Professional Documents
Culture Documents
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4.2 CLINICAL STAGING
Cervical cancer is clinically staged using the FIGO criteria (see Annex 5).
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FIGO staging does
not take into account results of computerised tomography (CT), magnetic resonance imaging
(MRI) or positron emission tomography (PET).
4.2.1 SENTINEL NODE SURGERY
There is evidence from a number of small case studies that it is feasible to identify sentinel lymph
nodes during cervical cancer surgery. The evidence that the status of these nodes accurately
predicts the status of the remaining pelvic lymph nodes is conficting.
31,42-47
Comparison of the
results of these studies is hampered by variable methodology, and there have been no long
term studies of follow up.
At present there is no evidence to support the use of sentinel node surgery in preference to
pelvic lymphadenectomy in cervical cancer. Larger standardised studies are required.
4.2.2 PELVIC LYMPHADENECTOMY
No evidence was identifed to address the adequacy of pelvic lymphadenectomy specifcally in
cervical cancer. Evidence from many studies indicates that there is considerable variation in the
number of lymph nodes obtained from this procedure.
31,48-51
There is no evidence relating the
number of lymph nodes retrieved to long term outcome. Many of the studies lack information
about how the tissue is handled by the pathologist.
This lack of good quality evidence illustrates the need for standardisation of pathological
assessment. Further guidance is available from the Royal College of Pathologists (www.rcpath.
org).
4.3 RADIOLOGICAL STAGING
Radiological assessment of patients with visible cervical carcinoma is an essential part of
the strategy in determining the most appropriate management of patients, both at primary
presentation and with relapsed disease or complications of treatment.
Radiological studies often have inherent design weaknesses, which are diffcult to eliminate.
Some of the disparity of results between individual studies may be dependent on:
heterogeneity of equipment
image interpretation and training
clinical setting (specialist centre compared to district general/community hospital)
13,52
MRI, CT methodology and sequences
advances in MRI, CT and PET technology.
13,53-56
The staging accuracy (sensitivity and specifcity) of MRI, CT, and PET is shown in Table 2.
4.3.1 PRIMARY TUMOUR ASSESSMENT
There is consistent evidence that MRI is more accurate than CT for radiological staging of
cervical carcinoma (accuracies 4097%)
13,56-58
and both modalities are more accurate than
clinical staging.
56,57
For women with contraindications to MRI scanning CT is appropriate. For women with clinically
apparent stage IVA or IVB disease, post contrast spiral or multislice CT scans of chest, abdomen
and pelvis are more appropriate than MRI.
13,58,59
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B
Patients who have undergone surgery for cervical carcinoma and have positive nodes
should be considered for adjuvant treatment with concurrent chemoradiotherapy with
platinum based chemotherapy.
Consideration should be given to the relative risks and benefts of treatment for each
individual patient.
6.2.2 NEGATIVE LYMPH NODES
Compared to no further treatment, adjuvant radiotherapy reduces the risk of recurrence in
patients with cervical carcinoma with negative lymph nodes following surgery and with at least
two of the following risk factors:
124
invasion of more than a third of the total cervical stromal volume
LVSI, or
tumour diameter of >4 cm.
The addition of adjuvant radiotherapy reduces overall risk of recurrence from 30.7% to 17.5%
(HR 0.54; p=0.007), local recurrence from 20.7% to 13.95% and distant recurrence from
8.6% to 2.9%.
124
Given the body of evidence supporting the superiority of concurrent chemoradiation over
radiation alone in other settings (see sections 6.1 and 6.2.1),
118,120,121
strong consideration should
be given to using concurrent chemoradiation in preference to radiation alone.
B Patients who have undergone surgery for cervical carcinoma, have negative nodes
and any two of the following risk factors should be considered for adjuvant treatment
with radiotherapy, if ft enough:
greater than a third stromal invasion
lymphovascular space invasion
tumour diameter of >4 cm.
Consideration should be given to the relative risks and benefts of treatment for each
individual patient.
D Concurrent chemoradiation should be considered in preference to radiation alone.
6.3 BRACHYTHERAPY
Brachytherapy is short wave radiotherapy delivered by the insertion of applicators into the
uterus via the vagina.
Guidelines from the American Brachytherapy Society indicate that brachytherapy should be
considered an essential component of defnitive radiotherapy treatment.
125,126
D Brachytherapy should be considered an essential component of radical radiotherapy
or chemoradiotherapy.
Precise applicator placement is essential for improved local control and reduced
morbidity.
Brachytherapy should be carried out by practitioners experienced in the procedures
and dosimetry of brachytherapy.
If a brachytherapy insertion is not possible then a further boost should be given using
external beam radiotherapy.
6 NON-SURGICAL TREATMENT
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6.4 NEOADJUVANT CHEMOTHERAPY
No data from RCTs were identifed describing the value of using neoadjuvant chemotherapy to
make large inoperable tumours surgically resectable. An ongoing randomised phase III study
of neoadjuvant chemotherapy followed by surgery compared to concomitant radiotherapy
and chemotherapy in patients with FIGO IB2, IIA >4 cm or IIB cervical cancer is addressing
this issue.
127
6.5 TREATMENT OF STAGE IVB DISEASE
There have been no randomised trials comparing chemotherapy to best supportive care in stage
IVB cervical carcinoma. Single-agent cisplatin was the treatment of choice until a recent report
demonstrated a modest survival advantage for the combination of toptecan plus cisplatin over
cisplatin alone. There are also data indicating that cisplatin plus paclitaxel is an acceptable
alternative (see section 11.2).
6.6 TREATMENT OF ANAEMIA
Anaemia during treatment is a stronger indicator of poor prognosis in patients being treated for
carcinoma of the cervix than the presence of pre-treatment anaemia.
128-133
Correction of anaemia
by blood transfusion appears to reverse some of the detrimental effect on prognosis.
130,131
A meta-analysis of the use of erythropoietin or darbepoetin in patients with cancer was not
specifcally restricted to patients with cervical cancer and included patients with solid and
haematological malignancies.
134
Treatment with erythropoietin or darbepoetin decreased the
relative risk of requiring a blood transfusion (RR 0.64; 95% CI 0.60 to 0.68) and decreased
the volume of blood transfusion (on average one unit of blood less than control group).
134
For
patients with a baseline haemoglobin below 12 g/dl, haematological response was observed
more often in patients receiving erythropoietin or darbepoetin compared to those not (RR
3.43; 95% CI 3.07 to 3.84).
134
Treatment also increased the relative risk for thromboembolic
complications compared to patients receiving placebo/no treatment (RR 1.67; 95% CI 1.35
to 2.06).
134
There was no evidence of improved overall survival of patients treated with
erythropoietin or darbepoetin.
134
C Patients with cervical carcinoma undergoing radiotherapy or chemoradiotherapy
should have their haemoglobin level monitored and corrected if it falls below
12 g/dl.
B Anaemia should be corrected with either blood transfusion or erythropoietin and iron
products after consideration of the attendant costs, risks and benefts.
6.7 TREATMENT OF RADIATION INDUCED COMPLICATIONS
During radiation treatment of cervical cancer, other pelvic organs receive a signifcant radiation
dose, resulting in both acute and late toxicity. Late radiation changes occur at least three months
after the completion of radiotherapy. Late radiation complications are due to small vessel injury
with endothelial damage, infammation, fbrosis, ischaemia and necrosis. The management
of late radiation complications is complex with little high quality evidence to guide practice.
Surgical treatment may be required if medical intervention fails.
Patients should have access to specialist multiprofessional teams for treatment and
management of severe radiation induced complications.
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6.7.1 BLADDER
Symptoms of late radiation effects to the bladder can include urinary frequency, urgency,
dysuria, detrusor instability,
135,136
haematuria, ulceration and the potential for perforation and
fstula formation. Radiation ischaemia and necrosis may be a cause of ureteric obstruction in
addition to bladder problems.
A Cochrane meta-analysis concluded that the absence of any randomised controlled trials made
it impossible to draw any defnitive conclusions regarding the treatment of radiation cystitis.
137
Management options included hydration, bladder irrigation, antibiotics to treat infection as
required and blood transfusion. Early cystoscopy with diathermy of bleeding points before
the cycle of repeated bladder washouts, clot retention and mucosal trauma has started may
be benefcial.
137
Nineteen case reports and case series suggested that hyperbaric oxygen was
benefcial.
137
One phase III RCT was identifed showing that intravenous treatment with tetrachlorodecaoxygen
(TCDO, or drug WF10) showed no signifcant difference in objective or subjective symptoms
on an intention to treat analysis.
138
Patients should be managed by a urologist with experience of late radiation effects
to the bladder, who is able to offer complex reconstructive surgery in the event of severe
complications.
6.7.2 RECTUM
Acute radiation proctitis is frequently experienced during pelvic radiotherapy with symptoms
including tenesmus, urgency, diarrhoea and occasionally bleeding.
An RCT of 87 patients with prostate cancer showed that sucralfate enemas made no difference
compared to placebo for the treatment of acute radiation induced proctitis.
139
Another RCT
of 134 patients with prostate cancer randomly assigned to sucralfate (63 patients), mesalazine
(8 patients) or hydrocortisone (63 patients) found that mesalazine was detrimental and there
was no difference between the sucralfate and hydrocortisone. There was no no treatment
control arm.
140
Oral sucralfate showed no beneft over placebo for acute radiation induced proctitis in patients
with localised pelvic tumours. Patients receiving sucralfate showed signifcantly increased
diarrhoea at two and six weeks after pelvic radiotherapy (p=0.49 and p=0.33 respectively),
causing the trial to be stopped.
141
B Rectal or oral sucralfate is not recommended to reduce acute radiation induced
proctitis.
Late radiation proctitis can lead to tenesmus, urgency, either diarrhoea or constipation, anal
sphincter dysfunction, mucus discharge, bleeding, stricture, ulceration and fstula formation.
Sucralfate enema reduced the duration and severity of late radiation induced proctitis, compared
to steroid enema in 11 out of 14 patients (13 of whom had cervical cancer) in a small case
series.
142
Another study suggested that combining steroid, sulphasalazine and sucralfate enemas
is worse than sucralfate alone.
143
Patients with late appearance of symptoms had a shorter time
to healing than patients with an early appearance of symptoms.
143
D Rectal sucralfate may be considered to reduce late radiation induced proctitis.
6 NON-SURGICAL TREATMENT
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6.8 HORMONE REPLACEMENT THERAPY
In women with absent ovarian function following surgery and/or radiotherapy for cervical cancer,
hormone replacement therapy (HRT) reduces post-menopausal symptoms. HRT signifcantly
reduced long term post-radiation rectal, bladder and vaginal complications (p=0.01).
144
After
fve years symptoms persisted in 17% of women taking HRT and in 45% of patients receiving
no hormonal therapy.
144
There is no evidence that HRT increases risk of squamous cell cancer but a small study reported
a possible increase in the risk of recurrence in women with adenocarcinoma.
145
C HRT is recommended for women who have lost ovarian function as a result of treatment
for cervical cancer.
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7 Treatment during pregnancy
No evidence was identifed to suggest that pregnancy accelerates the natural history of cervical
cancer.
94
The prognosis for a pregnant patient with cervical cancer is similar to that of a non-
pregnant patient when matched for stage, tumour type and tumour volume.
94
Disease-specifc
survival is independent of the trimester of pregnancy in which the diagnosis is made.
94
The evidence indicates that the choice of therapeutic modality for cervical cancer diagnosed
during pregnancy should be decided in the same manner as for non-pregnant patients.
94
C For pregnant women with cervical cancer, the choice of therapeutic modality should
be decided in the same manner as for non-pregnant patients.
The evidence supports immediate treatment for patients diagnosed with cervical cancer at or
before 16 weeks of gestation, irrespective of stage.
46,47,94
After 16 weeks of gestation, in patients
with early stage disease (FIGO 1A1, 1A2, 1B), delivery may be delayed until fetal maturity
occurs.
46,47,94
C For pregnant women diagnosed with cervical cancer before 16 weeks of gestation,
immediate treatment is recommended.
C For pregnant women with early stage disease (FIGO IA1, IA2, IB) diagnosed after 16
weeks of gestation, treatment may be delayed to allow fetal maturity to occur.
An individualised treatment plan should be determined, in consultation with the patient,
by the multidisciplinary team, which should include an obstetrician.
For women with late stage disease, there is no good evidence to support delaying treatment to
allow fetal maturity as very few cases are described in the literature. No evidence was identifed
that compared maternal survival after diagnosis at different periods of gestation.
If gestational age is less than 20 weeks at diagnosis of advanced cervical cancer (FIGO 1B2
or greater) a systematic review supports immediate delivery and treatment of the disease. If
gestational age is more than 20 weeks, delivery and treatment should be initiated within four
weeks of diagnosis.
94
C For pregnant women with advanced disease (FIGO 1B2 or greater) diagnosed after
16 weeks of gestation, consideration for delay must be based on gestational age at time
of diagnosis.
No RCTs were identifed describing outcomes after delivery by caesarean section compared to
vaginal delivery.
Several retrospective studies concluded that there is no statistically different survival beneft
given either delivery method.
46,47,94
Decisions on the mode and timing of delivery should be made in consultation with the
patient and her obstetrician.
7 TREATMENT DURING PREGNANCY
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8 Sexual morbidity
Sexual problems suffered by women with cervical cancer may include loss of libido, change in
sexual activity and decreased orgasm. Up to 65% of women experience one or more of these
problems due to vaginal dryness, vaginal bleeding, stenosis, dyspareunia, atrophic vaginitis
and pain.
148
Given the incidence of physical and psychosexual dysfunction following cervical cancer
womens sexual function and concerns need to be assessed prior to treatment. There is no good
evidence to suggest when the appropriate time to carry out an assessment is.
The sexual function and concerns of women diagnosed with cervical cancer should be
assessed prior to treatment.
8.1 PHYSICAL INTERVENTIONS
A systematic review identifed evidence from retrospective studies that vaginal stents/dilators
can prevent development of vaginal stenosis and treat vaginal occlusion in patients receiving
radiotherapy for cervical or uterine cancer.
149
Vaginal stenosis was prevented and patency
maintained at one-year follow up in 20/35 patients compared to 4/35 patients who had not
used a stent.
149
Vaginal oestrogens appear to be effective for reducing dyspareunia, alterations
in the vaginal epithelium and vaginal narrowing. Benzydamine douches appear to be effective
for treating acute radiation vaginal mucositis. The included studies were old, small and
underpowered and large placebo controlled trials are required.
149
C Women should be offered a vaginal stent or dilator to prevent post-radiotherapy vaginal
complications.
Topical oestrogens or benzydamine douches may be considered to alleviate post-
radiotherapy vaginal complications.
A small pilot study suggested that symptoms of sexual dysfunction were reduced with a clitoral
therapy device. The results need to be validated in larger controlled trials before the device
can be recommended.
150
8.2 PSYCHOEDUCATIONAL INTERVENTIONS
Compliance with vaginal dilation following pelvic radiotherapy is variable and generally poor.
Assistance in overcoming womens fears and teaching behavioural skills is likely to reduce
concerns and improve both knowledge of sexual activity and sexual rehabilitation following
pelvic radiotherapy. Consensus guidelines on the use of vaginal dilators in women receiving
pelvic radiotherapy are available.
151
Women should be offered training and support to maximise the beneft of using a stent
or dilator.
Psychoeducational group sessions, guided by the information-motivation-behavioural skills
model, provide the necessary information, motivate individuals to engage in the target
behaviours and teach behavioural skills for performing specifc tasks, such as objective skills and
a sense of self effcacy for performing them.
152
Two one and a half hour sessions signifcantly
reduced womens fears about their sexuality (p=0.01) and increased their knowledge,
particularly in the older age group (over 41.5 years of age, p<0.001) compared with written
information alone. The intervention also increased vaginal dilation compliance rates and the
ability to have sexual intercourse in younger women.
152
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In this study group, therapy was delivered at the cancer centre post-radiotherapy. In Scotland
it may prove diffcult to gather together women who are at the same stage of treatment. The
intervention-motivation-behavioural skills model could be used to address issues of concern
to women after surgery if tailored to meet the need.
Relaxation and counselling sessions delivered within 24 hours of discharge by a member of
the patients care team signifcantly reduce anxiety and moderate depression in the frst six
weeks after surgery.
153
B Information about female sexual function should be offered to patients by a relevantly
trained healthcare professional using a model of care that involves addressing
motivational issues and teaching behavioural skills.
C Patients should be offered support sessions by a designated member of their care team,
as soon as possible after treatment, which may include one or more of the following:
relaxation
personalised information about their disease and treatment
emotional support and care.
Women should be offered one to one sessions if appropriate.
8 SEXUAL MORBIDITY
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9 Lymphoedema
Lymphoedema, presenting as swelling of one or both lower limbs, is a possible complication
of cervical cancer and may be treatment or disease related. Reported incidence rates vary from
3.6-49%.
154-160
Studies are not generally comparable due to different patient groups, treatment
techniques and lack of standardised reporting of lymphoedema.
