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    Cervix Cancer

 the best, current advice on treating cervix cancer is from the NCCN here

 

Cervix cancer is believed to be caused by HPV infection, and a vaccine is available to prevent these infections (go here). A recent nomogram was published to predict the cure rate after radiation (here).

Both surgery and radiation are effective in treating early cases of cervix cancer, but surgery is generally preferred in younger women because they have less long term problems with sexual function (see studies. ) Sometimes for a woman with a larger cancer (bulky tumor, ie 5 or 6 cm) radiation will be used first, followed by a hysterectomy. The basic techniques of external radiation are discussed here and internal radiation here. For more advanced cases a combination of surgery and postOp radiation is used (go here and here) and for very advanced cases where surgery is not an option chemotherapy plus radiation is used (go here and see topics above.) See ABS guidelines here.

Squamous cell carcinoma accounts for 85% of cancer of the uterine cervix. Although the etiology is not fully understood, certain facts are clear. Associated factors exhibit the epidemiology of a venereal disease: lower socioeconomic status, early onset of coitus, and frequent coitus with multiple partners and with partners who either are uncircumcised or practice poor genital hygiene. Human papillomavirus (HPV) infection is strongly associated with the development of cervical cancer, and HPV exposure appears to explain the association between sexual history and the risk of premalignant disease of the uterine cervix.


Premalignant Disease
The well-described premalignant state of carcinoma of the cervix is variously called cervical intraepithelial neoplasia or squamous intraepithelial lesions. These lesions can be detected by cervical cytology (the Papanicolaou staining test), the most effective screening test for cancer. The transition from mild to severe dysplasia and carcinoma in situ to frankly invasive cancer may take years, permitting early diagnosis and cure for most patients.

Malignant Disease
The most important prognostic factor for invasive disease is the extent of disease at diagnosis Evaluation of patients to determine extent of disease should include a careful history and physical examination (including pelvic and rectal examination), complete blood count, tests reflecting hepatic and renal status, urinalysis, flexible sigmoidoscopy, barium enema, intravenous pyelogram, and CT scan of the abdomen and pelvis. Histologic diagnosis is mandatory through one or more of the following: cytologic smears, colposcopy, conization, punch biopsy specimens of four quadrants of the cervix, and dilation and curettage. The extent of the work-up may vary, but sufficient information to accurately stage the disease must be obtained.

Management of limited disease
Limited disease includes that confined to the cervix with invasion no deeper than 5 mm from the base of the epithelium and horizontal spread no greater than 7 mm (stages 0, IA1 and IA2). Definitive treatment is total abdominal hysterectomy. Selected patients (with carcinoma in situ or minimal invasion < 1 mm in depth) can be treated with more conservative measures, such as conization if all margins are clear. Patients who are not candidates for surgery may be treated with radiation alone.

Management of locoregionally advanced disease
Locoregionally advanced disease includes stages IB to IVA with or without involved para-aortic nodes. Definitive therapy for patients with stage IB or IIA disease consists of either pelvic radiotherapy or radical hysterectomy, both of which yield 5-year survival rates exceeding 80%. For those patients with bulky lesions (> 4 cm or barrel shaped), combined chemoradiation (radiation plus concurrent weekly cisplatin) yields results superior to those achieved with radiation therapy alone Current research evaluates alternative combined-modality regimens (surgery preceded by platinum-based chemotherapy, ie, neoadjuvant chemotherapy)'

For patients with stage IIB, III, or IVA disease, randomized trials support the enhanced efficacy of concomitant cisplatin-based chemotherapy and radiation. Acceptable chemotherapy regimens include weekly cisplatin or cisplatin plus 5-fluorouracil. Five-year survival, depending on stage, ranges from 14% to better than 60%. For patients with involved para-aortic lymph nodes, survival is poor. The standard approach is radiation therapy with port extension to include the para-aortic node area. Five-year survival rates are approximately 10% to 15%.

Management of advanced or recurrent disease
Stage IVB or recurrent disease requires systemic therapy. Five systemic agents yield response rates approximating 20%: the platinum compounds, ifosfamide, dibromodulcitol, doxorubicin, and paclitaxel. Most trials of combination chemotherapy are uncontrolled studies in selected patients; hence, interpretation is difficult. One notable exception is the Gynecologic Oncology Group trial comparing cisplatin alone with combinations of cisplatin plus ifosfamide and cisplatin plus dibromodulcitol. This study demonstrated superiority for the ifosfamide plus cisplatin combination with respect to response rate and progression-free survival and is currently the regimen of choice. Ongoing or
recently completed trials compare ifosfamide plus cisplatin with the same two drugs plus bleomycin and paclitaxel plus cisplatin with cisplatin alone. Current standard therapy is cisplatin plus ifosfamide, with an overall response rate of 33%, a clinical complete response rate of 20%, and a median response duration in excess of 8 months.