Cervical Cancer Management
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Direct answer
Cervical cancer — virtually always human papillomavirus-driven (types 16 and 18 causing about 70 per cent) — is managed by FIGO 2018 staging (now incorporating imaging and nodes: IIIC1 pelvic, IIIC2 para-aortic): microinvasive IA1 by cone biopsy or extrafascial hysterectomy, tumours below 4 cm (IB1-IIA1) by type C radical hysterectomy (Wertheim's) with pelvic lymphadenectomy, and locally advanced disease (IB3-IVA) by concurrent chemoradiation — external beam plus weekly cisplatin 40 mg per square metre followed by brachytherapy. India carries roughly a fifth of the world's cases, which makes the national response — acetic-acid screening for women over 30 with screen-and-treat ablation, and HPV vaccination for 9-14-year-old girls — as examinable as the surgery.
What you must remember
- Staging skeleton (FIGO 2018): IA1 under 3 mm, IA2 3-5 mm, IB1 under 2 cm, IB2 2-4 cm, IB3 over 4 cm; IIA upper vagina, IIB parametrium; III pelvic wall, lower vagina, or hydronephrosis (IIIC1 pelvic, IIIC2 para-aortic nodes); IV mucosa or distant spread.
- Early-stage surgery: IA1 without lymphovascular invasion — cone biopsy (fertility preserved) or extrafascial hysterectomy; IB1-IIA1 — type C1 nerve-sparing radical hysterectomy (Wertheim's) with pelvic lymphadenectomy; radical trachelectomy (Dargent's) plus node dissection for tumours under 2 cm in selected young women.
- The chemoradiation standard: IB3, IIA2 and IIB-IVA receive external beam radiotherapy (45-50 Gy) with weekly cisplatin 40 mg/m² for five to six weeks, then intracavitary brachytherapy (point A about 28-30 Gy); chemoradiation beat radiotherapy alone by about 12 per cent absolute survival in the landmark meta-analysis.
- Adjuvant treatment after surgery: chemoradiation for high-risk factors (nodes, margins, parametrium); radiotherapy alone for intermediate-risk combinations (deep invasion, lymphovascular space invasion, large tumour — Sedlis).
- Recurrent disease: central recurrence after radiation — pelvic exenteration; after surgery — chemoradiation; metastatic — platinum doublets, bevacizumab adding survival.
- Screening in India: visual inspection with acetic acid for women 30-65 every five years, with immediate cryotherapy or thermal ablation of precancer (screen-and-treat); Pap every three years and HPV DNA every 5-10 years as alternatives.
- Precursor management: CIN2/3 by LEEP or cold-knife conisation; adenocarcinoma in situ demands conisation with clear margins, usually hysterectomy once fertility is complete.
- Vaccines: quadrivalent (6, 11, 16, 18) and nonavalent products globally, and Cervavac, India's indigenous quadrivalent vaccine; the national immunisation for 9-14-year-old girls is rolling out — two doses below 15 years (0 and 6 months), three at 15 or older.
One algorithm, three women
Woman one, 34, screen-positive on visual inspection with acetic acid: colposcopy shows a high-grade lesion, LEEP returns CIN3 with clear margins — cured, annual follow-up. Woman two, 46, a 3 cm carcinoma under the 4 cm threshold: surgical after imaging excludes nodes — type C radical hysterectomy with pelvic nodes; a positive node converts her to IIIC1 and adjuvant chemoradiation follows. Woman three, 52, fungating growth with left hydronephrosis — IIIB, nodes unknown: a radiotherapy patient, full stop; the surgeon biopsies and stages, the oncologist delivers external beam with weekly cisplatin and image-guided brachytherapy. The teaching spine is the fork at 4 cm and the parametrium: below it surgery, beyond it chemoradiation — trials showed only added morbidity when surgery entered bulky, parametrial disease.
India's burden and its programme math
India registers about 1.2 lakh new cases and 77,000 deaths yearly (GLOBOCAN-era figures) — roughly one in five of the world's cases, most diagnosed at stage III-IV because screening coverage is low. The national response has three prongs: screening women 30-65 with visual inspection with acetic acid at Ayushman Arogya Mandirs, with immediate thermal ablation or cryotherapy — a single-visit screen-and-treat policy from WHO's elimination strategy; colposcopy referral at district hospitals; and HPV vaccination — Cervavac, the indigenous quadrivalent vaccine, rolling out nationally for 9-14-year-old girls, the highest-leverage prevention decision in the country's history. The remaining realities: brachytherapy access rate-limits cure in government oncology, palliative care reaches a minority, and the viva asks for point A (2 cm above the external os on the uterine axis), the weekly cisplatin dose (40 mg/m²), and the IIIC1/IIIC2 distinction.
Frequently asked questions
What defines stage IA1 and how is it treated?
Under 3 mm depth and 7 mm width — cone biopsy with clear margins (fertility preserved) or extrafascial hysterectomy; lymphovascular invasion upgrades management.
Which stages receive radical hysterectomy rather than radiotherapy?
IB1-IIA1 — tumours up to 4 cm without parametrial or lower-vaginal extension — type C radical hysterectomy with pelvic nodes, chemoradiation reserved for adjuvant or bulky situations.
What is the chemoradiation regimen for locally advanced disease?
External beam 45-50 Gy with weekly cisplatin 40 mg per square metre for five to six cycles, then intracavitary brachytherapy delivering roughly 28-30 Gy to point A.
What are the Sedlis intermediate-risk criteria?
Combinations of deep (outer-third) invasion, lymphovascular space invasion, and tumour size — any two warrant adjuvant radiotherapy.
What is India's indigenous HPV vaccine and who receives it?
Cervavac, the Serum Institute of India's quadrivalent HPV vaccine (6, 11, 16, 18), rolling out nationally for 9-14-year-old girls — two doses if under 15.