Quality of life is affected in patients with lower limb lymphoedema including changes in
sensation, appearance, pain,
161,162
restricted activities,
158,163
and distress.
163
Treatment may
positively infuence quality of life.
161
All healthcare professionals involved in the care of patients with cervical cancer should
receive education on the identifcation of lymphoedema.
9.1 RISK FACTORS
Hysterectomy with pelvic node dissection for early stage cervical cancer has been associated
with a 7-14% incidence of swelling.
163-165
Lymphoedema has also been reported in those who
had radiotherapy alone.
163,166
The incidence of lymphoedema following pelvic lymph node dissection and radiotherapy for
FIGO IB/IIA cervical cancer in a cohort of 99 patients was reported as 19% at one year and
12% at fve years.
156
Similar fgures were reported in a cohort of 77 patients.
167
A study of women undergoing surgery for cancer of the uterine corpus showed that removal
of 10 lymph nodes is associated with a greater risk of lymphoedema.
168
External radiotherapy doses of >50.4Gy to the low pelvis appear to be associated with an
increased risk of complications such as lymphoedema.
157
A retrospective study of 118 patients
showed no difference in the incidence of lymphoedema in those who had irradiation to small
pelvic feld or whole pelvic feld.
158
Around one third of patients in one study said they had not received either written or oral
information about lymphoedema.
162
Well timed advice and appropriate written and oral
information on lymphoedema risk and management is needed.
162,167
D Patients with lymphoedema, or at risk of lymphoedema, should have access to
appropriate information.
Information should be delivered by a healthcare professional with relevant training.
Specialist lymphoedema practitioners, usually nurses or physiotherapists, are available in
some healthcare settings to provide specialist treatments (see section 9.4). Other healthcare
professionals are trained in some aspects of lymphoedema management but may not provide
regular, specialist treatments.
Designated lymphoedema practitioners should be available at all centres treating women
with cervical cancer.
9.2 TRIGGER FACTORS
Factors that may trigger the onset of clinical lymphoedema include:
160
injury or trauma, for example, insect bite, cut, injection, sunburn
extreme temperatures
air travel
cellulitis.
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9.3 DIAGNOSIS
Diagnosis is mainly based on clinical examination and the following criteria have been
identifed:
160,163,167
increase in circumference of the limb
changed sensations such as feelings of fullness, tightness, heaviness, throbbing, shooting
pains
reduced fexibility in the limb
palpable changes to the skin or subcutaneous tissue such as fbrosclerosis that may be pitting
or non-pitting.
The International Society of Lymphology identifes staging criteria for lymphoedema according
to severity (see Annex 6).
169
Lymphoedema often occurs in the frst two years following cancer treatment.
155-157,160
Swelling
subsides on elevation at early stages but may become chronic, with skin and tissue changes,
including thickening, skin folds and fat deposits.
169
Oedema of the trunk can occur in some
patients. One study showed that 16% of patients with lymphoedema developed cellulitis
requiring antibiotic treatment.
159
Lymphoedema may be exacerbated if patients gain weight or have concurrent problems such as
cardiac failure or medication-related fuid retention.
168
Intrapelvic or intra-abdominal tumours
that involve or compress lymphatic or venous return may produce a severe and intractable
oedema, particularly near the end of life.
169
Cancer recurrence should be considered in patients with new onset lymphoedema. The
possibility of deep venous thrombosis should also be explored.
Evaluation of lymphoedema risk by healthcare professionals and communication between
healthcare teams is essential to ensure early diagnosis and appropriate referral for treatment
and to minimise complications.
159,160,167,168
D Patient review should include identification and recording of lower limb
lymphoedema.
D Patients with symptoms suggestive of lymphoedema should be referred early for
assessment by a designated lymphoedema practitioner.
9.4 TREATMENT
Expert opinion supports the use of conservative physical therapies in lymphoedema
management.
169
For some patients this includes decongestive lymphatic therapy (DLT)
with compression bandaging and manual lymph drainage (MLD) massage, combined with
lymphoedema hosiery, skin care and exercise.
There is evidence from a systematic review to suggest that multi layer bandaging followed by
hosiery is more effective in reducing limb volume than hosiery alone.
170
Early and appropriate antibiotic therapy is important in managing cellulitis and antibiotic
prophylaxis may be required for patients with recurrent cellulitis.
159,169
D Patients with severe or poorly controlled lymphoedema should be offered DLT with a
specialist lymphoedema practitioner.
D Early and appropriate use of antibiotic therapy is recommended for patients with
cellulitis.
Prophylactic antibiotic treatment should be considered for patients with more than two
episodes of cellulitis in a year.
9 LYMPHOEDEMA
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A consensus report identifed no evidence to support the long term use of diuretics to reduce
lower limb lymphoedema.
169
Two systematic reviews found insuffcient evidence to draw conclusions about the effectiveness
of selenium or benzopyrones in the treatment of cellulitis or lymphoedema.
171,172
Evidence from a non-randomised study, that did not include patients with cervical cancer,
suggests that intermittent compression pump therapy may lead to genital oedema.
173
9.5 PATIENT SELF MANAGEMENT
Patient self management that may include use of lymphoedema hosiery, exercise, skin care and
self massage is recognised as important in the effective management of lymphoedema.
160,169
A common sense approach to reducing the risk of lymphoedema or preventing complications
such as cellulitis has been described including:
159,169
taking care of skin and nails and avoidance of interdigital fungal infection
maintaining an optimal body weight
avoiding injury to the affected limb/s including scratches and insect bites
avoiding temperature extremes
protecting the limbs from the sun
wearing comfortable, supportive shoes.
D Patients with lymphoedema should be supported to self manage by a practitioner
qualifed in lymphoedema management.
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10 Follow up
10.1 POST-TREATMENT SURVEILLANCE
Evidence for the effectiveness of post-treatment surveillance is inconsistent.
In an observational study of 993 patients with FIGO IB disease reviewed after primary surgery
or primary radiotherapy, 13% developed recurrent disease (see Table 3).
174
Nine per cent of
surgical patients and 17% of radiotherapy patients developed recurrences. All asymptomatic
recurrences occurred in the frst 16 months of follow up.
174
Cervical cytology did not detect
a single asymptomatic recurrence.
174
Thirty seven of the 993 patients developed recurrent
disease in the central pelvis, 21 patients had recurrences in either lung or pelvic side wall and
22 patients had recurrences in the nodes.
174
All asymptomatic pelvic recurrences occurred in
the frst 16 months after completion of treatment. Symptom status at time of recurrence is a
signifcant predictor of survival.
174
The median survival from recurrence was 11 months for
symptomatic disease and 42 months for asymptomatic.
174
Another study reviewed 1,292 women
of all FIGO stages after radiotherapy (see Table 3).
175
Twenty nine per cent had either local or
distant recurrence and around a 10% fve-year survival rate.
175
In a study of 291 patients followed up for fve years after surgery for cervical cancer, 18.2%
developed recurrent disease (see Table 3).
176
The median time from surgery to recurrence was
17.6 months.
176
Recurrent disease was only detected in seven of the 53 patients at routine
follow up and two were asymptomatic. Detection of recurrence on routine follow up was not
an independent prognostic factor for survival when compared with age, stage and whether the
patient received postoperative adjuvant treatment.
176
Routine clinical follow up after radical hysterectomy and pelvic lymph node dissection is not
a sensitive way of detecting recurrent disease, as a high proportion of patients are found to be
symptomatic at the time of detection of recurrence. Sixty three per cent of recurrences occurred
before 24 months and 77% before 36 months.
174
Table 3: Recurrence detected during follow up
Study
Number of patients Number of recurrences
Survival
Total Primary treatment Total Type
Bodurka-
Bevers,
2000
174
933 surgery 461 40 symptomatic 33 11 months*
asymptomatic 7 42 months*
radiotherapy 532 93 symptomatic 81 11 months*
asymptomatic 12 42 months*
Hong,
2004
175
1292 radiotherapy 375 local 162 10% (5-year)
distant 213 11% (5-year)
Lim,
2004
176
291 surgery 53 symptomatic 5
37.5 months*
asymptomatic 2
8.3 months*
* median survival post-recurrence
recurrent disease detected at a planned follow-up clinic
D History taking and clinical examination should be carried out during follow up of
patients with cervical cancer to detect symptomatic and asymptomatic recurrence.
D Cervical cytology or vault smears are not indicated to detect asymptomatic recurrence
of cervical cancer.
10 FOLLOW UP
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Although routine follow up after radical hysterectomy or radiotherapy is not a sensitive way of
detecting recurrent disease, it is current practice for patients to be followed up because of other
benefts, such as detection of treatment complications, and psychosexual and psychosocial
morbidity.
Patients should be followed up every four months for at least two years.
Patients with early stage disease who have had fertility conserving surgery should have
a smear at six months, 12 months and annually for four years before being returned to
the cervical screening programme.
10.2 DETECTION OF RELAPSED DISEASE
Annex 7 shows an algorithm for the detection of relapsed disease.
CT or MRI is more easily available, cheaper and in symptomatic patients is better than PET
at differentiating metastatic complications from post-treatment complications,
177
for example,
insuffciency fractures of the pelvis.
There is some evidence supporting the use of intravenous contrast in post-therapy MRI scans
in symptomatic and asymptomatic patients to differentiate fbrosis post-radiotherapy from
recurrent tumour.
56
There is evidence from a small study (19 patients) that PET-CT scans may
be more accurate than either postcontrast CT or MRI in differentiating post-treatment fbrosis
from recurrent disease.
178
A whole body PET or PET-CT scan is a sensitive post-therapy surveillance modality for the
detection of recurrent and persistent cervical carcinoma in both asymptomatic and symptomatic
patients.
64,81,179-181
There is little evidence to support the optimal timing or frequency of post-therapy scans.
179
In
several studies whole body PET scans were generally performed no sooner than three months
post primary treatment to avoid false positives associated with post-surgical or radiotherapy
oedema or infammatory response in the pelvis. A PET scan at nine months would be expected
to detect the majority of recurrences, whether or not patients are symptomatic.
181-183
Recurrence
may still occur before and after nine months, but rarely after 30 months. A study of 152 patients
showed that early persistent post-therapy fdg-PET uptake may be predictive of tumour recurrence
and death from cervical cancer.
182
PET is more accurate in the detection of metastatic or nodal disease than CT or MRI.
81
At the
time of publication PET-CT imaging combined is the modality of choice rather than PET scans
alone. CT, CT-PET or MRI are more accurate in the detection of recurrent disease than clinical
examination alone.
If fdg-PET uptake is positive only in the pelvis and cross-sectional imaging has not been
performed, CT or MRI is still required to assess resectibility.
64,85
If performed prior to pelvic exenteration, a whole body PET or PET-CT scan can improve
selection of operable patients and potentially improve their survival rates,
180,184
and can eliminate
unnecessary morbidity associated with salvage procedures in unsuitable patients.
180,181,184,185
There is no evidence to demonstrate that prior radiotherapy or chemotherapy alters the sensitivity
of detection of recurrence.
C MRI or CT should be considered initially to assess potential clinical recurrence in
symptomatic patients.
B A whole body PET scan or PET-CT should be performed on all patients in whom
recurrent or persistent disease has been demonstrated on MRI or CT and in whom
salvage therapy (either pelvic exenteration or radiotherapy) is being considered.
A PET-CT scan at nine months of follow up is recommended in women who have had
chemoradiotherapy.
29
3
10.2.1 TUMOUR MARKERS
The clinical value of routine SCCA measurement during follow up of patients with early stage
cervical cancer treated by radical hysterectomy and PLND with or without radiotherapy has
been investigated.
186
SCCA analysis resulted in earlier detection of recurrence in only 14%
of patients (in 5/35 who had recurrent disease elevated SCCA was the frst measured clinical
indicator), but did not contribute to better overall survival.
186
Routine post-treatment SCCA monitoring is not cost effective for all stages of squamous cervical
cancer in the absence of curative treatment for recurrent disease (see section 15.7).
187
The routine use of SCCA to determine disease recurrence is not recommended.
10 FOLLOW UP
30
MANAGEMENT OF CERVICAL CANCER
2
++
2
+
11 Management of recurrent disease
The prognosis for patients with recurrent disease is six months to two years.
In addition, women
may experience substantial morbidity from both local recurrence and metastatic disease.
Therapeutic options for those patients with cervical cancer whose frst line treatment has failed
include:
surgery (salvage)
chemotherapy
palliative treatment only, including best supportive care (see sections 12 and 13), if further
surgery or chemotherapy is not appropriate either due to the advanced nature of the tumour,
the poor general condition of the patient, or at the patients request.
Decisions regarding the appropriate management of recurrent cervical cancer should be
made on an individual basis taking into account:
the patients wishes
the stage of recurrent tumour and its potential resectability
previous treatment
likely treatment effcacy
likely treatment-related morbidity and functional outcome and consequent effects
on quality of life
the patients general health.
Decisions regarding the management of recurrent cervical cancer should be made by
the multidisciplinary team in consultation with the patient following histological or
cytological confrmation of recurrence and full restaging (clinical and radiological).
Patients and their relatives or carers should be carefully counselled about the likely
outcome of treatment for recurrent disease, with respect to survival, risk of treatment-
related morbidity and mortality and quality of life.
Early referral to palliative care services for symptom control should be considered.
11.1 SURGERY
Following primary treatment for cervical cancer the incidence of isolated relapse confned to
the pelvis is infrequent. For women who do present with relapsed disease following biopsy
confrmation additional restaging is needed to rule out extrapelvic metastases. The majority
of women who develop recurrent disease will have previously received pelvic radiotherapy.
For these women the only potentially curative option is pelvic exenteration provided relapsed
disease is confned to the central pelvis.
11.1.1 TOTAL PELVIC EXENTERATION
Total pelvic exenteration (TPE) is a high morbidity procedure.
188
Less than 50% of patients
survive fve years after TPE.
188
A whole body PET or PET-CT can identify distant nodal and metastatic disease which may not
be detected on CT or MRI scans.
If performed prior to pelvic exenteration, a whole body PET or PET-CT scan can improve the
selection of operable patients and potentially improve their survival rates,
180,184
and eliminate
unnecessary morbidity associated with salvage procedures in unsuitable patients.
180,181,184,185
CT
or MRI is still required to assess resectibility.
64,85
31
3
3
3
3
1
+
1
+
In one small study, postoperative morbidity following TPE was reported as 35.7%, with
reoperations being carried out in 28.6% of patients.
189
Having a dedicated multiprofessional
team reduces morbidity and mortality. Recurrence occurred in 50% of cases.
189
In a phase II trial, the survival and operative mortality rates attainable with TPE for recurrent
cervical cancer are comparable to those achieved with chemoradiotherapy.
190
Urinary diversion represents a fundamental part of surgical reconstruction at the time of TPE.
In the UK the most commonly performed procedure is an ileal loop urinary diversion.
A self selected series of patients with prior pelvic irradiation were given an ileocolic continent
pouch rather than loop ileal conduit with no apparent increase in morbidity.
191
Good
postoperative nutrition, and adequate stenting of the ureteric/intestinal anastomosis site decrease
the incidence of complications and increase quality of life.
188
Reconstruction of the vagina and pelvic foor at the time of pelvic exenteration can be safely
done. Surgical time is increased but morbidity is not signifcantly increased. The rectus abdominal
fap is the preferred reconstruction technique. Incidence of fap necrosis was 18.8%.
192
D Pelvic exenteration should be reserved as salvage surgery for women with recurrent
cervical cancer in the central pelvis whose chemoradiotherapy has failed.
C MRI or CT should be considered initially to assess potential clinical recurrence in
symptomatic patients.
B A whole body PET scan or PET-CT should be performed on all patients in whom
recurrent or persistent disease has been demonstrated on MRI or CT and in whom
salvage therapy (either pelvic exenteration or radiotherapy) is being considered.
To minimise mortality and morbidity, a dedicated multiprofessional team should carry
out total pelvic exenteration in women with recurrent cervical cancer.
11.2 CHEMOTHERAPY
There have been no randomised trials comparing chemotherapy to best supportive care in
advanced cervical carcinoma. Cisplatin is the standard chemotherapy despite low response
rates.
A trial published in 1985 randomised patients to three different schedules of cisplatin. There
was no difference in overall survival or time to progression although response rates were higher
with a higher dose of cisplatin.
193
As a result cisplatin at 50 mg/m
2
three weekly has been the
standard approach.
Two trials looked at the addition of ifosfamide to cisplatin therapy.
194,195
One closed early due
to poor accrual,
194
but no signifcant differences were seen in survival in either trial. There was
an improved progression free survival with cisplatin and ifosfamide but signifcantly increased
toxicity.
195
The addition of paclitaxel (135 mg/m
2
) to cisplatin resulted in an increase in overall response
rate from 19% to 36% and a statistically signifcant increase in the median progression-free
survival of two months from 2.8 months to 4.8 months but there was no improvement in overall
survival.
196
Quality of life was the same in both treatment arms.
