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    Drugs & Diseases > Oncology

    Cervical Cancer Treatment Protocols 

    Updated: Jun 03, 2021
    • Author: Jessica Katz, MD, PhD, FACP; Chief Editor: Yukio Sonoda, MD  more...
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    Treatment Protocols

    Treatment protocols for cervical cancer are provided below, including treatment by stage, chemoradiation therapy, and chemotherapy.

    Treatment recommendations for early stage disease

    Stage IA1 disease:

    • Primary treatment of stage 1A1 cervical cancer depends on the results of cone biopsy and whether the patient wishes to preserve her fertility. [1, 2, 3, 4, 5, 6, 7, 8]

    • For patients who desire fertility preservation and have negative margins on cone biopsy (3 mm) and no evidence of lymphovascular invasion, observation may be an option. [37, 13, 9]

    • Surgical options for all other individuals may include trachelectomy, pelvic lymph node dissection, sentinel lymph node mapping, and simple hysterectomy [38, 11, 17, 15]

    Treatment recommendations for stage IA2

    Stage IA2 disease:

    • For patients who wish to preserve their fertility, radical trachelectomy and pelvic lymph node dissection is recommended

    • Patients with stage IA2 tumors are treated with radical hysterectomy or radical trachelectomy with pelvic lymph node dissection

    • For medically operable patients who do not desire fertility preservation, radical hysterectomy and bilateral pelvic lymph node dissection with or without para-aortic lymph node sampling is recommended; radiation therapy may also be an option in select cases. [10]

    • Pelvic external beam radiation with brachytherapy (generally dosed at 70-80 Gy to total point A dose) is a treatment option for patients who are medically inoperable or who refuse surgery [39]

    Treatment recommendations for stage IB and IIA

    Stage IB and IIA:

    • Patients with stage IB or IIA disease can be treated with surgery, radiation therapy, or concurrent chemoradiation, depending on the stage and bulk of their disease. [11, 12, 13, 14, 15, 16, 17, 18, 19, 20]

    • Primary surgery consists of radical hysterectomy plus bilateral pelvic lymph node dissection with or without para-aortic lymph node sampling (for tumors < 2 cm). [7, 40]
    • In general, surgery is the most appropriate option for patients with stage IB1 or IIA1 disease, whereas concurrent chemoradiation is most appropriate for those with stage IB2 or IIA2 disease. [7, 41, 23, 29, 27]

    • If lymph nodes are positive, then a hysterectomy is not recommended; instead, the patient should receive chemoradiation.

    • Patients with stage IB or IIA may also be given pelvic radiotherapy and brachytherapy with (or without) concurrent cisplatin-based chemotherapy (category 1) . The addition of concurrent cisplatin-containing chemotherapy has been shown to improve survival [1, 21, 22, 7, 23, 24, 25, 26, 27, 28, 29, 10, 41]

    • Cisplatin 40 mg/m 2 IV once weekly plus  radiation therapy, 1.8-2 Gy daily per fraction, for six cycles or
    • Cisplatin 50-75 mg/m 2 IV on day 1 plus  5-flurouracil (5-FU) 1000 mg/m 2 continuous IV infusion over 24 h on days 1-4 (total dose 4000 mg/m 2 each cycle) every 3 wk plus radiation therapy, 1.8-2.0 Gy daily, for a total of three to four cycles

    Treatment recommendations for advanced stage disease

    Stage IIB, IIIA, IIIB, and IVA:

    • Traditionally, advanced disease includes stages IIB-IVA; however, many oncologists now also include patients with IB2 and IIA2 in the advanced disease category. [10]

    • Radiologic imaging studies (including PET/CT) are recommended for stage IB2 or greater disease, especially for evaluation of nodal or extrapelvic tumors. [42]

    • Treatment recommendations for advanced disease include concomitant chemoradiation and brachytherapy (category 1). [10, 21, 22, 23, 24, 25, 26, 27, 28, 29]

    • Cisplatin 40 mg/m2 IV once weekly (not to exceed 70 mg/wk) plus  radiation therapy 1.8-2 Gy per fraction (minimum 4 cycles; maximum 6 cycles) for a total of 45 Gy or

    • Cisplatin 50-75 mg/m2 IV on day 1 plus  5-fluorouracil (5-FU) 1000 mg/m2 continuous IV infusion over 24 h on days 1-4 (total dose 4000 mg/m2 each cycle) every 3 wk for a total of three or four cycles; plus radiation therapy, 1.8-2 Gy per day for a total for 45 Gy or

    • Cisplatin 40 mg/m2 IV once weekly and gemcitabine 125 mg/m2 weekly for 6 weeks with concurrent radiation therapy for total of 50.4 Gy in 28 fractions, followed by brachytherapy 30 to 35 Gy in 96 hours, and then two adjuvant 21-day cycles of cisplatin, 50 mg/m2 on day 1, plus gemcitabine, 1000 mg/ m2 on days 1 and 8) [43]  

    Treatment recommendations for metastatic disease

    Stage IVB:

    • Patients with metastatic disease are primarily treated with cisplatin-based chemotherapy

    • Individualized radiation therapy can be considered for control of pelvic disease and other symptoms [1, 7, 10]

    • If cisplatin was previously used as a radiosensitizer, combination platinum-based regimens are preferred over single agents in the setting of metastatic disease [32, 30]

    First-line therapy for stage IV recurrent or metastatic disease [10] [30] 30, [31] 31, [32] 32, [33] 33, [34] 34] :

    • Bevacizumab 15 mg/kg IV over 30-90 min on dayt 1 plus  cisplatin 50 mg/m2 IV over 60 min on days 1 or 2 plus  paclitaxel 175 or 135 mg/m2 IV over 3 h or 24 h on day 1 every 3 wk (category 1) or

    • Bevacizumab 15 mg/kg IV over 30-90 min plus  paclitaxel 175 mg/m2 IV over 3 h on day 1 plus  topotecan 0.75 mg/m2 IV over 30 min on days 1-3 every 3 wk (category 1) or

    • Paclitaxel 135 mg/m2 IV over 24 h on day 1 (dosing at 175 mg/m2 IV over 3 h on same day as cisplatin is also acceptable) followed by  cisplatin 50 mg/m2 IV on day 2 every 3 wk (category 1) or

    • Paclitaxel 175 mg/m2 IV over 3 h followed by carboplatin area under the curve (AUC) 5 IV over 30 minutes on day 1 every 3 wk(category 1 for patients who received prior cisplatin therapy)

    • Other combinations—including cisplatin/topotecan, carboplatin/paclitaxel, and topotecan/paclitaxel—can also be considered for appropriate individuals (category 2A)
    • Cisplatin is generally the most active agent and may be used as first-line single-agent chemotherapy for recurrent or metastatic cervical cancer.

    Second-line therapy for stage IV recurrent or metastatic disease:

    Agents that the National Comprehensive Cancer Network (NCCN) recommends as useful in second-line therapy (category 2B) include the following [10] :

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