HOW IS CERVICAL CANCER TREATED?
The option for treating each patient with cervical cancer depends on the stage of disease. The stage of cancer describes its size, depth of invasion and how far it has spread.
After establishing the stage of cancer, the treatment depends largely on the stage of the disease at the time of diagnosis, other factors that may influence the choice of treatment are age and general health. The 3 main methods of cancer treatment are surgery, radiation and chemotherapy. Sometimes the best approach uses 2 or more of these methods. If a cure is not possible, the goal may be to remove or destroy as much of the cancer as possible to prevent the tumor from growing or spreading. The treatment is aimed at relieving symptoms. This is called palliative treatment.
Cryosurgery: A metal probe cooled with liquid nitrogen is inserted in the vagina and placed on the cervix. This kills the abnormal cells by freezing them. Cryosurgery is used to treat pre-invasive cervical cancer (stage O), but not for treating invasive cancer.
Laser surgery: A focused laser beam, directed through the vagina, is used to vaporize (burn off) abnormal cells or to remove a small piece of tissue for further study. Laser surgery is also used to treat invasive cancer.
Conization: A cone-shaped piece of tissue is removed from the cervix. This is done using a surgical or laser knife (cold knife cone biopsy) or using thin wire heated by electricity (the LEEP or LEETZ procedure). A cone biopsy may be used to diagnose the cancer before additional treatment with surgery or radiation. It can also be used as the only treatment in women with early (stage IA1) cancer who might want to have children. After the biopsy, the tissue removed (the “cone”) is examined under the microscope. If the margins (outer edges) of the cone contain cancer cells, another treatment (like surgery) is needed to make sure that all of the cancer is removed.
Simple hysterectomy: This surgery is to remove the uterus (both the body of the uterus and the cervix). The structures next to the uterus (parametria and uterosacral ligaments) are not removed. The vagina remains entirely intact, and pelvic lymph nodes are not removed. The ovaries and fallopian tubes are usually left in place unless there are reasons to remove them. If the uterus is removed through a surgical incision in the front of the abdomen, it is called an abdominal hysterectomy and when the uterus is removed through the vagina, it is called a vaginal hysterectomy. A simple hysterectomy is used to treat stage IA1 cervical cancers and some non-cancerous conditions. The most common of these is leiomyomas, a type of benign tumour commonly known as fibroids.
Radical hysterectomy and pelvic lymph node dissection: For this operation the surgeon removes more than just the uterus. The tissues next to the uterus (parametria and uterosacral ligaments), the upper part (about 1 inch) of the vagina next to the cervix, and some lymph nodes (bean-shaped collections of immune system tissue) from the pelvis are also removed.
Another surgical approach is called laparoscopic- assisted radical vaginal hysterectomy. This operation combines a radical vaginal hysterectomy with a laparoscopic pelvic node dissection. Laparoscopy allows the inside of the abdomen and pelvis to be seen through a tube inserted into a very small surgical incision. Small instruments can be controlled through the tube; the surgeon can remove lymph nodes through the tube without making a large cut in the abdomen. The laparoscope can also make it easier for the doctor to remove the uterus, ovaries and fallopian tubes through the vaginal incision.
A radical hysterectomy and pelvic lymph node dissection are the usual treatment for stages IA2, IB and less commonly stage IIA cervical cancer, especially in young women.
Cancer of the cervix removed through hysterectomy
Trachelectomy: Most women with stage IA2 and stage IB are treated with hysterectomy. However, another procedure, known as a radical trachelectomy, allows some of these young women to be treated without losing their ability to have children. This procedure involves removing the cervix and the upper part of the vagina and placing a “purse-string” stitch to act as an artificial internal opening of the cervix (the opening of the cervix inside the uterine cavity). The nearby lymph nodes are also removed using laparoscopy. The operation is done either through the vagina or the abdomen. After trachelectomy, some women are able to carry a pregnancy to term and deliver a healthy baby by cesarean section. In one study, the pregnancy rate after 5years was over 50%, but the risk of miscarriage after this surgery is higher than in normal healthy women. The risk of cancer reoccurring after this procedure is low.
Pelvic exenteration: This is a more extensive operation that may be used to treat recurrent cervical cancer. In this surgery, all of the organs and tissues as in radical hysterectomy with pelvic lymph node dissection are removed; bladder, vagina, rectum and part of the colon may also be removed. This operation is used to treat recurrent cervical cancer.
If the balder is removed, a new way to store and eliminate urine will be needed. A short segment of intestine will function as a new bladder. The new bladder may be connected to the abdominal wall so that urine is drained continuously into the small plastic bag attached to the front of the abdomen or periodically when the patient places a catheter into a urostomy (a small opening).
If the bladder is removed, a new way to store and eliminate solid waste will be created. This is done by attaching the remaining intestine to the abdominal wall so that fecal material can pass through a colostomy (a small opening) into a small plastic bag worn on the front of the abdomen. It may be possible to remove the involved colon (next to the cervix) and reconnect the colon so that no bags or external appliances are needed. If the vagina is removed, a new vagina can be surgically created out of skin, intestinal tissue or myocutaneous (muscle and skin) grafts.
