Overview
Cervical cancer diagnosed as stage II disease is commonly detected from an abnormal Pap smear or pelvic examination. Following a staging evaluation of cervical cancer, a stage II cancer is said to exist if the cancer has extended beyond the cervix to the upper portion of the vagina (stage IIA) or to the tissues next to the cervix, called the parametria (stage IIB). Patients with stage II cervical cancer are generally treated with a combination of radiation therapy and chemotherapy. Some patients with stage IIA disease can undergo a radical hysterectomy, sometimes followed by a course of radiation therapy.
A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.
The following is a general overview of the treatment of stage II cervical cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.
Stage II cervical cancer is currently best managed by a combination of radiation therapy and chemotherapy. Radiation therapy is treatment with high energy x-rays that have the ability to kill cancer cells. Radiation therapy can be administered via a machine that aims x-rays at the body (external beam radiation) and/or by placing small capsules of radioactive material directly into and near the cervix (internal or implant radiation). Most patients will receive both types of radiation therapy during their course of treatment. External beam radiation therapy (EBRT) for cervical cancer is administered on an outpatient basis for approximately 4 to 6 weeks.
During or immediately following the external beam portion of radiation therapy, patients may also undergo an implant radiation procedure. Placing the radiation within the cervix allows a high dose of radiation to be delivered to the cancer, while reducing the radiation to the surrounding normal tissues and organs. During a procedure in the operating room, a small device is placed into the cervix and vagina and later is “loaded” with radioactive material. The radioactive material is left in place while the patient stays in the hospital for 1-3 days. This process may be performed once or twice during the course of treatment.
Prior to the 1990s, the standard treatment of stage II cervical cancer had utilized external beam and internal radiation therapy and no significant progress in the treatment of cervical cancer occurred for many years. Approximately 60% of patients with stage II cervical cancer survived 5 years from treatment with radiation therapy alone. More recently, however, the addition of chemotherapy (anti-cancer drugs) has improved long-term outcomes in patients with this disease.
Chemotherapy, such as Platinol®, 5-fluorouracil and other drugs, has the ability to kill cancer cells and make radiation therapy more effective at killing cancer cells. The strategy of administering chemotherapy concurrently with radiation treatment is appealing because chemotherapy and radiation therapy may act together to increase the killing of cancer cells. Chemotherapy may also destroy cells independently of radiation therapy. Several clinical studies performed in patients with locally advanced cervical cancer utilizing concurrent chemotherapy and radiation therapy have suggested that this strategy may improve remission rates and prolong survival. In order to definitively determine whether radiation therapy administered with concurrent chemotherapy is superior to radiation therapy alone, several clinical studies were designed to directly compare the two treatments in patients with locally advanced cervical cancer.
One recent pivotal clinical trial conducted by various oncology groups in the United States has shown that radiation therapy combined with chemotherapy for locally advanced cervical cancer is superior to treatment with radiation therapy alone. In this study, 403 patients were treated with radiation therapy alone or radiation therapy plus concomitant 5-fluorouracil and Platinol® chemotherapy. The 5-year survival rate of patients with stage IB, IIA, or IIB cervical cancer was 77% for patients treated with concurrent radiation therapy and chemotherapy, compared to only 50% for patients treated with radiation therapy alone. Concurrent chemotherapy and radiation therapy were well tolerated except for minor gastrointestinal and hematologic side effects, which were reversible.
In summary, the combination Platinol® chemotherapy administered concurrently with radiation produces superior overall survival and a decreased risk of cancer recurrence compared to treatment with radiation therapy alone. Continued research is ongoing to determine whether additional chemotherapy drugs or doses of radiation may improve the outcome of patients with locally advanced cervical cancer. At least four other clinical studies have confirmed that treatment of locally advanced cervical cancer with concurrent Platinol®-based chemotherapy and radiation therapy is superior to radiation therapy alone.
Even with combination chemotherapy and radiation treatment, approximately 20-40% of patients with stage II cervical cancer experience recurrence of their cancer. In some patients, cancer cells may have survived near the cancer despite the radiation therapy. Other patients with stage II disease already have small amounts of cancer that have spread outside the cervix and were not treated by the chemotherapy. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix gland are referred to as micrometastases. The presence of these microscopic areas of cancer or surviving cancer cells can cause the relapses that follow treatment.
Strategies to Improve Treatment
The progress that has been made in the treatment of cervical cancer has resulted from improved development of treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of stage II cervical cancer.
Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Supportive Care.
New Adjuvant Chemotherapy Regimens: Platinol® chemotherapy administered concurrently with radiation improves the survival of women with stage IB bulky cervical cancer. Evaluation of new chemotherapy drugs in addition to or in place of Platinol® that can kill cancer cells more effectively are now being tested as adjuvant therapies.
In one study, Ellence® was found to be an effective drug for the treatment of cervical cancer when combined with radiation therapy. Ellence® was evaluated in 220 patients with bulky stage I-III cervical cancer receiving radiation therapy. The results indicated that 15% of patients treated with Ellence® and radiation therapy relapsed, compared to 30% of patients treated with radiation therapy alone. Overall survival was 80% for patients treated with Ellence® and radiation therapy, compared to 70% for patients treated with radiation alone. The primary benefit of Ellence® was the prevention of distant relapses. Further improvements might result from combining Ellence® with Platinol® or chemotherapy agents.
Biological Therapy: Biologic therapies are naturally occurring or synthesized substances that direct, facilitate or enhance the body’s normal immune defenses. The goal of biologic therapies is to have the patient’s own immune defenses attack and destroy the cancer cells. Biologic therapies include interferons, interleukins, monoclonal antibodies and vaccines. In an attempt to improve survival rates, these and other agents are being tested alone or in combination with chemotherapy in clinical trials.
Newer Radiation Techniques: External beam radiation therapy can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum.
Newer Imaging Techniques: The ability of current imaging technology to detect small areas of cancer within and around the cervix and elsewhere in the body is limited. Magnetic resonance imaging, or MRI, provides better images of the cervix and locates growths of cancer in the pelvis. The MRI can be used to guide radiation therapy.