Treatment options

Treatment options for cervical cancer depend on:^[1]

• the type of cervical cancer
• the stage of the cancer
• whether you would like to have children
• your age.

Treatment for precancerous abnormalities or very early cervical cancer may include loop excision, cone biopsy or laser. These are all methods for removing the abnormal cells.

Treatment for cervical cancer (early stage or localised) may include surgery, or a combination of radiation therapy and chemotherapy.

Treatment for precancerous abnormalities

Not all precancerous abnormalities need treatment. Those that do can be treated quite easily and very successfully. The type of treatment you have after an abnormal Cervical Screening Test will depend on the type of abnormality.

In most cases, the precancerous tissue can be removed and no further treatment is needed. Tissue can be removed by:

• loop excisions – large loop excision of the transformation zone (LLETZ) or loop electrosurgical excision procedure (LEEP)
• cone biopsy
• laser surgery, which uses a laser beam to make bloodless cuts in tissue, or to remove a surface abnormality such as a tumour.
• cryosurgery, which uses a very cold metal probe to freeze and kill the abnormal cells.

Sometimes, a very small cancer may be discovered in the sample, and further treatment may be needed.

Loop excisions

LLETZ or LEEP are procedures that remove a large sample of the cervix for examination or treatment^[2]. They are the most common way of removing cervical tissue to treat precancerous abnormalities.

The transformation zone is where the squamous cells in the cervix meet the glandular cells (also called the squamocolumnar junction). Your transformation zone is partly located in your cervical canal, but its position varies, depending on your age and whether or not you have been pregnant.

In a loop excision, a thin loop of wire heated by an electric current is used to cut out abnormal tissue from the cervix. Sometimes the doctor can completely remove all visible abnormal cells. These are then sent to a lab for examination under a microscope.

This procedure takes about 10–20 minutes; it may be performed under a local anaesthetic in the doctor’s office or in hospital under general anaesthetic. In some cases, the doctor may do a loop excision at the same time as a colposcopy.

After a loop excision procedure, you may have some vaginal bleeding and cramping. This will usually ease in a few days, but there may be some spotting for 3–4 weeks. If bleeding lasts longer than this, becomes heavy or smells bad, see your doctor.

To give your cervix time to heal and to prevent infection, you should not have sex or use tampons for 4–6 weeks. During this time, you should also avoid submerging your pelvic area into a hot spa or sauna, because this can slow the healing process.

Cone biopsy

A cone biopsy is a procedure to determine if the abnormal cells have spread to tissue beneath the surface of the cervix^[3]. A cone biopsy is also used to treat very early and very small tumours, or for older people needing a larger excision.

This procedure removes a cone-shaped piece of tissue containing the abnormal cells from the cervix. It is usually performed under a general anaesthetic and involves a day or overnight admission to hospital.

Results of a cone biopsy are usually available within one week.

After the cone biopsy, it is common to have some light bleeding or cramping for a few days. There may also be a dark brown discharge for a few weeks. You may have a small gauze pack put into your vagina to help stop the bleeding.

When the gauze is removed, you should avoid doing anything physically strenuous for about 3 weeks, since this could restart your bleeding or make you bleed more heavily. If the bleeding lasts longer than 3–4 weeks or has a bad smell, see your doctor.

To allow your cervix to heal and to prevent infection, you should not have sex or use tampons for 4–6 weeks.

If you would like to become pregnant, talk to your doctor before the cone biopsy, because the procedure may weaken the cervix and increase the risk of miscarriage. You may need to have a stitch inserted into the cervix to strengthen it and to reduce this risk. The stitch would be removed before you give birth.

Laser surgery

Laser surgery may be used to remove abnormal cells or pieces of tissue from the cervix^[4]. This procedure directs a very strong, hot beam of light at the abnormal cells through the vagina.

The procedure takes about 10–15 minutes. You will have an anaesthetic to numb the cervix so you don’t feel any pain. You can go home straight after the treatment, and most people can return to their normal activities within 2–3 days. However, sex should still be avoided for 4–6 weeks.

Cryosurgery

Cryosurgery is a procedure that kills abnormal cells by freezing them^[5]. A very cold metal probe is placed directly on the cervix.

This procedure can be done in your doctor’s office. After the surgery, you may have a watery brown discharge, but this should only last for a few weeks.

Treatment for cervical cancer

The type of treatment that is required will be based on:

• the results of your tests
• where your cancer is
• whether your cancer has spread
• your age
• your general health
• whether you want to have children.

Surgery

If the tumour is very small, a cone biopsy may be the only treatment you need.

