STEP 6: Managing recurrent, residual or metastatic disease
Step 6 is concerned with managing recurrent or residual local and metastatic disease.
Patients with metastatic or recurrent cervical cancer are commonly symptomatic. Some cases of recurrent disease will be detected by routine follow-up in a woman who is asymptomatic.
There should be timely referral to the original multidisciplinary team (where possible), with referral to a specialist centre for recurrent disease as appropriate.
Treatment will depend on the location and extent of the recurrence and on previous management and the woman’s preferences.
Patients with a localised recurrence after initial treatment may be candidates for further treatment; options include radiation therapy and chemotherapy, or radical, including exenterative, surgery (NCCN 2017).
For most patients with distant metastases, an appropriate approach is chemotherapy plus/minus biological agents and/or palliative radiotherapy or best supportive care (NCCN 2017). The role of chemotherapy in such patients is palliative, with the primary objective to relieve symptoms and improve quality of life (ESMO Guidelines Working Group 2012).
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).
The lead clinician should ensure timely and appropriate referral to palliative care services. Referral to palliative care services should be based on need, not prognosis.
Women should be encouraged to develop an advance care plan (AHMAC 2011).
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).
Begin discussions with the woman and her carer about her preferred place of death.
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.
Screening, assessment and referral to appropriate health professionals is required to meet the identified needs of an individual, their carer and family.
In addition to the common issues outlined in the Appendix, specific issues that may arise include:
- emotional and psychological distress resulting from fear of death/dying, existential concerns, anticipatory grief, communicating wishes to loved ones, interpersonal problems and sexuality concerns including disclosure of past history of sexual abuse or trauma
- increased practical and emotional support needs for families and carers, including help with family communication, teamwork and care coordination where these prove difficult for families
- loss of fertility, sexual dysfunction or other symptoms associated with treatment-induced or related menopause, which requires sensitive discussion and possible referral to a clinician skilled in this area
- coping with hair loss and changes in physical appearance (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, a common treatment side effect in women with gynaecological cancers (NBCC & NCCI 2003) that can restrict mobility (referral to a lymphoedema clinic, physiotherapist or trained lymphoedema specialist may be needed) (Beesley et al. 2007)
- physical symptoms including pain and fatigue
- bladder or bowel dysfunction and gastrointestinal or abdominal symptoms, which may need monitoring and assessment
- urinary tract obstruction and renal failure
- bowel obstruction due to malignancy (women need to be alerted to possible symptoms and advised to seek immediate medical assessment)
- abdominal ascites (abdominal symptoms need monitoring and assessment)
- 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
- decline in mobility and/or functional status as a result of recurrent disease and treatments (a referral to physiotherapy and occupational therapy may be needed)
- cognitive changes as a result of treatment (such as altered memory, attention and concentration)
- financial and employment issues (such as loss of income and assistance with returning to work, and cost of treatment, travel and accommodation)
- 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 and women from culturally and linguistically diverse backgrounds.
Rehabilitation may be required at any point of the care pathway from preparing for treatment through to disease-free survival and palliative care. Issues that may need to be addressed include managing cancer-related fatigue, cognitive changes, improving physical endurance, achieving independence in daily tasks, returning to work and ongoing adjustment to disease and its sequelae.
The lead clinician should ensure there is adequate discussion with the woman and her carer about the diagnosis and recommended treatment, including the intent of treatment and possible outcomes, likely adverse effects and supportive care options available.
