Cervical Flashcards
HPV 16 and 18 - involved in what % of cervical cancer -1
70%
screening - <21yo
none
screening - 21-29yo
cytology alone q3y
screening - 30-65yo
preferred: HPV DNA (looks at 16 and 18) and cytology “co-testing” q5y
acceptable: cytology alone q3y (NOT annual)
screening - >65yo
none
screening - guidelines
after hysterectomy for benign dz - no screening
if HPV vax - follow std screening, no difference
if abnormal test result - follow NCCN cervical screening guideline
tx - basic concepts -surgery -4
WHEN IS CURE POSSIBLE?
primary tx,
varies with stage of dz and desire for fertility (determines surgery type),
MAJOR role in early stage (stage Ia-b, IIa) - GOAL CURE
preferred over XRT as less tox
tx - basic concepts -XRT -4
MAJOR OR MINOR ROLE?
MAJOR role in locally adv to advanced dz,
also in adjuvant setting for pts with high risk of recurrence
external beam: outside going in
internal beam: probe in cervix (can not give external beam at doses higher enough to not damage bowel and bladder) (also called intracavitary) VERY IMPT!
tx - basic concepts -chemo -3
COMMON OR LIMITED ROLE?
WHEN WOULD YOU USE CHEMO ALONE?
limited role,
- concurrent with XRT for currative tx,
- palliative tx for advanced or recurrent dz
NOT used alone in absence of metastatic dz
tx - adjuvant XRT by stage Ia-IIa -3
SURGERY THEN +/- ADJ
node neg, positive LVSI, tumor >4cm: adj XRT (cat 1) +chemosensitization (cat 2b)
LN (+) and/or +surgical margins and/or +parametria:
adj XRT +chemosens (cat 1) +/- vaginal brachy
adenosquamous OR neuroendocrine small cell histology (THESE ARE RARE):
adj XRT
primary tx - advanced stage IB2-IVA - XRT + chemosens - SOC -4
NO SURGERY BECAUSE NOT AN OPTION
WHAT SIZE IS TOO LARGE?
lesion too large to surgically resect, >4cm
external beam pelvic radiation (40-60 Gy) + vaginal brachytherapy (80-85 Gy Point A) + concurrent cis 40 mg/m2 weekly
adding chemo reduced death by 20%, 6% improvement in 5yr OS
can also use 5-FU, mitomycin, and paclitaxel (also effective) for women who can not tolerate cis (those with renal dysfunction) (NOTE ALL RADIOSENSITIZING DRUGS)
staging - effect of size and location of dz -2
> 4cm
III: if dz outside cervical area LIKE HYDRONEPHROSIS
cisplatin chemoXRT concepts
Goal 6 wks of XRT without breaks with 5-6 doses of cis (OS improves with at least 5)
start cis within 24-48h of XRT
cisplatin chemoXRT acute ADR -5
myelosuppression,
diarrhea,
electrolyte abnormalities (mostly from diarrhea),
anemia,
N, V
cisplatin chemoXRT long term ADR -3
vaginal stenosis (vaginal dialators),
menopause,
bowel obstruction / fistulas (FROM XRT FIBROSIS)
cisplatin chemoXRT monitoring -3
labs: CBC, chem, pt wt
others: pain scores (local tissue swelling can make worse prior to getting better),
analgesic use in pts with large tumors
recurrence - general principles (5pts)
OPTIONS ARE LIMITED
cure unlikely (especially if recurrence in field that was previously radiated)
XRT +/- cis if recurrence isolated AND outside the previously irradiated field
FOR ISOLATED LOCALIZED RECURRENCE ONLY: pelvic exenteration (massive procedure, not common) surgery for highly selected pts
palliative chemo if not candidate for XRT or surgery
single agent tx or BSC appropriate for recurrence within previously irradiated field as responds poorly to chemo
recurrence - salvage chemo (3pts)
WHAT IS TOC?
cisplatin 50mg/m2 historic TOC, OS 6-7mo, results prior to common use of concurrent XRT-cis,
last decade -> platinum-based doublets is TOC -> trend favors pac-cis doublet, improves OS by 4 months over cis alone
gem-cis doublet least toxic (less leukop, neutrop, anemia, infx)
advanced (metastatic) OR recurrent - NCCN 1st line (4pts)
WHICH 3 ARE CAT 1?
cis 50 +pac 135 over 3h (cat 1, even though no data) or over 24h (not preferred)
cis 50 D1 +topot 0.75 D1-3 (cat 1, vs cis alone only study to show OS improvement, BUT pac-cis still preferred, no hair loss BUT less convenient)
pac 175 +carbo 6 (cat 1, but phase III study in progress)
cis 50 D1 +gem 1000 D1, 8 (cat 2B, acceptable if pre-existing neuropathy)
advanced (metastatic) OR recurrent - NCCN 1st line FOR PTS THAT CAN NOT TOLERATE 2 DRUGS (3pts)
ALSO FOR recurrence within previously irradiated field as responds poorly to chemo
MANY PTS CAN NOT TOLERATE DOUBLETS
cis 50
pac 135-175
carbo 5-6
advanced (metastatic) OR recurrent - 2nd line -10
#bev #doce #5FU #ifos #irino #mitomycin #pemetrexed #topot #venorelbine