197
11 MANAGEMENT OF RECURRENT DISEASE
32
MANAGEMENT OF CERVICAL CANCER
1
+
1
+
A statistically signifcant 2.9 month improvement in median survival was seen with the
combination of cisplatin and topotecan (50 mg/m
2
on day one plus topotecan 0.75 mg/m
2
on
days one to three every three weeks) compared with cisplatin alone (50 mg/m
2
every three
weeks) from 6.5 months to 9.4 months.
198
The unadjusted RR estimate for survival was 0.76
(p=0.017). The 95% confdence interval comes close to unity (0.593 to 0.979), so the actual
overall beneft may be small. When adjusted for covariates of performance status, age, and
disease status at entry, the RR estimate is 0.738 (p=0.0075) favouring cisplatin and topotecan.
The greatest beneft was seen in patients who had not previously received chemotherapy, and
was poorest in those who received platinum therapy in the previous 12 months.
198
Increased toxicity, primarily haematological, was associated with the combination regimen.
There was an increase in episodes of febrile neutropenia from 7.5% to 17.7% and the incidence
of grade 3 or 4 thrombocytopenia increased from 3.4% to 31.3%. There was no reduction
in the recorded quality of life of patients treated with the combination regimen despite the
increased toxicity.
199
The SMC has assessed topotecan in combination with cisplatin (see section 14.1.1).
B Palliative chemotherapy should be offered to women with FIGO stage IVB or recurrent
cervical carcinoma, after discussion of the relative benefts and risks, with either:
cisplatin 50 mg/m
2
on day 1 plus topotecan 0.75 mg/m
2
on days 1 to 3 every 3
weeks, or
cisplatin 50 mg/m
2
on day 1 plus paclitaxel 135 mg/m
2
every 3 weeks.
Cisplatin and topotecan combination should be restricted to cisplatin nave patients.
Patients of performance status 0-2 should be considered for treatment with cisplatin and
topotecan combination.
Discussion of new drugs in the clinical trial setting should be considered with patients
who have relapsed within 12 months.
Chemotherapy should be prescribed, dispensed, administered and supervised in a safe and
effective manner in accordance with the Joint Collegiate Council for Oncology
guidelines,
200,201
clinical oncology good practice guidelines and Scottish Government
advice.
202,203
33
11.3 FISTULAE
Fistula formation is a rare but grave feature of cervical cancer. Few women are affected but
the distress created by rectovaginal or vesicovaginal fstula development is considerable. The
evidence for managing fstulae is poor and management is based on expert opinion.
204
Fistulae may occur as a late complication of radiotherapy (with a mean latent time of 17 months
to 8.1 years)
205
or as a result of progressive disease. Radiation dose and dose distribution are
the main risk factors for the development of post radiation rectovaginal fstulae.
206
Symptoms include:
persistent continuous watery discharge
persistent continuous faeculant discharge with pneumaturia.
For a bowel fstula, after appropriate radiological investigations to establish the site and
complexity of the fstula (see section 4.3.5), a treatment option may be stoma formation.
Urological fstulae due to radiotherapy may require temporary diversion by percutaneous
nephrostomies or insertion of internal ureteric stents prior to ureteric occlusion and
diversion.
205
Patients with advanced disease who develop fstulae are seldom able to undergo surgery to
attempt repair and are constantly reminded of the incurable nature of their condition. Appropriate
non-surgical treatments should be offered to maximise comfort and include:
octreotide, hyoscine butyl bromide or glycopyrronium to reduce volume of discharge
codeine phosphate or loperamide to frm stool
barrier creams to protect the perineal skin
topical steroids, for example, prednisolone foam enemata administered vaginally for local
effect
vaginal moulds
tampons
low residue diet.
35
3
3
3
3
3
The management of extrinsic malignant ureteric obstruction is a balance of the patients quality
of life, renal preservation and the risk of complications in a setting of poor prognosis.
212
There
is a lack of consensus on optimal management,
213
and treatment may differ between patients
with advanced disease at presentation and those with progressive disease following treatment.
Initial management options are:
no treatment
percutaneous nephrostomy (PCN), or
retrograde stenting.
Urology and gynaecology specialists should be involved in any discussion on the best
treatment for individual patients.
Advanced decisions taken by the patient should be recorded and respected.
In an emergency situation, and in the absence of an advanced directive, initial treatment
should be in favour of life.
An algorithm for the management of renal failure is shown in Annex 8.
PCN can substitute a peaceful uraemic death for a painful, poor quality life with minimal
improved survival.
214
Internal stents fail in at least a third of patients within six months.
212
Stent failure is represented by an increase in creatinine by 50% from nadir, pain, infection or
hydronephrosis.
212
A retrospective study of cancer patients receiving primary retrograde stents for malignant ureteric
obstruction indicated that gross tumour invasion at cystoscopy is a signifcant risk factor for
stent failure and progression to PCN. There is insuffcient evidence to compare different types
of stent.
212
Long term stents are designed to remain in place for either six or 12 months but some urologists
perform more frequent changes to keep the stents patent.
212
The frequency of change depends
on the level of ureteric obstruction. If the obstruction is due to pelvic cancer it may be more
appropriate to consider PCN.
212
If retroperitoneal lymphadenopathy is the cause of the
obstruction, stents will remain patent for considerably longer and will require less frequent
change.
212
If retrograde stent is unsuccessful PCN and/or antegrade stent may be a successful alternative.
212
Consequently open discussion with the patient and relatives is essential.
212
D Retrograde ureteric stents should be changed according to the level of ureteric
obstruction (ranging from 3-12 months).
D If a retrograde stent is unsuccessful:
the stent should be changed more frequently
an alternative stent should be tried
patients should be offered PCN and/or antegrade stent.
If stent placement permits further treatment, such as radiotherapy or chemotherapy, in patients
with advanced disease at presentation, urinary diversion may subsequently become feasible.
Patients require careful follow up,
215,216
with regular monitoring of renal status.
217
Patient selection
and counselling are important.
216
D Urinary diversion may be considered in suitable patients.
D Patients should have careful follow up and access to counselling.
37
3
4
12.3.2 HAEMORRHAGE
Relapsed cervical cancer can present with vaginal bleeding and massive haemorrhage may
occur. Bladder or bowel invasion may cause haematuria or rectal bleeding but haemorrhage
from thrombocytopenia related to marrow infltration is unusual in cervical cancer.
218
Drugs with antiplatelet activity, for example, non-steroidal anti-infammatory drugs (NSAIDs)
or antithrombotic activity, for example, LMWH may exacerbate bleeding.
227
Minor bleeds and/or infection may herald a major haemorrhage.
12.3.3 TREATMENT OF MINOR HAEMORRHAGE
If a minor haemorrhage occurs:
systemic causes of bleeding should be excluded
drugs that may exacerbate bleeding should be discontinued
antibiotics should be considered if sepsis is present.
Fibrinolytic inhibitors, such as oral tranexamic acid or aminocaproic acid, have been shown
to reduce bleeding.
228
Topical application of tranexamic acid to superfcial fungating wounds
or by rectal or bladder instillation may also reduce bleeding
228
as may a single fraction of
radiotherapy.
229
D Treatment for minor haemorrhage may include:
oral tranexamic acid or aminocaproic acid
tranexamic acid applied topically to superfcial fungating wound
tranexamic acid by rectal or bladder instillation
a single fraction of radiotherapy.
12.3.4 MANAGEMENT OF MAJOR HAEMORRHAGE
A major haemorrhage is defned as arterial blood loss of 1.5 litres in 30 seconds in a patient for
whom active treatment is neither appropriate nor possible and which will inevitably be fatal
within minutes in the palliative situation.
The aim is to relieve patient distress as quickly as possible. Drugs which are benefcial in this
situation are:
230
midazolam for its anxiolytic effect (10 mg subcutaneously or by the buccal route), and
diamorphine for its hypotensive effect (10 mg subcutaneously if opiate-nave, two to four
times normal breakthrough dose if on regular opiates).
If the patient is peripherally constricted intravenous or intramuscular routes can be used.
If the patient wishes to be at home to die the risks of anticipated haemorrhage should
be explained to the relatives and appropriate support should be offered.
If haemorrhage is predictable when at home, dark coloured towels or blankets should
be made available to relatives to mask the extent of the haemorrhage.
Appropriate drugs should be immediately available by the bedside.
If bleeding is due to erosion of a major artery, local pressure with adequate packing
should be applied.
It is important to ensure that the patient is not left alone and, if possible, that a doctor or
nurse remains with the patient until death or resolution of the acute event.
39
suprapubic catheterisation was suggested for fstula-related urinary incontinence
for fstula-related faecal incontinence subcutaneous octreotide via a syringe driver was used
to reduce faecal loss and reduce malodour. Hyoscine butyl bromide to reduce bowel activity,
and constipating agents were also used
no unit was able to supply references but all the suggestions above have been recommended
on the Association of Palliative Medicine palliative drugs bulletin board (www.palliative-
medicine.org, www.bulletinboard@palliativedrugs.com).
3
4
13 Psychosocial care and support for patients and
carers
Cervical cancer has a signifcant psychological and psychosocial impact on the individual and
it is important to develop strategies to deal with this.
233
13.1 PSYCHOLOGICAL AND PSYCHOSOCIAL DISTRESS
Psychological distress is common in patients with all forms of cancer and usually remains
undetected.
234
Regardless of sociodemographic characteristics or clinical characteristics, the
well-being of patients with cervical cancer changes during the course of their disease.
235
A
study of 119 patients newly diagnosed with gynaecological cancer evaluated psychological
well-being and functions of daily living before surgery, three months after surgery and one year
after surgery.
235
There was a decline in psychological well-being and functions of daily living
scores at three months after surgery.
235
After one year there was a signifcant improvement in
psychological well-being (p<0.05) and no signifcant difference in functions of daily living
compared to before surgery.
235
In patients treated with surgery, the level of psychological distress
may be related to the extent of surgery.
235
Patients should be advised that their physical and psychological function is likely to
deteriorate in the initial post-treatment period, but that they should anticipate
improvement.
13.1.1 IDENTIFYING PSYCHOLOGICAL DISTRESS
A diagnosis of cancer can be diffcult to cope with and may lead to psychological distress due
to the interplay of a number of factors, including previous history of psychological disorder,
coping or adjustment style, and status and characteristics of the disease and its treatment.
Routine screening for psychological distress among people with cancer has been recommended
by the US National Comprehensive Cancer Network.
236
The National Health and Medical
Research Council of Australia recommends an approach to screening for signifcant psychological
problems that includes advice to document risk factors for the presence of psychological distress
(see Table 4).
148
Not all patients who present with risk factors will experience psychological distress and some
patients who present with no risk factors will present with very high levels of distress.
An example of a screening tool developed by the US National Comprehensive Cancer Network
is shown in Annex 9.
236
The multidisciplinary team (MDT) should routinely screen for the presence of
psychological distress and be aware of risk factors for very high levels of psychological
distress from the point of diagnosis onwards (including during follow-up review
phases).
Multidisciplinary teams across healthcare settings should have agreed protocols
for psychological distress assessment and management. These should include
recommendations for referral and care pathways.
Liaison psychiatry and clinical psychology services should be contacted if the results
from distress screening raise concerns about the psychological well-being of a
patient.
41
4
1+
2+
3
Table 4: Factors associated with increased risk of psychosocial problems in patients with
cancer
148
Characteristics of the individual
Younger
Single, separated, divorced or widowed
Living alone
Children younger than 21 years
Economic adversity
Lack of social support, perceived poor social support
Poor marital or family functioning
History of psychiatric problems
Cumulative stressful life events
History of alcohol or other substance abuse
Characteristics of disease and treatment
At the time of diagnosis and recurrence
During advanced stage of the disease
Poorer prognosis
More treatment side effects
Greater functional impairment and disease burden
Experiencing lymphoedema
Experiencing chronic pain
Fatigue
13.1.2 ISSUES THAT LEAD TO PSYCHOLOGICAL DISTRESS
Many of the psychological, physical and practical challenges facing women with cervical cancer
are common to all cancer patients. These include:
coping with the shock of diagnosis
pain, nausea, fatigue and disfgurement as a result of treatment
worries over practical issues such as travel costs and loss of income.
Other issues are specifc to patients with cervical cancer. The level of psychological distress
experienced will vary between individuals. Table 5 lists issues that are likely to be important
for patients with cervical cancer.
148
13.2 SUPPORT NEEDS
There is evidence that providing psychological and practical support may have a positive effect
on patients well-being.
237
Evidence identifed in relation to the support needs of cancer patients
was from small heterogeneous studies and the types of help offered are very varied.
238-240
None
of the studies was specifc to patients with cervical cancer but were generalisable to the cervical
cancer population. The interventions included structured psychological support, relaxation
techniques, orientation programmes and general psychological support. The interventions
reduced anxiety levels and improved quality of life.
43
1
+
1
+
2
+
3
1
+
4
1
++
3
1
+
2
+
13.3 INFORMATION NEEDS
Patients diagnosed with cancer for the frst time often want information addressing their
immediate concerns regarding their disease, treatment options, what they might expect during
return appointments and who to go to for information.
Among women with gynaecological cancer, the level of knowledge about their disease has
been found to be poor.
241
Four studies indicate that cancer patients want information on their treatment and prognosis.
242-
245
A cohort study carried out in the West of Scotland highlighted that cancer patients want
to know the medical name of their illness, their treatment choices, how treatments work, the
likely side effects and the chances of cure.
243
The preference for, and ability to cope with, information varies between patients.
246
Some patients
do not want extensive information, and the reasons for this may be complex.
247
Discrepancies
between the need for, and actual communication of, information can contribute to diffculties
in coping with psychosocial problems.
246
A systematic review of studies involving women with gynaecological cancer show that
providing patients with information is benefcial, can improve ability to cope and facilitate their
participation in treatment decisions.
241
C Patients should be offered information throughout their journey of care.
Health professionals should appreciate that information helps patients to understand
how their disease may affect them and to anticipate problems and plan their lives.
Patients should be offered the amount of information that is appropriate to their wishes
in a way which is sensitive, understandable and accurate.
Multidisciplinary teams across healthcare settings should have agreed protocols for
offering information to patients with cervical cancer.
13.4 COMMUNICATION METHODS
Effective communication with patients is a cornerstone of good practice. Poor communication
can increase patients psychological distress. Complaints from cancer patients about poor
communication with healthcare professionals and lack of continuity of care are common.
248
Communication skills training delivered by expert facilitators results in demonstrable
improvements in communication behaviours of participating senior clinicians.
249
There is evidence that training programmes for nurses can improve listening and communication
skills.
250
Although the included trials were small and heterogeneous, one systematic review suggested
that providing a record of the consultation with a specialist can increase both the amount of
information recalled and satisfaction with the information given.
245
One randomised trial showed
that patients preferred information based on their own medical records rather than general
information about their type of cancer.
251
Patients prefer to receive written information to assist in making an informed choice.
244
B Healthcare professionals in cancer care should be trained in listening and communication
skills.
B Healthcare professionals in cancer care should consider giving either written summaries
or audiotapes of consultations to people who have expressed a preference for them.
13 PSYCHOSOCIAL CARE AND SUPPORT FOR PATIENTS AND CARERS
44
MANAGEMENT OF CERVICAL CANCER
13.5 SOURCES OF FURTHER INFORMATION
Many cancer care centres and public libraries have access to the internet. While the internet can
provide a vast range of information, patients should be advised to act cautiously as they may
not have the means of determining the accuracy or reliability of a site. Healthcare professionals
should guide patients to appropriate sites and advise patients that any information found on the
internet should be discussed with members of their multidisciplinary team.
13.5.1 ORGANISATIONS SPECIFIC TO CERVICAL CANCER
Jos Trust
Weedon Villa, Everdon, Northamptonshire NN11 3BQ
Tel: 01327 341965 Fax: 01327 349397
www.jotrust.co.uk Email: pamela@jotrust.co.uk
Provides online cervical cancer information and free confdential expert medical advice and
support within 12-72 hours.
13.5.2 NATIONAL ORGANISATIONS RELATED TO CANCER
Cancer in Scotland
Scottish Government Health Department, St Andrews House, Regent Road,
Edinburgh, EH1 3DG
Tel: 0131 244 2364 Fax: 0131 244 2989
www.show.scot.nhs.uk/sehd/cancerinscotland/ Email: Cancer@scotland.gsi.gov.uk
Cancer in Scotland identifes the wide range of actions necessary to prevent, detect and improve
treatment and care for people with cancer in Scotland.
Cancer Research UK Scotland
Federation House, 222 Queensferry Road, Edinburgh EH4 2BN
Tel: 0131 343 1344
www.cancerresearchuk.org Email: christine.jason@cancer.org.uk
A free information service for patients with cancer and their families.
Cancer Research UK
PO Box 123, Lincolns Inn Fields, London WC2A 3PX
Tel: (Supporter Services) 020 7121 6699 Tel: (Switchboard) 020 7242 0200
Fax: 020 7121 6700
www.cancerresearchuk.org
A UK based charity dedicated to cancer research, which offers information about all aspects
of cancer.