Trachelectomy

A trachelectomy is removal of the cervix and the upper part of the vagina. For small cancers in young people, this type of surgery may preserve their fertility so they can still have children in the future. You will still have periods (menstruate) after a trachelectomy.

Hysterectomy, bilateral salpingectomy and bilateral salpingo-oophorectomy

A hysterectomy is the surgical removal of the uterus and cervix (called a total hysterectomy), or surgical removal of the uterus, cervix, soft tissue around the cervix and the top of the vagina (called a radical hysterectomy)^[6]. A radical hysterectomy is the most common type of surgery used to treat cervical cancer.

The hysterectomy can be performed using two different methods:

• Open surgery (or ‘laparotomy’) – where a cut is made in the belly, and the uterus and other organs are removed through the cut
• Laparoscopic surgery (or ‘keyhole’) – where thin instruments are inserted into small cuts made in the belly, and the uterus and other organs are removed through the vagina; robotic-assisted surgery is a type of laparoscopic surgery where the surgeon is assisted by a special machine (robot).^[7]

When a hysterectomy is performed, it is common for the fallopian tubes to be removed as well. This is called bilateral salpingectomy. If the ovaries are also removed, this is called bilateral salpingo-oophorectomy.

You might only have a hysterectomy, a bilateral salpingectomy or salpingo-oophorectomy, or both. Whether you have a bilateral salpingectomy or bilateral salpingo-oophorectomy will depend on your age and how far the cancer has spread (metastasised).

Some side effects of a hysterectomy include:

• feeling like you can’t fully empty your bladder
• feeling like you are emptying your bladder or bowel too slowly
• leakage of urine (called urinary incontinence)
• menopause (if your ovaries are removed)
• stomach pain or discomfort from internal scar tissue (adhesions)

Lymph node biopsy or removal

There are two procedures your doctor may perform to work out if cancer has spread to your lymph nodes^[8]:

• Sentinel lymph node biopsy – where the lymph node closest to the cancer is identified by injecting a dye into the cervix; the lymph node is then removed so that a pathologist can test it for cancer cells
• Lymphadenectomy (or ‘lymph node dissection’)­ – where some of the lymph nodes in your pelvic region are removed and tested for cancer cells; a lymphadenectomy is also performed if cancer cells are found following a sentinel lymph node biopsy.

If cancer is found in the lymph nodes following a lymphadenectomy, your doctor will advise you on additional (adjuvant) therapy.

The removal of lymph nodes may cause fluid to build up in the legs. This is called lymphoedema.

Pelvic exenteration

Pelvic exenteration is done if the cancer has spread beyond the uterus to the surrounding organs, such as the lower colon, rectum, bladder, cervix, vagina, ovaries, and nearby lymph nodes. The surgery involves removing all or part of the affected organs.

Openings called stoma are made to bring the openings of small or large intestine out onto the abdomen through the skin and into a bag. This allows urine and faeces to flow from inside the body to the collection bag. Common stomas include:

• ileostomy (formed from the lower half of the small bowel, called the ileum, which joins up with the colon)
• colostomy (formed from the colon)
• ileal conduit (formed by isolating a small piece of ileum and implanting the tubes from the kidney [ureters] into it).

For more information or to contact a stoma association, see the Stoma Appliance Scheme website.

Plastic surgery to reconstruct the vagina may also be offered at a suitable time after pelvic exenteration.

If you are premenopausal and feel concerned about how surgery or other treatment will affect your fertility, see Effects of treatment on fertility for more information.

Radiation therapy

Radiation therapy (also called radiotherapy) uses high-energy X-rays or other types of radiation to destroy cancer cells or stop them from growing^[9]. You might have radiation therapy to your pelvic area to treat cervical cancer. This may be the main treatment, or it may be used after surgery to get rid of any remaining cancer cells.

There are two main ways of delivering radiation therapy, and most people with cervical cancer will have both:

• External beam radiation therapy – where a machine outside the body directs radiation towards the cervix, lymph nodes, and other organs that need treatment; this includes intensity-modulated radiation therapy (IMRT)^[10]
• Internal radiation therapy (brachytherapy) – where an applicator containing a radiation source is placed into the cervix for 10–20 minutes; this is a type of high-dose-rate brachytherapy, where bigger doses of radiation therapy are given in fewer treatments.

If you have not had a hysterectomy or have not been through menopause, you should avoid getting pregnant during your radiation therapy because it can harm your unborn baby. If you become pregnant during treatment, talk to your doctor.

