Cervical — treatment notes

15Cervical

Snapshot. Mostly squamous cell carcinoma (also adenocarcinoma), driven by persistent HPV (human papillomavirus) infection — largely preventable (HPV vaccine + screening). Radiotherapy — especially brachytherapy — is central and curative in locally advanced disease, unlike most other solid tumours. Spreads locally (parametria → pelvic side wall) then to nodes. Staged by FIGO 2018 (now incorporates imaging + nodal status). ⚠ Major trials/FDA labels still use FIGO 2014 staging — trial-eligibility stages don't always map cleanly onto your clinic's FIGO 2018 stage.

Workup

Pelvic examination + biopsy · MRI pelvis (local/parametrial extent) + PET/CT (nodes/metastases) · HPV/p16 · FIGO 2018 stage (sentinel-node mapping increasingly used for early disease) · PD-L1 (CPS) in advanced/recurrent disease.

Treatment by setting

Setting	Treatment
Early IA–IB2, small, low-risk	Surgery — cone biopsy or radical trachelectomy (fertility-sparing) for very early disease Or radical hysterectomy + pelvic lymphadenectomy ± sentinel-node mapping Very-low-risk → simple hysterectomy is non-inferior (SHAPE) <2 cm, <10 mm invasion, no LVSI (lymphovascular space invasion) — less morbidity (urinary retention / incontinence) than radical surgery
Locally advanced IB3–IVA	Definitive concurrent chemoradiation (cisplatin) + BRACHYTHERAPY the cornerstone — brachytherapy is essential for cure ⚠ Overall treatment time matters — complete within ~8 weeks prolongation costs cure Add pembrolizumab to chemoradiation for HIGH-RISK disease (KEYNOTE-A18) improves both PFS and OS · FDA-approved specifically for FIGO 2014 stage III–IVA (the trial also enrolled IB2–IIB node-positive, but that subset isn't in the approved label) ⚠ NOT PD-L1-selected — do NOT require a CPS here CPS selection belongs to the METASTATIC setting (KEYNOTE-826), not to this row
Metastatic / recurrent	1st line → platinum + paclitaxel + bevacizumab + pembrolizumab (KEYNOTE-826) pembrolizumab requires PD-L1 CPS ≥1 per FDA label CPS <1 → platinum + paclitaxel + bevacizumab alone no pembrolizumab Later line → tisotumab vedotin (innovaTV 301) a tissue-factor-directed antibody-drug conjugate

Watch

Cisplatin (nephro/oto/neurotoxicity); pelvic radiotherapy → bowel/bladder/vaginal toxicity, ovarian failure (fertility); bevacizumab → fistula (GI/GU) and bowel perforation (notably higher in cervical), hypertension; pembrolizumab → irAEs (immune-related adverse events).