Cervical Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stages IB and IIA Cervical Cancer Treatment
Standard radiation therapy for cervical cancer includes brachytherapy after external-beam radiation therapy (EBRT). 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 improved outpatient management. The American Brachytherapy Society has published guidelines for the use of LDR and HDR brachytherapy as components of cervical cancer treatment.[11,12]
- In three randomized trials, HDR brachytherapy was comparable with LDR brachytherapy in terms of local-regional control and complication rates.[13,14,15][Level of evidence: 1iiDii]
Surgery after radiation therapy may be indicated for some patients with tumors confined to the cervix that respond incompletely to radiation therapy or for patients whose vaginal anatomy precludes optimal brachytherapy.
Pelvic node disease
The resection of macroscopically involved pelvic nodes may improve rates of local control with postoperative radiation therapy. Patients who underwent extraperitoneal lymph–node sampling had fewer bowel complications than those who had transperitoneal lymph–node sampling.[18,19,20] Patients with close vaginal margins (<0.5 cm) may also benefit from pelvic radiation therapy.
Radical hysterectomy and bilateral pelvic lymphadenectomy with or without total pelvic radiation therapy plus chemotherapy
Radical hysterectomy and bilateral pelvic lymphadenectomy may be considered for women with stages IB to IIA disease.
Evidence (radical hysterectomy and bilateral pelvic lymphadenectomy with or without total pelvic radiation therapy plus chemotherapy):
- An Italian group randomly assigned 343 women with stage IB and IIA cervical cancer to surgery or radiation therapy. 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). Patients in the surgery arm underwent a class III radical hysterectomy, pelvic lymphadenectomy, and selective, para-aortic lymph–node dissection. Adjuvant radiation therapy was given to patients with high-risk pathologic features in the uterine specimen or positive lymph nodes. Adjuvant radiation therapy was EBRT to a total dose of 50.4 Gy over 5 to 6 weeks.[Level of evidence: 1iiA]
- The primary outcome was OS at 5 years, with secondary measures of rate of recurrence and complications. With a median follow-up of 87 months, OS was the same in both groups at 83% (hazard ratio [HR], 1.2; confidence interval [CI], 0.7–2.3; P = .8).
- Complications were highest among the patients who received adjuvant radiation after surgery.
- In general, radical hysterectomy should be avoided in patients who are likely to require adjuvant therapy.