Cancerbackup Scotland
Suite 2, Third Floor, Cranston House, Morrison Court, 104/114 Argyle Street,
Glasgow G2 8BH
Tel: 0141 223 7676 Fax: 0141 248 8422 Freephone: 0808 800 1234
www.cancerbackup.org.uk
A free one to one service which provides counselling and emotional support for people with
cancer and their families and friends. Produces over 60 booklets free of charge.
Macmillan Cancer Support
89 Albert Embankment, London, SE1 7UQ
Cancerline: 0808 808 2020 Fax: 020 7840 7841
www.macmillan.org.uk Email: cancerline@macmillan.org.uk
A UK charity which supports people with cancer and their families with specialist information,
treatment and care.
45
Maggies Centres Scotland
www.maggiescentres.org
Maggies provides practical, emotional and social support to people with cancer, their family
and friends. Built alongside NHS cancer hospitals and staffed with professional experts, Maggies
Centres are warm and welcoming, full
of light and open space, with a big kitchen table at their heart.
Maggie's Dundee, Ninewells Hospital, Tom McDonald Avenue, Dundee DD2 1ZV
Tel: 01382 632 999 Fax: 01382 632998
Email: dundee@maggiescentres.org
Maggies Edinburgh, The Stables, Western General Hospital, Crewe Road South,
Edinburgh EH6 6AX.
Tel: 0131 537 3131 Fax: 0131 537 3130
Email: edinburgh@maggiescentres.org
Maggie's Fife, Victoria Hospital, Kirkcaldy, Fife, KY2 5AH
Tel: 0159 264 3355, ext. 8868 Fax: 0159 264 8062
Email: ruth@maggiescentres.org
Maggies Glasgow, The Gatehouse, Western Infrmary, 10 Dumbarton Road,
Glasgow G11 6PA
Tel: 0141 330 3311 Fax: 0141 330 3363
Email: glasgow@maggiescentres.org
Maggie's Highlands, Raigmore Hospital, Old Perth Road, Inverness IV2 3UJ
Tel: 01463 706306
Email: highlands@maggiescentres.org
Maggie's Lanarkshire, c/o Ward 9, Wishaw General, 50 Netherton Street, Wishaw ML2 0DP
Tel: 01698 366 107
Email: mhairi@maggiescentres.org
Marie Curie Cancer Care (Scotland)
29 Albany Street, Edinburgh, EH1 3QN
Tel: 0131 456 3700 Fax: 0131 456 3701
www.mariecurie.org.uk
Marie Curie Cancer Care, a comprehensive cancer care charity, provides practical nursing care
at home and specialist multidisciplinary care through its ten Marie Curie Centres.
Pain Association Scotland
Cramond House, Cramond Glebe Road, Edinburgh EH4 6NS
Tel: 0131 312 7955 Freephone: 0800 783 6059 Fax: 0131 312 6007
www.painassociation.com
For all cancer patients suffering from pain. Offers the opportunity for patients and their carers
to join support groups.
Tak Tent Cancer Support Scotland
Flat 5, 30 Shelley Court, Gartnavel Complex, Glasgow G12 0YN
Tel: 0141 211 0122 Fax: 0141 211 0010
www.taktent.org Email: tak.tent@care4free.net
Promotes the care of cancer patients, their families, friends and the staff involved professionally
in cancer care by providing practical and emotional support, information, counselling and
therapies as required. Network of local support groups throughout Scotland, including a youth
project for 16-25 year olds.
13 PSYCHOSOCIAL CARE AND SUPPORT FOR PATIENTS AND CARERS
46
MANAGEMENT OF CERVICAL CANCER
13.5.3 LOCAL ORGANISATIONS RELATED TO CANCER
Cancer Link Aberdeen and North (CLAN)
Cancer Support Centre, Clan House, Caroline Place, Aberdeen AB25 2TH
Tel: 01224 647 000 Freephone: 0800 783 7922 Fax: 01224 640 802
www.clanhouse.org Email: enquiries@clanhouse.org
Provides emotional support and information through a team of volunteers trained in listening
skills; CLAN counsellors, with their personal experience of cancer, provide the opportunity to
talk with someone who cares and understands.
Macmillan Citizens Advice Bureau Partnership
Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
Tel: 01463 706178
Email: macmillan.macmillancab@virgin.net
A service for those living with cancer, their carers and families. It provides advice on many
issues including benefts, employment, housing, debt, holiday insurance and community care
issues.
NoSCAN (North of Scotland cancer network)
Westburn House, Foresterhill, Westburn Road, Aberdeen, AB25 2XG
Tel: 01224 552 745 Fax: 01224 553 941
www.noscan.scot.nhs.uk Email: ruth.nisbet@.nhs.net
A network of the people in the north of Scotland striving to improve cancer care and improve
information to patients, the public and health professionals.
SCAN (South East Scotland cancer network)
Deaconess House, 148 The Pleasance, Edinburgh, EH8 9RS
Tel: 0131 536 9304 Fax: 0131 536 9071
www.scan.scot.nhs.uk Email: scan@lhb.scot.nhs.uk
Aims to bring together up-to-date, relevant and accurate information about local services for
people affected by cancer and healthcare professionals in south east Scotland.
WoSCAN (West of Scotland cancer network)
www.woscan.scot.nhs.uk Email: susan.paton@ggc.scot.nhs.uk
Strives to produce a regional service, which provides equitable access to good quality clinical
care for all cancer patients regardless of any geographical or socioeconomic factors.
13.5.4 NATIONAL ORGANISATIONS
Dipex (Database of individual experiences)
www.dipex.org
Dipex is a website that reports on a wide variety of personal experiences of health and illness.
People can watch, listen to or read interviews, fnd reliable information on treatment choices
and where to fnd support. The site covers heart disease, epilepsy, screening programmes and
cancers.
Family Planning and Reproductive Health Care
The Sandyford Initiative, 6 Sandyford Place, Sauchiehall Street, Glasgow G3 7NB
Tel: 0141 211 8130 Fax: 0141 211 8139
www.sandyford.org/sandyford/pubpages/reproductivehealth/reproductivehealth.html
Family Planning Association Scotland
Unit 10, Firhill Business Centre, 76 Firhill Road, Glasgow, G20 7BA
Tel: 0141 576 5088 Helpline: 0141 576 5088 (Monday to Thursday 9am - 5pm, Friday
9am - 4.30pm)
47
Family Planning and Well Woman Services
Dean Terrace Clinic, 18 Dean Terrace, Edinburgh, EH4 1NL
Tel: 0131 332 7941 / 0131 343 6243
Open: Monday-Thursday: 9 30 am to 7.30 pm; Friday: 9.00 am to 3.30 pm; Saturday: 9.30 am
to 12 noon (drop-in clinic for under-25s)
British Lymphology Society
Tracy Hirst-Marsden, Administration Offce, British Lymphology Society, PO Box 196,
Shoreham, Sevenoaks, Kent TN13 9BF
Tel: 01959 525524 Fax: 01959 525524
www.lymphoedema.org/bls/ Email: admin@blsac.demon.co.uk
Aims to promote awareness about lymphoedema to the public and healthcare professionals.
Produces guidelines and evidence based standards to underpin treatment for the long term
management of lymphoedema.
Lymphoedema Support Network
St Lukes Crypt, Sydney Street, London, SW3 6NH
Tel: 020 7351 0990 Fax: 020 7349 9809 Helpline: 020 7351 4480
www.lymphoedema.org/lsn Email: adminlsn@lymphoedema.freeserve.co.uk
A national patient-led organisation educating and supporting patients with lymphoedema by
providing a high standard of information and promoting self help.
Samaritans
The Upper Mill, Kingston Road, Ewell, Surrey, KT17 2AF
Tel: 020 8394 8300 Fax: 020 8394 8301 Helpline: 08457 90 90 90
www.samaritans.org.uk Email: jo@samaritans.org
Write to: Chris, PO Box 90 90, Stirling, FK8 2SA
Samaritans is available 24 hours a day to provide confdential emotional support for people who
are experiencing feelings of distress or despair, including those which may lead to suicide.
Well-being of Women
27 Sussex Place, Regents Park, London, NW1 4SP
Tel: 020 7772 6400 Fax: 020 7724 7725
www.wellbeingofwomen.org.uk Email: wellbeingofwomen@rcog.org.uk
Funds research that will translate into patient treatments, increases knowledge amongst experts
and publishes widely the outcomes of work funded and improves awareness of obstetric and
gynaecological conditions amongst women.
Womens Health Concern
Womens Health Concern Ltd, Whitehall House, 41 Whitehall, London, SW1A 2BY
Helpline: 0845 123 2319 Fax: 01628 474 042
www.womens-health-concern.org Email: info@womens-health-concern.org
Provides advice through a telephone helpline managed by experienced nurse counsellors, a
confdential question-answering service via email and information leafets and fact sheets on
the most common gynaecological conditions.
13 PSYCHOSOCIAL CARE AND SUPPORT FOR PATIENTS AND CARERS
48
MANAGEMENT OF CERVICAL CANCER
14 Implementation and recommendations for
research
14.1 LOCAL IMPLEMENTATION
Implementation of national clinical guidelines is the responsibility of each NHS Board and is
an essential part of clinical governance. It is acknowledged that every Board cannot implement
every guideline immediately on publication, but mechanisms should be in place to ensure
that the care provided is reviewed against the guideline recommendations and the reasons for
any differences assessed and, where appropriate, addressed. These discussions should involve
both clinical staff and management. Local arrangements may then be made to implement the
national guideline in individual hospitals, units and practices, and to monitor compliance. This
may be done by a variety of means including patient-specifc reminders, continuing education
and training, and clinical audit.
14.1.1 ADVICE TO NHSSCOTLAND FROM THE SCOTTISH MEDICINES CONSORTIUM
The SMC advises that topotecan is accepted for restricted use within NHSScotland in combination
with cisplatin for patients with carcinoma of the cervix recurrent after radiotherapy, and for
patients with stage IVB disease. It is restricted to patients who are cisplatin-nave (www.
scottishmedicines.org.uk).
Overall survival and progression-free survival are signifcantly longer for cisplatin plus topotecan
compared with cisplatin alone. Topotecan plus cisplatin is cost effective compared to cisplatin
alone in cisplatin-nave patients. The treatments cost in relation to its health beneft is not
suffcient to be accepted by SMC for use in patients with previous exposure to cisplatin.
14.2 RECOMMENDATIONS FOR RESEARCH
Only 30% of cervical cancers are screen detected and the majority of cases occur in women
who have never had a smear or have not been regular participants in the screening
programme. Research is required to explore how to encourage patients who do not attend
for screening to take advantage of early detection.
During radiation treatment of cervical cancer other pelvic organs receive a signifcant
radiation dose resulting in both acute and late toxicity. The management of late radiation
complications is complex and requires high quality evidence to guide practice.
What are the specifc support needs of women, who are diagnosed with cervical cancer or
who are undergoing treatment, at different stages of their patient journey?
Research is required on the sexual rehabilitation needs of women following treatment for
cervical cancer.
Compliance with vaginal dilation following pelvic radiotherapy is variable and generally
poor. Assistance in overcoming womens fears and teaching behavioural skills is likely
to reduce concerns and improve both knowledge of sexual activity and sexual rehabilitation
following pelvic radiotherapy. Research into psychoeducational interventions to aid this is
required.
Less radical forms of surgery for early invasive disease (eg cold knife conisation and large
loop excision of the transformation zone) need to be evaluated.
A comparison of ileal loop conduit with other methods of urinary diversion.
More research is required on the incidence and prevalence of cervical cancer related
lymphoedema. Evidence is lacking and studies are not generally comparable due to different
patient groups, treatment techniques and lack of standardised reporting of lymphoedema.
49
Alternative methods of performing post-treatment surveillance. Designing programmes that
are more individualised to suit patients needs and expectations (including nurse-led follow
up compared to hospital-led) are required.
Evaluating the measurement of SCCA after treatment and using elevated levels post-
treatment to trigger PET-CT scanning to identify persistent or recurrent disease before it
becomes symptomatic.
Evidence is lacking on how to manage malodour. Good quality studies are required to
guide practice.
Pre-menopausal Post-menopausal
No clinically
obvious cancer
Test for Chlamydia trachomatis D
Chlamydia +ve
Chlamydia -ve
no local cause
Refer
to gynaecology
Asymptomatic women
attending for cervical
screening
Refer to gynaecology
Women with symptoms
suggestive of cervical cancer
eg abnormal vaginal bleeding
Clinical suspicion of cancer
Annex 2
Algorithm for the investigation of post-coital bleeding
59
Annex 3
WHO histological classifcation of tumours of the uterine cervix
26
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ANNEXES
60
MANAGEMENT OF CERVICAL CANCER
National Minimum Dataset Cervical Biopsy Histopathology Report
Surname ........................... Forenames .............................. Date of birth .......... Sex.....
Hospital ......................... Hospital No ........... NHS No ..............
Date of request .................. Date of reporting............. Report No.....
Pathologist .................. Surgeon .................
MACROSCOPY
Wedge Cone Loop biopsy of cervix measuring ....mm x .. mm and mm deep
The cervix was divided into .. blocks labelled A ..
(A) separate fragment(s) labelled , was (were) also received.
MICROSCOPY
Wart virus (HPV) infection Absent Koilocytosis HPV-associated features
CIN (cervical intra-epithelial neoplasia) Absent Epithelial changes of uncertain significance
CIN 1 CIN 2 CIN 3
Endocervical edge Clear Involved
Ectocervical edge Clear Involved
Deep lateral edge Clear Involved
Endocervical epithelium Normal Low grade CGIN High Grade CGIN
Endocervical epithelium at end of canal Yes No
Invasive malignancy Absent Microinvasive Squamous cell carcinoma
Adenocarcinoma Adenosquamous carcinoma
Microinvasive carcinoma, early stromal invasion
Microinvasive carcinoma, small confluent tumour
Maximum horizontal dimension .. mm
Maximum depth of invasion mm
N.B. If invasive foci are seen in three or more blocks of tissue, the third dimension of the lesion
(which is not routinely measured) may exceed 7 mm (i.e. more than Stage IA2).
Is there lymphovascular space involvement? Yes No
Comments
SNOMED codes
T83000 (Cervix) E3345 (HPV) / M74001 (Koilocytosis) / M74005 (Epithelial changes, uncertain
significance)
*M74008 (CIN 3) / *M74007 (CIN 2) / *M74006 (CIN 1)
M80715 (Microinvasive squamous cell carcinoma)
M80703 (Squamous cell carcinoma) M74009 (CGIN, low or high grade)
M81402 (Adenocarcinoma in situ) / M81403 (Adenocarcinoma)
Signature ....................... Date .../..../....
Signature .................................................... Date .............../ ...................../ .....................
Annex 4
National minimum dataset proforma for the histopathological reporting of
cervical neoplasia (see footnote)
38
Footnote 2007, The Royal College of Pathologists www.rcpath.org Registered charity in England and Wales, no. 261035
61
National Minimum Dataset Cervical Cancer Histopathology Report
Surname ........................... Forenames .............................. Date of birth .......... Sex.....
Hospital ......................... Hospital No ........... NHS No ..............
Date of request .................. Date of reporting............. Report No.....
Pathologist .................. Surgeon .................
Gross description
Dimensions of uterus: Length ..........mm Transverse .......mm Antero-posterior........mm
Vaginal cuff: Present Absent Length .......mm
Maximum dimensions of tumour: .......mm
Histology
Type: squamous carcinoma adenocarcinoma adenosquamos
other (please specify) .
Histological differentiation: Well Moderate Poor
Tumour size: maximum horizontal dimension .......mm depth of invasion .......mm
distance from closest resection margin (minimum tumour-free rim) .......mm position of
this .
Paracervical involvement: Yes No
Parametrical involvement: Yes No
Vaginal involvement: Yes Distance from vaginal margin .......mm No
Lymphovascular invasion: Present Absent
CIN: Present Grade (please circle) 1 2 3 Absent
CGIN: Present Grade (please circle) High Low Absent
Pelvic nodes
(including obturator,
internal and external iliac)
right left Common iliac nodes right left
total number of nodes
retrieved .. ..
total number of nodes
retrieved .. ..
lymph nodes with
tumour deposits .. ..
lymph nodes with
tumour deposits .. ..
Extranodal spread Yes No Yes No
Para-aortic nodes: not sampled positive negative
Extranodal spread: Yes No
Endometrium: Normal Abnormal (please state) .
Myometrium: Normal Abnormal (please state) .
Right ovary/tube: Normal Abnormal (please state) .
Left ovary/tube: Normal Abnormal (please state) .
Comments
SNOMED codes
T83000 (Cervix) M80703 (Squamous cell carcinoma) M81403 (Adenocarcinoma)
T08000 (Lymph node) M85603 (Adenosquamos carcinoma)
M80706 (Metastatic squamous carcinoma) M81406 (Metastatic Adenocarcinoma)
Signature .................................................... Date .............../ ...................../ .....................
