Cervical cancer


Treatment for cervical cancer

Sunday 16 August, 2020

The most common treatment for cervical cancer is surgery, or a combination of chemotherapy and radiotherapy (chemoradiotherapy), or surgery with chemoradiotherapy. When cervical cancer has spread beyond the cervix, targeted therapy may also be used.

Your medical team will recommend treatment based on these factors:

  • the results of your tests
  • the location of the cancer and whether it has spread
  • your age and general health
  • whether you would like to have children in the future.

If becoming a parent is important to you, talk to your doctor before starting treatment and ask for a referral to a fertility specialist.

Surgery

For some people, surgery may be the only treatment needed. Surgery is usually recommended for people who have a tumour that is only in the cervix. The type of surgery you have will depend on how far within the cervix the cancer has spread. Your surgeon will talk to you about the most appropriate surgery for you, as well as the risks and any possible complications (in both the short and long term).

The main type of surgery is called a hysterectomy. A hysterectomy is an operation to remove the uterus (womb) and cervix.  The surgeon may also remove other organs of the reproductive system or the lymph glands on the side wall of the pelvis (see below).

A hysterectomy may also involve removing both ovaries and fallopian tubes (a bilateral salpingo-oophorectomy) and some pelvic lymph nodes.

Types of surgery

Depending on how far the cancer has spread and your age, you may have one or more of these six procedures.

Cone biopsy

The surgeon removes a cone of tissue around the cancer, including a margin of healthy tissue. This is used to treat very early cervical cancers, particularly for young women who would like to have children.

Trachelectomy

The surgeon removes part or all of the cervix, along with the upper part of the vagina. The uterus, fallopian tubes and ovaries are left in place. This is not a common procedure, but it may be used in young people with early stage
cancer who would like to have children.

Total hysterectomy

The surgeon removes the uterus and cervix. This operation can be suitable for early cervical cancers. The fallopian tubes are also commonly removed (see bilateral salpingectomy, below). Some premenopausal women are able to keep their ovaries.

Radical hysterectomy

The surgeon removes the uterus, cervix, and soft tissue around the cervix and top of the vagina. This is the standard operation for most cervical cancers treated with surgery. The fallopian tubes are also commonly removed . Some premenopausal women are able to keep their ovaries.

Bilateral salpingectomy

The surgeon removes both fallopian tubes. This is commonly recommended for people having a hysterectomy performed through the  abdomen (open surgery). Your doctor will talk to you about the risks and benefits of removing the fallopian tubes.

Bilateral salpingo-oophorectomy

The surgeon removes both fallopian tubes and ovaries. This is considered when your doctor is concerned that the cancer may have spread to the ovaries, or for people approaching menopause or of menopausal age.

How the surgery is done

The surgery will be performed under a general anaesthetic. The hysterectomy can be done in two different ways: open surgery or keyhole surgery

Open surgery (laparotomy)

The surgery is performed through the abdomen. A cut is usually made from the pubic area to the bellybutton. Sometimes the cut is made along the pubic line instead. The uterus and other organs are then removed. Research has shown that open surgery is the better option for most cervical cancers.

Keyhole surgery (laparoscopy or robotic surgery)

These methods use thin cameras and instruments that are inserted through small cuts into the abdomen. The uterus and other organs are removed through the vagina. Laparoscopic surgery may be used for small, early stage tumours.

Treatment of lymph nodes

Cancer cells can spread from the cervix to the lymph nodes in the pelvis. You may have one of the following two procedures: sentinel lymph node biopsy or lymph node dissection (lymphadenectomy).

Sentinel lymph node biopsy

This test helps to identify the lymph node that the cancer is most likely to spread to first (the sentinel lymph node).

While you are under anaesthetic, your doctor will inject a dye into the cervix. The dye will flow to the sentinel lymph node, and the surgeon will remove it for testing.

If it contains cancer cells, the remaining nodes in the area may be removed in a procedure called a lymphadenectomy. Alternatively, your doctors may decide you need other treatments such as chemoradiation.

