Cervical cancer treatment: options based on stage

Surgery or chemoradiotherapy: what criteria guide the decision

The choice between surgery and chemoradiotherapy is primarily based on two criteria: the tumor size and its spread beyond the cervix.

A tumor limited to the cervix measuring less than 4 cm (early stages I and IIA) points toward surgery. A tumor larger than 4 cm or one that has spread to the parametrium, vagina, bladder, or rectum (stage IIB and beyond) points toward concurrent chemoradiotherapy as the standard treatment.

Other factors are also taken into account: presence oflymphovascular invasion (presence of tumor cells in small vessels), lymph node involvement identified via PET scan, the patient's general health, and the desire to preserve fertility. These elements are analyzed together in an MDT meeting before a recommendation is made.

Understanding the specific criteria behind a recommendation and ensuring all aspects of the case have been considered is a valid concern before starting intensive treatment. A second opinion can provide this clarity.

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Surgical options: from conservative treatment to extensive surgery

For cancers detected at an early stage, the surgical procedure is tailored to the specific characteristics of the tumor. The spectrum ranges from the most limited to the most extensive approach:

• Conization : removal of a cone-shaped piece of cervical tissue, indicated for very early forms (stage IA1); sufficient in some cases if the margins are clear
• Radical trachelectomy : removal of the cervix while preserving the uterine body, an option for women wishing to become pregnant, provided strict criteria are met (tumor size of 2 cm or less, no lymph node involvement)
• Total hysterectomy : removal of the uterus and cervix, for early stages when pregnancy is not desired
• Radical hysterectomy (Wertheim procedure): removal of the uterus, cervix, and surrounding tissues (parametrium), indicated for more advanced stages

These procedures are systematically accompanied by a lymph node assessment : either a pelvic lymph node dissection (removal of lymph nodes in the pelvis) or the technique of the sentinel lymph node (analysis of one or two representative lymph nodes to limit the extent of the dissection).

The surgical approach is also part of the decision-making process: laparotomy (abdominal incision), laparoscopy (minimally invasive surgery), or robotic surgery. This choice depends on the characteristics of the tumor and the expertise of the surgical center. In some situations, it has a significant impact on oncological outcomes.

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Radiochemotherapy and brachytherapy: the gold standard for advanced stages

For locally advanced cancers, concurrent radiochemotherapy is the standard treatment. It combines external beam radiotherapy to the pelvis, delivered in several sessions over five to six weeks, with cisplatin-based chemotherapy administered in parallel. Cisplatin acts as a radiosensitizer: it enhances the effectiveness of radiotherapy on tumor cells.

At the end of treatment, utero-vaginal brachytherapy completes the care plan. This technique delivers a dose of radiation directly to the tumor site via an applicator placed in the vagina and uterus, precisely targeting tissues that did not receive a sufficient dose from external beam radiotherapy.

For metastatic or relapsed cases, additional options are available: chemotherapy combined with targeted therapy (bevacizumab) or, in some cases, immunotherapy. Access to clinical trials at an expert center may also open up further therapeutic avenues not yet offered as part of initial follow-up.