Stage I

Cervical Cancer

Stage I cancer of the cervix is commonly detected from an abnormal Pap smear or pelvic examination. Following a staging evaluation, a stage I cancer is said to exist if the cancer is confined to the cervix. Stage I cervical cancer is curable for the majority of patients if surgery, radiation, and chemotherapy are appropriately used.

A variety of factors ultimately influence a patient’s decision to receive treatment. The potential benefits of each cancer treatment must be carefully balanced with the potential risks.

The following is an overview of the treatment of stage I cervical cancer.  The information is intended to help educate you about treatment options and to facilitate a shared decision-making process with your treating physician.

Stage IA Cervical Cancer

Treatment of stage IA cervical cancer typically consists of surgical removal of the cancer. This can be accomplished with a hysterectomy or a conization procedure. A simple hysterectomy involves surgical removal of the uterus, including the cervix and a small amount of surrounding normal tissue. This can be performed through a low abdominal incision (below the belly button and above the pelvic bone) or through the vagina, which avoids an abdominal incision. A simple hysterectomy is very effective therapy for most stage IA cervical cancers.

Women with stage IA cervical cancer who wish to have children in the future may elect to undergo a procedure called a conization. In a conization procedure, the surgeon removes only a portion of the cervix in the operating room. If the cancer is completely removed, no additional surgery is necessary. If cancer is detected at the edge of the removed specimen, a complete hysterectomy is required. To learn more about surgical treatment and its side effects, go to Surgical Management of Cervical Cancer.

Some patients do not want to or cannot undergo an operation such as a hysterectomy because of co-existing medical conditions. For these patients, radiation therapy can be used to treat the cancer. The possible complications and the relative inconvenience usually determine whether surgery or radiation is the most appropriate treatment. For example, surgery is a one-time procedure, whereas external beam radiation therapy requires 3-6 weeks of daily treatments and implant radiation may require additional hospitalization time.

Implant radiation is a procedure that is performed in the operating room and involves the placement of radioactive material or seeds in or near the cancer. This process may be repeated depending on the necessary radiation dose. Radiation therapy appears to be as effective as surgery in curing stage IA cervical cancer. To learn more about radiation therapy and its side effects, go to Radiation Therapy for Cervical Cancer.

Approximately 95% of patients with stage IA cervical cancer survive without evidence of cancer recurrence 10 years after surgery or radiation therapy. Less than 5% of patients with stage IA cervical cancer experience recurrence.

Stage IB Cancer of the Cervix

Small stage IB cervical cancers can be successfully cured with hysterectomy or radiation therapy in approximately 90% of patients. Bulky stage IB cancers (greater than 4 centimeters in size) are only cured in 70-75% of patients when surgery or radiation therapy is administered alone. Bulky stage IB cancers are best treated with combined modality therapy using radiation, surgery and chemotherapy.

Before a hysterectomy is performed in a patient suspected of having a stage IB cancer, the doctor will often remove the lymph nodes in the pelvis to see if they contain cancer. This is called a pelvic lymph node dissection. If the lymph nodes contain cancer, the surgeon will not usually proceed with a hysterectomy because treatment over a larger area is necessary to destroy all the cancer cells. Radiation therapy and chemotherapy are generally recommended.

Even with surgical removal of all visible cancer, 10% of patients with small stage IB and 30-40% of patients with bulky stage IB cancers will experience a recurrence. This is because some patients already have small amounts of cancer that spread outside the cervix and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix are referred to as micrometastases. The presence of micrometastases or residual cancer causes the relapses that follow treatment with surgery alone.

In order to improve the cure rate of cervical cancer, it is important to develop strategies to cleanse the body of micrometastases and prevent recurrences. Adjuvant therapy is additional treatment that increases the effectiveness of a primary therapy. The goal of adjuvant treatment is to improve the chance of a cure, prevent cancer from recurring and/or to improve the duration of overall survival. Adjuvant therapy may consist of radiation, chemotherapy or other treatments. The role of adjuvant treatment for small stage IB cancers is not clear; however, patients with bulky stage IB cancers have improved survival if treated with adjuvant therapy.

