How is cervical cancer treated?

A woman's treatment options will mainly depend on the following factors:

• The stage of the disease
• Her general health
• Her life situation
• Whether she wishes to have (more) children
• Whether she has already been through the menopause
• How effective the treatments are, and what side effects they have

In curative treatment, the aim is to get rid of ("cure") the cancer. If that is no longer possible, treatment can relieve the symptoms and perhaps help the person to live longer. The aim is then to maintain a good quality of life for as long as possible. This is known as palliative treatment.

Cervical cancer can be treated with surgery, radiation (radiotherapy) or medication (chemotherapy). 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, women can use medication to relieve symptoms caused by the tumor and reduce the side effects of treatment. Good psychological support, help in everyday life and rehabilitation after the cancer treatment are important too.

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. Tumors are classified accordingly. This affects the treatment options:

• If the tumor is still small and hasn't spread to 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.

If cancer can no longer be cured, palliative care is the focus of treatment. This includes relieving symptoms such as pain and improving quality of life as much as possible. Practical help in daily life and good psychological support are particularly important then, too.

Surgery is usually the first step of treatment. The aim is to completely remove the cancer. To remove very small tumors or abnormal cells that could turn into cancer, a type of surgery called conization may be enough. In conization, a roughly cherry-sized, cone-shaped wedge of tissue containing the tumor is removed from the opening of the cervix and the cervix itself. The operation is done through the vagina, under local or general anesthetic.

If conization isn't enough, a larger area of the cervix and/or the entire womb are removed. Sometimes parts of nearby organs or tissue are removed too. This is done under a general anesthetic – either through the vagina, laparoscopy (small cuts in the abdominal wall) or open surgery (a larger cut across the abdominal wall). Depending on whether the cancer has spread, and how much, other operations may be needed too.

After conization and 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). Women who have had their womb removed often find it hard to deal with, both physically and emotionally. If younger women have their ovaries removed as well, they may experience menopause-like symptoms. Women's sexuality and sex life may also be affected.

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). The latter is known as brachytherapy. During radiotherapy, doctors try to protect the surrounding tissue as much as possible. But this is often unavoidable: Healthy tissue might be exposed to radiation too, leading to side effects and longer-term problems such as bladder issues, vaginal dryness or inflammation of the 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 divide uncontrollably. The medications used here are called cytostatic drugs. They are usually given through an infusion (drip) into a vein, but are sometimes taken in the form of tablets instead. 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 metastases). Because chemotherapy also affects healthy cells, it can have distressing side effects such as nausea, diarrhea and inflammations (for instance, of the mucous membranes in the mouth). The medication can either be given in a doctor's practice or at a hospital. The treatment is repeated at regular intervals.

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. Immunotherapy medications are given through a drip, too. This treatment is generally only used if the tumor has spread to other parts of the body (metastasis) or if it has come back.

Various measures can help to reduce the effects of the disease and the side effects of cancer treatment. The side effects and other consequences of surgery, radiotherapy or chemotherapy can often be treated successfully – for instance, with medication for pain relief, anemia, nausea, diarrhea or infections.

Psycho-oncological 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 emotional distress associated with the disease and treatment. A range of services offer assistance in everyday life and help people to return to work. There are also special relaxation, exercise and nutrition programs for people who have cancer. Many people find help in cancer information centers or support groups, and some make use of couples therapy or sex therapy.

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 advice and psychological counseling.

Follow-up care starts once the 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 top end of 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.

Some women can still have children after having cancer treatment. It is sometimes possible to adapt the treatment so that the woman stays fertile. But it may still become more difficult to get pregnant. Surgery on the cervix can also increase the risk of babies being born too soon (preterm birth) in future pregnancies.

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.

Women who don't wish to have any (more) children are often advised to have their womb removed. This is meant to reduce the risk of the cancer returning. But, like any operation, this procedure is associated with risks. And many women consider having a womb to be an important part of being a woman. So it's generally a good idea to think carefully about the pros and cons of this operation before making a decision.

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.

After being diagnosed with cervical cancer, there's usually enough time to find out about the various treatment options and then decide which path to take. There's no need to rush the decision. If you have any doubts, it can be helpful to get a second opinion. It is 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. Help is available from the treatment team as well as from support groups, cancer information centers or organizations such as the Cancer Information Service (Krebsinformationsdienst).