Cervical Cancer Medication

  • Author: Cecelia H Boardman, MD; Chief Editor: Warner K Huh, MD   more...
 
Updated: Mar 28, 2012
 

Medication Summary

Chemotherapy should be administered in conjunction with radiation therapy to most patients with stage IB (high risk) to IVA. Cisplatin is the agent used most commonly, although 5-fluorouracil also is used frequently. For patients with metastatic disease, cisplatin remains the most active agent. Topotecan, ifosfamide, and paclitaxel also have significant activity in this setting. The combination of topotecan and cisplatin improves overall survival. However, acute toxicities are also increased.

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Chemotherapy Agents

Class Summary

These agents inhibit cell growth and proliferation.

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Cisplatin

 

Intrastrand cross-linking of DNA and inhibition of DNA precursors are among the proposed mechanisms of action for cisplatin. This agent is used in combination with radiation therapy.

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Fluorouracil (Adrucil)

 

Fluorouracil is a pyrimidine antagonist. Several mechanisms of action have been proposed, including inhibition of thymidylate synthase and inhibition of RNA synthesis. This agent is also a potent radiosensitizer.

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Ifosfamide (Ifex)

 

Ifosfamide forms DNA interstrand and intrastrand bonds that interfere with protein synthesis.

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Paclitaxel (Abraxane)

 

The mechanisms of action of paclitaxel are tubulin polymerization and microtubule stabilization.

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Topotecan (Hycamtin)

 

Topotecan inhibits topoisomerase I, inhibiting DNA replication. Patients who have received prior chemotherapy should be given a lower dose initially.

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Vaccines

Class Summary

Two human papillomavirus (HPV) vaccines are now available for prevention of HPV-associated dysplasias and neoplasias, including cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions. The immunization series should be completed in girls and young women aged 9-26 years.[43]

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Papillomavirus vaccine, quadrivalent (Gardasil)

 

This quadrivalent HPV recombinant vaccine is the first vaccine indicated to prevent cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions (eg, cervical adenocarcinoma in situ; cervical intraepithelial neoplasia grades 1, 2, and 3; vulvar intraepithelial neoplasia grades 2 and 3; vaginal intraepithelial neoplasia grades 2 and 3) due to HPV types 6, 11, 16, and 18. Vaccine efficacy is mediated by humoral immune responses following the immunization series.

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Papillomavirus vaccine, bivalent (Cervarix)

 

This recombinant HPV vaccine is prepared from the L1 protein of HPV types 16 and 18. It is indicated in girls and women (ages 10-25 y) for prevention of diseases caused by oncogenic HPV types 16 and 18 (ie, cervical cancer, cervical intraepithelial neoplasia grade 2 or higher, adenocarcinoma in situ, cervical intraepithelial grade 1).

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Contributor Information and Disclosures
Author

Cecelia H Boardman, MD  The Dianne Harris Wright Professorship for Obstetrics and Gynecology Oncology Research, Virginia Commonwealth University Medical Center; Associate Professor (Collateral), Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Virginia Commonwealth University School of Medicine

Cecelia H Boardman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, Minnesota Medical Association, and Society of Gynecologist Oncologists

Disclosure: Merck Salary Speaking and teaching; Glaxo Salary Speaking and teaching; Depuy Salary Speaking and teaching

Coauthor(s)

Kirk J Matthews Jr, MD  Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Warner K Huh, MD  Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine

Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Society of Clinical Oncology, Massachusetts Medical Society, and Society of Gynecologist Oncologists

Disclosure: MERCK Consulting fee Consulting; ROCHE PHARMA/DIAGNOSTICS Consulting fee Consulting; INTUITIVE SURGICAL Proctor Fee Consulting; Qiagen Consulting fee Consulting

Additional Contributors

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Anthony El-Khoueiry, MD Assistant Professor of Medicine, Clinical Instructor, Division of Medical Oncology, Keck School of Medicine, University of Southern California

Disclosure: Nothing to disclose.

