STEP 4: Treatment

Step 4 outlines the treatment options for cervical cancer.

The intent of treatment can be defined as one of the following:

  • curative
  • anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
  • symptom palliation.

The morbidity and risks of treatment need to be balanced against the potential benefits.

The lead clinician should discuss treatment intent and prognosis with the woman and carer before beginning treatment.

If appropriate, advance care planning should be initiated with the woman at this stage because there can be multiple benefits such as ensuring her preferences are known and respected after the loss of decision-making capacity (AHMAC 2011).

Depending on the stage of the disease, primary treatment consists of surgery, radiotherapy or a combination of radiotherapy and chemotherapy. For situations involving fertility, pregnancy and immunocompromised women (such as those with HIV) refer to section 4.3.

Where possible, sequential multimodality treatment should be avoided.

The advantages and disadvantages of each treatment and associated potential side effects should be discussed with the woman.

Surgery is typically reserved for women who have small tumours found only within the cervix (early-stage disease and smaller lesions) (NCCN 2017).

For women with early-stage disease who do not require fertility-sparing approaches, cone biopsy, simple/extrafascial hysterectomy and radical hysterectomy are options. Radical hysterectomy and bilateral salpingectomy with bilateral pelvic lymph node assessment is the preferred treatment approach. Removal of the ovaries should be individualised according to disease indications.

In selected cases surgery for fertility preservation may be possible.

The training and experience required of the surgeon are as follows:

  • Gynaecological oncologist (FRANZCOG) with adequate training and experience in gynaecological cancer surgery and institutional cross-credentialling and agreed scope of practice within this area (ACSQHC 2004).

Hospital or treatment unit characteristics for providing safe and quality care include:

  • appropriate nursing and theatre resources to manage complex surgery
  • 24-hour medical staff availability
  • 24-hour operating room access
  • specialist pathology
  • in-house access to radiology
  • an intensive care unit.

Concurrent chemoradiation is generally the primary treatment of choice for managing women with cervical cancer either as a definitive treatment for those with locally advanced disease or for those who are poor surgical candidates (NCCN 2017).

Definitive radiation therapy should consist of pelvic external beam radiation (EBRT) and intracavitary brachytherapy (ESMO Guidelines Working Group 2012) to be completed within 56 days. Concurrent radiosensitising chemotherapy with radiotherapy has been shown to significantly improve patient survival compared with radiotherapy alone (NCCN 2017).

In women with high-risk disease (lymph node metastases, parametrial invasion, lymphovascular space invasion, thickness of the residual muscular layer, tumour depth and tumour growth pattern) (Shinohara et al. 2004) postoperative radiation therapy plus/minus chemotherapy following surgery should be offered (ESMO Guidelines Working Group 2012). Where possible, patients with high-risk features who are likely to require adjuvant therapy following surgery should be identified upfront and considered for definitive chemoradiation to minimise the toxicities of trimodality treatment.

For women who present with distant metastatic disease, EBRT may be considered to control pelvic disease and other symptoms.

Training and experience of the radiation oncologist:

  • Radiation oncologist (FRANZCR or equivalent) with adequate training and experience that enables institutional credentialling and agreed scope of practice within this area (ACSQHC 2004) and who is also a core member of a gynaecological oncology multidisciplinary team.

Hospital or treatment unit characteristics for providing safe and quality care include:

  • trained radiotherapy nurses, physicists and therapists
  • access to CT/MRI scanning for simulation and planning
  • mechanisms for coordinating combined therapy (chemotherapy and radiation therapy), especially where the facility is not collocated
  • access to allied health, especially nutrition health and advice.

There is evidence to suggest that higher caseloads have better clinical outcomes for patients treated with brachytherapy (Moon-Sing et al. 2014). Centres that do not have sufficient caseloads should establish processes to routinely refer brachytherapy cases to a high-volume centre.

Chemotherapy may be used as part of primary chemoradiation or adjuvant chemoradiation. It may also be used as neoadjuvant treatment in patients who have metastatic disease outside of the pelvis.

For women who present with distant metastatic or recurrent disease, primary treatment is often chemotherapy plus/ or minus biological therapy.

Training, experience and treatment centre characteristics

The following training and experience is required of the appropriate specialist(s):

  • Medical oncologists (RACP or equivalent) must have adequate training and experience with institutional credentialling and agreed scope of practice within this area (ACSQHC 2004).
  • Nurses must have adequate training in chemotherapy administration and handling and disposal of cytotoxic waste.
  • Chemotherapy should be prepared by a pharmacist with adequate training in chemotherapy medication, including dosing calculations according to protocols, formulations and/or preparation.
  • In a setting where no medical oncologist is locally available, some components of less complex therapies may be delivered by a medical practitioner and/or nurse with training and experience with credentialling and agreed scope of practice within this area under the guidance of a medical oncologist. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

Hospital or treatment unit characteristics for providing safe and quality care include:

  • a clearly defined path to emergency care and advice after hours
  • access to basic haematology and biochemistry testing
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including safe prescribing, preparation, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring the effects of medicines (ACSQHC 2011)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs).

Timeframes for surgery should be informed by evidence-based guidelines (where they exist) while recognising that shorter timelines for appropriate consultations and treatment can reduce the woman’s distress.

The following recommended timeframes are based on expert advice from the Cervical Cancer Working Group:

  • Treatment should begin within four weeks of the decision to treat.

For women wishing to preserve their fertility, early cervical cancer (cancers that are small and confined to the cervix) can be managed conservatively, with cone biopsy or trachelectomy in selected cases (ESMO Guidelines Working Group 2012).

