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Stage 4 Cervical Cancer
Patients diagnosed with Stage 4 Cervical Cancer have disease that has spread from the original cancer to one or more distant sites in the body. Stage 4 Cervical Cancer is commonly detected from an abnormal pelvic examination or symptoms produced by the patient’s cancer. Following a staging evaluation of cervical cancer, a stage IV cancer is said to exist if the cancer has extended beyond the cervix into adjacent organs, such as the rectum or bladder (stage IVA), or the cancer has spread to distant locations in the body which may include the bones, lungs or liver (stage IVB).
The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival.
The following is an overview of the treatment of stage IV cervical cancer. Circumstances unique to your situation and prognostic factors of your cancer will influence how these general treatment principles are applied to your situation. The information on this web-site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed by following the cancer news to learn about new treatments and the results of clinical trials.
Patients diagnosed with stage IV cervical cancer can be broadly divided into two groups. Patients with disease that is locally confined, but involves adjacent organs in the pelvis, such as the rectum and bladder, have localized stage IVA cervical cancer. Other patients have disease that has spread to distant organs, most commonly the bones, lungs or liver, and have metastatic stage IVB cervical cancer. Management of patients with metastatic stage IVB disease is aimed at control of symptoms and pain. After undergoing treatment for cervical cancer, your doctor will continue to follow you to check to see that the cancer has not returned or is not progressing.
Treatment of Localized Stage IVA Cervical Cancer
Stage IVA cervical cancer is currently best managed by a combination of radiation therapy and chemotherapy. Radiation therapy is treatment with high energy x-rays that have the ability to kill cancer cells. Radiation therapy can be administered by a machine that aims x-rays at the body (external beam radiation) or by placing small capsules of radioactive material directly near the cervix (internal or implant radiation). Most patients will receive both kinds of radiation therapy during their course of treatment. External beam radiation therapy for cervical cancer is administered on an outpatient basis for approximately 4 to 6 weeks.
During or immediately following the external beam portion of radiation therapy, patients may also undergo an implant radiation procedure. Placing the radiation within the cervix allows a high dose of radiation to be delivered to the cancer while reducing the radiation to the surrounding normal tissues and organs. During a procedure in the operating room, a small device is placed into the cervix and vagina and later is “loaded” with radioactive material. The radioactive material is left in place while the patient stays in the hospital for 1-3 days. This process may be performed once or twice during the course of treatment.
Chemotherapy, such as Platinol®, 5-fluorouracil and other drugs, has the ability to kill cancer cells and make radiation therapy more effective at killing cancer cells. The strategy of administering chemotherapy concurrently with radiation treatment is appealing because chemotherapy and radiation therapy may act together to increase the killing of cancer cells. Chemotherapy may also destroy cells independently of radiation therapy. Several clinical studies performed in patients with locally advanced cervical cancer utilizing concurrent chemotherapy and radiation therapy have suggested that this strategy may improve remission rates and prolong survival. To definitively determine whether radiation therapy administered with concurrent chemotherapy is superior to radiation therapy alone, several clinical studies were designed to directly compare the two treatments in patients with locally advanced cervical cancer.
One recent pivotal clinical trial conducted by various oncology groups in the United States has shown that radiation therapy combined with chemotherapy for locally advanced cervical cancer is superior to treatment with radiation therapy alone.
Even with combination chemotherapy and radiation treatment, approximately 20-40% of patients with stage IV cervical cancer experience recurrence of their cancer. In some patients, cancer cells may have survived near the cancer despite the radiation therapy. Other patients with stage IV disease already have small amounts of cancer that have spread outside the cervix and were not treated by the chemotherapy. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix gland are referred to as micro-metastases. The presence of these microscopic areas of cancer or surviving cancer cells can cause the relapses that follow treatment.
Treatment of Metastatic Stage IVB Cervical Cancer
Cervical cancer that has spread to distant organs and bones is difficult to treat. Historically, patients with metastatic cervical cancer have been considered incurable and rarely survive more than a year or two. Some patients are offered treatment with chemotherapy for the purpose of prolonging their duration of survival and alleviating symptoms from progressive cancer. Other patients are managed with efforts to reduce pain or bleeding, including local radiation therapy to affected parts of the body.
There is no good single chemotherapy approach that can improve the length of survival in patients with metastatic cervical cancer. Treatment with Platinol® can produce shrinkage in 15-25% of patients with metastatic cervical cancer. Many clinical trials have combined Platinol® with other chemotherapy drugs in hopes of improving cancer shrinkage and survival.
Possibilities to Improve Treatment
The progress that has been made in the treatment of cervical cancer has resulted from development of better treatments in patients with more advanced stages of cancer and participation in clinical trials.
New Chemotherapy Regimens: Several newer chemotherapeutic drugs have demonstrated ability to kill cervical cancer cells in patients with advanced cancer. One area of active investigation is the development and exploration of single or multi-agent chemotherapy regimens as a treatment approach for patients with widespread cervical cancer. In particular, drugs such as paclitaxel, ifosfamide, Taxotere®, Navelbine® and Camptosar® appear to have promising activity against cervical cancer cells and are being tested alone or in combination with radiation and other anticancer agents in clinical trials.
Newer Radiation Techniques: External beam radiation therapy can be delivered more precisely to the cervix by using a special CT scan and targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures, such as the bladder or rectum.
Biological Therapy: Biologic therapies are naturally occurring or synthesized substances that direct, facilitate or enhance the body’s normal immune defenses. The goal of biologic therapy is to have the patient’s own immune defenses attack and destroy the cancer cells. Biologic therapies include interferons, interleukins, monoclonal antibodies and vaccines. In an attempt to improve survival rates, these and other agents are being tested alone or in combination with chemotherapy in clinical trials.
New anti-cancer therapies continue to be developed and evaluated in clinical trials. There are three phases of clinical trials before approval. See our clinical trials section for more information.
Managing Liver Metastases
When cervical cancer spreads to the liver, it doesn’t always cause symptoms. It may be picked up by liver function tests, which are blood tests that measure certain levels of enzymes and proteins in the blood. Abnormal levels can indicate liver disease or damage.
If liver metastasis causes symptoms, they can include:
• pain or discomfort in the mid-section
• fatigue and weakness
• weight loss/poor appetite
• swelling in the legs
• a yellow tint to the skin or the whites of the eyes
In addition to liver function tests, doctors use imaging tests to diagnose liver metastases. These may include MRI (magnetic resonance imaging), CT scan (computed tomography), ultrasound, and/or PET scan (positron emission tomography). Sometimes, a combined PET/CT scan is used.
Your doctor also may recommend getting a sample of the suspicious area(s) for examination under a microscope (biopsy). He or she may involve an interventional radiologist to obtain precise and minimally invasive imaging.
The most common treatments for metastatic cervical cancer in any location (bone, brain, lung, or liver) are systemic medications, which treat cancer throughout the entire body. Systemic medications include chemotherapy, targeted therapies, and clinical trials that have already been discussed. Liver directed therapies, including surgery, may be an option.
Liver Directed Therapies: There are numerous liver directed therapies available for those who are faced with a Stage 4 cervical cancer diagnosis with liver metastases or cervical cancer that has spread to the liver. These therapies are dependent on the size, number, and location of the liver tumors. These liver directed therapies may include chemoembolization, cryoablation, cyberknife, hepatic arterial infusion, liver resection, proton beam therapy, radioembolization or SIRT, radiofrequency ablation, or SBRT. You can learn more on our treatment page under liver directed therapies.
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