A sentinel lymph node biopsy can help the doctor avoid removing more lymph nodes than necessary and minimise side effects such as lymphoedema. This procedure may be used for some people with early cervical cancer and is only available in some treatment centres. Research into its role in treating cervical cancer is ongoing.

Lymph node dissection (lymphadenectomy)

The surgeon will remove an area of lymph nodes from the pelvic or abdominal areas, or both, to see if the cancer has spread beyond the cervix. If cancer is found in the lymph nodes, your doctor may recommend you have additional treatment, such as radiation therapy.

What to expect after surgery

When you wake up from surgery, you will be in a recovery room near the operating theatre. Once you are fully conscious, you will be taken to your bed on the hospital ward.

Tubes and drips

You may have an intravenous (IV) drip to give you fluid and medicine, a tube in your abdomen to drain fluid from the operation site and a small plastic tube (catheter) in your bladder to drain urine. These tubes will be removed before you go home.

After the catheter is removed from your bladder, the nurses will perform a test to check that your bladder is emptying properly. This is done by measuring the amount of urine you pass each time you go to the toilet, then using an ultrasound scan to check that your bladder is empty. It is a quick, painless test that is done on the hospital ward.

Pain and discomfort

After a major operation, it is common to feel some pain. You will be given pain medicine as a tablet, through a drip (intravenously) or through a catheter inserted in the spaces in the spine (epidural). If you still have pain, let your doctor or nurse know so they can change your medicine to one that provides more relief.

Moving your legs

While you are in bed, you may have to wear compression stockings or “calf compressors” around your lower legs. These help the blood in your legs circulate and prevent blood clots forming in the deep veins of the legs or pelvis (deep vein thrombosis). You will be encouraged to walk around as soon as you can.

Recovery time

You will spend three to five days in hospital after a hysterectomy. The recovery time depends on the type of surgery and your fitness. You will be able to go home when the medical team is satisfied with your recovery and the results of your bladder function tests.

Anne’s story

“After the operation, I had radiation therapy daily for six weeks. The treatment made me feel very tired and also affected my bowels and bladder.

“But for me, the hardest part of cancer and treatment is the ongoing emotional side of it. The physicality of having treatment is one thing, but the emotional roller-coaster was the worst part.

“My doctors have told me to be vigilant about everything abnormal, such as any vaginal bleeding or pain. Even many years later, there is a lot of uncertainty.

“Sometimes I panic when I feel unwell and rush to my doctor for reassurance. Mostly now, it feels like it was a bad dream, and I focus on living my life to the full.”

Tell your cancer story.

Side effects

After surgery for cervical cancer, you may experience some of the following side effects. For more information about the side effects listed below, see managing side effects.

Problems with bladder or bowel function

If some of the nerves to the bladder were removed during the hysterectomy, you may feel that you’re not able to empty your bladder completely or that you’re emptying your bladder or bowel too slowly. These problems improve with time. Some people experience accidental leakage of urine after surgery. This is called urinary incontinence.

Lymphoedema

Sometimes the removal of lymph nodes in the pelvis can stop or slow the natural flow of lymphatic fluid. This may cause lymphoedema, which is excess fluid in the legs. Symptoms of lymphoedema may appear immediately or years after surgery.

Menopause

If your ovaries are removed and you have not been through menopause, removal will cause sudden menopause. After menopause you will not be able to become pregnant.

Impact on sexuality

The physical and emotional changes you experience after surgery may affect how you feel about sex, but surgery doesn’t change the ability to have sex or feel pleasure during sexual intercourse.

Internal scar tissue (adhesions)

Tissues in the pelvis may stick together. Sometimes adhesions to the bowel or bladder may cause abdominal pain or discomfort. Rarely, adhesions may need to be treated with surgery.

What to expect when you get home

Your recovery time after a hysterectomy will depend on the type of surgery you had, your age and general health. Most people say they feel better within six weeks.

Rest

Take things easy for the first few weeks and only do what is comfortable. Ask family or friends to help you with chores so you can rest as much as you need to.