Annex 4 (continued)
National minimum dataset proforma for the histopathological reporting of
cervical neoplasia (see footnote)
38
Footnote 2007, The Royal College of Pathologists www.rcpath.org Registered charity in England and Wales, no. 261035
ANNEXES
62
MANAGEMENT OF CERVICAL CANCER
Annex 5
FIGO staging classifcation for cancer of the cervix uteri
37
FIGO
stage
Description
0 Carcinoma in situ (pre-invasive carcinoma)
I
Cervical carcinoma confned to uterus (extension to corpus should be
disregarded)
IA
Invasive carcinoma diagnosed only by microscopy. All macroscopically
visible lesions even with superfcial invasion are stage IB
IA1
Stromal invasion no greater than 3.0 mm in depth and 7.0 mm or less in
horizontal spread
IA2
Stromal invasion more than 3.0 mm and not more than 5.0 mm with a
horizontal spread 7.0 mm or less
a
IB
Clinically visible lesion confned to the cervix or microscopic lesion
greater than IA2
IB1 Clinically visible lesion 4.0 cm or less in greatest dimension
IB2 Clinically visible lesion more than 4.0 cm in greatest dimension
II
Tumour invades beyond the uterus but not to pelvic wall or to lower third
of the vagina
IIA Without parametrial invasion
IIB With parametrial invasion
III
Tumour extends to pelvic wall and/or involves lower third of vagina and/or
causes hydronephrosis or non-functioning kidney
IIIA Tumour involves lower third of vagina no extension to pelvic wall
IIIB
Tumour extends to pelvic wall and/or causes hydronephrosis or non-
functioning kidney
IVA
Tumour invades mucosa of bladder or rectum and/or extends beyond true
pelvis
b
IVB Distant metastasis
a: The depth of invasion should not be more than 5 mm taken from the base of the epithelium, either
surface or glandular, from which it originates. The depth of invasion is defned as the measurement
of the tumour from the epithelial-stromal junction of the adjacent most superfcial epithelial papilla
to the deepest point of invasion. Vascular space involvement, venous or lymphatic, does not affect
classifcation.
b: The presence of bullous oedema is not suffcient to classify a tumour as stage IV.
63
Annex 6
Staging criteria for lymphoedema
155
Stage Criteria
0
Subclinical stage, where swelling is not evident but lymphatic damage has
occurred.
1 Early onset of oedema that subsides with elevation.
2 Pitting oedema that does not subside on elevation.
3 Oedema with fbrotic changes.
4
Skin and tissue changes including thickening, skin folds, fat deposits and warty
overgrowths.
ANNEXES
64
MANAGEMENT OF CERVICAL CANCER
C MRI or CT should be
considered to assess potential
clinical recurrence.
Cervical cancer treated with chemoradiotherapy
asymptomatic symptomatic
Consider for salvage therapy
C
Whole body PET scan or
PET-CT for all patients
with recurrent or persistent
disease demonstrated on
MRI or CT.
PET-CT scan at
nine months.
Annex 7
Algorithm of imaging to detect relapsed disease
65
Investigations should be performed to exclude
additional treatable causes of renal failure
ureteric
obstruction
urethral catheter
suprapubic catheter
debulking therapy
bladder outlet
obstruction
successful
D
More frequent
changes or
alternative
stents
D
PCN and
attempt
antegrade
stent
D
Change
stent
every 3-4
months
D
Urinary
diversion may
be considered in
suitable patients
Identify obstructive uropathy
There should be a careful assessment of results
of the investigations and discussion with the
patient
no
treatment
retrograde
stent
PCN
unsuccessful
Annex 8
Algorithm for management of renal failure in patients with cervical cancer
(adapted from Ganatra et al)
212
ANNEXES
66
MANAGEMENT OF CERVICAL CANCER
I
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09876543210
1
09876543210
Annex 9
Screening tool for measuring distress (see footnote)
236
Reproduced with permission from The NCCN 1.2007 Distress Management Clinical Practice Guidelines in Oncology. National Comprehensive
Cancer Network, 2007. Available at: http://www.nccn.org. Accessed [August 1, 2007]. To view the most recent and complete version of the guideline,
go online to www.nccn.org.
These Guidelines are a work in progress that will be refned as often as new signifcant data becomes available. The NCCN Guidelines are a statement
of consensus of its authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult any NCCN
guideline is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patients care or
treatment. The National Comprehensive Cancer Network makes no warranties of any kind whatsoever regarding their content, use or application
and disclaims any responsibility for their application or use in any way. These Guidelines are copyrighted by the National Comprehensive Cancer
Network. All rights reserved. These Guidelines and illustrations herein may not be reproduced in any form for any purpose without the express
written permission of the NCCN.
67
References
1. Cancer Research UK. UK Cervical Cancer incidence statistics. London:
Cancer Research UK; 2003. [cited 3 Jan 2007]. Available from url:
http://info.cancerresearchuk.org/cancerstats/types/cervix/incidence/
2. Information Services Division. Carcinoma in situ of cervix uteri (ICD-10
D06) Scotland: trends in incidence 1980-2004. Edinburgh: The Division;
2007. [cited 26 Apr 2007]. Available from url: http://www.isdscotland.
org/isd/fles/cancer_cervix_insitu_inc.xls
3. Information Services Division. Cancer of the cervix uteri (ICD-10 C53):
Scotland: trends in mortality 1980-2006. Edinburgh: The Division;
2007. [cited 6 Sep 2007]. Available from url: http://www.isdscotland.
org/isd/fles/cancer_cervix_mort_m.xls
4. Information Services Division. Cervix Uteri (ICD-9 180; ICD-10 C53);
Trends in survival by age group and period of diagnosis. Observed and
relative survival (%) at 1,3,5 and 10 years; patients diagnosed 1977-
2001. Edinburgh: The Division; 2004. [cited 6 Sep 2007]. Available
from url: http://www.isdscotland.org/isd/fles/cancer_cervix_surv7701.
xls
5. Sigurdsson K. The Icelandic and Nordic cervical screening programs:
trends in incidence and mortality rates through 1995. Acta Obstet
Gynecol Scand 1999;78(6):478-85.
6. Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic
that screening has prevented in the UK. Lancet 2004;364(9430):249-
56.
7. Information Services Division. Results of cervical smears carried out at
NHS laboratories in Scotland: Percentages for quarter ending 31 March
2007. Edinburgh: The Division; 2007. [cited 6 Sep 2007]. Available
from url: http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile
=Cervical_cancer_screening_smear_results(percentages).xls
8. Information Services Division. Incidence of cervical cancer, European
age standardised rates. Females in Scotland, 1975-2004. Edinburgh: The
Division. [cited 3 Jan 2007]. Available from url: http://www.isdscotland.
org/isd/servlet/FileBuffer?namedFile=Cervical_cancer_screening_
change_in_incidence.xls
9. de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H.
Classifcation of papillomaviruses. Virology 2004;324(1):17-27.
10. Wiley DJ, Douglas J, Beutner K, Cox T, Fife K, Moscicki AB, et al.
External genital warts: diagnosis, treatment, and prevention. Clin Infect
Dis 2002;35(Suppl 2):S210-24.
11. Scottish Government. Cervical cancer vaccine. Edinburgh: The
Government; 2007. [cited 12 Nov 2007]. Available from url: http://
www.scotland.gov.uk/News/Releases/2007/10/26114714
12. Department of Health. HPV vaccine recommended for NHS
immunisation programme. London: The Department; 2007. [cited 12
Nov 2007]. Available from url: http://www.gnn.gov.uk/environment/
fullDetail.asp?ReleaseID=325799&NewsAreaID=2
13. Hricak H, Gatsonis C, Chi DS, Amendola MA, Brandt K, Schwartz
LH, et al. Role of imaging in pretreatment evaluation of early invasive
cervical cancer: results of the intergroup study American College of
Radiology Imaging Network 6651-Gynecologic Oncology Group 183.
J Clin Oncol 2005;23(36):9329-37.
14. Downing A, Mikeljevic JS, Haward B, Forman D. Variation in the
treatment of cervical cancer patients and the effect of consultant
workload on survival: a population-based study. Eur J Cancer
2007;43(2):363-70.
15. Pretorius R, Semrad N, Watring W, Fotheringham N. Presentation of
cervical cancer. Gynecol Oncol 1991;42(1):48-53.
16. Kolstad P. Follow-up study of 232 patients with stage Ia1 and 411
patients with stage Ia2 squamous cell carcinoma of the cervix
(microinvasive carcinoma). Gynecol Oncol 1989;33(3):265-72.
17. Orlandi C, Costa S, Terzano P, Martinelli GN, Comerci G, Guerra B,
et al. Presurgical assessment and therapy of microinvasive carcinoma
of the cervix. Gynecol Oncol 1995;59(2):255-60.
18. Scottish Intercollegiate Guidelines Network (SIGN). Management
of genital Chlamydia trachomatis. Edinburgh: SIGN; 2000. (SIGN
publication no. 42). [cited 20 Nov 2007]. Available from url: http://
www.sign.ac.uk/guidelines/fulltext/42/index.html
19. Scottish Intercollegiate Guidelines Network (SIGN). Investigation of
post-menopausal bleeding. Edinburgh: SIGN; 2002. (SIGN publication
no. 61). [cited 20 Nov 2007]. Available from url: http://www.sign.
ac.uk/guidelines/fulltext/61/index.html
20. Shapley M, Jordan J, Croft PR. A systematic review of postcoital bleeding
and risk of cervical cancer. Br J Gen Pract 2006;56(527):453-60.
21. Shalini R, Amita S, Neera MA. How alarming is post-coital bleeding--a
cytologic, colposcopic and histopathologic evaluation. Gynecol Obstet
Invest 1998;45(3):205-8.
22. Viikki M, Pukkala E, Hakama M. Bleeding symptoms and subsequent
risk of gynecological and other cancers. Acta Obstet Gynecol Scand
1998;77(5):564-9.
23. Jha S, Sabharwal S. Outcome of colposcopy in women presenting with
postcoital bleeding and negative or no cytology--results of a 1-year audit.
J Obstet Gynaecol 2002;22(3):299-301.
24. Bosch FX, Iftner T. The aetiology of cervical cancer. Sheffeld: NHS
Cancer Screening Programmes; 2005. [cited 20 Nov 2007]. Available
from url: http://www.cancerscreening.nhs.uk/cervical/publications/
nhscsp22.pdf
25. Information Services Division. Cancer of the cervix uteri (ICD-9 180)
incidence, mortality and cause-specifc survival at 5 years by deprivation
quintile. Edinburgh: The Division. [cited 27 Apr 2007]. Available from
url: http://www.isdscotland.org/isd/fles/cancer_cervix_depcat.xls
26. Tavassoli FA, Devilee P, editors. Pathology and genetics of tumours
of the breast and female genital organs. Lyon: International Agency for
Research on Cancer; 2003.
27. Silverberg SG, Ioffe OB. Pathology of cervical cancer. Cancer J
2003;9(5):335-47.
28. Ayhan A, Al RA, Baykal C, Demirtas E, Ayhan A, Yuce K. Prognostic
factors in FIGO stage IB cervical cancer without lymph node metastasis
and the role of adjuvant radiotherapy after radical hysterectomy. Int J
Gynecol Cancer 2004;14(2):286-92.
29. Grafund M, Sorbe B, Hussein A, Bryne M, Karlsson M. The prognostic
value of histopathologic grading parameters and microvessel density
in patients with early squamous cell carcinoma of the uterine cervix.
Int J Gynecol Cancer 2002;12(1):32-41.
30. Morice P, Piovesan P, Rey A, Atallah D, Haie-Meder C, Pautier P, et al.
Prognostic value of lymphovascular space invasion determined with
hematoxylin-eosin staining in early stage cervical carcinoma: Results
of a multivariate analysis. Ann Oncol 2003;14(10):1511-7.
31. Puente R, Guzman S, Israel E, Poblete MT. Do the pelvic lymph nodes
predict the parametrial status in cervical cancer stages IB-IIA? Int J
Gynecol Cancer 2004;14(5):832-40.
32. Van de Putte G, Lie AK, Vach W, Baekelandt M, Kristensen GB. Risk
grouping in stage IB squamous cell cervical carcinoma. Gynecol Oncol
2005;99(1):106-12.
33. Raspagliesi F, Ditto A, Solima E, Quattrone P, Fontanelli R, Zanaboni F,
et al. Microinvasive squamous cell cervical carcinoma. Crit Rev Oncol
Hematol 2003;48(3):251-61.
34. Baalbergen A, Ewing-Graham PC, Hop WC, Struijk P, Helmerhorst TJ.
Prognostic factors in adenocarcinoma of the uterine cervix. Gynecol
Oncol 2004;92(1):262-7.
35. Chernofsky MR, Felix JC, Muderspach LI, Morrow CP, Ye W, Groshen
SG, et al. Infuence of quantity of lymph vascular space invasion on
time to recurrence in women with early-stage squamous cancer of the
cervix. Gynecol Oncol 2006;100(2):288-93.
36. Delgado G, Bundy B, Zaino R, Sevin BU, Creasman WT, Major
F. Prospective surgical-pathological study of disease-free interval
in patients with stage IB squamous cell carcinoma of the cervix: a
Gynecologic Oncology Group study. Gynecol Oncol 1990;38(3):352-
7.
37. Benedet JL, Bender H, Jones H 3rd, Ngan HY, Pecorelli S. FIGO staging
classifcations and clinical practice guidelines in the management of
gynecologic cancers. FIGO Committee on Gynecologic Oncology. Int
J Gynaecol Obstet 2000;70(2):209-62.
38. Royal College of Pathologists. Minimum dataset for the histopathological
reporting of cervical neoplasia. London: The College; 2001.
(Standards and minimum datasets for reporting cancers). [cited 20
Nov 2007]. Available from url: http://www.rcpath.org/resources/pdf/
datasetrecervicalcancer.pdf
39. Hoshina M, Kimura A, Shibata K, Maruo T, Mochizuki M.
Immunocytological distribution of the tumor antigen TA-4: expression
during carcinogenesis and maturation of squamous epithelium of human
uterine cervix. Asia Oceania J Obstet Gynaecol 1986;12(1):119-26.
40. Maruo T, Shibata K, Kimura A, Hoshina M, Mochizuki M. Tumor-
associated antigen, TA-4, in the monitoring of the effects of therapy for
squamous cell carcinoma of the uterine cervix. Serial determinations
and tissue localization. Cancer 1985;56(2):302-8.
41. Gaarenstroom KN, Kenter GG, Bonfrer JM, Korse CM, Van de Vijver MJ,
Fleuren GJ, et al. Can initial serum cyfra 21-1, SCC antigen, and TPA
levels in squamous cell cervical cancer predict lymph node metastases
or prognosis? Gynecol Oncol 2000;77(1):164-70.
42. Levenback C, Coleman RL, Burke TW, Lin WM, Erdman W, Deavers
M, et al. Lymphatic mapping and sentinel node identifcation in
patients with cervix cancer undergoing radical hysterectomy and pelvic
lymphadenectomy. J Clin Oncol 2002;20(3):688-93.
43. Malur S, Krause N, Kohler C, Schneider A. Sentinel lymph node detection
in patients with cervical cancer. Gynecol Oncol 2001;80(2):254-7.
44. Marchiole P, Buenerd A, Scoazec JY, Dargent D, Mathevet P. Sentinel
lymph node biopsy is not accurate in predicting lymph node status for
patients with cervical carcinoma. Cancer 2004;100(10):2154-9.
REFERENCES
68
MANAGEMENT OF CERVICAL CANCER
45. Martinez-Palones JM, Gil-Moreno A, Perez-Benavente MA, Roca I,
Xercavins J. Intraoperative sentinel node identifcation in early stage
cervical cancer using a combination of radiolabeled albumin injection
and isosulfan blue dye injection. Gynecol Oncol 2004;92(3):845-50.
46. Plante M, Renaud MC, Tetu B, Harel F, Roy M. Laparoscopic
sentinel node mapping in early-stage cervical cancer. Gynecol Oncol
2003;91(3):494-503.
47. Basta A, Pitynski K, Basta P, Hubaiewska-Hola A, Oplawski M,
Przeszlakowski D. Sentinel node in gynaecological oncology. Rep
Pract Oncol Radother 2005;10(2):91-4.
48. Benedetti-Panici P, Maneschi F, Cutillo G, Congiu M, Amoroso M,
Croce C. Tailored surgery in Stage IA2-IB1 cervical cancer based on
lymphadenectomy of primary pelvic groups. Preliminary results of a
pilot study. Ital J Gynaecol Obstet 2000;12(1):1-5.
49. Fanfani F, Ludovisi M, Zannoni GF, Distefano M, Fagotti A, Ceccaroni
M, et al. Frozen section examination of pelvic lymph nodes in
endometrial and cervical cancer: accuracy in patients submitted to
neoadjuvant treatments. Gynecol Oncol 2004;94(3):779-84.
50. Morice P, Sabourin JC, Pautier P, Gerbaulet A, Duvillard P, Castaigne D.
Isolated para-aortic node involvement in stage IB/II cervical carcinoma.
Eur J Gynaecol Oncol 2000;21(2):123-5.
