GENERAL BACKGROUND
About 16,000 women in the United States develop cervical cancer each year. Roughly 5,000 deaths from cervical cancer will occur in a given year. Patients are most likely to be diagnosed in their mid to late 40s. At the time of presentation and diagnosis, 45 percent of cases are localized, 34 percent have regional spread, and 10 percent have widely spread disease.

The risk of developing cervical cancer is dropping significantly due to development and implementation of effective screening techniques that identify and remove preinvasive lesions.

Increases in mortality rates in young women have been noted in Canada, Great Britain, New Zealand, and Australia. This increase appears to be due in part to changes in the classification of lesions, but is also likely attributable to sexual transmission of human papilloma virus (HPV), which is a contributing factor in the development of cervical cancer. Two strains of HPV are considered to have high malignant potential, while 15 other strains have a moderate malignant potential.

The epidemiologic characteristics of HPV growth resemble those of cervical cancer and support the theory that infection with this virus can lead to the development of cervical cancer. Herpes simplex virus type II appears to be a potential co-factor with HPV and the initiation of malignant degeneration of premalignant lesions.

Other risk factors include early age of initiation of sexual activity and multiple sexual partners. Cigarette smoking has been implicated as possibly doubling the potential incidence of cervical carcinoma, and the nonsteroidal estrogen compound DES carries malignant potential.

Cervical cancer typically presents with abnormal vaginal bleeding and/or pelvic pain or discomfort. The cervix is sandwiched between the bladder and ureters anteriorly, and the rectum and sigmoid colon posteriorly. The cervix is, of course, the lower portion of the uterus which is attached to the bones of the pelvis by pelvic ligaments and muscles.

DIAGNOSIS | Back to Top
Examination by a gynecologist is the first step to determining the presence or absence of cervical cancer. Any abnormality felt or seen is sampled and a thorough pathologic review is performed. Non-invasive cancers can often be managed conservatively by the gynecologist, while invasive cancers are typically staged and then appropriately managed by a gynecologic oncologist and a radiation oncologist.

TREATMENT | Back to Top
Treatment options are basically defined by the extent of disease, the patient's basic health status, and patient choices. Early stage disease in otherwise healthy women can often be treated with curative intent by radical hysterectomy. This procedure is a rather extensive operation in which the cervix and uterus are removed, and all possible lymph nodes are removed from the pelvis in continuity up to just below the diaphragm.

It is a long and difficult operation and sometimes requires a significant recovery period -- and has significant potential side effects such as incontinence -- but can have high curative potential in selected patients.

Radiation is often used in conjunction with surgery when disease is found to be extensive at the time of operation and it is felt that the operative procedure is not likely to be curative. The goal of radiation treatment is to kill any cancer cells that may remain in the pelvis or within the lymph node chains within the abdomen.

Cervical cancer is often frequently treated by radiation alone. Typically, the pelvis is treated with high-energy (18-25 MEV) external beam radiation treatment with delivery of a moderately high dose of radiation to the pelvis with coverage of the cervix, uterus, and lymph node chains. The vagina and cervix are the two organs in the body most tolerant to radiation, and radiation oncologists are therefore able to augment their treatments by what is known as brachytherapy.

Brachytherapy simply means "close range" radiation therapy. As such, applicators are placed within the vagina and uterus and radioactive sources, which deliver a finite amount of radiation to a finite volume of tissue are inserted for a specific length of time. In this manner, doses can be achieved that can eradicate cancers that otherwise could not be destroyed because of the limitations imposed by the radiotolerance of surrounding normal tissues.
IMRT and Cervical Cancer

An interesting emerging and progressive aspect of radiation treatment is intensity modulated pelvic radiotherapy for women with gynecologic malignancies. Intensity modulated radiation therapy (IMRT) allows us to conform the radiation "dose cloud" to the specific volume of tissue that needs to be treated. This is particularly useful in treatment of the pelvis where IMRT allows us to enhance sparing of the radiosensitive small bowel, bladder, and rectum.

A recent study published in The International Journal of Radiation Oncology and Physics in April 2002 showed that IMRT treatment planning resulted in excellent coverage of the tissues to be treated. Treatments were very well tolerated and associated with less acute gastrointestinal sequelae than with conventional external beam radiation treatment delivered to the pelvis.

As stated above, this is an emerging technology where more and longer clinical studies will need to accrue, but there is no doubt that intensity modulated whole pelvic radiotherapy is an extremely promising approach in cervical cancer patients and, in fact, any patients with a gynecologic malignancy.

Also of consideration is the use of IMRT to potentially replace the brachytherapeutic aspect of treatment. This area of investigation is in its very early stages, but physicists have already developed and published a theoretic example illustrating how IMRT can accurately mimic the dose distributions that are attained using brachytherapy. Such an approach is not the standard of care at this time but holds significant investigational promise.