Lifting

Avoid heavy lifting for about a month, although this will depend on the type of surgery you had.

Exercise

Walk regularly if your doctors say it is okay to do so. Gentle exercise can help speed up recovery. Speak to your doctor about when it is suitable to start more vigorous exercise.

Sex

You’ll need to avoid sexual intercourse for at least six weeks to give the vaginal wound time to heal properly.

Diet

Drink plenty of water and eat lots of fresh vegetables and fruit to avoid becoming constipated.

Bathing

Take showers instead of baths and avoid swimming for four to six weeks after surgery.

 

Radiation therapy

Radiotherapy, also called radiation therapy, uses radiation such as x-rays to kill cancer cells or injure them so they cannot multiply. The radiation is targeted at parts of the body with cancer, and treatment is carefully planned to do as little harm as possible to healthy body tissues. 

You may have radiation therapy on its own as the main treatment for cervical cancer, or you may have it after surgery to help get rid of any remaining cancer cells. If the cervical cancer that has spread to the tissues or lymph nodes surrounding the cervix, you will usually have radiation therapy in combination with chemotherapy (chemoradiation) to reduce the chance of the cancer coming back.

There are two main ways of delivering radiation therapy: externally or internally. Most people who have radiation therapy for cervical cancer will have both types.

External radiation therapy (external ) beam radiation therapy and internal radiation therapy (high-dose rate – HDR – brachytherapy) will not make you radioactive. It is safe for you to be with both adults and children after your treatment sessions.

Chemoradiation

When radiation therapy is combined with chemotherapy, it is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy.

If you have chemoradiation, you will usually receive chemotherapy once a week a few hours before the radiation therapy appointment.

Chemoradiation can have a number of side effects:

  • diarrhoea
  • needing to wee more often or in a hurry
  • cystitis (an infection that makes you want wee more often and causes pain when weeing)
  • dry and itchy skin in the treatment area
  • nausea
  • low blood counts; low numbers of bloods cells may cause anaemia, infections or bleeding problems.

Talk to your treatment team about ways to manage the side effects of chemoradiation. 

 

External beam radiation therapy

In external beam radiation therapy, a machine precisely directs radiation beams from outside the body to the cervix, lymph nodes and other organs that need treatment. The initial planning session will include a CT scan to work out where to direct the radiation beams, and may take up to 45 minutes. The actual treatment takes only a few minutes each time.

You will probably have external radiation therapy as daily treatments, Monday to Friday, over four to six weeks as an outpatient. You will lie on a table under the radiation therapy machine. Before the machine is turned on, the radiation therapist will leave the room, but they will be able to talk to you through an intercom and they will watch you on a screen while you have treatment. The treatment itself is painless.

Internal radiation therapy

Internal radiation therapy is known as brachytherapy. It is a way of delivering radiation therapy from inside your body directly to the tumour, while reducing the amount of radiation delivered to nearby organs such as the bowel and bladder. The main type of internal radiation therapy used for cervical cancer is high-dose-rate (HDR) brachytherapy. With HDR, bigger doses are given in a few treatments.

During treatment

You will probably have three to four sessions over 2 to 4 weeks. You will be given a general or spinal anaesthetic at each brachytherapy session.

Applicators are used to deliver the radiation source to the cancer. They are available in different sizes and your radiation oncologist will examine you to choose a suitable applicator for your situation. The applicator is placed into the cervix under the guidance of an ultrasound to make sure it is in the right place.

To hold the applicator in place, you may have gauze padding put into your vagina, and a stitch or two in the area between the vulva and the anus (perineum). You will also have a small tube (catheter) inserted to empty your bladder of urine during treatment.

You will have a CT (computerised tomography) or MRI (magnetic resonance imaging) scan to check the position of the applicator. This scan helps your doctor deliver the brachytherapy to the correct area. Once your doctor has completed the treatment plan, the radiation source will be placed into the applicator for 10 to 20 minutes. If you have a general anaesthetic, this will happen while you are asleep.

