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.

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.