((FIGO) stages IB2 to IVA cervical cancer treated with primary radiation therapy and women with FIGO stages I to IIA disease who, at the time of primary surgery, were found to have poor prognostic factors, which include the following:
- Metastatic disease in pelvic lymph nodes.
- Parametrial disease.
- Positive surgical margins.
Although the positive trials vary somewhat in terms of stage of disease, dose of radiation, and schedule of cisplatin and radiation, the trials demonstrate significant survival benefit for this combined approach. The risk of death from cervical cancer was decreased by 30% to 50% with the use of concurrent chemoradiation therapy. Based on these results, strong consideration should be given to the incorporation of concurrent cisplatin-based chemotherapy with radiation therapy in women who require radiation therapy for treatment of cervical cancer.[2,3,4,5,6,7,8,9,10]
Standard treatment options:
- Radiation therapy plus chemotherapy: Intracavitary radiation therapy and external-beam pelvic radiation therapy combined with cisplatin or cisplatin/fluorouracil.[2,3,4,5,6,7,11]
Although low-dose rate (LDR) brachytherapy, typically with cesium Cs 137, has been the traditional approach, the use of high-dose rate (HDR) therapy, typically with iridium Ir 192, is rapidly increasing. HDR brachytherapy provides the advantage of eliminating radiation exposure to medical personnel, a shorter treatment time, patient convenience, and outpatient management. In three randomized trials, HDR brachytherapy was comparable with LDR brachytherapy in terms of local-regional control and complication rates.[12,13,14][Level of evidence: 1iiDii]. The American Brachytherapy Society has published guidelines for the use of LDR and HDR brachytherapy as a component of cervical cancer treatment.[11,15,16]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IVA cervical cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
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