Cervical cancer treatment

Treatment for cervical cancer depends on how large the cancer is or how far it has spread.

Cancer treatments can be complex. Because of this, hospitals use multidisciplinary teams (MDTs) to treat cervical cancer.

An MDT is a team of different medical specialists. They will be your cancer team.

Your cancer team will recommend what they think the best treatment options are. They will explain these to you.

Early-stage cervical cancer treatment

In most cases, the recommended treatments for early-stage cervical cancer will be:

• surgery to remove the cervix and some, or all, of the womb
• radiotherapy
• a combination of both

Advanced-stage cervical cancer treatment

In most cases, the recommended treatments for advanced-stage cervical cancer will be:

• chemotherapy and radiotherapy
• radiotherapy on its own
• surgery - this is less likely

Cervical cancer is often curable if it's diagnosed early.

When it's not curable, it's often possible to:

• slow it down
• help you live longer
• relieve symptoms, such as pain and vaginal bleeding

This is called palliative care.

Removing very early cancer

Large loop excision of the transformation zone (LLETZ)

LLETZ involves removing the cancerous cells using a thin wire loop. This is heated with an electric current.

It's usually done under local anaesthetic. This mean you're awake, but the area is numb.

You can have LLETZ during a colposcopy appointment.

If you become pregnant, it is important to tell your GP or doctor that you have had a LLETZ.

Cone biopsy

A cone biopsy is a minor operation to cut out a cone-shaped piece of tissue containing the abnormal cells.

This is usually done under general anaesthetic. This means you're asleep when it's done.

If you become pregnant, it is important to tell your GP or doctor that you have had a cone biopsy.

Surgery

There are 3 main types of surgery for cervical cancer:

• trachelectomy
• hysterectomy
• pelvic exenteration

Pelvic exenteration is only offered when cervical cancer has come back.

Trachelectomy

A trachelectomy removes:

• the cervix
• surrounding tissue
• upper part of the vagina

The womb is left in place. It is reattached to the lower section of your vagina. This is usually done by keyhole surgery.

A trachelectomy is usually only suitable if cervical cancer is diagnosed very early. You'll usually be offered this surgery if you want to have children in the future.

Your surgeon may also remove lymph nodes from your pelvis. Lymph nodes are part of the body's waste-removal system.

Able to have children

The advantage of this type of surgery is that your womb remains in place. This means you may still be able to have children. This is not the case with a hysterectomy or pelvic exenteration.

But it's important to be aware that there is no guarantee that you will still be able to have children.

You may need a stitch in the bottom of your womb. This is to help support and keep a baby in your womb in future pregnancies.

If you do get pregnant after the operation, your baby will have to be delivered by caesarean section.

You'll usually be advised to wait 6 to 12 months after surgery before trying for a baby. This is so your womb and vagina have time to heal.

Trachelectomy is a highly-skilled procedure. It's only available at certain specialist centres. So it may not be offered in your area. You may need to travel for treatment.

Hysterectomy

A hysterectomy is when the cervix and womb are removed.

The surgeon may also need to remove your ovaries. But this will depend on the stage of the cancer.

A hysterectomy is usually advised for early-stage cervical cancer.

Two types of hysterectomies are used to treat cervical cancer:

• simple hysterectomy
• radical hysterectomy

You may also need to have a course of radiotherapy. This is to help prevent the cancer coming back.

Radiotherapy after surgery

Around 1 in 5 women will need radiotherapy after surgery.

Your MDT care team will decide after your hysterectomy. They will wait until all your results are available.

If you have surgery and radiotherapy, you may experience more severe side effects. These side effects will be long-term.

Simple hysterectomy

In a simple hysterectomy the cervix and womb are removed. In some cases, the ovaries and fallopian tubes are too. A simple hysterectomy is only suitable for very early-stage cervical cancers.

Radical hysterectomy

This is the preferred option for small, visible cancer tumours. You'll usually only have this surgery if your tumour is smaller than 3cm.

A radical hysterectomy removes:

• the cervix
• womb
• top of the vagina
• surrounding tissue
• lymph nodes
• fallopian tubes
• ovaries (sometimes)

Short-term complications of a hysterectomy include:

• infection
• bleeding
• blood clots
• accidental injury to your ureter, bladder or rectum

There is a risk of long-term complications. These complications are more common if you have both a hysterectomy and radiotherapy.

Complications include:

• your vagina becoming shorter and drier - this can make sex painful
• urinary urgency and having to get up during the night to pee - a small number of women may need a catheter
• swelling of your legs, caused by a build-up of fluid (lymphoedema)
• a build-up of scar tissue in the bowel - this may cause pain and may need surgery
• constipation - you may need to use laxatives in the long-term

Your womb is removed during a hysterectomy. This means you will not be able to give birth.

If your ovaries are removed, there is a very small chance of premature menopause.

See complications of cervical cancer for more information about the menopause.

Pelvic exenteration

A pelvic exenteration is a major operation.

It may remove your:

• cervix
• vagina
• womb
• ovaries
• fallopian tubes
• bladder
• rectum
• lymph notes in the pelvic region and around the aorta artery - lymph nodes are part of the body's waste-removal system.

This surgery is usually only advised when cervical cancer comes back. It's offered if the cancer returns to the pelvis but has not spread.

A pelvic exenteration involves 2 phases.