51. Scambia G, Ferrandina G, Distefano M, Fagotti A, Manfredi R, Zannoni
GF, et al. Is there a place for a less extensive radical surgery in locally
advanced cervical cancer patients? Gynecol Oncol 2001;83(2):319-
24.
52. Postema S, Pattynama PM, van den Berg-Huysmans A, Peters LW,
Kenter G, Trimbos JB. Effect of MRI on therapeutic decisions in invasive
cervical carcinoma. Direct comparison with the pelvic examination as
a preperative test. Gynecol Oncol 2000;79(3):485-9.
53. Fujiwara K, Yoden E, Asakawa T, Shimizu M, Hirokawa M, Mikami Y,
et al. Negative MRI fndings with invasive cervical biopsy may indicate
stage IA cervical carcinoma. Gynecol Oncol 2000;79(3):451-6.
54. Rockall AG, Sohaib SA, Harisinghani MG, Babar SA, Singh N, Jeyarajah
AR, et al. Diagnostic performance of nanoparticle-enhanced magnetic
resonance imaging in the diagnosis of lymph node metastases in patients
with endometrial and cervical cancer. J Clin Oncol 2005;23(12):2813-
21.
55. Sironi S, Bellomi M, Villa G, Rossi S, Del Maschio A. Clinical stage
I carcinoma of the uterine cervix value of preoperative magnetic
resonance imaging in assessing parametrial invasion. Tumori
2002;88(4):291-5.
56. Medical Services Advisory Committee. Magnetic resonance imaging
for staging cervical and endometrial cancer. Canberra: The Committee;
2001. [cited 20 Nov 2007]. Available from url: http://www.msac.gov.
au/internet/msac/publishing.nsf/Content/ref07b-1/$FILE/msacref07b.
pdf
57. Bipat S, Glas AS, van der Velden J, Zwinderman AH, Bossuyt PM, Stoker
J. Computed tomography and magnetic resonance imaging in staging
of uterine cervical carcinoma: a systematic review. Gynecol Oncol
2003;91(1):59-66.
58. Hricak H, Yu KK. Radiology in invasive cervical cancer. AJR Am J
Roentgenol 1996;167(5):1101-8.
59. Hricak H, Akin O, Sala E, Fleischer AC, Bohm-Velez M, Fishman
EK, et al. Role of imaging in cancer of the cervix. Reston (VA):
American College of Radiology; 2006. (ACR Appropriateness
Criteria). [cited 17 Aug 2007]. Available from url: http://www.acr.
org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/
ExpertPanelonWomensImaging/InvasiveCanceroftheCervixDoc5.aspx
60. Shiraiwa M, Joja I, Asakawa T, Okuno K, Shibutani O, Akamatsu N,
et al. Cervical carcinoma: effcacy of thin-section oblique axial T2-
weighted images for evaluating parametrial invasion. Abdom Imaging
1999;24(5):514-9.
61. Choi SH, Kim SH, Choi HJ, Park BK, Lee HJ. Preoperative magnetic
resonance imaging staging of uterine cervical carcinoma: Results of
prospective study. J Comput Assist Tomogr 2004;28(5):620-7.
62. Sheu MH, Chang CY, Wang JH, Yen MS. Preoperative staging of cervical
carcinoma with MR imaging: a reappraisal of diagnostic accuracy and
pitfalls. Eur Radiol 2001;11(9):1828-33.
63. Follen M, Levenback CF, Iyer RB, Grigsby PW, Boss EA, Delpassand ES,
et al. Imaging in cervical cancer. Cancer 2003;98(9 Suppl):2028-38.
64. Amit A, Beck D, Lowenstein L, Lavie O, Bar Shalom R, Kedar Z, et al.
The role of hybrid PET/CT in the evaluation of patients with cervical
cancer. Gynecol Oncol 2006;100(1):65-9.
65. Loft A, Berthelsen AK, Roed H, Ottosen C, Lundvall L, Knudsen J, et
al. The diagnostic value of PET/CT scanning in patients with cervical
cancer: a prospective study. Gynecol Oncol 2007;106(1):29-34.
66. Mayr NA, Taoka T, Yuh WT, Denning LM, Zhen WK, Paulino AC, et
al. Method and timing of tumor volume measurement for outcome
prediction in cervical cancer using magnetic resonance imaging. Int J
Radiat Oncol Biol Phys 2002;52(1):14-22.
67. Subak LL, Hricak H, Powell CB, Azizi L, Stern JL. Cervical carcinoma:
computed tomography and magnetic resonance imaging for preoperative
staging. Obstet Gynecol 1995;86(1):43-50.
68. Kodama J, Mizutani Y, Hongo A, Yoshinouchi M, Kudo T, Okuda
H. Optimal surgery and diagnostic approach of stage IA2 squamous
cell carcinoma of the cervix. Eur J Obstet Gynecol Reprod Biol
2002;101(2):192-5.
69. Miller TR, Pinkus E, Dehdashti F, Grigsby PW. Improved prognostic value
of 18F-FDG PET using a simple visual analysis of tumor characteristics
in patients with cervical cancer. J Nucl Med 2003;44(2):192-7.
70. Togashi K, Nishimura K, Sagoh T, Minami S, Noma S, Fujisawa I,
et al. Carcinoma of the cervix: staging with MR imaging. Radiology
1989;171(1):245-51.
71. Hricak H, Powell CB, Yu KK, Washington E, Subak LL, Stern JL, et
al. Invasive cervical carcinoma: role of MR imaging in pretreatment
work-up--cost minimization and diagnostic effcacy analysis. Radiology
1996;198(2):403-9.
72. Grigsby PW, Siegel BA, Dehdashti F. Lymph node staging by positron
emission tomography in patients with carcinoma of the cervix. J Clin
Oncol 2001;19(17):3745-9.
73. Chung JJ, Kim MJ, Cho NH, Park S, Lee JT, Yoo HS. T2-weighted fast spin-
echo MR fndings of adenocarcinoma of the uterine cervix: comparison
with squamous cell carcinoma. Yonsei Med J 1999;40(3):226-31.
74. Liang CC, Tseng CJ, Soong YK. The usefulness of cystoscopy in the
staging of cervical cancer. Gynecol Oncol 2000;76(2):200-3.
75. Massad LS, Calvello C, Gilkey SH, Abu-Rustum NR. Assessing disease
extent in women with bulky or clinically evident metastatic cervical
cancer: yield of pretreatment studies. Gynecol Oncol 2000;76(3):383-
7.
76. Landoni F, Maneo A, Colombo A, Placa F, Milani R, Perego P, et al.
Randomised study of radical surgery versus radiotherapy for stage Ib-IIa
cervical cancer. Lancet 1997;350(9077):535-40.
77. Reinhardt MJ, Ehritt-Braun C, Vogelgesang D, Ihling C, Hogerle S,
Mix M, et al. Metastatic lymph nodes in patients with cervical cancer:
detection with MR imaging and FDG PET. Radiology 2001;218(3):776-
82.
78. Yang WT, Lam WW, Yu MY, Cheung TH, Metreweli C. Comparison
of dynamic helical CT and dynamic MR imaging in the evaluation
of pelvic lymph nodes in cervical carcinoma. AJR Am J Roentgenol
2000;175(3):759-66.
79. Narayan K, Hicks RJ, Jobling T, Bernshaw D, McKenzie AF. A
comparison of MRI and PET scanning in surgically staged loco-regionally
advanced cervical cancer: potential impact on treatment. Int J Gynaecol
Cancer 2001;11(4):263-71.
80. Lin WC, Hung YC, Yeh LS, Kao CH, Yen RF, Shen YY. Usefulness of
(18)F-fuorodeoxyglucose positron emission tomography to detect para-
aortic lymph nodal metastasis in advanced cervical cancer with negative
computed tomography fndings. Gynecol Oncol 2003;89(1):73-6.
81. Havrilesky LJ, Kulasingam SL, Matchar DB, Myers ER. FDG-PET
for management of cervical and ovarian cancer. Gynecol Oncol
2005;97(1):183-91.
82. Rose PG, Adler LP, Rodriguez M, Faulhaber PF, Abdul-Karim FW,
Miraldi F. Positron emission tomography for evaluating para-aortic
nodal metastasis in locally advanced cervical cancer before surgical
staging: a surgicopathologic study. J Clin Oncol 1999;17(1):41-5.
83. Havrilesky LJ, Wong TZ, Secord AA, Berchuck A, Clarke-Pearson DL,
Jones EL. The role of PET scanning in the detection of recurrent cervical
cancer. Gynecol Oncol 2003;90(1):186-90.
84. Roh JW, Seo SS, Lee S, Kang KW, Kim SK, Sim JS, et al. Role of positron
emission tomography in pretreatment lymph node staging of uterine
cervical cancer: a prospective surgicopathologic correlation study. Eur
J Cancer 2005;41(14):2086-92.
85. Sakurai H, Suzuki Y, Nonaka T, Ishikawa H, Shioya M, Kiyohara H, et
al. FDG-PET in the detection of recurrence of uterine cervical carcinoma
following radiation therapy--tumor volume and FDG uptake value.
Gynecol Oncol 2006;100(3):601-7.
86. Yen TC, Ng KK, Ma SY, Chou HH, Tsai CS, Hsueh S, et al. Value of
dual-phase 2-fuoro-2-deoxy-d-glucose positron emission tomography
in cervical cancer. J Clin Oncol 2003;21(19):3651-8.
87. Chung H, Ahn HS, Kim YS, Lee EJ, Ryu HS, Chang KH, et al. The value
of cystoscopy and intravenous urography after magnetic resonance
imaging or computed tomography in the staging of cervical carcinoma.
Yonsei Med J 2001;42(5):527-31.
88. Scheidler J, Hricak H, Yu KK, Subak L, Segal MR. Radiological evaluation
of lymph node metastases in patients with cervical cancer. A meta-
analysis. JAMA 1997;278(13):1096-101.
89. Hertel H, Kohler C, Elhawary T, Michels W, Possover M, Schneider A.
Laparoscopic staging compared with imaging techniques in the staging
of advanced cervical cancer. Gynecol Oncol 2002;87(1):46-51.
69
90. Suprasert P, Srisomboon J, Charoenkwan K, Siriaungul S, Khunamornpong
S, Siriaree S, et al. Outcomes of abandoned radical hysterectomy in
patients with stages IB-IIA cervical cancer found to have positive nodes
during the operation. Int J Gynaecol Cancer 2005;15(3):498-502.
91. Landoni F, Maneo A, Cormio G, Perego P, Milani R, Caruso O, et al.
Class II versus class III radical hysterectomy in stage IB-IIA cervical
cancer: a prospective randomized study. Gynecol Oncol 2001;80(1):3-
12.
92. Piver MS, Chung WS. Prognostic signifcance of cervical lesion size
and pelvic node metastases in cervical carcinoma. Obstet Gynecol
1975;46(5):507-10.
93. Kenter GG, Heintz AP. Surgical treatment of low stage cervical
carcinoma: back to the old days? Int J Gynaecol Cancer 2002;12(5):429-
34.
94. Boyd SC, Look KY. Prognostic factors for carcinoma of the cervical stump
and cervical carcinoma associated with pregnancy. Cme J Gynecol
Oncol 2001;6(3):347-56.
95. Smith HO, Qualls CR, Romero AA, Webb JC, Dorin MH, Padilla LA,
et al. Is there a difference in survival for IA1 and IA2 adenocarcinoma
of the uterine cervix? Gynecol Oncol 2002;85(2):229-41.
96. Hirai Y, Takeshima N, Tate S, Akiyama F, Furuta R, Hasumi K. Early
invasive cervical adenocarcinoma: its potential for nodal metastasis or
recurrence. BJOG 2003;110(3):241-6.
97. Kasamatsu T, Okada S, Tsuda H, Shiromizu K, Yamada T, Tsunematsu
R, et al. Early invasive adenocarcinoma of the uterine cervix: criteria
for nonradical surgical treatment. Gynecol Oncol 2002;85(2):327-32.
98. Magrina JF, Goodrich MA, Lidner TK, Weaver AL, Cornella JL, Podratz
KC. Modifed radical hysterectomy in the treatment of early squamous
cervical cancer. Gynecol Oncol 1999;72(2):183-6.
99. Koliopoulos G, Sotiriadis A, Kyrgiou M, Martin-Hirsch P, Makrydimas
G, Paraskevaidis E. Conservative surgical methods for FIGO stage IA2
squamous cervical carcinoma and their role in preserving women's
fertility. Gynecol Oncol 2004;93(2):469-73.
100. Kwon JS, Case AM. Effects of cancer treatment on reproduction and
fertility. J Obstet Gynaecol Can 2002;24(8):619-27.
101. Bernardini M, Barrett J, Seaward G, Covens A. Pregnancy outcomes
in patients after radical trachelectomy. Am J Obstet Gynecol
2003;189(5):1378-82.
102. Covens A, Shaw P, Murphy J, DePetrillo D, Lickrish G, Laframboise S,
et al. Is radical trachelectomy a safe alternative to radical hysterectomy
for patients with stage IA-B carcinoma of the cervix? Cancer
1999;86(11):2273-9.
103. Dargent D, Martin X, Sacchetoni A, Mathevet P. Laparoscopic vaginal
radical trachelectomy: A treatment to preserve the fertility of cervical
carcinoma patients. Cancer 2000;88(8):1877-82.
104. McHale MT, Le TD, Burger RA, Gu M, Rutgers JL, Monk BJ. Fertility
sparing treatment for in situ and early invasive adenocarcinoma of the
cervix. Obstet Gynecol 2001;98(5 Pt 1):726-31.
105. Plante M, Renaud MC, Hoskins IA, Roy M. Vaginal radical trachelectomy:
A valuable fertility-preserving option in the management of early-stage
cervical cancer. A series of 50 pregnancies and review of the literature.
Gynecol Oncol 2005;98(1):3-10.
106. Hertel H, Kohler C, Grund D, Hillemanns P, Possover M, Michels W,
et al. Radical vaginal trachelectomy (RVT) combined with laparoscopic
pelvic lymphadenectomy: prospective multicenter study of 100 patients
with early cervical cancer. Gynecol Oncol 2006;103(2):506-11.
107. Plante M, Renaud MC, Francois H, Roy M. Vaginal radical trachelectomy:
an oncologically safe fertility-preserving surgery. An updated series of
72 cases and review of the literature. Gynecol Oncol 2004;94(3):614-
23.
108. Shepherd JH, Spencer C, Herod J, Ind TE. Radical vaginal trachelectomy
as a fertility-sparing procedure in women with early-stage cervical
cancer-cumulative pregnancy rate in a series of 123 women. BJOG
2006;113(6):719-24.
109. Mota F. Microinvasive squamous carcinoma of the cervix: treatment
modalities. Acta Obstet Gynecol Scand 2003;82(6):505-9.
110. Stegeman M, Louwen M, van der Velden J, ten Kate FJ, den Bakker
MA, Burger CW, et al. The incidence of parametrial tumor involvement
in select patients with early cervix cancer is too low to justify
parametrectomy. Gynecol Oncol 2007;105(2):475-80.
111. Naik R, Cross P, Nayar A, Mayadevi S, Lopes A, Godfrey K, et al.
Conservative surgical management of small-volume stage IB1 cervical
cancer. BJOG 2007;114(8):958-63.
112. Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W,
Paraskevaidis E. Obstetric outcomes after conservative treatment for
intraepithelial or early invasive cervical lesions: systematic review and
meta-analysis. Lancet 2006;367(9509):489-98.
113. Hertel H, Kohler C, Michels W, Possover M, Tozzi R, Schneider
A. Laparoscopic-assisted radical vaginal hysterectomy (LARVH):
prospective evaluation of 200 patients with cervical cancer. Gynecol
Oncol 2003;90(3):505-11.
114. Malur S, Possover M, Schneider A. Laparoscopically assisted radical
vaginal vs radical abdominal hysterectomy type II in patients with
cervical cancer. Surg Endosc 2001;15(3):289-92.
115. Nam JH, Kim JH, Kim DY, Kim MK, Yoo HJ, Kim YM, et al. Comparative
study of laparoscopico-vaginal radical hysterectomy and abdominal
radical hysterectomy in patients with early cervical cancer. Gynecol
Oncol 2004;92(1):277-83.
116. Tan AL, Mackintosh AR, Bhat R. Laparoscopic pelvic lymphadenectomy
and radical vaginal hysterectomy vs. radical abdominal hysterectomy
and pelvic lymphadenectomy: A feasibility study. Gynaecol Endosc
1999;8(3):149-52.
117. Trimbos JB, Franchi M, Zanaboni F, Velden JVD, Vergote I. 'State of
the art' of radical hysterectomy; current practice in European oncology
centres. Eur J Cancer 2004;40(3):375-8.
118. Green J, Kirwan J, Tierney J, Symonds P, Fresco L, Williams C, et al.
Concomitant chemotherapy and radiation therapy for cancer of the
uterine cervix. Cochrane Database of Systematic Reviews 2005, Issue
3.
