Treating cervical cancer

Cancer treatment team

Many hospitals use multidisciplinary teams (MDTs) to treat cervical cancer. MDTs are made up of a number of different specialists who work together to make decisions about the best way to proceed with your treatment.

Members of your MDT will probably include:

• a surgeon
• a clinical oncologist (a specialist in chemotherapy and radiotherapy)
• a medical oncologist (a specialist in chemotherapy only)
• a pathologist (a specialist in diseased tissue)
• a radiologist (a specialist in imaging scans)
• a gynaecologist (a doctor who specialises in treating conditions that affect the female reproductive system)
• occasionally a social worker
• occasionally a psychologist
• a specialist cancer nurse, who will usually be your first point of contact with the rest of the team

Your treatment plan

Deciding what treatment is best for you can often be confusing. Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

The recommended treatment plan will depend on what stage the cervical cancer is at. In most cases, the recommendations will be:

• for stage zero cervical cancer (cervical intraepithelial neoplasia) – any abnormal cells are removed, which can be done by different methods, including using lasers to burn away the cells or a very cold instrument to freeze them away
• for early stage one cervical cancer – surgery is used to remove some or all of the womb
• for advanced stage one and stage two cancer – surgery or radiotherapy is used; sometimes surgery is followed by a course of radiotherapy
• for stage three and early stage four cancer – radiotherapy is combined with chemotherapy
• for advanced stage four cancer – chemotherapy, radiotherapy and possibly surgery is used to provide palliative care.

Palliative care is care provided to make a person feel as comfortable as possible when there’s no prospect of a cure.

The prospect of a complete cure is usually good for stage one cervical cancer. It is moderate for stage two cervical cancer. 

A complete cure is less likely for stage three cervical cancer, and very unlikely for stage four cervical cancer.

However, even in cases where cervical cancer isn’t curable, it’s often possible to slow its progression, prolong lifespan and relieve any associated symptoms, such as pain and vaginal bleeding.

The various treatment options are discussed in more detail below.

Removing abnormal cells

If your screening results show that you don’t have cervical cancer but there are biological changes that could turn cancerous in the future (cervical intraepithelial neoplasia), a number of treatment options are available. These are:

• laser therapy – a laser is used to burn away the abnormal cells
• cold coagulation – a hot probe is used to destroy the abnormal cells
• cryotherapy – a cold probe is used to freeze away the abnormal cells
• cone biopsy – the area of abnormal tissue is removed during surgery

Surgery

There are three main types of surgery for cervical cancer. They are:

• radical trachelectomy – the cervix, surrounding tissue and the upper part of the vagina are removed but the womb is left in place
• radical hysterectomy – the cervix and womb are removed; depending on the stage of the cancer, it may also be necessary to remove the ovaries and fallopian tubes
• pelvic exenteration – a major operation in which the cervix, vagina, womb, bladder, ovaries, fallopian tubes and rectum are removed

The three types of surgery are discussed below.

Radical trachelectomy

A radical trachelectomy is usually only suitable if you have very early stage one cancer. It is usually offered to women who want to preserve their child-bearing potential.

During the procedure, the surgeon will make a number of small incisions in your abdomen. Specially designed instruments will be passed through the incisions and used to remove your cervix and the upper section of your vagina.

Lymph nodes from your pelvis may also be removed.

Your womb will then be reattached to the lower section of your vagina.

The advantage of this type of surgery compared to a hysterectomy or pelvic exenteration is that your womb remains intact, which means that you’ll still be able to have children.

However, your child would have to be delivered by caesarean section (where the baby is removed through an incision in your abdomen). It’s also usually recommended that you wait six to 12 months after having surgery before trying for a baby so that your womb and vagina have time to fully heal.

Radical trachelectomy is a highly skilled procedure. It’s only available at a number of specialist centres in England, so you may have to travel to another city to be treated.

Hysterectomy

A hysterectomy is usually recommended for advanced stage one cervical cancer and early stage two cervical cancer. Surgery may be followed by a course of radiotherapy to help prevent the cancer coming back.

Two types of hysterectomies are used in treating cervical cancer. They are:

• simple hysterectomy – where the cervix and womb are removed and, in some cases, the ovaries and fallopian tubes; this is only appropriate for very early stage cervical cancers
• radical hysterectomy – where the cervix, womb, surrounding tissue and lymph nodes, ovaries and fallopian tubes are all removed; this is the preferred option in advanced stage one and some early stage two cervical cancers

As your womb is removed during a hysterectomy you will no longer be able to have children.

Also, if your ovaries are removed, it will trigger the menopause if you haven’t already experienced it. Read more about the menopause.

