Stage 0 Cervical Cancer
Consensus guidelines have been issued for managing women with cervical intraepithelial neoplasia or adenocarcinoma in situ. Properly treated, tumor control of in situ cervical carcinoma should be nearly 100%. Either expert colposcopic-directed biopsy or cone biopsy is required to exclude invasive disease before therapy is undertaken. A correlation between cytology and colposcopic-directed biopsy is also necessary before local ablative therapy is done. Even so, unrecognized invasive disease treated with inadequate ablative therapy may be the most common cause of failure. Failure to identify the disease, lack of correlation between the Pap smear and colposcopic findings, adenocarcinoma in situ, or extension of disease into the endocervical canal makes a laser, loop, or cold-knife conization mandatory. The choice of treatment will also depend on several patient factors including age, desire to preserve fertility, and medical condition. Most importantly, the extent of disease must be known. The World Health Organization has made recommendations about the use of cryotherapy for providers in low-resource settings and has recognized the need to consider the availability of cryotherapy in relation to the availability of other treatment options.
In selected cases, the outpatient loop electrosurgical excision procedure (LEEP) may be an acceptable alternative to cold-knife conization. This quickly performed in-office procedure requires only local anesthesia and obviates the risks associated with general anesthesia for cold-knife conization.[4,5] However, controversy exists as to the adequacy of LEEP as a replacement for conization. A trial comparing LEEP with cold-knife cone biopsy showed no difference in the likelihood of complete excision of dysplasia. However, two case reports suggested that the use of LEEP in patients with occult invasive cancer led to an inability to accurately determine depth of invasion when a focus of the cancer was transected.
In a randomized, double-blind, placebo-controlled, phase II trial of 59 patients, a vaginal preparation of imiquimod, an immune-modulating agent, showed improved clearance rates for cervical intraepithelial neoplasia (CIN), or CIN 2/3, and high-risk human papillomavirus. This is the first proven medical treatment for preinvasive cervical disease; however, the vaginal preparation is not yet commercially available.
Standard treatment options:
Methods to treat ectocervical lesions include the following:
- Laser therapy.
- Total abdominal or vaginal hysterectomy for postreproductive patients, only if excisional biopsy is not feasible.
- Internal radiation therapy for medically inoperable patients.
When the endocervical canal is involved, laser or cold-knife conization may be used for selected patients to preserve the uterus and avoid radiation therapy and/or more extensive surgery.
Total abdominal or vaginal hysterectomy is an accepted therapy for the postreproductive age group and is particularly indicated when the neoplastic process extends to the inner cone margin. For medically inoperable patients, a single intracavitary insertion with tandem and ovoids for 5,000 mg hours (80 Gy vaginal surface dose) may be used.
After treatment for CIN, women remain at a higher risk of developing cervical cancer, even if they follow accepted posttreatment screening guidelines.Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage 0 cervical cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.References
- Wright TC Jr, Massad LS, Dunton CJ, et al.: 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol 197 (4): 340-5, 2007. [PUBMED Abstract]
- Shumsky AG, Stuart GC, Nation J: Carcinoma of the cervix following conservative management of cervical intraepithelial neoplasia. Gynecol Oncol 53 (1): 50-4, 1994. [PUBMED Abstract]
- Santesso N, Schünemann H, Blumenthal P, et al.: World Health Organization Guidelines: Use of cryotherapy for cervical intraepithelial neoplasia. Int J Gynaecol Obstet 118 (2): 97-102, 2012. [PUBMED Abstract]
- Wright TC Jr, Gagnon S, Richart RM, et al.: Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Obstet Gynecol 79 (2): 173-8, 1992. [PUBMED Abstract]
- Naumann RW, Bell MC, Alvarez RD, et al.: LLETZ is an acceptable alternative to diagnostic cold-knife conization. Gynecol Oncol 55 (2): 224-8, 1994. [PUBMED Abstract]
- Widrich T, Kennedy AW, Myers TM, et al.: Adenocarcinoma in situ of the uterine cervix: management and outcome. Gynecol Oncol 61 (3): 304-8, 1996. [PUBMED Abstract]
- Girardi F, Heydarfadai M, Koroschetz F, et al.: Cold-knife conization versus loop excision: histopathologic and clinical results of a randomized trial. Gynecol Oncol 55 (3 Pt 1): 368-70, 1994. [PUBMED Abstract]
- Eddy GL, Spiegel GW, Creasman WT: Adverse effect of electrosurgical loop excision on assignment of FIGO stage in cervical cancer: report of two cases. Gynecol Oncol 55 (2): 313-7, 1994. [PUBMED Abstract]
- Grimm C, Polterauer S, Natter C, et al.: Treatment of cervical intraepithelial neoplasia with topical imiquimod: a randomized controlled trial. Obstet Gynecol 120 (1): 152-9, 2012. [PUBMED Abstract]
- Wright VC, Chapman W: Intraepithelial neoplasia of the lower female genital tract: etiology, investigation, and management. Semin Surg Oncol 8 (4): 180-90, 1992 Jul-Aug. [PUBMED Abstract]
- Bloss JD: The use of electrosurgical techniques in the management of premalignant diseases of the vulva, vagina, and cervix: an excisional rather than an ablative approach. Am J Obstet Gynecol 169 (5): 1081-5, 1993. [PUBMED Abstract]
- Tsukamoto N: Treatment of cervical intraepithelial neoplasia with the carbon dioxide laser. Gynecol Oncol 21 (3): 331-6, 1985. [PUBMED Abstract]
- Benedet JL, Miller DM, Nickerson KG, et al.: The results of cryosurgical treatment of cervical intraepithelial neoplasia at one, five, and ten years. Am J Obstet Gynecol 157 (2): 268-73, 1987. [PUBMED Abstract]
- Grigsby PW, Perez CA: Radiotherapy alone for medically inoperable carcinoma of the cervix: stage IA and carcinoma in situ. Int J Radiat Oncol Biol Phys 21 (2): 375-8, 1991. [PUBMED Abstract]
- Rebolj M, Helmerhorst T, Habbema D, et al.: Risk of cervical cancer after completed post-treatment follow-up of cervical intraepithelial neoplasia: population based cohort study. BMJ 345: e6855, 2012. [PUBMED Abstract]