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Cervical Malignancy

- With completion of definitive therapy and based on individual risk factors, patients are evaluated with physical/pelvic examinations: - Every 3 to 6 months for 2 years - Every 6 to 12 months until the 5th year - Yearly thereafter (8)[C]

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  • Management is guided by consideration of stage of lesion, gestational age, and maternal assessment of risks and benefits from treatment.
  • Abnormal cytology is best followed up by colposcopy with directed biopsies.
  • CIN1 or less: postpartum follow-up
  • CIN2-3: management per established guidelines
  • Microinvasive carcinoma: conization or trachelectomy. If depth of invasion ≤3 mm, follow up at the 6-week postpartum visit
  • Invasive carcinoma: definitive therapy, with timing determined by maternal preference, stage of disease, and gestational age

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INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Signs of active bleeding
  • Urinary symptoms
  • Dehydration
  • Complications from surgery, chemotherapy, or radiation
  • Active vaginal bleeding can be controlled with timely vaginal packing and radiation therapy.
  • Recognition of ureteral blockage, hydronephrosis, urosepsis, and timely intervention

Discharge Criteria

Discharge criteria based on multidisciplinary assessment пїЅ

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • With completion of definitive therapy and based on individual risk factors, patients are evaluated with physical/pelvic examinations:Every 3 to 6 months for 2 yearsEvery 6 to 12 months until the 5th yearYearly thereafter (8)[C]
  • Pap smears may be performed yearly but have a low sensitivity for detecting recurrence (8)[C].
  • CT and PET scan are useful in locating metastases when recurrence is suspected (8)[C].
  • Signs of recurrence include vaginal bleeding, unexplained weight loss, leg edema, and pelvic or thigh pain.

PATIENT EDUCATION

  • Patient education material available through the ACOG at http://www.acog.org, the Society of Gynecologic Oncology at http://www.sgo.org, the Foundation for Women's Cancer at http://www.foundationforwomenscancer.org, the American Cancer Society at http://www.cancer.org, and the National Cancer Institute at http://www.cancer.gov.

PROGNOSIS

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View LargeStage5-y Survival (%)176-98266-73340-4249-22

COMPLICATIONS

  • Loss of ovarian function from radiotherapy or indication for bilateral oophorectomy
  • Hemorrhage
  • Pelvic infection
  • Genitourinary fistula
  • Bladder dysfunction
  • Sexual dysfunction
  • Ureteral obstruction with renal failure
  • Bowel obstruction
  • Pulmonary embolism
  • Lower extremity lymphedema

REFERENCES

11 Committee on Practice Bulletins-Gynecology. ACOG Practice Bulletin Number 131: screening for cervical cancer. Obstet Gynecol. 2012;120(5):1222-1238.22 International Federation of Obstetrics and Gynecology. Global guidance for cervical cancer prevention and control. http://www.rho.org/files/FIGO_cervical_cancer_guidelines_2009.pdf.33 Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration. Reducing uncertainties about the effects of chemoradiotherapy for cervical cancer: individual patient data meta-analysis. Cochrane Database Syst Rev. 2010;(1):CD008285.44 Rydzewska пїЅL, Tierney пїЅJ, Vale пїЅCL, et al. Neoadjuvant chemotherapy plus surgery versus surgery for cervical cancer. Cochrane Database Syst Rev. 2012;(12):CD007406.55 Tewari пїЅKS, Sill пїЅMW, Long пїЅHJIII, et al. Improved survival with bevacizumab in advanced cervical cancer. N Engl J Med. 2014;370(8):734-743.66 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: cervical cancer. http://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf.77 Smith пїЅTJ, Temin пїЅS, Alesi пїЅER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880-887.88 Salani пїЅR, Backes пїЅFJ, Fung пїЅMF, et al. Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations. Am J Obstet Gynecol. 2011;204(6):466-478.

ADDITIONAL READING

  • American Society for Colposcopy and Cervical Pathology. Algorithms: updated consensus guidelines for managing abnormal cervical cancer screening tests and cancer precursors. http://www.asccp.org/Portals/9/docs/ASCCP%20Management%20Guidelines_August%202014.pdf.
  • Martin-Hirsch пїЅPP, Paraskevaidis пїЅE, Bryant пїЅA, et al. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2013;(12):CD001318.
  • Scarinci пїЅIC, Garcia пїЅFA, Kobetz пїЅE, et al. Cervical cancer prevention: new tools and old barriers. Cancer. 2010;116(11):2531-2542.

SEE ALSO

Abnormal Pap and Cervical Dysplasia пїЅ

CODES

ICD10

  • C53.9 Malignant neoplasm of cervix uteri, unspecified
  • C53.0 Malignant neoplasm of endocervix
  • C53.1 Malignant neoplasm of exocervix
  • C53.8 Malignant neoplasm of overlapping sites of cervix uteri

ICD9

  • 180.9 Malignant neoplasm of cervix uteri, unspecified site
  • 180.0 Malignant neoplasm of endocervix
  • 180.1 Malignant neoplasm of exocervix
  • 180.8 Malignant neoplasm of other specified sites of cervix

SNOMED

  • 363354003 Malignant tumor of cervix (disorder)
  • 372097009 Malignant neoplasm of endocervix
  • 372099007 Malignant neoplasm of exocervix

CLINICAL PEARLS

  • Cervical cancer is the third most common gynecologic malignancy in the United States. Improving access to screening is likely to have the greatest impact in reduction of burden of disease.
  • Women with cervical cancer may be asymptomatic and have a normal physical exam.
  • Surgical management is an option for patients with early-stage tumors.
  • Chemoradiation is the first-line therapy for higher stage tumors.