Phase one

Your surgeon will remove the cancer and the vagina. They may also remove your bladder, rectum or lower section of the bowel. Or they may remove all 3.

Phase two

In the second phase, 1 or 2 holes are made in your tummy. These are called stomas. The holes are used to pass pee and poo out of your body into pouches called colostomy bags.

It may be possible to reconstruct your vagina after a pelvic exenteration.

This is done using skin and tissue taken from other parts of your body.

It means you could still have sex after the procedure. But it could be several months until you feel well enough to do so.

Radiotherapy

Radiotherapy is sometimes used as a treatment with surgery.

If you have advanced cervical cancer, you might have radiotherapy with chemotherapy.

In this case, it can be used to control bleeding and pain.

You can have radiotherapy either:

• externally
• internally (brachytherapy)

In most cases, a combination of both will be used. A course of radiotherapy usually lasts about 5 to 8 weeks.

External radiotherapy

A machine beams high-energy waves into your pelvis to destroy cancerous cells.

Internal radiotherapy (brachytherapy)

A radioactive implant is put next to the tumour inside your vagina.

Internal radiotherapy aims to reduce harm to nearby tissue. It does this by delivering the radiation as close as possible to the tumour. But it can still cause side effects.

Side effects of radiotherapy

Radiotherapy destroys cancerous cells.

But sometimes it can also harm healthy tissue. This means it can cause significant side effects.

These side effects can last for months, or even years, after treatment.

But the benefits of radiotherapy often outweigh the risks. For some people, radiotherapy offers the only hope of getting rid of the cancer.

Long-term side effects to the pelvic area can include:

• diarrhoea – medicines can help to reduce this
• bladder inflammation - this can cause pain and a feeling of needing to pee
• pain in your tummy due to urine infection, bowel changes or fine cracks in the pelvic bones
• your digestive system to stop taking in vitamin B12 from food - this can cause a vitamin B12 deficiency
• bleeding from the bladder, bowel or vagina - always let your doctor know if this happens
• weaker pelvic bones - you might have a scan to check them
• tingling, weakness or loss of sensation in one or both legs

Loss of sensation in the legs is very rare. It is called radiotherapy induced lumbosacral plexopathy (RILP).

These changes can appear over a long time. They can sometimes take years.

Talk to your GP or doctor if you are worried about side effects.

Infertility

If you are worried about infertility, it may be possible to surgically remove eggs from your ovaries. This can be done before radiotherapy. They can then be implanted in your womb later. But you may have to pay for this.

Ovarian transposition

Ovarian transposition is a surgery to help prevent an early menopause.

It's done by moving your ovaries away from the area of radiation. This is to protect the ovaries while you have radiotherapy. Your ovaries are moved to outside the pelvis.

Ovarian transposition is not always successful.

Your doctors can give you more information about these options. They will tell you if you're suitable for an ovarian transposition.

Chemotherapy

Chemotherapy is often used with radiotherapy to treat cervical cancer.

It can also be used on its own to treat advanced cervical cancer. This can help slow the cancer's progress and relieve symptoms. In this case, it's known as palliative chemotherapy.

Chemotherapy is also used if the cancer comes back.

Chemotherapy for cervical cancer can involve using a single drug, called cisplatin.

You might also be given a combination of different chemotherapy drugs. These are used to kill the cancerous cells.

Chemotherapy is usually given straight into your vein using a drip. You will probably be seen as an outpatient. So you'll be able to go home after you have your dose.

Side effects of chemotherapy

Like radiotherapy, these drugs can sometimes damage healthy tissue. Side effects are common.

Side effects can include:

• feeling and being sick
• diarrhoea
• feeling tired all the time
• reduced production of blood cells
• mouth ulcers
• loss of appetite
• hair loss

Cisplatin does not usually cause you to lose your hair, but other chemotherapy drugs may. If you do lose your hair, it should grow back within 6 months of finishing chemotherapy.

Some types of chemotherapy drugs can damage your kidneys.

You may need to have regular blood tests to check the health of your kidneys.

Follow-up after treatment

Treatment should remove the cancer. But you'll need to attend regular appointments for testing.

This will usually involve a doctor checking your vagina and cervix (if it hasn't been removed).

Because cervical cancer can return, these exams will look to see if this happening. If anything suspicious is found, a further biopsy can be done.

Follow-up appointments are usually every 3 to 6 months for the first 2 years.

You will then have them every 6 to 12 months for the following 3 years.

Your multidisciplinary team (MDT)

Members of your MDT may include a:

• gynaecologist (a doctor specialising in the female reproductive system)
• clinical oncologist (a specialist in chemotherapy and radiotherapy)
• medical oncologist (a specialist in chemotherapy only)
• pathologist (a specialist in diseased tissue)
• radiologist (a specialist in imaging scans)
• social worker
• psychologist
• specialist cancer nurse, who'll usually be your first point of contact with the rest of the team

Palliative care

If your doctors cannot treat your cancer, they will focus on controlling symptoms. They will try to help you be as comfortable as possible.

This is called palliative care.

Palliative care also includes psychological, social and spiritual support. This support is for you and your family or carers.

There are different options for palliative care in the late stages of cancer. You may want to think about if you'd like to be cared for in hospital, in a hospice or at home.

Discuss these issues with your doctor.

The Irish Hospice Foundation provides information about hospice care and how to find a hospice.