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How should I manage patients with locally advanced cervical cancer?

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Key concept

Cervical cancer is one of the leading causes of cancer-related death among women in developing countries. It is strongly linked with human papillomavirus (HPV) infection (types 16 and 18). PAP smear is effective for early detection and reduces mortality. In the developed world, women with lower socioeconomic status and those with multiple sexual partners are more likely to develop cervical cancer.1

Clinical scenario

A 44-year-old single mother with multiple sexual partners presents with post-coital bleeding. She also reports lower pelvic pain. Local examination reveals a large fungating mass in cervix. Biopsy confirms squamous cell cancer.

Action items
  • Pelvic examination should be performed for biopsy and clinical staging

  • Staging studies such as CT and MRI can be performed

  • Patients with stage IA1 to IIA1 disease can be treated with surgery

  • Surgery can be fertility sparing, such as trachelectomy, or radical hysterectomy with bilateral pelvic lymph node dissection

Discussion

Patients are diagnosed at screening, or they may present with symptoms such as post-coital bleeding, vaginal discharge, or pelvic pain. Gynecological examination is needed for diagnosis and clinical staging (International Federation of Gynecology and Obstetrics). Most patients have squamous cell cancer; other types are adenocarcinoma and neuroendocrine histology.

Patients with stage IB2 to IVA, non-metastatic disease are treated with concurrent chemoradiation.2 Concurrent chemoradiation reduces risk of death by 30%–50%. Radiation is given by external beam radiation therapy concurrent with weekly cisplatin chemotherapy. Another chemotherapy option includes cisplatin/5-fluorouracil. After concurrent chemoradiation, brachytherapy is considered the standard of care.

Patients with metastatic cervical cancer are treated with doublet chemotherapy (cisplatin/paclitaxel or topotecan/paclitaxel) and bevacizumab.

Pearls

HPV vaccines such as Gardasil are very effective against HPV type 16 and 18 infection. They are indicated for female and male patients ages 9–26 years.

References
  1. National Comprehensive Cancer Network (NCCN) guidelines for cervical cancer. Version 1.2017. Available at: www.nccn.org.

  2. Rose PG, Bundy BN, Watkins EB, et al. Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med 1999;340:1144-53.

How do I treat early stage endometrial cancer?

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Key concept

Endometrial cancer is the most common gynecological malignancy in developed countries, including the United States.1

Risk factors for hormone-sensitive (type 1) endometrial cancer include prolonged unopposed estrogen associated with early age of menarche, nulliparity, late age at menopause, obesity, diabetes, a high-fat diet, Lynch syndrome,* age ≥55 years, unopposed estrogen for control of menopausal symptoms, and tamoxifen use. Smoking and combination oral contraceptives are protective against this type of malignancy.1,2

Around 70% of endometrial cancers are confined to the uterus at diagnosis and less than 10% present with metastatic disease.1

Clinical scenario

A 64-year-old post-menopausal woman presents with vaginal bleeding for the past ~5 days. She undergoes evaluation by a gynecologic ...

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