Treatment Options for Cervical Cancer, by Stage

The stage of cervical cancer is the most important factor in choosing a treatment. But other factors can also affect your treatment options, including the location of the cancer within the cervix, the type of cancer (squamous cell or adenocarcinoma), your age, your overall health, and if you want to keep your fertility.

Stage IA1

Treatment for this stage depends on whether or not you want to be able to have children (maintain fertility) and if the cancer has grown into blood or lymph vessels (called lymphovascular invasion).

Treatment options if you want to maintain fertility

A cone biopsy is the preferred procedure if you want to have children after the cancer is treated.

• If there are no cancer cells in the edges of the cone (called negative margins), the woman can be watched closely without further treatment as long as the cancer doesn’t come back.
• If the edges of the cone biopsy have cancer cells (called positive margins), then cancer might have been left behind. This can be treated with a repeat cone biopsy or a radical trachelectomy.
• If the cone biopsy shows that the cancer has grown into blood or lymph vessels, it would then be treated the same as stage IA2 disease (see below).

Treatment options if you don’t need to maintain fertility

• A simple hysterectomy may be an option if the cancer shows no lymphovascular invasion and the edges of the biopsy have no cancer cells. If the edges of the biopsy have cancer cells present, a repeat cone biopsy or a radical hysterectomy with removal of the pelvic lymph nodes might be an option.
• If the cancer has grown into blood or lymph vessels, you might need a radical hysterectomy along with removal of the pelvic lymph nodes. Sometimes, surgery is not done and external beam radiation to the pelvis followed by brachytherapy is used.

If none of the lymph nodes have cancer cells, radiation may still be discussed as an option if the tumor is large, if the tumor has grown into blood or lymph vessels, or if the tumor is invading the surrounding connective tissue (the stroma) that supports organs such as the uterus, bladder, and vagina.

If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, or if the tissue removed has positive margins, radiation (EBRT) with chemotherapy is usually recommended. The doctor may also advise brachytherapy after combined chemo and radiation .

Stage IA2

Treatment for this stage depends in part on whether or not you want to continue to be able to have children (maintain fertility).

Treatment options if you want to maintain fertility

• Cone biopsy with removal of pelvic lymph nodes (pelvic lymph node dissection)
• Radical trachelectomy with pelvic lymph node dissection

Treatment options if you don’t need to maintain fertility

• External beam radiation therapy (EBRT) to the pelvis plus brachytherapy
• Radical hysterectomy with removal of pelvic lymph nodes

 If none of the lymph nodes have cancer cells, radiation may still be an option if the tumor is large, if the tumor has grown into blood or lymph vessels, or if the tumor has grown into the surrounding connective tissue (the stroma) that supports organs such as the uterus, bladder, and vagina.

If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, or if the tissue removed has positive margins, radiation (EBRT) with chemotherapy is usually recommended. The doctor may also advise brachytherapy after combined chemo and radiation.

Stages IB and IIA

Stages IB1 and IB2: Treatment options if you want to maintain fertility

• Radical trachelectomy with pelvic lymph node dissection and sometimes removal of the para-aortic lymph nodes

Stage IB1, IB2, and IIA1: Treatment options if you don’t need to maintain fertility

• Radical hysterectomy with removal of lymph nodes in the pelvis and sometimes lymph nodes from the para-aortic area. If none of the lymph nodes are found to have cancer, radiation may still be discussed as an option if the tumor is large, if the tumor has grown into blood or lymph vessels, or if the tumor is invading the surrounding connective tissue (the stroma) that supports organs such as the uterus, bladder, and vagina. If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, or if the tissue removed has positive margins, radiation (EBRT) with chemotherapy is usually recommended. The doctor may also advise brachytherapy after the combined chemo and radiation are done.
• Radiation to the pelvis using both brachytherapy and external beam radiation therapy may be an option if a patient is not healthy enough for surgery or decides they do not want surgery. Chemotherapy (chemo) may be given with radiation (concurrent chemoradiation).

Stages IB3 and IIA2

Treatment options

• Chemoradiation: The chemo may be cisplatin or carboplatin, given concurrently with external beam radiation (EBRT).  This may be followed by brachytherapy.
• Radical hysterectomy with pelvic lymph node dissection and possibly para-aortic lymph node sampling: If cancer cells are found in the removed lymph nodes, or in the edges of the tissue removed (positive margins), surgery may be followed by radiation therapy, which is often given with chemo (concurrent chemoradiation).
• Chemoradiation and brachytherapy followed by a hysterectomy: This is not commonly done but might be an option for certain patients.

Stages IIB, III, IVA

Treatment options

• Chemoradiation: The chemo may be cisplatin or carboplatin, given concurrently (at the same time) with external beam radiation (EBRT). This may be followed by brachytherapy. 
• Pembrolizumab with chemoradiation: For patients with aggressive (high-risk) stages III or IVA cervical cancer, pembrolizumab can be given once every 3 weeks with chemoradiation, followed by pembrolizumab alone.

Stage IVB

At this stage, the cancer has spread outside the pelvis to other areas of the body. Stage IVB cervical cancer is not usually considered curable. Treatment options include chemo alone or with pembrolizumab if the tumor is PD-L1 positive. If chemo is given alone, it's usually a combination of cisplatin or carboplatin with paclitaxel and bevacizumab. If chemo is given with pembrolizumab, it is usually cisplatin or carboplatin with paclitaxel, with or without bevacizumab. Radiation therapy may be given to help relieve symptoms. For a recurrence after initial systemic therapy, other chemo drugs, or immunotherapy alone, or targeted therapy may also be options.

Clinical trials are testing other combinations of chemo drugs, as well as some other experimental treatments.

Recurrent cervical cancer

Cancer that comes back after treatment is called recurrent cancer. Cancer can come back locally (in or near where it first started, such as the cervix, uterus or near the pelvic organs), or it can come back in distant areas (such as the lungs or bone).

If the cancer has recurred in the center of the pelvis only, extensive surgery (such as pelvic exenteration) may be an option for some patients and offers the best chance for possibly curing the cancer (although it can have major side effects). Radiation therapy (sometimes along with chemo) might be another option. If not, chemotherapy, immunotherapy, or targeted therapy may be used to slow the growth of the cancer or help relieve symptoms, but they aren’t expected to cure the cancer.

No matter which type of treatment your doctor recommends, it's important that you understand the goal of treatment (to try to cure the cancer, control its growth, or relieve symptoms), as well as its possible side effects and limitations. For example, sometimes chemo can improve your quality of life, and other times it might diminish it. You might need to discuss this with your doctor.

New treatments that may benefit patients who have distant recurrence of cervical cancer are being evaluated in clinical trials.

Cervical cancer in pregnancy

A small number of cervical cancers are found in pregnant women. Most of these (70%) are stage I cancers. The treatment plan during pregnancy is determined by:

• Tumor size
• If nearby lymph nodes have cancer
• How far along the pregnancy is
• The specific type of cervical cancer

If the cancer is at a very early stage, such as stage IA, most doctors believe it is safe for a woman to continue the pregnancy to term and have treatment several weeks after birth. Surgery options after birth for early-stage cancers include a hysterectomy, radical trachelectomy, or a cone biopsy.

If the cancer is stage IB or higher, you and your doctor must decide whether to continue the pregnancy. If not, treatment would be radical hysterectomy and/or radiation. Sometimes chemotherapy can be given during the pregnancy (in the second or third trimester) to shrink the tumor.

If you decide to continue the pregnancy, the baby should be delivered by cesarean section (C-section) as soon as it is able to live outside the womb. More advanced cancers typically need to be treated immediately.