If you’ve had surgery to remove the cervix and uterus (hysterectomy), your doctor may want to deliver some extra radiation to the top of the vagina. An applicator will be placed into your vagina. You will not need to have a general anaesthetic or gauze padding.

After treatment

The applicator is taken out after the radiation dose is delivered. If several sessions are needed, the applicator will be reinserted each time.

Side effects

The side effects you experience vary depending on the dose of the radiotherapy and the length of the treatment. Many will be short-term side effects that occur during treatment or within a few weeks of finishing. Some side effects may be late effects, not appearing until some time after treatment.

Short-term side effects

Side effects can take several weeks to get better, though some may continue longer.

Fatigue (tiredness)

Your body uses a lot of energy dealing with the effects of radiation on healthy cells. Tiredness usually builds up slowly during the course of the treatment, particularly near the end. It may last for some time after treatment ends.

Bladder and bowel problems

You may wee more often or with more urgency, or with a burning sensation. Try to drink plenty of water to make your wee less concentrated.

You may need to poo more often, or you may have diarrhoea (runny poo). You may pass more wind than normal. Less commonly, there may be some blood in the poo. Your treatment team will prescribe medicines to reduce these side effects.

Skin redness, soreness and swelling

Radiation therapy may make the skin in the treatment area dry and itchy. Occasionally, your skin may look red and peel, like sunburn. The treatment team will recommend creams to use to make you more comfortable.

Hair loss

If radiation therapy is aimed at your pelvic area, you may lose your pubic hair. This hair may grow back after the treatment ends, but it will usually be thinner. The radiation therapy will not cause you to lose hair from your head or other parts of your body.

Vaginal discharge

Radiation therapy may cause or increase vaginal discharge. Let your treatment team know if it smells bad or has blood in it. Do not wash inside the vagina with douches as this may cause infection.

Long-term or late effects

Some side effects from radiation therapy may not show up until many months or years after treatment. These are called late effects.

Lymphoedema (swelling of the legs)

Radiation can scar the lymph nodes and vessels and stop them draining lymph fluid properly from the legs. This may lead to swelling of the legs. This can occur months or years after radiation therapy.

Bladder and bowel problems

Bladder and bowel changes can also be late effects, appearing months or years after radiation therapy finishes.

You may wee more often or need to go in a hurry.

The movement of poo through the large bowel can become faster, meaning you need to go to the toilet more urgently and more often. It is important to let your doctor know if you have any bleeding or if you have pain in the abdomen and cannot open your bowels.

Narrowing of the vagina

The vagina may become drier, shorter and narrower (vaginal stenosis), which may make sex and follow-up pelvic examinations uncomfortable or difficult. Your treatment team will suggest strategies to prevent this.

Menopause

If your ovaries have not been removed, radiation therapy can stop the ovaries producing hormones, which leads to early menopause. Your periods will stop, you will no longer be able to become pregnant. You may also have menopausal symptoms, such as hot flushes.

Pelvic fracture

In rare cases, radiation therapy to the pelvic area can weaken the bones and cause a fracture. Pelvic fractures are the most common. This may not occur for two to four years after treatment.

See more information about radiation therapy and its side effects or call Cancer Council 13 11 20.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells or slow their growth while causing the least possible damage to healthy cells. Chemotherapy may be given if the cervical cancer is advanced or returns after treatment, and may be combined with radiation therapy (when it is called chemoradiation therapy)

The drugs are usually given through a vein (intravenously) and most people have treatment as an outpatient. The number of chemotherapy sessions you have depends on the type of cervical cancer and any other treatments you may be having. If you have chemotherapy without radiation therapy, you are likely to have six sessions, scheduled every three to four weeks over several months.

Side effects

The side effects of chemotherapy vary according to the drugs given, how often you have treatment and your general health and fitness. They will also depend on if you have chemotherapy alone or as part of chemoradiotherapy. You may experience nausea or vomiting, feel tired (fatigued) or lose some hair from your body or head. Chemotherapy can also cause temporary or permanent menopause.