Sexual impact of pelvic exenteration: Recovery from total pelvic exenteration takes a long time. Most women do not begin to feel like their normal selves again for 6 months after surgery. It takes a year or two to adjust completely.
Nevertheless, these women can live happy and productive lives. With practice and determination, they can also have sexual desire, pleasure and orgasms.
Sexual impact of hysterectomy: Radical hysterectomy does not change a woman’s ability to feel sexual pleasure. Although the vagina is shortened, the area round the clitoris and the lining of the vagina remains as sensitive as before. A woman does not need a uterus or cervix to reach orgasm.
Some women feel less feminine after a hysterectomy. They may view themselves as an “empty shell”. Such thoughts do not enhance sexual pleasure. However, when cancer has caused pain or bleeding with intercourse, the hysterectomy may actually improve a woman’s sex life by stopping these symptoms.
Radiation therapy: Radiation therapy uses high energy x-rays to kill cancer cells. These x-rays may be given externally in a procedure that is much like having a diagnostic x-ray. This treatment usually takes 6 to 7 weeks to complete.
Another type of radiation therapy is called brachytherapy, or internal radiation therapy. For cervical cancer, the radioactive material is placed in a cylinder in the vagina. For some cancers, radioactive material may be placed in thin needles that are inserted directly into the tumor. Low-dose brachytherepy is completed in just a few days. During that time, the patient remains in the hospital with instrument holding the radioactive material in place. High-dose rate brachytherapy is done as an outpatient over several treatments. For each treatment, the radioactive material is inserted for a few minutes and then removed. The advantage of high-dose rate is that it does not require prolonged immobilization.
Common side effects of radiation therapy include tiredness, upsets stomach or loose bowels. Some people have problems with nausea and vomiting. Pelvic radiation therapy may cause scare tissue to form in the vagina. The scar tissue can make the vagina more narrow (called vaginal stenosis) or even shorter, which makes sex (vaginal intercourse) painful. Pelvic radiation can irritate the bladder and problems with urination may occur. Estrogen may also be used to help with vaginal dryness and atrophy. Radiation therapy can also weaken the bones, leading to fractures. Hip fractures are the most common and may occur 2 to 4 years after radiation. It also leads to low blood counts causing anemia (low red blood cells) and leucopenia (low white blood cells). The blood counts usually return to normal after radiation is stopped. It is important to know that smoking increases the side effects from radiation.
Chemotherapy: Systemic chemotherapy uses anticancer drugs that are injected into the vein or given orally. These drugs enter the blood stream and reach all areas of the body, making this treatment potentially useful for cancers include cisplatin, paclitaxel, topotecan, ifosfamide and fluorouracil. If chemotherapy is chosen, patient may receive a combination of drugs. Chemotherapy drugs kill cancer cells but also damage some normal cells, which can lead to side effects.
Chemotherapy side effects depend on the type of drugs, the amount taken, and the period of time.
Temporary side effects of chemotherapy might include:
- Nausea and vomiting
- Loss of appetite
- Loss of hair
- Mouth soars
Chemotherapy can damage the blood-producing cells of the bone marrow; the blood cell counts might become low. This results in:
- An increased chance of infection (due to a shortage of white blood cells).
- Bleeding or bruising after minor cuts or injuries (due to shortage of blood platelets)
- Shortness of breath (due to low red blood cell counts)
Fatigue is also quite common and may be caused by low red blood cell counts, by other reasons related to chemotherapy or by the cancer itself.
Most side effects of chemotherapy (except premature menopause and infertility) disappear once treatment is stopped. Hair will grow back after treatment ends. Premature menopause can be treated with hormones. There are other remedies for the temporary side effects of chemotherapy. For example, there are very good drugs that can prevent or reduce nausea and vomiting. Other drugs can be given to boost blood cell production. For some stages of cervical cancer, chemotherapy is given to help the radiation work well. When chemotherapy and radiation therapy are given together, it is called concurrent chemoradiation. Problems with low blood counts can also be worse. Health care team will watch for side effects and can administer medicines that will help patient feel better.
The treatment information in this booklet is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help patient make informed decision.
Doctors may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask questions about your treatment options. If there is anything you do not understand, ask for an explanation. It is often a good idea to get a second opinion, especially from doctors experienced in treating cervical cancer. A second opinion can provide more information and help you feel more confident about the treatment plan you are considering.
THE DECISION IS YOURS
Decisions about how to treat or manage cancer are always yours to make. If you are thinking about using a complementary or alternative method, be sure to learn about the method and talk to your doctor about it. With reliable information and the support of your health care team, you can use safe methods that might help you while avoiding those that could be harmful.
Your primary doctor can often treat pre-cancers. If there is a question of invasive cancer, your local doctor will refer you to a gynecologic oncologist (a doctor who specialized in women’s reproductive system cancers). Some patients will also be referred to a radiation oncologist (a doctor who specializes in treating cancers with radiation).