A clinical study conducted by the Gynecologic Oncology Group demonstrated a reduction in cancer recurrence when radiation therapy was used after radical hysterectomy for patients with high-risk stage IB cancer of the cervix. Patients treated with external beam radiation therapy to the pelvis were directly compared with a group of patients who received no radiation therapy. The results indicated that patients treated with adjuvant radiation therapy after surgery experienced a cancer recurrence rate of 12%, compared to 21% in patients treated with surgery alone. The addition of adjuvant radiation therapy reduced the chance of cancer recurrence by almost 50% in this study.

Adjuvant therapy can also consist of combined treatment with external beam radiation therapy and chemotherapy. Patients with cancer cells in the pelvic lymph nodes or cancer at the edge of the surgical specimen may additionally benefit from treatment with combined radiation therapy and chemotherapy. Several chemotherapy drugs including Platinol® and 5-fluorouracil have the ability to kill cancer cells directly and increase the effectiveness of radiation therapy in killing cancer cells.

The New England Journal of Medicine published the results of a clinical study that compared adjuvant treatment with radiation only to treatment with radiation and concurrently administered Platinol® chemotherapy following surgical hysterectomy in patients with high-risk stage IB cancers. Patients treated with chemotherapy and radiation after surgery were more likely to survive without cancer recurrence. At 3 years from treatment, 80% of patients receiving combined radiation and chemotherapy were alive without recurrence, compared to only 63% of patients treated with radiation alone. Currently, the combination of surgery, radiation and chemotherapy appears to produce the best results for treatment of patients with high-risk stage IB cervical cancer.

Strategies to Improve Treatment

The progress that has been made in the treatment of cervical cancer has resulted from improved development of treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of stage I cervical cancer.

Preservation of Reproductive Function: Generally, women who receive treatment for stage I cervical cancer have an excellent prognosis, with a cure rate of greater than 90% following a hysterectomy. However, some women of childbearing age would prefer a therapy that preserves their reproductive function. One procedure for preserving reproduction function is a radical trachelectomy, which only removes a portion of the uterus. In a recent clinical study, 32 patients with stage I cervical cancer measuring 2cm or less treated with radical trachelectomy experienced a 2-year survival rate of 95%, without any relapse of the cancer. Approximately 40% of women were able to conceive after treatment.

New Adjuvant Chemotherapy Regimens: Platinol® chemotherapy administered concurrently with radiation improves the survival of women with stage IB bulky cervical cancer. Evaluation of new chemotherapy drugs in addition to or in place of Platinol® that can kill cancer cells more effectively are now being tested as adjuvant therapies.

Neoadjuvant Therapy: The practice of administering treatment before surgery is referred to as neoadjuvant therapy. In theory, neoadjuvant chemotherapy can decrease the size of the cancer, making it easier to remove with surgery. With the development of new chemotherapy regimens and radiation therapy, clinical trials of neoadjuvant therapy performed in patients with cervical cancer are currently ongoing.

The use of radiation prior to a simple hysterectomy is being evaluated in clinical trials for patients with larger stage IB cervical cancers. This combination of treatment appears to reduce the chance of a cancer recurrence in the area of the cancer by removing cancer cells that may have survived through the radiation therapy.

Newer Radiation Techniques: External beam radiation therapy can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum.

Immunotherapy:  The immune system is an elaborate network of cells and organs that protect the body from infection.  The immune system is also part of the body’s innate disease-fighting capability to treat cancer.  With cancer, part of the problem is an ineffective immune system. The immune system recognizes cancer cells as foreign and up to a point can get rid of them or keep them in check.  Cancer cells are very good at finding ways to hide from, suppress, or wear out the immune system and avoid immune destruction.  The immune system may not attack cancer cells because it fails to recognize them as foreign and harmful.

The goal of immunotherapy is to help the immune system recognize and eliminate cancer cells by either activating the immune system directly, or by inhibiting mechanisms of suppression of the cancer.

General types of immunotherapy include interferon, interleukin, and colony stimulating factors (cytokines), which generally activate the immune system to attack the cancer. These general immunotherapies however are not specific and their activation of the immune system can cause severe side effects by attacking normal cells along with cancer cells.  Immunotherapy treatment of cancer has progressed considerably over the past 30 years and has evolved from a general to more precisely targeted immunotherapy treatment. Examples of precision immunotherapy include checkpoint inhibitors, CAR T cells, and vaccines.

Next: Stage II Cervical Cancer

References

https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site