Chemotherapy

Chemotherapy is a cancer treatment that uses medicines to slow the growth of cancer cells, either by destroying the cells or stopping them from dividing. You might have chemotherapy to treat advanced cervical cancer, or cancer that has recurred (come back).

Chemotherapy is usually given through a vein (intravenously) as an outpatient. The treatment is repeated on a regular basis, with intervals of a few weeks called a cycle.

Chemotherapy is usually given as single drug or multiple drug combination. The type of regimen used depends on the stage of the disease. A platinum-based chemotherapy regimen is usually administered in stage II and III cervical cancer, and may be in combination with radiation treatment. For stage IV cervical cancer a combination of different chemotherapy drugs is common.^[11],[12]

If you have not had a hysterectomy or have not been through menopause, you should avoid getting pregnant during your chemotherapy because it can harm your unborn baby. If you become pregnant during treatment, talk to your doctor.

Combination therapy

A combination of radiation therapy and chemotherapy (called chemoradiation) is usually used to treat advanced cervical cancer.

Chemoradiation causes more severe side effects than either chemotherapy or radiation therapy alone. The side effects include nausea, vomiting and a lowered number of white blood cells (which fight infection). If you have a low number of white blood cells, you may need to stop chemotherapy until your blood counts rise, and then restart the combined treatment.

For more information about side effects of chemotherapy see Cancer Australia’s webpage on chemotherapy treatment.

Targeted therapy

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells with less harm to normal cells^[13]. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells.

Targeted therapy is used to treat people with cervical cancer that has spread to other parts of the body or has recurred (come back) and cannot be treated by surgery or radiation therapy.

A medicine used for targeted therapy of cervical cancer is bevacizumab, which is an angiogenesis inhibitor that stops cancer cells from developing new blood vessels and growing. Common side effects of taking this drug include high blood pressure, fatigue and loss of appetite.

Effects of treatment on fertility

Some treatments for cervical cancer can affect your ability to have children in the future. There may be some options available that can allow you to have children (called fertility-sparing options) – your doctor will discuss these with you.

In most cases, cervical cancer is treated either by radical hysterectomy (which removes the uterus but leaves the ovaries and fallopian tubes) or by chemoradiation (which destroys cancer cells, but also affects the lining of the uterus and causes the ovaries to stop producing eggs). Treatment can also include a bilateral salpingectomy (which removes the fallopian tubes) or a bilateral salpingo-oophorectomy (which removes the fallopian tubes and the ovaries). ^[14] These treatments can mean that you can no longer have children.

Minor surgery to treat early cervical cancer, such as a cone biopsy, has little effect on fertility because the uterus, cervix, fallopian tubes and ovaries are not removed.

People who have had a radical trachelectomy may be able to become pregnant because this surgery removes the cervix but not the body of the uterus, ovaries or fallopian tubes. However, there is a higher risk of miscarriage.

Fertility-sparing options

People who have not already been through menopause should ask about ways to preserve their fertility, including egg or embryo storage for use in the future^[15].

Younger people who have a radical hysterectomy may be able to keep their ovaries, which are usually transposed (moved out of the pelvis; this is called oophoropexy) so that they will not be affected by any postoperative radiation treatment. If you still have your ovaries after surgery, you will still produce your own eggs. This means that, in the future, you could choose to have a baby through surrogacy (where your own eggs are fertilised with sperm and the embryo is implanted in another woman to carry the baby for you).

Follow-up

After treatment, you may need regular physical examinations. Depending on the results of these physical examinations, you might also need a follow-up HPV test or imaging tests. You should tell your doctor if you experience symptoms, including^[16]:

• stomach pain
• back pain
• problems with urination
• cough
• fever.

Recurrent or advanced cervical cancer

Recurrent cervical cancer is cancer that has recurred (come back) after it has been treated. It grows back from the cells of the original primary cancer that have not responded to treatment. Secondary cancer, or metastasis, is cancer that has spread from the original site to another part of the body. Cervical cancer may come back in the cervix or in another part of the body.

Treatment options for recurrent cervical cancer depend on the location of the cancer and other treatments you have already had^[24]. They may include the following:

• If the cancer is in the centre of the pelvis, surgery may be possible. This involves removing the lower bowel (rectum) and/or bladder, along with the cervix, uterus and vagina – this is called a pelvic exenteration.
• Surgery may be followed by radiation therapy combined with chemotherapy.
• If the cancer is not limited to the centre of the pelvis, treatment is usually by radiation therapy and/or chemotherapy.

It may be possible for you to join a clinical trial of new anticancer drugs or drug combinations.