After childbearing is complete, hysterectomy can be considered for women who have had either radical trachelectomy or a cone biopsy for early-stage disease if they have chronic, persistent HPV infection, they have persistent abnormal cervical tests, or they desire this surgery (NCCN 2017).

For premenopausal women undergoing radiation therapy, consideration for ovarian transposition should be individualised (Gubbala et al. 2014; Mossa et al. 2015; Shou et al. 2015).

When diagnosed in pregnancy, management of cervical cancer will depend on the gestation at diagnosis and the stage of the cancer. In early pregnancy (before 24 weeks) termination of

pregnancy to facilitate cancer treatment may be recommended. After 24 weeks it may be possible to delay treatment until viability of the baby (around 34 weeks).

In a woman known to be HIV positive, cervical cancer is an AIDS-defining illness, and management in conjunction with infectious diseases experts is recommended (Maiman et al. 1997).

Ongoing assessment of the effects of treatment-related menopause is required.

Early referral to palliative care can improve the quality of life for people with cancer and, in some cases, may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). Communication about the value of palliative care in improving symptom management and quality of life and should be emphasised to women and their carers.

The multidisciplinary team should ensure women receive timely and appropriate referral to palliative care services. Referral should be based on need rather than prognosis.

Ensure the needs and preferences of the person’s family and carers are assessed and directly inform support and guidance about their role (Palliative Care Australia 2018).

The woman and her carer should be encouraged to develop an advance care plan (AHMAC 2011).

Further information

Refer patients and carers to Palliative Care Australia.

Participation in research and/or clinical trials should be encouraged where available and appropriate. Cross-referral between clinical trials centres should be encouraged to facilitate participation.

For more information visit Australian Cancer Trials.

The lead clinician should broach the woman’s use (or intended use) of complementary or alternative therapies not prescribed by the multidisciplinary team to discuss safety and efficacy and identify any potential toxicity or drug interactions.

The lead clinician should seek a comprehensive list of all complementary and alternative medicines being taken and explore the woman’s reason for using these therapies and the evidence base.

Most alternative therapies and some complementary therapies have not been assessed for efficacy or safety. Some have been studied and found to be harmful or ineffective.

Some complementary therapies may assist in some cases, and the treating team should be open to discussing the potential benefits for the individual.

If the woman expresses an interest in using complementary therapies, the lead clinician should consider referring them to health professionals within the multidisciplinary team who have knowledge of complementary and alternative therapies (such as a clinical pharmacist, dietitian or psychologist) to help her reach an informed decision.

The lead clinician should assure women who use complementary or alternative therapies that they can still access multidisciplinary team reviews (NBCC & NCCI 2003) and encourage full disclosure about therapies being used (Cancer Australia 2010).

Further information

Screening with a validated screening tool, assessment and referral to appropriate health professionals and/or organisations is required to meet the needs of individual women, their families and carers.

In addition to the common issues outlined in the Appendix, specific issues that may arise include:

  • treatment-related side effects including loss of fertility, sexual dysfunction and menopause, which require sensitive discussion and possible referral to a clinician skilled in this area
  • maintaining vaginal health, managing dryness, bleeding, stenosis, dyspareunia, atrophic vaginitis, fistulas and pain as well as prevention of treatment-induced vaginal stenosis through early referral to a specialist nurse or women’s health physiotherapist for advice
  • comorbidities where treatment for depression is required
  • coping with hair loss (refer to Look Good, Feel Better; see ’Resource List’)
  • malnutrition risk as identified by a validated malnutrition screening tool or unintentional weight loss of greater than five per cent of usual body weight
  • lower limb lymphoedema and lymphadenectomy, a common treatment side effect in women with gynaecological cancers (NBCC & NCCI 2003) that can restrict mobility (referral to a lymphoedema clinic or lymphoedema specialist may be needed)
  • physical symptoms such as pain and fatigue
  • bladder or bowel dysfunction, gastrointestinal or abdominal symptoms, which may need monitoring and assessment
  • decline in mobility and/or functional status as a result of treatment (a referral to physiotherapist, occupational therapist or exercise physiologist may be needed)
  • assistance with managing complex medication regimens, multiple medications, assessment of side effects and assistance with difficulties swallowing medications (referral to a pharmacist may be required)
  • emotional and psychological issues such as body image concerns, fatigue, existential anxiety, treatment phobias, anxiety/depression, relationship or interpersonal problems and sexuality concerns and disclosure of past history of sexual abuse or trauma
  • potential isolation from normal support networks, particularly for rural women who are staying away from home for treatment
  • financial issues related to loss of income and additional expenses as a result of illness and/or treatment
  • legal issues including advance care planning, appointing a power of attorney or enduring guardian, completing a will and making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability
  • the need for appropriate information for Aboriginal and Torres Strait Islander women or women from culturally and linguistically diverse backgrounds.

The lead clinician should:

  • discuss the treatment plan with the woman and carer, including the intent of treatment and expected outcomes, and provide a written plan
  • provide the woman and carer with information on the possible side effects of treatment, self-management strategies and emergency contacts
  • initiate a discussion regarding advance care planning with the woman and carer.

The lead clinician should:

  • discuss with the general practitioner their role in symptom management, psychosocial care and referral to local services
  • ensure regular and timely two-way communication regarding:
  • the treatment plan, including intent and potential side effects
  • supportive and palliative care requirements
  • the woman’s prognosis and their understanding of this
  • enrolment in research and/or clinical trials
  • changes in treatment or medications
  • recommendations from the multidisciplinary team.