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NCCN Clinical Practice Guidelines in Oncology™
Cervical Cancer
V.1.2010
www.nccn.org
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
NCCN Cervical Cancer Panel Members
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Gynecology oncology
Medical oncology
Hematology
Radiotherapy/Radiation oncology
Pathology
Writing committee member
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‡
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Continue
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Benjamin E. Greer, MD/Co-Chair
Fred Hutchinson Cancer Research
Center/Seattle Cancer Care Alliance
Wui-Jin Koh, MD/Co-Chair
Fred Hutchinson Cancer Research
Center/Seattle Cancer Care Alliance
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Nadeem R. Abu-Rustum, MD
Memorial Sloan-Kettering Cancer Center
Sachin M. Apte, MD, MS
H. Lee Moffitt Cancer Center
& Research Institute
Michael A. Bookman, MD
Fox Chase Cancer Center
Robert E. Bristow, MD
The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins
Susana M. Campos, MD, MPh, MS
Dana-Farber/Brigham and Women’s
Cancer Center
John Chan, MD
UCSF Helen Diller Family
Comprehensive Cancer Center
Kathleen R. Cho, MD
University of Michigan
Comprehensive Cancer Center
Larry Copeland, MD
The Ohio State University Comprehensive
Cancer Center - James Cancer Hospital
and Solove Research Institute
Marta Ann Crispens, MD
Vanderbilt-Ingram Cancer Center
Nefertiti duPont, MD, MPH
Roswell Park Cancer Institute
Patricia J. Eifel, MD
The University of Texas
M. D. Anderson Cancer Center
Warner K. Huh, MD
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University of Alabama at Birmingham
Comprehensive Cancer Center
Daniel S. Kapp, MD, PhD
Stanford Comprehensive Cancer Center
John R. Lurain, III, MD
Robert H. Lurie Comprehensive Cancer
Center of Northwestern University
Mark A. Morgan, MD
Fox Chase Cancer Center
Robert J. Morgan, Jr., MD
City of Hope
Comprehensive Cancer Center
Nelson Teng, MD, PhD
Stanford Comprehensive Cancer Center
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Steven W. Remmenga, MD
UNMC Eppley Cancer Center at
The Nebraska Medical Center
R. Kevin Reynolds, MD
University of Michigan
Comprehensive Cancer Center
Angeles Alvarez Secord, MD
William Small, Jr., MD
Robert H. Lurie Comprehensive Cancer
Center of Northwestern University
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Duke Comprehensive Cancer Center
NCCN Guidelines Panel Disclosures
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
These guidelines are a statement of evidence consensus of the authors regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties
of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These
guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not
be reproduced in any form without the express written permission of NCCN. ©2009.
Table of Contents
NCCN Cervical Cancer Panel Members
Clinical Stage (CERV-1)
Stage IA1 (CERV-2)
Stage IA2, IB1, and Stage IIA ( 4 cm) (CERV-2)
Stage IB2 and Stage IIA (> 4 cm) (CERV-2)
Selected bulky Stage IB2, IIA and Stages IIB, IIIA, IIIB, IVA (CERV-4)
Incidental findings of invasive cancer at simple hysterectomy (CERV-7)
Surveillance (CERV-8)
Local/regional recurrence (CERV-9)
Distant metastases (CERV-10)
Chemotherapy Regimens for Cervical Cancer (CERV-A)
Guidelines Index
Print the Cervical Cancer Guideline
Summary of Guidelines Updates
�
Clinical Trials:
Categories of Evidence and
Consensus:
NCCN
All recommendations
are Category 2A unless otherwise
specified.
See
The
believes that the best management
for any cancer patient is in a clinical
trial. Participation in clinical trials is
especially encouraged.
NCCN
To find clinical trials online at NCCN
member institutions, click here:
nccn.org/clinical_trials/physician.html
NCCN Categories of Evidence
and Consensus
For help using these
documents, please click here
Staging
Discussion
References
The NCCN Cervical Cancer Guidelines include the management of squamous cell carcinoma,
adenosquamous carcinoma, and adenocarcinoma of the cervix.
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Summary of the Guidelines updates
( )
( )
Table of contents
CERV-2
( )CERV-A
:
The following statement was added, “The NCCN Cervical Cancer Guidelines include the management of squamous cell carcinoma,
adenosquamous carcinoma, and adenocarcinoma of the cervix.”
Footnote “c” that states, “
First-line combination therapy: “Cisplatin/paclitaxel” changed from category 2A to category 1.
Possible first-line single agent therapy: After “Cisplatin”, the panel added “preferred as a single agent”.
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Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus
fluorouracil” was added for clarification.
Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer
Gemcitabine and Topotecan were removed from “Possible first-line single agent therapy” and placed under “Second-line therapy”.
