Cervical Cancer: Evaluation and Management

 

Human papillomavirus infection is the precursor for the development of cervical cancer and is detectable in 99.7% of squamous cell carcinoma and adenocarcinoma cases. Early detection of precancerous lesions with Papanicolaou testing remains the primary mechanism for cancer prevention. Once cervical cancer is diagnosed, treatment may involve surgery, radiation therapy, chemotherapy, or a combination. The choice of therapy depends on the stage of disease, lymph node involvement, patient comorbidities, and risk factors for recurrence. Early-stage, microinvasive disease may be treated with surgery alone if margins are negative and there is no lymph node involvement; adjuvant chemoradiation should be considered for other early-stage disease. Locally advanced disease is often treated with chemoradiation. The addition of bevacizumab, an antivascular endothelial growth factor monoclonal antibody, to combination chemotherapy improves survival among patients with recurrent, persistent, or metastatic cervical cancer. Disease stage and lymph node involvement are the most prognostic factors. Pregnancy status and desire to preserve fertility should be considered when developing a treatment strategy. After treatment, close follow-up with a gynecologist-oncologist for pelvic examinations at regular intervals is recommended to assess for recurrence.

Every year, nearly 13,000 cases of cervical cancer are diagnosed, with more than 4,000 deaths.1 Although the highest incidence of cervical cancer is among women 40 to 49 years of age (14 cases per 100,000 women per year), 40% of women are older than 40 years at diagnosis.2 Rates of cervical cancer are higher in the southern region of the United States.2 There are significant disparities in cervical cancer–related mortality among racial and ethnic groups. Black women are more than twice as likely to die from cervical cancer than white women.3 Mortality rates are also higher among Hispanic women.1

Human papillomavirus (HPV) infection is the precursor for the development of cervical cancer.4 Early detection of precancerous lesions with Papanicolaou (Pap) testing is the primary mechanism for cancer prevention.5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cervical cancer is staged clinically before surgery, based on tumor size, depth of invasion, spread into surrounding tissue, and distant metastases.

C

21

Adjuvant platinum-based chemoradiation should be considered after surgery for women with early cervical cancer (stage IA2–IIA) and risk factors for recurrence because it has been shown to reduce mortality.

A

26

Adding bevacizumab (Avastin) to combination chemotherapy should be considered for women with recurrent, persistent, or metastatic cervical cancer because it has been shown to improve overall survival.

B

32

Patients with cervical cancer should be referred to regional cancer centers with centralization of services.

B

33


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cervical cancer is staged clinically before surgery, based on tumor size, depth of invasion, spread into surrounding tissue, and distant metastases.

C

21

Adjuvant platinum-based chemoradiation should be considered after surgery for women with early cervical cancer (stage IA2–IIA) and risk factors for recurrence because it has been shown to reduce mortality.

A

26

Adding bevacizumab (Avastin) to combination chemotherapy should be considered for women with recurrent, persistent, or metastatic cervical cancer because it has been shown to improve overall survival.

B

32

Patients with cervical cancer should be referred to regional cancer centers with centralization of services.

B

33


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN ONCOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Avoid routine imaging for cancer surveillance in women with gynecologic cancer, specifically ovarian, endometrial, cervical, vulvar, and vaginal cancers.

Society of Gynecologic Oncology


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see

The Authors

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JENNIFER WIPPERMAN, MD, MPH, is an assistant professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita....

TARA NEIL, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita.

TRACY WILLIAMS, MD, is an associate professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita.

Address correspondence to Jennifer Wipperman, MD, MPH, University of Kansas School of Medicine, 1010 N. Kansas, Wichita, KS 67214 (e-mail: jennifer.wipperman1@ascension.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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