Treatment

After the diagnosis of cervical cancer is established and the degree of spread of the cancerous process is determined, the doctor, together with the patient, decides what therapy will be carried out.

When drawing up a treatment plan, physicians from different medical fields work interdisciplinary in close contact. In doing so, they are guided by the scientific advice valid throughout Germany (S3 guide), which has been developed by medical societies and is regularly updated.

Treatments used to treat cervical cancer:

• Operation
• Radiation therapy, almost always in combination with chemotherapy

Which therapy will be carried out depends primarily on the size of the tumor and its spread. However, the choice of treatment should also take into account age, general health and, as far as possible, the desire to have children.

Operation

In the early stages of the disease, surgery is the treatment of choice. Your goal is to completely remove the tumor tissue and lymph nodes affected by tumor cells and thus completely cure the disease. Also during surgery, the spread of the tumor can be accurately determined. The extent of the operation depends on the stage of the cancer process. If the tumor is detected at a precancerous or early stage of the disease, then the method of treatment is a cone-shaped excision of the cervix (conization) or partial amputation of the cervix (trachelectomy) if you want to have children. Tissue excision in the form of a cone can be performed through the vagina using an electric loop or a laser beam. If the tumor has already penetrated into the deeper layers of the tissues, in such cases, as a rule, a complete removal of the uterus (hysterectomy) is necessary. In some cases, it may also be necessary to remove part of the vagina and connective tissue that borders the uterus and contains the lymphatic drainage pathways, as well as the lymph nodes (pelvic, namely near the blood vessels). If a woman still wants to have children, the doctor carefully decides whether this surgery is really necessary, or the patient may be offered a special treatment in which the entire cervix (possibly including the pelvic lymph nodes) is removed through the vagina (trachelectomy). However, as a rule, removal of the uterus is still necessary later. Meanwhile, the operation is also performed laparoscopically (minimally invasive, endoscopically), that is, without an incision in the abdominal wall. (laparotomy). At the same time, there is a lower percentage of complications in the short term with a significantly longer operation time. Thus, if the general condition allows to withstand a long operation time, then, taking into account the spread of the tumor, the treatment of some patients can be carried out in this way. The long-term therapeutic result according to the available modern data is probably equivalent here. During the operation, an assessment is made of the spread of the cancer process to neighboring organs in the small pelvis. In the case of damage to the bladder and rectum, it may be necessary to partially or even completely remove these organs (exenteration). It is not always necessary to remove the ovaries, especially in premenopausal women. Rarely, after surgery (in the presence of certain risk factors or a significant tumor lesion), additional radiation therapy is performed, sometimes in combination with chemotherapy (adjuvant radiochemotherapy), in order to destroy possibly remaining tumor cells in the body and, thereby, reduce the risk of recurrence of the disease.

Radiation therapy

As an alternative to surgical treatment, especially in advanced disease, radiation therapy is performed. Studies have shown that in these cases, with radiotherapy alone (exception) or a combination of radiotherapy and chemotherapy (standard), the same long-term results are achieved as with surgical treatment. To reduce the risk of recurrence, some patients receive radiation therapy (adjuvant radiation therapy) as an additional measure after surgery. The goal of radiation therapy is to destroy malignant cells. To achieve this goal, irradiation is carried out almost always combined from the inside and outside. With so-called short-range irradiation (brachytherapy), the radiation source is placed in the uterine cavity or vagina and left there for a short time until the desired radiation dose is reached. The irradiation thus remains locally limited and thus does not damage neighboring organs. In addition to this, irradiation can be performed from the outside through the skin of the entire pelvic area, possibly also lymph nodes in the spine (external or percutaneous irradiation). Chemotherapy is almost always performed in addition to radiation therapy. By combining these two treatments (radio-chemotherapy), the chances of a cure can be improved. Drugs used for chemotherapy increase the sensitivity of tumor cells to radiation. In addition, chemotherapy can also affect already dispersed cancer cells in the body.

Chemotherapy

Chemotherapy seeks to destroy cancer cells throughout the body with drugs that inhibit cell growth (cytostatics). Cytostatics work very well on rapidly growing cells. Rapid growth is a feature that is especially characteristic of cancer cells. Due to the characteristics of cervical cancer, chemotherapy as an "adjuvant" additional therapy to surgical treatment is not used. Chemotherapy is used primarily to treat daughter tumors (metastases) and to reduce symptoms in advanced stages of the disease (palliative therapy). Studies have shown that the best result can be achieved with combination therapy (prescribing several drugs), including the drug platinum. For example, combinations such as cisplatin (a platinum derivative) plus topotecan (a topoisomerase inhibitor) or cisplatin plus paclitaxel (a taxane) are used. Other drug combinations and targeted therapies (antibodies) are currently in clinical trials. Platinum-free treatment options should also be developed for patients previously treated with platinum. Another field of application of chemotherapy is the combination of chemotherapy and radiation therapy (radio-chemotherapy) for the primary treatment of inoperable diseases. Such therapy gives significantly better results and a better prospect of recovery compared to the use of radiation therapy alone.

Antibody Therapy

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor (VEGF). It is a drug of so-called targeted therapy and acts more specifically on cancer cells than on normal cells. Bevacizumab prevents the growth of new blood vessels (called angiogenesis), which are required for the tumor to survive once it reaches a certain size. This reduces blood flow to the tumor, which can affect the growth and spread of the tumor.

Presented at the American Cancer Congress ASCO in 2013 and published by Tewari et al. in 2014, data from GOG 240, a studio (clinical study) with 452 patients (US/Spain) with metastasis, persistent or recurrent cervical carcinoma, showed that bevacizumab (VEGF inhibitor), in addition to conventional palliative chemotherapy, a modest survival advantage of 3.7 months (13.3 months versus 17 months) and an improved progression-free interval (8.2 months versus 5.9 months) can be achieved. ).

In this case, there are more side effects already known in the treatment of patients with other tumors (for example, ovarian cancer), such as: hypertension, neutropenia, thromboembolic complications. As far as can be estimated, with additional therapy, there is almost no deterioration in the quality of life.

Many years later, through clinical studies, data could be presented for the first time, according to which the therapeutic concept for the treatment of relapse showed a significant improvement in progression-free survival (progression-free survival). This is just very important for patients for whom there are still no effective methods of treatment. So far there is no direct comparison of the use of this drug with the only therapy approved in Germany (cisplatin/topotecan). Thus, this therapy is of interest primarily for patients treated with cisplatin. In addition, for this indication, this drug is not yet approved for use due to only recently emerging data, so an explanation of “intended use” is mandatory. A survey of the manufacturer showed that the approval procedure for the drug is planned for mid-2015.