119. Lukka H, Hirte H, Fyles A, Thomas G, Elit L, Johnston M, et al.
Concurrent cisplatin-based chemotherapy plus radiotherapy for cervical
cancer--a meta-analysis. Clin Oncol 2002;14(3):203-12.
120. Peters WA, Liu PY, Barrett RJ, Stock RJ, Monk BJ, Berek JS, et al.
Concurrent chemotherapy and pelvic radiation therapy compared with
pelvic radiation therapy alone as adjuvant therapy after radical surgery
in high-risk early-stage cancer of the cervix. J Clin Oncol 2000;18:1606-
13.
121. Monk BJ, Wang J, Im S, Stock RJ, Peters IW, Liu PY, et al. Rethinking the
use of radiation and chemotherapy after radical hysterectomy: A clinical-
pathologic analysis of a Gynecologic Oncology Group/Southwest
Oncology Group/Radiation Therapy Oncology Group trial. Gynecol
Oncol 2005;96(3):721-8.
122. Kinney WK, Alvarez RD, Reid GC, Schray MF, Soong SJ, Morley
GW, et al. Value of adjuvant whole-pelvis irradiation after Wertheim
hysterectomy for early-stage squamous carcinoma of the cervix with
pelvic nodal metastasis: a matched-control study. Gynecol Oncol
1989;34:258-62.
123. Morrow C, Shingleton H, Averette H. Is pelvic radiation benefcial in
the postoperative management of stage IB squamous cell carcinoma of
the cervix with pelvic node metastasis treated by radical hysterectomy
and pelvic lymphadenectomy? A report from the Presidential Panel at
the 1979 Annual Meeting of the Society of Gynecologic Oncologists.
Gynecol Oncol 1980;10:105-10.
124. Sedlis A, Bundy BN, Rotman MZ, Lentz SS, Muderspach LI, Zaino RJ.
A randomized trial of pelvic radiation therapy versus no further therapy
in selected patients with stage IB carcinoma of the cervix after radical
hysterectomy and pelvic lymphadenectomy: A gynecologic oncology
group study. Gynecol Oncol 1999;73(2):177-83.
125. Nag S, Chao B, Erickson J, Fowler N, Gupta A, Martinez B, et al. The
American Brachytherapy Society recommendations for low-dose-rate
brachytherapy for carcinoma of the cervix. [erratum appears in Int J
Radiat Oncol Biol Phys 2002 Mar 15;52(4):1157]. Int J Radiat Oncol
Biol Phys 2002;52:33-48.
126. Nag S, Erickson B, Thomadsen B, Orton C, Demanes JD, Petereit D. The
American Brachytherapy Society recommendations for high-dose-rate
brachytherapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys
2000;48:201-11.
127. European Organisation for Research and Treatment of Cancer.
Randomized phase III study of neoadjuvant chemotherapy followed by
surgery vs. concomitant radiotherapy and chemotherpy in FIGO Ib2, IIa
> 4 cm or IIb cervical cancer [protocol]. [cited 17 Aug 2007]. Available
from url: http://www.eortc.be/protoc/Details.asp?Protocol=55994
128. Dunst J, Kuhnt T, Strauss HG, Krause U, Pelz T, Koelbl H, et al.
Anemia in cervical cancers: impact on survival, patterns of relapse,
and association with hypoxia and angiogenesis. Int J Radiat Oncol Biol
Phys 2003;56(3):778-87.
129. Girinski T, Pejovic-Lenfant MH, Bourhis J, Campana F, Cosset JM, Petit
C, et al. Prognostic value of hemoglobin concentrations and blood
transfusions in advanced carcinoma of the cervix treated by radiation
therapy: results of a retrospective study of 386 patients. Int J Radiat
Oncol Biol Phys 1989;16(1):37-42.
130. Grogan M, Thomas GM, Melamed I, Wong FL, Pearcey RG, Joseph
PK, et al. The importance of hemoglobin levels during radiotherapy for
carcinoma of the cervix. Cancer 1999;86(8):1528-36.
131. Kapp KS, Poschauko J, Geyer E, Berghold A, Oechs AC, Petru E, et al.
Evaluation of the effect of routine packed red blood cell transfusion in
anemic cervix cancer patients treated with radical radiotherapy. Int J
Radiat Oncol Biol Phys 2002;54(1):58-66.
132. Obermair A, Cheuk R, Horwood K, Neudorfer M, Janda M, Giannis
G, et al. Anemia before and during concurrent chemoradiotherapy in
patients with cervical carcinoma: Effect on progression-free survival.
Int J Gynecol Cancer 2003;13(5):633-9.
REFERENCES
70
MANAGEMENT OF CERVICAL CANCER
133. Winter WE 3rd, Maxwell GL, Tian C, Sobel E, Rose GS, Thomas
G, et al. Association of hemoglobin level with survival in cervical
carcinoma patients treated with concurrent cisplatin and radiotherapy: a
Gynecologic Oncology Group Study. Gynecol Oncol 2004;94(2):495-
501.
134. Bohlius J, Wilson J, Seidenfeld J, Piper M, Schwarzer G, Sandercock J,
et al. Recombinant human erythropoietins and cancer patients: updated
meta-analysis of 57 studies including 9353 patients. J Natl Cancer Inst
2006;98(10):708-14.
135. Parkin DE, Davis JA, Symonds RP. Long-term bladder symptomatology
following radiotherapy for cervical carcinoma. Radiother Oncol
1987;9(3):195-9.
136. Parkin DE, Davis JA, Symonds RP. Urodynamic fndings following
radiotherapy for cervical carcinoma. Br J Urol 1988;61(3):213-7.
137. Denton AS, Clarke NW, Maher EJ. Non-surgical interventions for late
radiation cystitis in patients who have received radical radiotherapy to
the pelvis. Cochrane Database of Systematic Reviews 2002, Issue 3.
138. Veerasarn V, Khorprasert C, Lorvidhaya V, Sangruchi S, Tantivatana
T, Narkwong L, et al. Reduced recurrence of late hemorrhagic
radiation cystitis by WF10 therapy in cervical cancer patients: a
multicenter, randomized, two-arm, open-label trial. Radiother Oncol
2004;73(2):179-85.
139. O'Brien PC, Franklin CI, Dear KB, Hamilton CC, Poulsen M, Joseph
DJ, et al. A phase III double-blind randomised study of rectal sucralfate
suspension in the prevention of acute radiation proctitis. Radiother
Oncol 1997;45(2):117-23.
140. Sanguineti G, Franzone P, Marcenaro M, Foppiano F, Vitale V,
Sanguineti G, et al. Sucralfate versus mesalazine versus hydrocortisone
in the prevention of acute radiation proctitis during conformal
radiotherapy for prostate carcinoma. A randomized study. Strahlenther
Onkol 2003;179(7):464-70.
141. Hovdenak N, Sorbye H, Dahl O. Sucralfate does not ameliorate acute
radiation proctitis: Randomised study and meta-analysis. Clin Oncol
2005;17(6):485-91.
142. Gul YA, Prasannan S, Jabar FM, Shaker AR, Moissinac K.
Pharmacotherapy for chronic hemorrhagic radiation proctitis. World J
Surg 2002;26(12):1499-502.
143. Manojlovic N, Babic D, Manojlovic N, Babic D. Radiation-induced rectal
ulcer--prognostic factors and medical treatment. Hepatogastroenterology
2004;51(56):447-50.
144. Ploch E. Hormonal replacement therapy in patients after cervical cancer
treatment. Gynecol Oncol 1987;26(2):169-77.
145. Lacey JV, Jr., Brinton LA, Barnes WA, Gravitt PE, Greenberg MD,
Hadjimichael OC, et al. Use of hormone replacement therapy and
adenocarcinomas and squamous cell carcinomas of the uterine cervix.
Gynecol Oncol 2000;77(1):149-54.
146. Germann N, Haie-Meder C, Morice P, Lhomme C, Duvillard P, Hacene
K, et al. Management and clinical outcomes of pregnant patients with
invasive cervical cancer. Ann Oncol 2005;16(3):397-402.
147. Takushi M, Moromizato H, Sakumoto K, Kanazawa K. Management
of invasive carcinoma of the uterine cervix associated with
pregnancy: outcome of intentional delay in treatment. Gynecol Oncol
2002;87(2):185-9.
148. National Breast Cancer Centre and National Cancer Control Initiative.
Clinical practice guidelines for the psychosocial care of adults with
cancer. Camperdown, Australia: National Breast Cancer Centre; 2003.
[cited 20 Nov 2007]. Available from url: http://www.nhmrc.gov.au/
publications/synopses/_fles/cp90.pdf
149. Denton AS, Maher EJ. Interventions for the physical aspects of sexual
dysfunction in women following pelvic radiotherapy. Cochrane
Database of Systematic Reviews 2003, Issue 1.
150. Schroder M, Mell LK, Hurteau JA, Collins YC, Rotmensch J, Waggoner
SE, et al. Clitoral therapy device for treatment of sexual dysfunction
in irradiated cervical cancer patients. Int J Radiat Oncol Biol Phys
2005;61(4):1078-86.
151. National Forum of Gynaecological Oncology Nurses. Best practice
guidelines on the use of vaginal dilators in women receiving pelvic
radiotherapy. Woodstock, Oxon: Owen Mumford; 2005. [cited 20
Nov 2007]. Available from url: http://www.ukons.org/storage/dilators_
guidelines.pdf
152. Robinson JW, Faris PD, Scott CB. Psychoeducational group increases
vaginal dilation for younger women and reduces sexual fears for women
of all ages with gynecological carcinoma treated with radiotherapy. Int
J Radiat Oncol Biol Phys 1999;44(3):497-506.
153. Petersen RW, Quinlivan JA. Preventing anxiety and depression
in gynaecological cancer: a randomised controlled trial. BJOG
2002;109:386-94.
154. Abu-Rustum NR, Gemignani ML, Moore K, Sonoda Y, Venkatraman
E, Brown C, et al. Total laparoscopic radical hysterectomy with pelvic
lymphadenectomy using the argon-beam coagulator: Pilot data and
comparison to laparotomy. Gynecol Oncol 2003;91(2):402-9.
155. Chatani M, Nose T, Masaki N, Inoue T. Adjuvant radiotherapy after
radical hysterectomy of the cervical cancer. Prognostic factors and
complications. Strahlenther Onkol 1998;174(10):504-9.
156. Gerdin E, Cnattingius S, Johnson P. Complications after radiotherapy
and radical hysterectomy in early-stage cervical carcinoma. Acta Obstet
Gynecol Scand 1995;74(7):554-61.
157. Hong JH, Tsai CS, Lai CH, Chang TC, Wang CC, Lee SP, et al.
Postoperative low-pelvic irradiation for stage I-IIA cervical cancer
patients with risk factors other than pelvic lymph node metastasis. Int
J Radiat Oncol Biol Phys 2002;53(5):1284-90.
158. Ohara K, Tsunoda H, Satoh T, Oki A, Sugahara S, Yoshikawa H. Use
of the small pelvic feld instead of the classic whole pelvic feld in
postoperative radiotherapy for cervical cancer: reduction of adverse
events. Int J Radiat Oncol Biol Phys 2004;60(1):258-64.
159. Yeh SA, Wan Leung S, Wang CJ, Chen HC. Postoperative radiotherapy
in early stage carcinoma of the uterine cervix: treatment results and
prognostic factors. Gynecol Oncol 1999;72(1):10-5.
160. Ryan M, Stainton MC, Slaytor EK, Jaconelli C, Watts S, Mackenzie
P. Aetiology and prevalence of lower limb lymphoedema following
treatment for gynaecological cancer. Aus N Z J Obstet Gynaecol
2003;43(2):148-51.
161. Franks PJ, Moffatt CJ, Doherty DC, Williams AF, Jeffs E, Mortimer PS.
Assessment of health-related quality of life in patients with lymphedema
of the lower limb. Wound Repair Regen 2006;14(2):110-8.
162. Ryan M, Stainton MC, Jaconelli C, Watts S, MacKenzie P, Mansberg T.
The experience of lower limb lymphedema for women after treatment
for gynecologic cancer. Oncol Nurs Forum 2003;30(3):417-23.
163. Bergmark K, Avall-Lundqvist E, Dickman PW, Henningsohn L, Steineck
G. Lymphedema and bladder-emptying difficulties after radical
hysterectomy for early cervical cancer and among population controls.
Int J Gynecol Cancer 2006;16(3):1130-9.
164. Ceballos KM, Shaw D, Daya D. Microinvasive cervical adenocarcinoma
(FIGO stage 1A tumors): results of surgical staging and outcome analysis.
Am J Surg Pathol 2006;30(3):370-4.
165. Snijders-Keilholz A, Hellebrekers BW, Zwinderman AH, van de Vijver
MJ, Trimbos JB. Adjuvant radiotherapy following radical hysterectomy
for patients with early-stage cervical carcinoma (1984-1996). Radiother
Oncol 1999;51(2):161-7.
166. Eifel PJ, Levenback C, Wharton JT, Oswald MJ. Time course and
incidence of late complications in patients treated with radiation therapy
for FIGO stage IB carcinoma of the uterine cervix. Int J Radiat Oncol
Biol Phys 1995;32(5):1289-300.
167. Nesvold IL, Fossa SD. Lymphedema after surgical treatment of cervical
and vulvar cancer [Norwegian]. Tidsskrift for Den Norske Laegeforening
2002;122(26):2531-3.
168. Abu-Rustum NR, Alektiar K, Iasonos A, Lev G, Sonoda Y, Aghajanian
C, et al. The incidence of symptomatic lower-extremity lymphedema
following treatment of uterine corpus malignancies: A 12-year
experience at Memorial Sloan-Kettering Cancer Center. Gynecol Oncol
2006;103(2):714-8.
169. Lymphoedema Framework. Best practice for the management of
lymphoedema. International consensus. London: MEP Ltd; 2006.
170. Badger C, Preston N, Seers K, Motimer P. Physical therapies for reducing
and controlling lymphoedema of the limbs. Cochrane Database of
Systematic Reviews 2004, Issue 4.
171. Badger C, Preston N, Seers K, Mortimer P. Antibiotics / anti-
inflammatories for reducing acute inflammatory episodes in
lymphoedema of the limbs. Cochrane Database of Systematic Reviews
2004, Issue 2.
172. Badger C, Preston N, Seers K, Motimer P. Benzo-pyrones for reducing
and controlling lymphoedema of the limbs. Cochrane Database of
Systematic Reviews 2003, Issue 4.
173. Boris M, Weindorf S, Lasinski BB. The risk of genital edema after
external pump compression for lower limb lymphedema. Lymphology
1998;31(1):15-20.
174. Bodurka-Bevers D, Morris M, Eifel PJ, Levenback C, Bevers MW, Lucas
KR, et al. Posttherapy surveillance of women with cervical cancer: an
outcomes analysis. Gynecol Oncol 2000;78(2):187-93.
175. Hong JH, Tsai CS, Lai CH, Chang TC, Wang CC, Chou HH, et
al. Recurrent squamous cell carcinoma of cervix after definitive
radiotherapy. Int J Radiat Oncol Biol Phys 2004;60(1):249-57.
176. Lim KCK, Howells REJ, Evans AS. The role of clinical follow up in early
stage cervical cancer in South Wales. BJOG 2004;111(12):1444-8.
177. Park DH, Kim KH, Park SY, Lee BH, Choi CW, Chin SY. Diagnosis of
recurrent uterine cervical cancer: computed tomography versus positron
emission tomography. Korean J Radiol 2000;1(1):51-5.
178. Husain A, Akhurst T, Larson S, Alektiar K, Barakat RR, Chi DS. A
prospective study of the accuracy of 18Fluorodeoxyglucose positron
emission tomography (18FDG PET) in identifying sites of metastasis
prior to pelvic exenteration. Gynecol Oncol 2007;106(1):177-80.
71
179. Belhocine T. An appraisal of 18F-FDG PET imaging in post-therapy
surveillance of uterine cancers: clinical evidence and a research
proposal. Int J Gynaecol Cancer 2003;13(2):228-33.
180. Lai CH, Huang KG, See LC, Yen TC, Tsai CS, Chang TC, et al. Restaging
of recurrent cervical carcinoma with dual-phase [18F]fuoro-2-deoxy-d-
glucose positron emission tomography. Cancer 2004;100(3):544-52.
181. Yen TC, See LC, Chang TC, Huang KG, Ng KK, Tang SG. Defning the
priority of using 18F-FDG PET for recurrent cervical cancer. J Nucl Med
2004;45(10):1632-9.
182. Grigsby PW, Siegel BA, Dehdashti F, Rader J, Zoberi I. Posttherapy [18F]
fuorodeoxyglucose positron emission tomography in carcinoma of the
cervix: response and outcome. J Clin Oncol 2004;22(11):2167-71.
183. Ryu SY, Kim MH, Choi SC, Choi CW, Lee KH. Detection of early
recurrence with 18F-FDG PET in patients with cervical cancer. J Nucl
Med 2003;44(3):347-52.
