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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 �
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 years
- Every 6 to 12 months until the 5th year
- Yearly 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 �L, Tierney �J, Vale �CL, et al. Neoadjuvant chemotherapy plus surgery versus surgery for cervical cancer. Cochrane Database Syst Rev. 2012;(12):CD007406.55 Tewari �KS, Sill �MW, Long �HJIII, 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 �TJ, Temin �S, Alesi �ER, 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 �R, Backes �FJ, Fung �MF, 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 �PP, Paraskevaidis �E, Bryant �A, et al. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2013;(12):CD001318.
- Scarinci �IC, Garcia �FA, Kobetz �E, et al. Cervical cancer prevention: new tools and old barriers. Cancer. 2010;116(11):2531-2542.
SEE ALSO
Abnormal Pap and Cervical Dysplasia �
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.