CERVICAL CANCER V.1.2009-NCCN.PDF
CERVICAL CANCER V.1.2009-NCCN.PDF
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NCCN Clinical Practice Guidelines in Oncology™
Cervical Cancer
V.1.2009
www.nccn.org
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Cervical Cancer
Version 1.2009, 02/06/09 © 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
Gynecology oncology
Medical oncology
Hematology
Radiotherapy/Radiation oncology
Pathology
Writing committee member
†
‡
§
*
Continue
*
*
*
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
§
†
†
Nadeem Abu-Rustum, MD
Memorial Sloan-Kettering Cancer Center
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
Dana-Farber/Brigham and Women’s
Cancer Center
Kathleen R. Cho, MD
University of Michigan
Comprehensive Cancer Center
Larry Copeland, MD
Arthur G. James Cancer Hospital &
Richard J. Solove Research Institute at
The Ohio State University
Marta Ann Crispens, MD
Vanderbilt-Ingram Cancer Center
Patricia J. Eifel, MD
The University of Texas
M. D. Anderson Cancer Center
Warner K. Huh, MD
Wainwright Jaggernauth, MD
Roswell Park Cancer Institute
Fox Chase Cancer Center
§
§
§
†
University of Alabama at Birmingham
Comprehensive Cancer Center
Daniel S. Kapp, MD, PhD
Stanford Comprehensive Cancer Center
John J. Kavanagh, MD
The University of Texas
M. D. Anderson Cancer Center
John R. Lurain, III, MD
Robert H. Lurie Comprehensive Cancer
Center of Northwestern University
Mark Morgan, MD
Robert J. Morgan, Jr., MD
City of Hope Comprehensive
Cancer Center
Nelson Teng, MD, PhD
Stanford Comprehensive Cancer Center
† ‡
§
C. Bethan Powell, MD
UCSF Helen Diller Family
Comprehensive Cancer Center
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
Duke Comprehensive Cancer Center
NCCN Guidelines Panel Disclosures
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Cervical Cancer
Version 1.2009, 02/06/09 © 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.
This manuscript is being
updated to correspond
with the newly updated
algorithm.
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)
Pelvic recurrence (CERV-9)
Extrapelvic or para-aortic recurrence (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
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Cervical Cancer
Version 1.2009, 02/06/09 © 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
(CERV-1
CERV-2
CERV-6
CERV-7
CERV-8
)
( )
( )
( )
( )
Workup, Fifth bullet: “Chest x-ray, PET scan...” changed to
“...PET/ scan...”.
Stage IB1 and Stage IIA; Primary Treatment:
“... + para-aortic lymph node sampling” changed to “... ± para-
aortic lymph node sampling”.
The panel removed “
“...Radical trachelectomy for fertility preservation for lesions
2 cm (Stage IB1)”.
Footnote regarding cystoscopy/proctoscopy was removed.
Primary Treatment for Negative margins; negative imaging:
“
Surveillance; Second bullet: “Pap test + visit every 3 mo for 1 y,
every 4 mo for 1 y, then every 6 mo for 3 y, then annually” changed
to “
“Suggest use of vaginal dilator after RT” changed to “
use of vaginal...”.
CT
Recommend
2 cm” from the recommendation
First column: The panel removed “FNA if clinically indicated” after
the phrase “Positive adenopathy by CT, MRI and/or PET”.
Complete parametrectomy + pelvic lymph node dissection...”
changed to “Complete parametrectomy + ...”
Cervical/vaginal cytology every 3-6 mo for 2 y, then every 6 mo
for 3-5 y, then annually”.
“Chest x-ray annually (category 2B)” changed to “Chest x-ray
annually ( )”
upper vaginectomy
optional
UPDATES
Summary of changes in the 1.2009 version of the Cervical Cancer guidelines from the 1.2008 version include:
( )
(
CERV-9
CERV-10)
( )CERV-A
First column: “Pelvic recurrence” changed to “
recurrence”.
Top pathway:
The panel added the recommendation “Consider surgical
resection, if feasible”.
“Definitive pelvic RT + platinum-based chemotherapy...”
changed to “ RT +...”
“Extrapelvic or para-aortic recurrence” changed to “Distant
metastases”.
The pathway “Isolated site” changed to “Resectable”.
“Resection ± IORT or Tumor-directed RT...” changed to
“ resection ± IORT or + concurrent
chemotherapy...”
Recommendations for RT, Adjuvant chemotherapy, and Best
supportive care were removed and the pathway is now directed
to “Surveillance” on ENDO-8.
Local/regional
Tumor-directed
Consider RT
Chemotherapy Regimens for Recurrent or Metastatic
Cervical Cancer
The title now includes the phrase “Strongly consider clinical
trial”.
First-line combination therapy: Cisplatin/paclitaxel and
Cisplatin/topotecan changed from (category 1) to
(category 2A) designation.
Possible first-line single agent therapy: “Gemcitabine
(category 2B)” was added.
Second-line therapy: The following agents were added:
bevacizumab, liposomal doxorubicin, pemetrexed.
Guidelines Index
Cervical Cancer TOC
Staging, Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Cervical Cancer
Version 1.2009, 02/06/09 © 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
H&P
CBC, platelets
Cervical biopsy, pathologic
review
Cone biopsy as indicated
Chest x-ray, PET/CT scan,
CT/MRI (optional for stage IB1)
LFT/renal function studies
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.
...