184. Chang TC, Law KS, Hong JH, Lai CH, Ng KK, Hsueh S, et al. Positron
emission tomography for unexplained elevation of serum squamous
cell carcinoma antigen levels during follow-up for patients with cervical
malignancies: a phase II study. Cancer 2004;101(1):164-71.
185. Unger JB, Ivy JJ, Connor P, Charrier A, Ramaswamy MR, Ampil FL,
et al. Detection of recurrent cervical cancer by whole-body FDG
PET scan in asymptomatic and symptomatic women. Gynecol Oncol
2004;94(1):212-6.
186. Esajas MD, Duk JM, De Bruijn HWA, Aalders JG, Willemse PHB, Sluiter
W, et al. Clinical value of routine serum squamous cell carcinoma
antigen in follow-up of patients with early-stage cervical cancer. J Clin
Oncol 2001;19(19):3960-6.
187. Chan YM, Ng TY, Ngan HY, Wong LC. Monitoring of serum squamous
cell carcinoma antigen levels in invasive cervical cancer: is it cost-
effective? Gynecol Oncol 2002;84(1):7-11.
188. Chang HK, Lo KY, Chiang HS. Complications of urinary diversion after
pelvic exenteration for gynecological malignancy. Int Urogynecol J
2000;11(6):358-60.
189. Ho YH, Cheng C, Tay SK. Total pelvic exenteration: results from a
multispecialty team approach to complex cancer surgery. Int Surg
2001;86(2):107-11.
190. Bramhall SR, Harrison JD, Burton A, Wallace DMA, Chan KK, Harrison
G, et al. Phase II trial of radical surgery for locally advanced pelvic
neoplasia. Br J Surg 1999;86(6):805-12.
191. Houvenaeghel G, Moutardier V, Karsenty G, Bladou F, Lelong B,
Buttarelli M, et al. Major complications of urinary diversion after pelvic
exenteration for gynecologic malignancies: a 23-year mono-institutional
experience in 124 patients. Gynecol Oncol 2004;92(2):680-3.
192. Jurado M, Bazan A, Elejabeitia J, Paloma V, Martinez-Monge R, Alcazar
JL. Primary vaginal and pelvic foor reconstruction at the time of pelvic
exenteration: a study of morbidity. Gynecol Oncol 2000;77(2):293-7.
193. Bonomi P, Blessing JA, Stehman FB, DiSaia PJ, Walton L, Major FJ.
Randomized trial of three cisplatin dose schedules in squamous-cell
carcinoma of the cervix: a Gynecologic Oncology Group study. J Clin
Oncol 1985;3(8):1079-85.
194. Cadron I, Jakobsen A, Vergote I. Report of an early stopped randomized
trial comparing cisplatin vs. cisplatin/ifosfamide/ 5-fuorouracil in
recurrent cervical cancer. Gynecol Obstet Invest 2005;59(3):126-9.
195. Omura GA, Blessing JA, Vaccarello L, Berman ML, Clarke-Pearson
DL, Mutch DG, et al. Randomized trial of cisplatin versus cisplatin
plus mitolactol versus cisplatin plus ifosfamide in advanced squamous
carcinoma of the cervix: a Gynecologic Oncology Group study. J Clin
Oncol 1997;15(1):165-71.
196. Moore DH, Blessing JA, McQuellon RP, Thaler HT, Cella D, Benda
J, et al. Phase III study of cisplatin with or without paclitaxel in stage
IVB, recurrent, or persistent squamous cell carcinoma of the cervix: a
gynecologic oncology group study. J Clin Oncol 2004;22(15):3113-
9.
197. McQuellon RP, Thaler HT, Cella D, Moore DH. Quality of life (QOL)
outcomes from a randomized trial of cisplatin versus cisplatin plus
paclitaxel in advanced cervical cancer: a Gynecologic Oncology Group
study. Gynecol Oncol 2006;101(2):296-304.
198. Long HJ 3rd, Bundy BN, Grendys EC Jr, Benda JA, McMeekin DS,
Sorosky J, et al. Randomized phase III trial of cisplatin with or without
topotecan in carcinoma of the uterine cervix: a Gynecologic Oncology
Group Study. J Clin Oncol 2005;23(21):4626-33.
199. Monk BJ, Huang HQ, Cella D, Long HJ 3rd. Quality of life outcomes
from a randomized phase III trial of cisplatin with or without topotecan
in advanced carcinoma of the cervix: a Gynecologic Oncology Group
Study. J Clin Oncol 2005;23(21):4617-25.
200. Joint Council for Clinical Oncology. Quality control in cancer
chemotherapy: managerial and procedural aspects. London: The
Council; 1994.
201. Royal College of Radiologists. Good practice guide for clinical
oncologists. London: The College; 2003. [cited 20 Nov 2007]. Available
from url: http://www.rcr.ac.uk/docs/oncology/other/Good%20Practice
%20Guide%20for%20Clinical%20Oncologists.htm
202. Parsons M, Baird P, Healy S, Kerr S, Alexander C, Bath S. Guidelines
for the safe use of cytotoxic chemotherapy in the clinical environment.
Edinburgh: Scottish Cancer Care Pharmacy Group; 2000. [cited 20 Nov
2007]. Available from url: http://www.show.scot.nhs.uk/sehd/mels/
HDL2001_13_report.pdf
203. Scottish Executive. Guidance for the safe use of cytotoxic chemotherapy.
Edinburgh: The Executive; 2005. (NHS HDL 29). [cited 20 Nov 2007].
Available from url: http://www.show.scot.nhs.uk/sehd/mels/HDL2005_
29.pdf.
204. Booth S, Bruera E, Tate T, editors. Palliative care consultations in
gynaecology. Oxford: Oxford University Press; 2004.
205. Gellrich J, Hakenberg OW, Oehlschlager S, Wirth MP. Manifestation,
latency and management of late urological complications after curative
radiotherapy for cervical carcinoma. Onkologie 2003;26(4):334-40.
206. Lebioda A. Rectovaginal fstula risk doses in patients with cervical
cancer. Rep Pract Oncol Radother 2004;9(2):37-45.
207. McCarthy EP, Phillips RS, Zhong Z, Drews RE, Lynn J. Dying with
cancer: patients' function, symptoms, and care preferences as death
approaches. J Am Geriatr Soc 2000;48(5 Suppl):S110-21.
208. Clinical Standards Board for Scotland. Clinical standards: Specialist
palliative care. Edinburgh: The Board; 2002. [cited 22 Nov 2007].
Available from url: http://www.nhshealthquality.org/nhsqis/fles/SPC.
pdf
209. Scottish Intercollegiate Guidelines Network (SIGN). Control of pain
in patients with cancer. Edinburgh: SIGN; 2000. (SIGN publication
no. 44). [cited 22 Nov 2007]. Available from url: http://www.sign.
ac.uk/guidelines/fulltext/44/index.html
210. National Institute for Clinical Excellence (NICE). Percutaneous
vertebroplasty. London: The Institute; 2003. (Interventional procedure
guidance no.12). [cited 22 Nov 2007]. Available from url: http://www.
nice.org.uk/nicemedia/pdf/ip/IPG012guidance.pdf
211. National Institute for Health and Clinical Excellence (NICE).
I nt er vent i onal pr ocedur e over vi ew of per cut aneous
cementoplasty. London: The Institute; 2005. [cited 22 Nov 2007].
Available from url: http://www.nice.org.uk/nicemedia/pdf/ip/
304%20cementoplasty%20overview%20for%20web.pdf
212. Ganatra AM, Loughlin KR. The management of malignant ureteral
obstruction treated with ureteral stents. J Urol 2005;174(6):2125-8.
213. Ku JH, Lee SW, Jeon HG, Kim HH, Oh SJ. Percutaneous nephrostomy
versus indwelling ureteral stents in the management of extrinsic ureteral
obstruction in advanced malignancies: are there differences? Urology
2004;64(5):895-9.
214. Feuer GA, Fruchter R, Seruri E, Maiman M, Remy JC, Boyce JG. Selection
for percutaneous nephrostomy in gynecologic cancer patients. Gynecol
Oncol 1991;42(1):60-3.
215. Salom EM, Mendez LE, Schey D, Lambrou N, Kassira N, Gomez-Marin
O, et al. Continent ileocolonic urinary reservoir (Miami pouch): the
University of Miami experience over 15 years. includes discussion.
Am J Obstet Gynecol 2004;190(4):994-1003.
216. Wilkin M, Horwitz G, Seetharam A, Hartenbach E, Schink JC, Bruskewitz
R, et al. Long-term complications associated with the Indiana pouch
urinary diversion in patients with recurrent gynecologic cancers after
high-dose radiation. Urol Oncol 2005;23(1):12-5.
217. Ramirez PT, Modesitt SC, Morris M, Edwards CL, Bevers MW, Wharton
JT, et al. Functional outcomes and complications of continent urinary
diversions in patients with gynecologic malignancies. Gynecol Oncol
2002;85(2):285-91.
218. Alison DL. Thrombosis and bleeding problems in gynaecological
malignancy. In: Booth S, Bruera E, Tate T, editors. Palliative care
consultations in gynaecology. Oxford: Oxford University Press;
2004.
219. ten Wolde M, Kraaijenhagen RA, Prins MH, Buller HR. The clinical
usefulness of D-dimer testing in cancer patients with suspected deep
venous thrombosis. Arch Intern Med 2002;162(16):1880-4.
220. Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, et al.
Low-molecular-weight heparin versus a coumarin for the prevention
of recurrent venous thromboembolism in patients with cancer. N Engl
J Med 2003;349(2):146-53.
221. Noble SI, Finlay IG. Is long-term low-molecular-weight heparin
acceptable to palliative care patients in the treatment of cancer
related venous thromboembolism? A qualitative study. Palliat Med
2005;19(3):197-201.
222. Noble SI, Nelson A, Turner C, Finlay IG. Acceptability of low molecular
weight heparin thromboprophylaxis for inpatients receiving palliative
care: qualitative study. BMJ 2006;332(7541):577-80.
223. Johnson MJ, Sherry K. How do palliative physicians manage venous
thromboembolism? Palliat Med 1997;11(6):462-8.
224. Partsch H. Ambulation and compression after deep vein thrombosis:
dispelling myths. Semin Vasc Surg 2005;18(3):148-52.
225. Partsch H. Immediate ambulation and leg compression in the treatment
of deep vein thrombosis. Dis Mon 2005;51(2-3):135-40.
REFERENCES
72
MANAGEMENT OF CERVICAL CANCER
226. Buller H, Agnelli G, Hull R, Hyers T, Prins M, Raskob G. Antithrombotic
therapy for venous thromboembolic disease: the Seventh ACCP
Conference on Antithrombotic and Thrombolytic Therapy. Chest
2004;126(3 Suppl):401s-28s.
227. British Medical Association, Royal Pharmaceutical Society of Great
Britain. British National Formulary 54. London: The Association, The
Society; 2007. [cited 22 Nov 2007]. Available from url: http://www.
bnf.org
228. Dean A, Tuffn P. Fibrinolytic inhibitors for cancer-associated bleeding
problems. J Pain Symptom Manage 1997;13(1):20-4.
229. Onsrud M, Hagen B, Strickert T. 10-Gy single-fraction pelvic irradiation
for palliation and life prolongation in patients with cancer of the cervix
and corpus uteri. Gynecol Oncol 2001;82(1):167-71.
230. Doyle D, Hanks G, Cherny N, Calman K. Oxford textbook of palliative
medicine. 3rd ed. Oxford: Oxford University Press; 2005.
231. Tate T. The management of odours and discharges in gynaecological
cancer. In: Booth S, Bruera E, Tate T, editors. Palliative care consultations
in gynaecology. Oxford: Oxford University Press; 2004.
232. Finlay IG, Bowszyc J, Ramlau C, Gwiezdzinski Z. The effect of topical
0.75% metronidazole gel on malodorous cutaneous ulcers. J Pain
Symptom Manage 1996;11(3):158-62.
233. Derogatis L, Morrow, GR, Fetting, J, Penman, D, Piasetsky, S, Schmale,
AM, et al. The prevalence of psychiatric disorders among cancer
patients. JAMA 1983;249:751-7.
234. Fallowfeld L, Ratcliffe V, Jenkins V, Saul J. Psychiatric morbidity
and its recognition by doctors in patients with cancer. Br J Cancer
2001;84:1011-5.
235. Greimel ER, Freidl W. Functioning in daily living and psychological
well-being of female cancer patients. J Psychosom Obstet Gynaecol
2000;21(1):25-30.
236. National Comprehensive Cancer Network. Distress management.
Jenkintown, PA: The Network; 2006. (Practice guidelines in oncology
v.1.2008). [cited 11 Jan 2007]. Available from url: http://www.nccn.
org/professionals/physician_gls/PDF/distress.pdf
237. Slevin ML, Nichols SE, Downe SM, Wilson P, Lister TA, Arnott S, et al.
Emotional support for cancer patients: what do patients really want? Br
J Cancer 1996;74(8):1275-9.
238. Fawzy FI FN, Hyun CS, Elashoff R, Guthrie D, Fahey JL, et al. Malignant
melanoma. Effects of an early structured psychiatric intervention,
coping, and affective state on recurrence and survival 6 years later.
Arch Gen Psychiatry 1993;50((9)):681-9.
239. McQuellon RP, Wells M, Hoffman S, Craven B, Russell G, Cruz J, et
al. Reducing distress in cancer patients with an orientation program.
Psychooncology 1998;7(3):207-17.
240. Walker LG, Walker MB, Ogston K, Heys SD, Ah-See AK, Miller ID,
et al. Psychological, clinical and pathological effects of relaxation
training and guided imagery during primary chemotherapy. Br J Cancer
1999;80(1-2):262-8.
241. University of York, NHS Centre for Reviews and Dissemination.
Management of gynaecological cancers. York: The Centre; 1999.
(Effective Health Care 5(3)). [cited 22 Nov 2007]. Available from url:
http://www.york.ac.uk/inst/crd/ehc53.pdf
242. Harris K. The informational needs of patients with cancer and their
families. Cancer Pract 1998;6(1):39-46.
243. Meredith C, Symonds P, Webster L, Lamont D, Pyper E, Gillis CR, et al.
Information needs of cancer patients in west Scotland: cross sectional
survey of patients' views. BMJ 1996;313(7059):724-6.
244. Mohide EA, Whelan TJ, Rath D, Gafni A, Willan AR, Czukar D, et al. A
randomised trial of two information packages distributed to new cancer
patients before their initial appointment at a regional cancer centre. Br
J Cancer 1996;73(12):1588-93.
245. Scott JT, Harmsen M, Prictor MJ, Entwistle VA, Sowden AJ, Watt I.
Recordings or summaries of consultations for people with cancer.
Cochrane Database of Systematic Reviews 2003, Issue 2.
246. McPherson CJ, Higginson IJ, Hearn J. Effective methods of giving
information in cancer: a systematic literature review of randomized
controlled trials. J Public Health Med 2001;23(3):227-34.
247. Jenkins V, Fallowfeld, L, Saul, J. Information needs of patients with
cancer: results from a large study in UK cancer centres. Br J Cancer
2001;84:48-51.
248. Fallowfeld L, Jenkins V. Effective communication skills are the key to
good cancer care. Eur J Cancer 1999;35(11):1592-7.
249. Fellowes D, Wilkinson S, Moore P. Communication skills training for
health care professionals working with cancer patients, their families
and/or carers. Cochrane Database of Systematic Reviews 2004, Issue
2.
250. Fallowfeld L SJ, Gilligan B. Teaching senior nurses how to teach
communication skills in oncology. Cancer Nurs 2001;24:185-91.
251. Jones R, Pearson J, McGregor S, Cawsey AJ, Barrett A, Craig N, et al.
Randomised trial of personalised computer based information for cancer
patients. BMJ 1999;319(7219):1241-7.
252. Scottish Executive Health Department. Cancer waiting times: National
delivery plan. Edinburgh: The Department; 2005. [cited 22 Nov
2007]. Available from url: http://www.cancerinscotland.scot.nhs.
uk/Documents/NationalDeliveryPlanpub100605.pdf
253. Information Services Division. Scottish Health Service Costs: Overview.
Edinburgh: The Division; 2006. [cited 12 Oct 2007]. Available from
url: http://www.isdscotland.org/isd/797.html
254. General Register Offce for Scotland. [cited 22 Nov 2007]. Available
from url: http://www.gro-scotland.gov.uk
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99
ALGORITHM FOR THE INVESTIGATION OF POST-COITAL BLEEDING
Local cause
(eg polyp)
Clinical cancer of
the cervix
Treat or refer to
gynaecology
Refer to SIGN 42:
Management of
genital Chlamydia
trachomatis
Treat as appropriate
Pre-menopausal Post-menopausal
No clinically
obvious cancer
Test for Chlamydia trachomatis D
Chlamydia +ve
Chlamydia -ve
no local cause
Refer
to gynaecology
Asymptomatic women
attending for cervical
screening
Refer to gynaecology
Women with symptoms
suggestive of cervical cancer
eg abnormal vaginal bleeding
Clinical suspicion of cancer
D Refer for a gynaecological
investigation
Chlamydia trachomatis testing
should be done if appropriate