Agustin A Garcia, MD Associate Professor of Medicine, Keck School of Medicine, University of Southern California

Disclosure: Nothing to disclose.

Omid Hamid, MD Associate Director of Melanoma Center, Medical Director of Neuro-oncology Clinic, USC/Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California

Disclosure: Nothing to disclose.

John J Kavanagh Jr MD, Chief, Professor, Department of Internal Medicine, Section of Gynecological and Medical Therapeutics, MD Anderson Cancer Center, University of Texas Medical School at Houston

John J Kavanagh Jr is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association for the History of Medicine, American College of Physicians, American Federation for Medical Research, American Medical Association, Society of Gynecologist Oncologists, Southern Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Cervical carcinoma with adnexa.
Squamous cell cervical carcinoma.
Table. Summary of 2012 Screening Guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology
ParametersACS Recommendations
Age to start screeningBegin screening with cytology at 21 years old, regardless of sexual history
Screening interval age 21–29Screen with cytology alone every 3 years.* HPV testing should not be used in this age group.
Screening interval age 30-65Screen with a combination of cytology and HPV testing every 5 years (preferred) or cytology alone every 3 years. Screening by HPV testing alone is generally not recommended.*
Age to stop screeningAge 65, if the woman has adequate negative prior screening and is not otherwise at high risk for cervical cancer
Screening after hysterectomyNot indicated for women without a cervix and without a history of a high-grade precancerous lesion (eg, CIN2 or CIN3) in the past 20 years or cervical cancer ever
HPV-vaccinated womenScreen according to the same recommendations as for unvaccinated women
These guidelines do not address special populations (eg, women with a history of cervical cancer, women who were exposed in utero to diethylstilbestrol, women who are immunocompromised) who may require more intensive or alternative screening.



*If abnormal test results are present, further testing and management should be performed according to the ASCCP Guidelines as noted below under Management of Abnormal Cytology.



Table 1. Cervical Cancer Staging (primary tumor [T])
TNM Stage FIGO Stage
Tx-Primary tumor cannot be assessed
T0-No evidence of primary tumor
Tis0Carcinoma in situ
T1ICervical carcinoma confined to uterus (extension to corpus should be disregarded)
T1aIAInvasive carcinoma diagnosed only by microscopy. All macroscopically visible lesions--even with superficial invasion--are T1b/1B. Stromal invasion with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less. Vascular space involvement, venous or lymphatic, does not affect classification.
T1a1IA1Measured stromal invasion 3 mm or less in depth and 7 mm or less in lateral spread
T1a2IA2Measured stromal invasion more than 3 mm but not more than 5 mm with a horizontal spread 7 mm or less
T1bIBClinically visible lesion confined to the cervix or microscopic lesion greater than IA2
T1b1IB1Clinically visible lesion 4 cm or less in greatest dimension
IB2Clinically visible lesion more than 4 cm
T2IICervical carcinoma invades beyond uterus but not to pelvic wall or to the lower third of vagina
T2aIIATumor without parametrial invasion
T2bIIBTumor with parametrial invasion
T3IIITumor extends to the pelvic wall and/or involves the lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney
T3aIIIATumor involves lower third of vagina; no extension to pelvic wall
T3bIIIBTumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney
-IVCervical carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the bladder mucosa or rectal mucosa. Bullous edema does not qualify as a criteria for stage IV disease.
T4IVASpread to adjacent organs (bladder, rectum, or both)
M1IVBDistant metastasis
Table 2. AJCC Stage Grouping
Stage Tumor Node Metastasis
0TisN0M0
IA1T1a1N0M0
IA2T1a2N0M0
IB1T1b1N0M0
IIAT2aN0M0
IIBT2bN0M0
IIIAT3aN0M0
IIIBT1N1M0
-T2N1M0
-T3aN1M0
-T3bAny NM0
IVAT4Any NM0
IVBAny TAny NM1
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