How is cervical cancer treated?

The following options are available:

• Surgery: Conization or the removal of the womb (hysterectomy), and possibly other nearby organs
• Radiotherapy
• Chemotherapy
• Immunotherapy

Sometimes just one of these is enough, and sometimes a combination of two or three of these approaches is recommended.

As well as having treatment to fight the cancer, medication can be used to relieve symptoms caused by the tumor and reduce the side effects of treatment. These include medications for treating pain, anemia, nausea, diarrhea or infections. Good psychological support, help in everyday life and rehabilitation after the cancer treatment are important too.

The treatment options will mainly depend on the following factors:

• How advanced is the cancer?
• How is your overall health?
• What is your general life situation?
• Do you want to get pregnant?
• Are you already in menopause?
• What are the possible side effects of the treatments?

In order to plan the treatment, doctors need to know as much as possible about the stage of the cancer and whether it has spread to lymph nodes, other tissue or other organs. There are various treatment options:

• If the tumor is still small and hasn't spread to the lymph nodes: Surgery is usually enough. If the cervical cancer is likely to grow again, radiotherapy is usually recommended too – with or without accompanying chemotherapy.
• If the cancer has advanced further, but may still be possible to get rid of: Surgery generally isn't performed. Instead, the tumor is treated with a combination of chemotherapy and radiotherapy (chemoradiotherapy).
• If treatment is unlikely to make the cancer go away: Surgery, chemotherapy or radiotherapy can be used to try to stop the growth of the tumor for as long as possible, help patients to live longer and relieve the symptoms of the disease. But some people who are in this situation decide not to have treatment.

In curative treatment, the aim is to get rid of ("cure") the cancer. If the cancer can no longer be cured, then the focus is on relieving the symptoms (like pain) as much as possible, maintaining quality of life for as long as possible and possibly increasing lifetime. This is known as palliative treatment.

If the tumor is small and the cancer has not spread to the lymph nodes, the chances of recovery are very good. At an advanced stage, they are quite low:

The first treatment is often surgery. The aim is to completely remove the cancer. To remove very small tumors or abnormal cells that could turn into cancer, a minor surgical procedure called conization may be enough. This removes the tumor and a cone-shaped wedge of tissue the size of a cherry from the opening of the cervix and the cervix itself. The operation is done through the vagina, under local or general anesthesia.

Conization is not enough if the cancer has spread further. Then a larger part of the cervix and/or the entire womb is removed. In some cases nearby organs or connective tissue may also be removed. This is done under general anesthesia – either through the vagina, by laparoscopy (small cuts in the abdominal wall) or through open surgery (a larger cut across the abdominal wall). Depending on whether the cancer has spread, and how much, several operations may be needed too.

Women who don't want to have any (more) children are often advised to have their womb removed. This is meant to reduce the risk of the cancer returning. The removal of the womb (hysterectomy) is often hard to deal with, both physically and emotionally, and it carries certain risks, like injury to blood vessels, nerves and organs. If women also have their ovaries removed before menopause, they may experience menopause-like symptoms. So it's generally a good idea to think carefully about the pros and cons of this operation before making a decision.

Radiotherapy involves exposing the tumor to high-energy radiation in order to destroy the cancer cells. This can be done from outside the body (through the skin) or from inside the body (through the vagina). This is known as brachytherapy.

Doctors make sure to perform this treatment as safely as possible. But it's often inevitable that nearby tissue is also exposed to some radiation. That can lead to side effects and complications like bladder problems, a dry vagina or inflammation in mucous membranes.

When radiotherapy is used in the treatment of cervical cancer, it is usually combined with chemotherapy (chemoradiotherapy).

The aim of chemotherapy is to stop cancer cells from continuing to multiply uncontrollably. The medications (cytostatic drugs) are usually given through an infusion (drip) into a vein. That is done at the doctor's or in the hospital. Sometimes these medications are available in tablet form as well, which you can then take on your own at home. The treatment is repeated at regular intervals.

Because chemotherapy also affects healthy cells, it can have unpleasant side effects such as nausea, diarrhea and inflammations (for instance, of the mucous membranes in the mouth).

When used in the treatment of cervical cancer, chemotherapy is usually combined with radiotherapy. Chemotherapy might be used on its own if the cancer comes back or spreads to other parts of the body (distant metastasis).

In addition to chemotherapy, a treatment approach known as immunotherapy (monoclonal antibody therapy) can be used. It specifically attacks cancer cells, for instance by cutting off their blood supply and preventing tumor growth in that way. These medications are given through a drip, too. This treatment is generally only used if the tumor has spread to other parts of the body or if it has come back.

After conization or the partial removal of the cervix, women are still able to have children. But both procedures increase the risk of babies being born too soon (preterm).

Chemotherapy and radiotherapy can affect fertility.

If a woman's whole womb is removed (hysterectomy), or if her womb and ovaries are exposed to radiation in radiotherapy, she can no longer become pregnant.

If a tumor is discovered during pregnancy, the treatment is adapted in order to limit the risk to the unborn child as much as possible. Whether or not the baby can stay in his or her mother's body for the normal amount of time (full-term) will depend on things like the week of pregnancy and the stage of cervical cancer.

Psychological support is an important part of treatment for people who have cancer. Medical professionals with special training in psycho-oncology can help patients to cope with the mental burden associated with the disease and treatment. Many people find support in cancer information centers or support groups, and some make use of couples therapy or sex therapy.

There are also special relaxation, exercise and nutrition programs for people who have cancer, as well as support in everyday life and for returning to work.

People who have had cancer treatment are generally entitled to rehabilitation therapy (follow-up treatment). This treatment aims to help people to cope with the effects of the disease and treatment, and to recover physically and emotionally. It takes place in special rehabilitation centers immediately after cancer treatment has been completed. Rehabilitation programs include things like physical exercises, relaxation techniques, strength training, nutritional counseling and psychological counseling.

Follow-up care starts once cancer treatment has been completed. It includes regular check-ups with specialists to see whether the cancer has come back. Here the doctor does a physical examination to feel (palpate) the internal sex organs, as well as taking samples of cells from the cervix (smear test or Pap test) or from the vagina. Depending on the results, further examinations may be recommended, for instance colposcopy (using a magnifying glass) or an ultrasound scan.

Counseling and psychological support are an important part of follow-up care, too. They may involve things like talking about your life situation, possible fears or problems in relationships. Cancer information centers can provide advice on these issues free of charge.

After being diagnosed with cervical cancer, there is usually enough time to find out about the various treatment options and then decide which path to take together with your doctors. There's no need to rush the decision.

If you have any doubts, it can be helpful to get a second opinion. It's particularly important to find out about the chances of full recovery, as well as the possible side effects and consequences of the various treatments – including those affecting everyday life and future plans in life. Support is available from the treatment team as well as from self-help groups, cancer information centers or organizations such as the Cancer Information Service (Krebsinformationsdienst).