Cervical cancer (see the image below) is the third most common malignancy in women worldwide, and it remains a leading cause of cancer- related death for women in developing countries. In the United States, cervical cancer is relatively uncommon.
Cervical carcinoma with
adnexa. View Media Gallery Essential update: FDA approves bevacizumab for late-stage cervical cancer In August 2014, the US Food and Drug Administration (FDA) approved bevacizumab (Avastin) for the management of persistent, recurrent or late- stage (metastatic) carcinoma of the cervix. [1, 2] This agent is approved for combination chemotherapy with paclitaxel and cisplatin or with paclitaxel and topotecan. [1, 2] Approval was based on the GOG-0240 study (n = 452) that assessed the efficacy and safety of bevacizumab plus chemotherapy (paclitaxel and cisplatin or paclitaxel and topotecan) in women with persistent, recurrent or metastatic carcinoma of the cervix. [1, 3] A statistically significant improvement in overall survival (OS) and an increase in the rate of tumor shrinkage was shown in women treated with bevacizumab plus chemotherapy compared with chemotherapy alone. However, hypertension, thromboembolic events, and gastrointestinal fistulas were higher in the bevacizumab group. [1, 3] Signs and symptoms The most common finding in patients with cervical cancer is an abnormal Papanicolaou (Pap) test result. Physical symptoms of cervical cancer may include the following: Abnormal vaginal bleeding Vaginal discomfort Malodorous discharge Dysuria See Clinical Presentation for more detail. Diagnosis Human papillomavirus (HPV) infection must be present for cervical cancer to occur. Complete evaluation starts with Papanicolaou (Pap) testing. Screening recommendations Current screening recommendations for specific age groups, based on guidelines from the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), the American Society for Clinical Pathology (ASCP), the US Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG), are as follows [4, 5, 6, 7] : < 21 years: No screening recommended 21-29 years: Cytology (Pap smear) alone every 3 years 30-65 years: Human papillomavirus (HPV) and cytology cotesting every 5 years (preferred) or cytology alone every 3 years (acceptable) >65 years: No screening recommended if adequate prior screening has been negative and high risk is not present See Workup for more detail. Management Immunization Evidence suggests that HPV vaccines prevent HPV infection. [8] The following 2 HPV vaccines are approved by the FDA: Gardasil (Merck, Whitehouse Station, NJ): This quadrivalent vaccine is approved for girls and women 9-26 years of age to prevent cervical cancer (and also genital warts and anal cancer) caused by HPV types 6, 11, 16, and 18; it is also approved for males 9-26 years of age [9] Cervarix (GlaxoSmithKline, Research Triangle Park, NC): This bivalent vaccine is approved for girls and women 9-25 years of age to prevent cervical cancer caused by HPV types 16 and 18 [10] The Advisory Committee on Immunization Practices (ACIP) recommendations for vaccination are as follows: Routine vaccination of females aged 11-12 years of age with 3 doses of either HPV2 or HPV4 Routine vaccination with HPV4 for boys aged 11-12 years of age, as well as males aged 13-21 years of age who have not been vaccinated previously Vaccination with HPV4 in males aged 9-26 years of age for prevention of genital warts; routine use not recommended Stage-based treatment The treatment of cervical cancer varies with the stage of the disease, as follows: Stage 0: Carcinoma in situ (stage 0) is treated with local ablative or excisional measures such as cryosurgery, laser ablation, and loop excision; surgical removal is preferred Stage IA1: The treatment of choice for stage IA1 disease is surgery; total hysterectomy, radical hysterectomy, and conization are accepted procedures Stage IA2, IB, or IIA: Combined external beam radiation with brachytherapy and radical hysterectomy with bilateral pelvic lymphadenectomy for patients with stage IB or IIA disease; radical vaginal trachelectomy with pelvic lymph node dissection is appropriate for fertility preservation in women with stage IA2 disease and those with stage IB1 disease whose lesions are 2 cm or smaller Stage IIB, III, or IVA: Cisplatin-based chemotherapy with radiation is the standard of care [11] Stage IVB and recurrent cancer: Individualized therapy is used on a palliative basis; radiation therapy is used alone for control of bleeding and pain; systemic chemotherapy is used for disseminated disease [11] See Treatment and Medication for more detail.