4.2 Treatment options

4.2 Treatment options

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.