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Conservative management of cervical cancer: Current status and obstetrical implications

https://doi.org/10.1016/j.bpobgyn.2018.06.009Get rights and content

Highlights

  • Many women with cervical cancer are diagnosed at a young age and desire fertility in the future.

  • Radical hysterectomy, the standard of care, is associated with significant morbidity and loss of fertility.

  • Conservative surgery is gaining more attention in the management of early-stage cervical cancer.

  • Conservative surgery may reduce treatment-related morbidity without compromising oncologic outcomes.

  • Following conservative surgery, many cervical cancer survivors are able to conceive and deliver at term.

Abstract

Recent advances in screening and early diagnosis have decreased cervical cancer incidence and mortality rates in high-resource settings. The postponement of childbearing, combined with an increased number of cervical cancer survivors, has yielded new paradigms in patient care. In recent years, radical surgery has been challenged as the standard of care for early-stage cervical cancer owing to its significant morbidity and fertility impairment. Attention has been directed to assessing more conservative procedures that can reduce treatment-induced morbidity without compromising oncologic safety and reproductive potential of patients with early-stage disease. In those with more advanced disease, neoadjuvant chemotherapy followed by conservative surgery has also been considered. These conservative treatment modalities including cervical conization, simple trachelectomy, and simple hysterectomy have been studied in various settings. In this chapter, we discuss the role of conservative surgery in the management of cervical cancer and the resulting obstetrical outcomes.

Section snippets

A growing concern about the benefit of radical surgery in early-stage disease

The standard treatment for early-stage cervical cancer has traditionally been radical hysterectomy to minimize residual tumor and prevent relapse of disease [1]. Despite excellent oncologic outcomes, radical hysterectomy is associated with several complications, primarily owing to the removal of the parametria [2]. These include bladder and rectal dysfunction, sexual dysfunction, and fistula formation [3], [4], [5], [6], [7]. While morbidity induced by parametrectomy can significantly alter the

Cervical conization

Cervical conization is defined as the excision of a cone-shaped or cylindrical wedge of the uterine cervix involving the transformation zone. It has been widely accepted for the treatment of patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA1 disease [42]. In patients with lymphovascular space invasion (LVSI), pelvic lymph node dissection or sentinel lymph node mapping is recommended in addition to conization. This consensus was reached following an analysis of

Neoadjuvant chemotherapy and conservative management of cervical cancer

The role of neoadjuvant chemotherapy (NACT) in the treatment of early-stage cervical cancer is being explored. Indications for NACT are to reduce tumor size to later facilitate surgical resection and to minimize prognostic factors associated with a poor response, thereby eliminating the need for postoperative adjuvant radiotherapy [59]. In patients with stages IB1 and IIA disease with tumor size of 2–4 cm, NACT has been shown to reduce nodal metastases, parametrial infiltration, and tumor size,

Future directions

There remain several unanswered questions regarding the safety of conservative management in early-stage cervical cancer.

Ongoing trials

To provide stronger evidence on the efficacy of conservative management for early-stage cervical cancer, larger prospective trials are currently ongoing. These include an international trial (ConCerv) led by our team at the University of Texas MD Anderson Cancer Center ∗[22], [75]. Started in 2009, ConCerv is a multi-institutional trial evaluating the safety of conservative surgery in women with early-stage cervical cancer with favorable prognostic features. Patients desiring fertility in the

Summary

Conservative surgery is being investigated as an alternative to radical surgery in the management of early-stage cervical cancer. Because of the effective implementation of cervical cancer screening and early detection programs in high-resource settings, a growing number of women are diagnosed with small-volume disease. Given the increased survival and the low risk of parametrial spread observed in this population, less radical surgery will likely gain wider attention in the coming years. While

Conflicts of interest

KMS is the PI of the ConCerv trial.

JFD has no conflict of interest to disclose.

Acknowledgments

This work was supported in part by a Cancer Prevention Fellowship for JFD supported by the Cancer Prevention and Research Institute of Texas grant award, RP170259, Shine Chang, PhD, Principal Investigator, and by the MD Anderson Cancer Center Support Grant, CA016672, funded by the National Cancer Institute (CA016672).

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      Generally, they were chosen from patients who had low rates of PI. Domgue et al. [9] listed the published studies about the prognostic factors used to identify patients with low risk of parametrial spread. Among patients who had a PI <1%, almost all the patients had tumor size ≤2 cm and a histology of SCC, AC, and AS.

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