UPDATES
Summary of changes in the 1.2010 version of the Cervical Cancer guidelines from the 1.2009 version include:
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-1
WORKUP
Stage IA1
Stage IA2
Stage IB1
Stage IIA ( 4 cm)�
Stage IB2
Stage IIA (> 4 cm)
Incidental finding of invasive
cancer at simple hysterectomy
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H&P
CBC, platelets
Cervical biopsy, pathologic
review
Cone biopsy as indicated
LFT/renal function studies
Imaging (optional for stage IB1)
including chest x-ray, PET/CT
scan, CT/MRI
EUA cystoscopy/proctoscopy
�
Optional ( Stage IB2):
a
CLINICAL STAGE
Selected bulky:
Stage IB2, IIA
Stage IIB
Stage IIIA, IIIB
Stage IVA
See Primary Treatment (CERV- 2)
See Primary Treatment (CERV-2)
See Primary Treatment (CERV-2 )
See Primary Treatment (CERV-4)
See Primary Treatment (CERV-7)
aFor suspicion of bladder/bowel involvement, cystoscopy/proctoscopy with biopsy is required.
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-2
Stage IB1
and stage IIA
( 4 cm)�
Stage IB2
and stage IIA (> 4 cm)
( )also see CERV-4
PRIMARY TREATMENT
These doses are recommended for most patients based on summation of conventional external-beam fractionation and low-dose rate (40-70 cGy/h)
brachytherapy equivalents. Modify treatment based on normal tissue tolerance.
Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil.
b
c
CLINICAL STAGE
Stage IA2
Radical hysterectomy + pelvic lymph node dissection
± para-aortic lymph node sampling
or
Brachytherapy + pelvic RT (point A dose: 75-80 Gy)
or
Radical trachelectomy
+ pelvic lymph node dissection
b
for fertility preservation
± para-aortic lymph node sampling
Radical hysterectomy + pelvic lymph node dissection
(category 1)
or
Pelvic RT + brachytherapy (point A dose: 80-85 Gy)
± para-aortic lymph node sampling
Radical trachelectomy for fertility preservation for lesions (Stage IB1)
+ pelvic lymph node dissection ± para-aortic lymph node sampling
b
or
Radical hysterectomy + pelvic lymph node dissection
+ para-aortic lymph node sampling
or
Pelvic RT + concurrent cisplatin-containing chemotherapy
+ brachytherapy (point A dose 85 Gy) (category 1)
or
Pelvic RT + concurrent cisplatin-containing chemotherapy
+ brachytherapy (point A dose 75-80 Gy) + adjuvant hysterectomy
(category 3)
(category 2B)
c
� b
b
c
See Surgical Findings (CERV-3)
See Surgical Findings (CERV-3)
See Surveillance (CERV-8)
See Surveillance (CERV-8)
See Surgical Findings (CERV-3)
See Surveillance (CERV-8)
Stage IA1
Extrafascial hysterectomy
or
Observe if patient desires fertility or if inoperable
(only if cone biopsy has negative margins)
or
Modified radical hysterectomy + pelvic lymph node dissection
if lymphovascular invasion (category 2B)
See Surveillance (CERV-8)
See Surgical Findings (CERV-3)
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-3
ADJUVANT TREATMENTSURGICAL FINDINGS
Negative
nodes
Observe
or
Pelvic RT if combination of high-risk factors (category 1)
(ie, large primary tumor, deep stromal invasion, and/or
lymphovascular space invasion)
± concurrent cisplatin-based chemotherapy
(category 2B for chemotherapy)
c
Positive pelvic nodes
or
Positive surgical margin
or
Positive parametrium
Pelvic RT + concurrent cisplatin-containing chemotherapy
(category 1)
± vaginal brachytherapy
c
See Surveillance (CERV-8)
Para-aortic lymph
node positive by
surgical staging
Negative
for distant
metastasis
Chest
CT/PET
scan
Consider biopsy
of suspicious
areas as
indicated
Positive
for distant
metastasis
Para-aortic lymph node RT
+ concurrent cisplatin-
containing chemotherapy
+ pelvic RT ± brachytherapy
c
cConcurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil.
dSee Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer (CERV-A).
Negative
Positive
Systemic therapy /
Individualized RT
d
See Surveillance
(CERV-8)
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-4
PRIMARY TREATMENT
Selected bulky
Stage IB2,
Stage IIA (> 4 cm)
Stage IIB, IIIA,
IIIB, IVA
Surgical
staging:
Extraperitoneal
or laparoscopic
lymph node
dissection
(category 2B)
or
Radiologic
imaging only
Negative
Pelvic
+ concurrent cisplatin-containing chemotherapy
(category 1)
+ brachytherapy
RT
c
e
Positive See Node Status
(CERV-5)
Pelvic RT
+ concurrent cisplatin-containing chemotherapy
(category 1)
+ brachytherapy
c
e
Negative
adenopathy
Positive
adenopathy
See Imaging
Results (CERV-6)
CLINICAL STAGE
cConcurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil.