Chemotherapy may also reduce the number of blood cells in your body. Depending on the type of blood cells affected, you may feel very tired and be more prone to infections. If your temperature rises to 38° C or above, seek urgent medical attention. You will have regular blood tests during treatment to monitor your levels of blood cells.

Most side effects are temporary, and your treatment team can help you to prevent or reduce them.

Our chemotherapy section has more information or call Cancer Council 13 11 20.

Targeted therapy

Targeted therapy drugs affect specific molecules within cells to block cell growth. They are used to treat some people with cervical cancer that has spread to other parts of the body or has come back and cannot be treated by surgery or radiation therapy.

Cancers develop their own blood vessels to help them grow. This process is called angiogenesis. Some targeted therapy drugs known as angiogenesis inhibitors are designed to stop this process.

Bevacizumab is an angiogenesis inhibitor that can be used to treat advanced cervical cancer. It is given with chemotherapy every three weeks through a drip into a vein (infusion). The total number of infusions you receive will depend on how you respond to treatment.

Side effects

These are the most common side effects experienced by people taking bevacizumab:

  •  high blood pressure
  • feeling tired
  • loss of appetite.

Less common side effects include bleeding and wound-healing problems.

For more information on treatments and managing side effects, look at the other sections on our website about surgerychemotherapy, radiation therapy and targeted therapy or call Cancer Council 13 11 20.

Palliative treatment

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease.

Many people think that palliative treatment is for people at the end of their life but it may be beneficial for people at any stage of advanced cervical cancer. It is about living as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve any pain and help manage other symptoms. Treatment may include radiation therapy, chemotherapy or other medicines such as hormone treatment.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, practical and spiritual needs. The team also provides support to families and carers.

See more information about palliative care or living with advanced cancer, or call Cancer Council 13 11 20.

Key points

Surgery

  • Surgery may be used to remove early cervical cancer. The type of surgery you have will depend on how far the cancer has spread.
  • Some people with early stage cervical cancer who still want to have children may have a cone biopsy or a trachelectomy to remove the cervix and some surrounding tissue..
  • Other operations include a hysterectomy to remove the cervix and uterus, and a bilateral salpingo-oophorectomy to remove the ovaries and fallopian tubes.
  • Sometimes the lymph nodes in the pelvic region are removed (a lymphadenectomy).

Radiation therapy and chemotherapy

  • Radiation therapy may be used on its own as the main treatment for cervical cancer, or you may have it after surgery to help  get rid of any remaining cancer cells.
  • Radiation therapy is often used with chemotherapy (chemoradiation) to treat more advanced cervical cancer.

Targeted therapy

  • Targeted therapy may be used for advanced cancer. The most commonly used targeted therapy drug for cervical cancer that has spread is bevacizumab.

Treatment side effects

  • All treatments can cause side effects, such as pain, skin problems or diarrhoea.
  • If having children is important to you, talk to your doctor before starting treatment.

Expert content reviewers:

Associate Professor Penny Blomfield, Gynaecological Oncologist, Hobart Women’s Specialists, and Chair, Australian Society of Gynaecological Oncologists, Tas; Karina Campbell, Consumer; Carmen Heathcote, 13 11 20 Consultant, Cancer Council Queensland; Dr Pearly Khaw, Consultant Radiation Oncologist, Peter MacCallum Cancer Centre, Vic; Associate Professor Jim Nicklin, Director, Gynaecological Oncology, Royal Brisbane and Women’s Hospital, and Associate Professor Gynaecologic Oncology, University of Queensland; Professor Martin K .Oehler, Director, Gynaecological Oncology, Royal Adelaide Hospital, SA; Dr Megan Smith, Program Manager – Cervix, Cancer Council NSW; Pauline Tanner, Cancer Nurse Coordinator – Gynaecology, WA Cancer & Palliative Care Network, WA; Tamara Wraith, Senior Clinician, Physiotherapy Department, Royal Women’s Hospital, Vic

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