When cervical cancer has been detected or has returned following initial treatment with surgery, radiation therapy and/or chemotherapy, it is said to be recurrent or relapsed. The course of treatment for relapsed cervical cancer depends on what treatment a patient has previously received and where the recurrence is located. Some patients who have recurrence of cervical cancer within the pelvis can be treated with additional surgery or with radiation therapy, if no radiation therapy was given previously. Recurrence of cervical cancer outside the pelvis is difficult to treat.
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 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 recurrent 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.
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Treatment depends on many factors, including what treatment the patient had before, the location of the recurrence and the overall condition of the patient. If the patient had surgery to remove the cervix and the cancer comes back only in a small area near the operation, radiation therapy may be administered. If the patient already received radiation therapy to the pelvis, radiation therapy cannot be administered again to the same part of the body. Some patients with recurrent cervical cancer in the pelvis can undergo an extensive surgical procedure that removes the cancer and many pelvic organs. Other patients have recurrent cervical cancer outside the pelvis and may receive chemotherapy or radiation therapy to alleviate symptoms.
Recurrent Cervical Cancer After Surgery
A radical hysterectomy is a very effective therapy if the cancer has not spread beyond the cervix. At times, a small area of cancer has spread beyond the cervix and cancer cells may be present at the edge of the surgical specimen. Usually, this can be determined only after the surgery when the specimen is examined under the microscope. Other times, the region of the operation may be contaminated with microscopic cancer cells. The presence of microscopic areas of cancer cells can cause the cancer to return some time after the surgery. This situation occurs more frequently in patients with large stage IB or stage II cervical cancer.
Patients with a small amount of cancer recurrence in the area of previous surgery can be treated in an attempt to rid the cancer again. If the patient has not received radiation therapy to the pelvis, external beam radiation therapy to the area of the recurrence can kill cancer cells after the surgery. Patients who have received prior radiation therapy may be able to undergo a pelvic exenteration, which is an extensive surgical procedure that removes the cancer and many pelvic organs. A pelvic exenteration is only performed if cancer cannot be detected elsewhere in the body and all of the cancer can be removed by the surgery. Approximately one-third of patients with recurrent cancer will survive free of cancer after treatment with radiation therapy or pelvic exenteration.
Other patients already have small amounts of cancer that have spread outside the pelvis and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the pelvis are referred to as micrometastases. The presence of microscopic areas of cancer cells can cause the cancer to return outside the pelvis some time after the surgery. Please see the section below for more information.
Recurrent Cervical Cancer After Radiation Therapy
Depending on the features of the cervical cancer, some patients will experience a recurrence of the cervical cancer after radiation therapy. In these patients, cancer cells may have survived despite the radiation therapy. Other patients already have small amounts of cancer that have spread outside the pelvis and were not treated by the radiation. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the pelvis are referred to as micrometastases. The presence of these microscopic areas of cancer or surviving cancer cells can cause the relapses that follow treatment with radiation therapy.
Once a patient has received radiation therapy to the pelvis, more radiation therapy cannot safely be administered to the same area. Patients who have received prior radiation therapy may be able to undergo a pelvic exenteration, which is an extensive surgical procedure that removes the cancer and many pelvic organs. A pelvic exenteration is only performed if cancer cannot be detected elsewhere in the body and all of the cancer can be removed by the surgery. Approximately one-third of patients with recurrent cancer will survive free of cancer after treatment with radiation therapy or pelvic exenteration.
Recurrent Cervical Cancer Outside the Pelvis
Cervical cancer that has spread to distant organs and bones is difficult to treat. Historically, patients with metastatic cervical cancer have been considered incurable. Some patients are offered treatment with chemotherapy for the purpose of prolonging their duration of survival and alleviating symptoms from progressive cancer. Other patients are managed with efforts to reduce pain or bleeding, including local radiation therapy to affected parts of the body.
There is no good single chemotherapy approach that can improve the length of survival in patients with metastatic cervical cancer. Treatment with Platinol® can produce shrinkage in 15-25% of patients with metastatic cervical cancer. Many clinical trials have combined Platinol® with other chemotherapy drugs in hopes of improving cancer shrinkage and survival. Although these combination regimens can have more side effects, length of survival has not been improved over Platinol® alone. Unfortunately, these chemotherapies typically work for only a few months before the cervical cancer begins to grow again. Most patients ultimately succumb to cancer and better treatment strategies are clearly needed.
Strategies to Improve Treatment
The progress that has been made in the treatment of cervical cancer has resulted from development of better treatments in patients with more advanced stages of cancer and participation in clinical trials. While some progress has been made in the treatment of cervical cancer that has recurred outside the pelvis, nearly all patients still succumb to cancer and better treatment strategies are clearly needed. Future progress in the treatment of cervix cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of 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 Chemotherapy Regimens: Several new chemotherapy drugs show promising activity for the treatment of advanced or recurrent cervical cancer. Development of new multi-drug chemotherapy treatment regimens that incorporate new or additional anti-cancer therapies is an active area of clinical research.
One recent study demonstrated that the combination of Platinol® and Gemzar® appears to be an effective treatment option for recurrent cervical cancer. In this study, 17 women with advanced, resistant or recurrent cervical cancer received an average of 5 cycles of Platinol® plus Gemzar® in 21-day intervals. Following treatment, 41% of the women responded to treatment and one woman had a complete response of 14 months duration. The researchers concluded that the combination of Platinol® and Gemzar® demonstrated relatively high anti-cancer activity against cervical cancer.
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 therapy 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.
Phase I Trials: New chemotherapy drugs continue to be developed and evaluated in patients with recurrent cancers in phase I clinical trials. The purpose of phase I trials is to evaluate new drugs in order to determine the safety and tolerability of a drug and the best way of administering the drug to patients.
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