Radiation oncologist Karen Schupak works with colleagues at Memorial Sloan-Kettering's suburban cancer centers in New Jersey, Long Island, and Westchester County to ensure that women with cervical cancer receive the same high-quality care, wherever they go for treatment.
For women needing treating for cervical cancer, the primary forms of treatment are surgery and combined radiation therapy and chemotherapy.
Options for treating cervical cancer depend chiefly on the stage of disease — the size of the tumor, the depth of invasion, and whether the cancer has spread to other parts of the body. Other factors that are considered are the patient's age and if she wishes to have children.
Carcinoma In Situ
These cancers are preinvasive and can be treated conservatively. In most cases, it is possible to spare the uterus. Options for treatment include:
- cone biopsy, or conization (to surgically remove a cone-shaped piece of tissue containing the cancer); this procedure is generally used for diagnosis and treatment
- internal radiation therapy, also called high-dose brachytherapy (for women unable to have surgery)
- total, or complete, hysterectomy (surgery to remove the entire uterus, including some or all of the cervix)
These treatments are almost always effective in removing precancers and stopping them from developing into true cancers.
Early Cervical Cancer (Stages I-IIA)
For early cervical cancers that are confined to the cervix, surgical options may include hysterectomy (removal of the uterus), sometimes encompassing the tissue next to the uterus and cervix. Lymph nodes from the pelvis may also be removed and examined for cancer cells.
If the cancer is associated with “high-risk” features — such as involvement of the pelvic lymph nodes, invasion of the lymph channels or blood vessels of the cervix, or involvement of the tissue along the uterus — the doctor will usually recommend chemotherapy combined with radiation therapy.
Radical Trachelectomy
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For women whose cancer is confined to the cervix and who wish to have children, Memorial Sloan-Kettering surgeons may be able to remove just the cervical tissue and spare the womb (the upper part of the uterus known as the fundus) through a procedure known as radical trachelectomy. This procedure has the potential to preserve a woman's ability to bear children. Using either laparoscopy or open, traditional surgery, the surgeon removes the cervix and pelvic lymph nodes. If they are free of cancer cells, only a portion of the cervix needs to be removed, rather than the entire uterus. If the patient becomes pregnant, she is still able to have a full-term pregnancy and deliver the baby by cesarean section.
Use of Robotics for Surgery
To remove early-stage cervical cancers, our specially-trained surgeons may use an advanced robotic device — called the daVinci system — to assist him or her during the procedure. To use the robot, the surgeon is seated at a multifunctional console positioned next to the patient. The surgeon views the area of the operation on the console via a magnified, three-dimensional, high-definition visual system. The operation is performed by the surgeon at the console using finger and foot controls with the robot precisely copying every movement of the surgeon. As the surgeon uses the robot to operate, the surgical team at the bedside monitors the patient throughout the procedure, assisting as necessary.
Combination Treatments
For very large cancers of the cervix without evidence of spread beyond the cervix, treatment may include either chemotherapy and radiation therapy or radical hysterectomy. A few clinical studies have demonstrated that primary treatment with chemotherapy and radiation improves the survival of patients with these cancers compared to radiation therapy alone.
Sentinel Lymph Node Biopsy
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Memorial Sloan-Kettering gynecologic surgeons, led by Nadeem Abu-Rustum, developed a simple technique to identify and remove the most important lymph nodes during surgery for early-stage endometrial or cervical cancers.
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At Memorial Sloan-Kettering, we are evaluating an approach — called sentinel lymph node biopsy — that could eliminate the need to remove all the pelvic lymph nodes for analysis.
Using a blue dye and in some cases a special radioactive substance that can be traced with imaging techniques, doctors can identify during surgery the first lymph node (the sentinel node) to which cancer cells would travel after leaving the cervix. This technique is called intraoperative lymphatic mapping or sentinel node mapping. If this node is free of cancer cells, the goal is to avoid removing additional lymph nodes. If the node does contain cancer cells, the surgeon then removes additional lymph nodes for further examination.
Brachytherapy
At Memorial Sloan-Kettering, we have vast clinical experience in combined modality therapy (combination chemotherapy and radiation therapy), including brachytherapy. In high-dose brachytherapy, radioactive material is applied directly to the tumor. Brachytherapy is used in combination with intensity-modulated radiation therapy (IMRT), a type of external beam radiation which allows more precise treatment planning and the ability to deliver higher radiation doses with greater safety. With IMRT, radiation therapists can shape pencil-thin radiation beams of varying intensity to conform to specific tumor shapes and sizes, reducing the dosage of radiation to healthy tissues and possibly the side effects of treatment.
Advanced Cervical Cancer (Stages IIB-IVA)
If cervical cancer has spread beyond the cervix and into the surrounding pelvic tissues, surgery alone is usually not an effective cure. Patients with this degree of invasive cancer have traditionally also been treated with radiation therapy (the use of x-rays or other high-energy waves to kill cancer cells and shrink tumors), either alone or in addition to surgery.
In recent years, however, there has been a major shift in the treatment of advanced cervical cancer. Based on the results of large clinical trials, the standard of care for regionally advanced cervical cancer is now chemotherapy combined with radiation therapy. The radiation therapy may be delivered externally and/or internally through brachytherapy (by applying radioactive material directly to the cervix).
When chemotherapy drugs (such as cisplatin) are given with radiation therapy, the tumors are made more sensitive to the effects of the radiation. This combined action improves the survival of advanced cervical patients dramatically — by as much as 30 to 50 percent. Nearly all patients with invasive cervical cancer can benefit from this combination of radiation therapy and chemotherapy.
Stage IVB & Recurrent Cervical Cancer
For women whose cancer spreads beyond the pelvis (into the lungs or liver, for example) or who have recurrent disease, treatment is aimed at reducing cancer-related symptoms in order to improve a patient's quality of life, and hopefully to prolong her survival.
Chemotherapy is the primary modality of treatment for these patients, and several drugs, such as cisplatin and paclitaxel, are available. Treatment of this group of women — with a focus on new chemotherapy drugs and combinations of drugs — remains a major research priority at Memorial Sloan-Kettering Cancer Center.
Some women with recurrent cervical cancer may choose an extensive surgery known as pelvic exenteration, which requires Memorial Sloan-Kettering's gynecologic surgeons to remove cancerous tissue and reconstruct the remaining organs so the patient retains optimal function. This is an extremely radical procedure reserved for patients with limited treatment options. Pelvic exenteration may be combined with intraoperative brachytherapy. This radiation — administered directly to any remaining cancer cells — can only be given in specialized operating rooms, available at hospitals such as Memorial Sloan-Kettering.
Because this procedure is physically and emotionally demanding, investigators at Memorial Sloan-Kettering have initiated a trial to learn more about the physical, emotional, educational, and sexual needs of women treated with pelvic exenteration.