Short-term complications of a hysterectomy include:

• infection
• bleeding
• blood clots
• accidental injury to your ureter, bladder and rectum

The risk of long-term complications are small but they can be troublesome. They include:

• your vagina becomes shortened and dryer; this can make sex painful
• urinary incontinence
• swelling of your arms and legs due to a build-up of fluid (lymphoedema)
• your bowel becomes obstructed due to a build-up of scar tissue; this may require further surgery to correct

Pelvic exenteration

A pelvic exenteration is a major operation that’s usually only recommended when cervical cancer returns after what was thought to be a previously successful course of treatment. It is offered if the cancer returns to the pelvis but hasn’t spread elsewhere outside of the pelvis.

A pelvic exenteration involves two phases of treatment:

• the cancer is removed, plus your bladder, rectum, vagina and the lower section of your bowel
• two holes, called stomas, are created in your abdomen – the holes are used to pass urine and faeces out of your body into collection pouches called colostomy bags

Following a pelvic exenteration, your vagina can be reconstructed using skin and tissue taken from other parts of your body. This means that you’ll be able to have sex after the procedure, although it may be several months until you feel well enough to do so.

Radiotherapy

Radiotherapy is used on its own for early stage one cancer. It can be combined with chemotherapy to treat advanced stage two, three and early stage four cervical cancer.

Radiotherapy is sometimes used after surgery. Radiotherapy is not routinely combined with surgery because of the higher risk of side effects. In advanced cancers where cancer has spread widely, radiotherapy can be used as a palliative treatment to control bleeding and pain. 

There are two ways that radiotherapy can be delivered. These are:

• externally – a machine similar to an X-ray scanner beams high energy waves into your pelvis to destroy cancerous cells
• internally – a radioactive implant is placed inside your vagina

In most cases, a combination of internal and external radiotherapy will be used. A course of radiotherapy usually lasts for around five to eight weeks.

Unfortunately, as well as destroying cancerous cells, radiotherapy can sometimes harm healthy tissue too. Unlike surgery, significant side effects can occur many months and years after treatment. In spite of side effects, the benefits of radiotherapy outweigh any risks in most cases. For some patients, radiotherapy offers the only hope of getting rid of the cancer.

This means that side effects are common and include:

• diarrhoea
• pain when urinating
• bleeding from your vagina or rectum
• feeling very tired (fatigue)
• feeling sick (nausea)
• sore skin in your pelvis region, similar to sunburn
• narrowing of your vagina, which can make having sex painful
• infertility
• damage to the ovaries, which will usually trigger an early menopause (if you haven’t already experienced it)
• bladder and bowel damage, which could lead to incontinence

If infertility is a concern for you, it may be possible to surgically remove eggs from your ovaries before you have radiotherapy so that they can be implanted in your womb at a later date. However, you may have to pay for this.

It may also be possible to prevent an early menopause by surgically removing your ovaries and replanting them outside of the area of your pelvis that will be affected by radiation. This is known as an ovarian transposition.

Your MDT will be able to provide more information about the possible options for treating infertility and whether you’re suitable for an ovarian transposition.

Read more about radiotherapy.

Chemotherapy

Chemotherapy can be combined with radiotherapy to try and cure a cancer. Or it can be used as a sole palliative treatment for advanced stage four cervical cancer to slow the progression of the cancer and relieve symptoms (palliative chemotherapy).

Chemotherapy involves using either a single chemotherapy medication called cisplatin, or sometimes a combination of different chemotherapy medications to kill cancerous cells. 

Chemotherapy is usually given using an intravenous drip on an out-patient basis, so you’ll be able to go home once you have received your dose.

As with radiotherapy, these medications can also damage healthy tissue, and side effects are common. They include:

• feeling sick
• being sick (vomiting)
• diarrhoea
• feeling tired all the time
• reduced production of blood cells, which can make you feel tired and breathless (anaemia) and vulnerable to infection (due to a lack of white blood cells)
• mouth ulcers 
• loss of appetite
• hair loss – your hair should grow back within three to six months of your course of chemotherapy being completed – though not all chemotherapy medications cause hair loss

Some types of chemotherapy medication can damage your kidneys, so you may need to have regular blood tests to assess the health of your kidneys.

Read more about chemotherapy.

Follow-up

After your treatment has been completed and the cancer has been removed from your body, you will need to attend regular appointments for testing. This will usually involve a physical examination of your vagina and, if present, your cervix.

If the examination finds anything potentially suspicious then a further biopsy can be performed.

In around 1 in 5 cases, cervical cancer can return. This usually occurs around 18 months after a course of treatment has been completed.

Follow-up appointments are quite variable and are usually recommended every four months after treatment has been completed for the first two years, and then every six to 12 months for a further three years.