Management of early cancer cervix

Despite preventive measures such as HPV vaccination and regular screenings, cancer cervix (CC) continues to pose a significant threat to women’s health globally. Early-stage CC, often asymptomatic, requires diligent screening for detection. Post-coital bleeding or unusual vaginal discharge may be the only visible signs. A gold-standard diagnosis involves a biopsy of suspicious lesions, accompanied by a thorough vaginal and rectal examination. Majority of cervical cancers are squamous cell cancers followed by adenocarcinomas, or adenosquamous cancers.

Once a CC diagnosis is confirmed, staging becomes paramount for determining the appropriate course of treatment. The International Federation of Gynecology and Obstetrician (FIGO) staging system, includes pelvic and para-aortic lymph node status and guides clinicians in assessing tumor size and degree of spread.

Imaging studies including Ultrasound, MRI (Magnetic Resonance Image), CT (Computerized Tomography), or PET (Positron Emission Tomography) have been included as complementary tools to guide staging. The final staging defines the tumour (T), nodes (N) and metastasis (M), hence it is called TNM staging system.

The treatment options for early-stage CC are: radiotherapy and surgery. Comparative studies show similar success rates, but management decisions are tailored to individual cases.

Currently, radical hysterectomy (RH) with bilateral pelvic lymphadenectomy is considered the primary treatment for patients early-stage CC particularly for FIGO stages IA1 with lymph-vascular space invasion (LVSI), IA2, IB1, IB2, and IIA.

RH includes the removal of the uterus, vagina, parametrium, and bilateral pelvic lymphadenectomy. This surgical approach, preserving hormonal and sexual functions, is favored over radiotherapy due to quality-of-life concerns and the risk of ovarian failure, especially in younger patients where preservation of hormonal and sexual functions is relevant.

Conversely, for elderly patients (>45 years or the women who have completed their family) or those patients who cannot undergo surgery because of poor general condition and the risks of radical surgery, radiotherapy with or without chemotherapy is recommended.

Patients in IA1 should be diagnosed to establish depth of penetration of cancer, tumor extension (sideways spread), margins, and LVSI. In the absence of LVSI, there is a risk of only1% of lymph node spread or recurrence. Therefore, these patients can be treated conservatively, by conization with free margins or an extrafascial hysterectomy if they do not wish to preserve fertility.

In case of early stage CC, post-surgery patients may need adjuvant radiation, if they have lymph node positive disease, there is lymphovascular involvement, depth of invasion or stromal invasion is present.
In patient who are not suitable for surgery they are treated with concurrent radiation and chemotherapy followed by brachytherapy or with radiation beam using external radiation and weekly brachytherapy. If the primary cancer on the cervix is >4cms radiation along with chemotherapy is a better choice of treatment.