**6. Treatment**

As a result of the fact that those with cervical cancer typically present with a mass that is clinically limited to the pelvis, achieving locoregional disease control is the fundamental obstacle that must be overcome throughout therapy [19]. Patients with an illness limited to a specific area see unprecedented rates of cure after receiving individualized treatment depending on the features of their tumors (**Table 4**).

Microinvasive cancers invading less than 3 mm (stage IA1) are treated with conservative surgery, including excisional conization or extra fascial hysterectomy. Earlystage invasive tumors, meaning stage IA2 and IB1 and some small stage IIA1, are treated with radical or modified radical hysterectomy, radical trachelectomy (when fertility preservation is needed/desired), or RT. Selected patients with centrally recurring illness following radical dose RT may have radical pelvic exenteration; isolated pelvic recurrence after hysterectomy is often treated with RT.

The standard of care for stage IA1 patients is usually cervical conization or total (Type I) hysterectomy. Because less aggressive tumors have less than a 1% chance of developing pelvic lymph node metastases, pelvic lymph node dissection is often not recommended for patients with these tumors. Lymph node metastases are possible in 5% of patients whose tumors extend 3–5 mm into the stroma (FIGO stage IA2) [20]. For such patients, a modified radical (type II) hysterectomy should be performed along with bilateral pelvic lymphadenectomy. The modified radical hysterectomy is a less invasive surgery than the traditional radical hysterectomy (type III). Patients with stages IA2 to IB1 cervical cancer who have low-risk factors are being considered for potential fertility-sparing surgery. Women treated with radical hysterectomy or


#### **Table 4.**

*Primary therapy and survival by disease extenta.*

radical trachelectomy tend to have comparable outcomes, and a considerable percentage of patients treated with radical trachelectomy report successful pregnancies [21]. Although surgery is the treatment of choice for in situ and microinvasive cancer, people with significant medical conditions or other contraindications to surgery can be effectively treated with radiation therapy. Depending on the depth of invasion, these early lesions are treated with brachytherapy or brachytherapy combined with external RT, with cure rates over 95% [22].

Early-stage IB and IIA cervical carcinomas may be efficaciously handled with a combination of external-beam radiation therapy (EBRT) and brachytherapy or with radical hysterectomy and bilateral pelvic lymphadenectomy. Patients undergoing radical hysterectomy high-risk disease may gain from postoperative RT or chemoradiation [23]. Overall, disease-specific survival rates for individuals with stage IB cervical cancer treated with surgery or radiation are typically in the 80–90% range. The decision of therapy for patients with stage IB1 squamous carcinomas depends primarily on patient desire, risks associated with general anesthesia and surgery, physician preference, and an awareness of the nature and occurrence of problems with hysterectomy and radiation. Some surgeons have also advocated radical hysterectomy as the first line of therapy for individuals with stage IB2 tumors [24, 25]. Then again, patients with tumors larger than 4 cm in diameter usually have enough risk factors to necessitate adjuvant EBRT or chemoradiation, increasing the treatment time and adverse events [23, 26]. As a result, many gynecologic and radiation oncologists

#### *Cervical Cancer DOI: http://dx.doi.org/10.5772/intechopen.110131*

claim that patients with stage IB2 carcinomas benefit from chemoradiation, although these two therapies have never been directly compared in a prospective trial.

Radiation therapy is the recommended main local therapy for the vast majority of patients with advanced locoregional cervical cancer. The effectiveness of radiation therapy depends on establishing a delicate balance between external beam radiation therapy and brachytherapy, as well as maximizing the distribution of the radiation dose to both malignant and healthy tissue while decreasing the overall treatment duration. Patients treated with radiation therapy alone for stages IIB, IIIB, and IVA had 5-year survival rates of 65–75%, 35–50%, and 5–15%, respectively [27, 28]. This first treatment can increase the efficacy of later intracavitary brachytherapy by lowering the size of the tumor and bringing it back within the dose distribution of brachytherapy. External irradiation is always combined with concomitant chemotherapy to offer a consistent initial dosage to both the primary cervical cancer and any regional spread locations. The objective underlying brachytherapy, a crucial component of definitive radiation therapy, is to follow the inverse square rule in order to provide a higher dose to the cervix and paracervical regions while limiting damage to nearby normal tissue. If you wish to complete radiation therapy in less than 7–8 weeks, avoiding delays between an external beam surgery and an intracavitary procedure is one of the most crucial things to bear in mind [29].

For the majority of patients with an isolated pelvic recurrence after the first therapy with radical hysterectomy alone, definitive radiation is the preferred treatment. Vaginal recurrence is routinely treated with EBRT and brachytherapy, following the same techniques as for patients with vaginal cancer. Recurrences of pelvic wall cancer are frequently treated with EBRT. Certain patients may benefit from surgery combined with intraoperative radiation for local management. A vaginal recurrence is associated with a more favorable prognosis than a pelvic wall recurrence [30]. An isolated central recurrence of the subsequent radiation can be treated surgically in individuals. Due to the difficulty in assessing the extent of pathology following highdose radiation and the significant risk of major urinary tract complications associated with pelvic surgery, surgical salvage treatment typically requires a pelvic exenteration, most commonly an anterior or complete exenteration [31, 32]. Less invasive procedures, including radical hysterectomy, are reserved for women with cervical cancer or tumors that do not spread into the rectum. In all situations, pelvic exenteration preparation must include a comprehensive medical and radiological evaluation and meticulous counseling of the patient and family regarding the extent of the treatment and postoperative difficulties. PET/CT scans should be performed to rule out the presence of severe pelvic sidewall involvement or extra pelvic metastases. Cancerous infiltration of the pelvic sidewall is a contraindication to exenteration; however, this may be difficult to determine if there is considerable radiation fibrosis.

Patients with unresectable recurrent cervical cancer who have undergone final radiation therapy have few therapeutic options available to them. However, chemotherapy is administered to the majority of patients with unresectable pelvic recurrences following radiation therapy. This results in relatively low response rates and large death rates.

Patients who present symptoms or experience relapses related to sickness in distant organs typically cannot be cured. The treatment for these individuals should focus on reducing their symptoms as much as possible by using effective painkillers and local RT. Tumors can be treated, although the results of treatment are typically very temporary. Metastases can produce pain in various locations, including the bone, brain, lymph nodes, and other areas. Localized RT can successfully treat this

discomfort. Individuals who are toward the end of their lives and have an extended disease may find relief from pelvic pain and bleeding by undergoing a course of palliative pelvic radiation [33].