ePelvic RT + brachytherapy total point A dose 85 Gy.�
See Surveillance
(CERV-8)
FNA if clinically
indicated
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-5
Pelvic lymph node
positive/para-aortic
lymph node negative
by surgical staging
Para-aortic lymph
node positive by
surgical staging
Negative
for distant
metastasis
Further
radiologic
workup as
clinically
indicated
Pelvic RT
+ concurrent cisplatin-containing
chemotherapy (category 1)
+ brachytherapy
c
e
Consider biopsy
of suspicious
areas as
indicated
Positive for
distant
metastasis
Pelvic RT
+ para-aortic lymph node RT
+ concurrent cisplatin-containing
chemotherapy
+ brachytherapy
f
c
e
SELECTED BULKY Stage IB2, IIA (> 4 cm);
Stage IIB, IIIA, IIIB, IVA
NODE STATUS
PRIMARY TREATMENT
Negative
Positive
Systemic therapy /
Individualized RT
d
c
d
Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil.
clinical tumor volume
e
f
Pelvic RT + brachytherapy total point A dose 85 Gy.
RT dose is 45-50 Gy to (CTV).
�
See Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer (CERV-A).
See Surveillance
(CERV-8)
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-6
Pelvic node
positive;
Para-aortic lymph
node negative
Pelvic node
positive; Para-
aortic lymph
node positive
Pelvic RT
+ brachytherapy
+ concurrent cisplatin-
containing
chemotherapy
± para-aortic lymph
node RT
or
Retroperitoneal lymph
node dissection
e
c
(category 1)
f
SELECTED BULKY Stage IB2, IIA
Stage IIB, IIIA, IIIB, IVA
IMAGING RESULTS
(> 4 cm) PRIMARY TREATMENT
Distant metastases;
with biopsy
confirmation as
clinically indicated
Consider
retroperitoneal
lymph node
dissection
Systemic therapy /
Individualized RT
d
See Surveillance
(CERV-8)
c
d
Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil.
RT dose is 45-50 Gy to clinical tumor volume (CTV).
ePelvic RT + brachytherapy total point A dose 85 Gy.�
f
See Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer (CERV-A).
Positive
adenopathy
by CT, MRI
and/or PET
Para-aortic
negative
Para-aortic
positive
Pelvic RT
+ brachytherapy
+ concurrent
cisplatin-containing
chemotherapy
e
c
(category 1)
Extended-field RT
+ brachytherapy
+ concurrent
cisplatin-containing
chemotherapy
f
e
c
See Surveillance
(CERV-8)
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-7
INCIDENTAL FINDING
OF INVASIVE CANCER
AT SIMPLE HYSTERECTOMY
Stage IA1 with
lymphovascular
space invasion
or Stage IA2�
Negative
margins;
negative
imaging
Positive
marginsg, gross
residual disease,
or positive
imaging
Pelvic RT +
brachytherapy
± concurrent
cisplatin-
containing
chemotherapy
or
f
c
Complete
parametrectomy
+ upper
vaginectomy
+ pelvic lymph
node dissection
± para-aortic lymph
node sampling
Negative
nodes
Observe
or
Optional pelvic RT
± vaginal brachytherapy
if large primary tumor,
deep stromal invasion
and/or lymphovascular
space invasion
f
Positive nodes
or
Positive
surgical margin
or
Positive
parametrium
Pelvic RT
(para-aortic lymph node
RT if para-aortic lymph
node positive)
+ concurrent cisplatin-
containing
chemotherapy
± individualized
brachytherapy
(if positive vaginal
margin)
f
c
PRIMARY TREATMENT
�
�
�
�
�
�
H&P
CBC, platelets
Optional ( Stage IB2):
EUA cystoscopy/proctoscopy
LFT/renal function studies
Imaging (optional for stage IB1)
including chest x-ray, PET/CT
scan, CT/MRI
�
a
a
f
g
For suspicion of bladder/bowel involvement, cystoscopy/proctoscopy with biopsy is required.
RT dose is 45-50 Gy to clinical tumor volume (CTV).
Invasive cancer at surgical margin.
cConcurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil.
Stage IA1
Pathologic
review
No lymphovascular
space invasion
See Surveillance
CERV-8
Imaging
negative for
nodal disease
Imaging
positive for
nodal disease
Consider surgical
debulking of
grossly enlarged
nodes
See Surveillance
(CERV-8)
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2010NCCN
®
Cervical Cancer
Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CERV-8
SURVEILLANCE
�
�
�
�
�
�
Interval H&P
Cervical/vaginal cytology
every 3-6 mo for 2 y,
then every 6 mo for 3-5 ,
then annually
Chest x-ray annually (optional)
CBC, BUN, creatinine every 6 mo
(optional)
PET/CT scan as clinically
indicated
Recommend