CERVICAL CANCER TREATMENT IN GERMANY

• Cervical cancer is suspected when a woman has abnormal Pap smear results, visible cervical lesions, or abnormal — particularly post-coital — vaginal bleeding.

• To confirm the diagnosis, a Pap smear and, where indicated, a biopsy are performed.

• Cervical cancer is staged clinically using biopsy, gynaecological examination and chest X-ray; if the stage is higher than IB1, various imaging modalities are used — PET/CT, MRI or CT — in order to detect metastases.

• Treatment consists of surgical removal of the tumour at an early stage (usually stages IA to 1B1), radiotherapy combined with chemotherapy for locally advanced cancer (usually stages 1B2 to IVA), and chemotherapy for metastatic cancer.

• Screen women at regular intervals with a Pap smear test and an HPV test.

• HPV vaccination is recommended for girls and boys from the age of 9.

Pap test

For women aged 21 to 30, a preventive Pap smear test every 2 years is recommended. From the age of 30 the Pap test and the HPV test should be performed at the same time. If both results are negative, the screening interval should be extended to once every 3 – 5 years. Testing continues until the age of 65. If a woman has had a hysterectomy for a condition other than cancer and has had no abnormal Pap smear results, screening is not indicated.
HPV testing is the preferred method of follow-up assessment for all women with ASC-US (atypical squamous cells of undetermined significance), that is, with equivocal Pap smear results. If HPV testing shows that a woman does not have HPV, screening should continue regularly at the scheduled intervals. If the result is positive, colposcopy is required.

Human papillomavirus vaccine

Preventive vaccines are currently available that target HPV subtypes 16 and 18 and, in some cases, 6 and 11. These viral subtypes are most often associated with cervical intraepithelial lesions, genital warts and cervical cancer. The vaccine is intended to prevent cervical cancer but is not used to treat it. Three doses are given over 6 months. The vaccine is recommended for boys and girls, ideally before they become sexually active. The standard recommendation is to vaccinate boys and girls from the age of 9.

Two HPV vaccines are currently in use: Cervarix® and Gardasil®9.

There are three methods of treating cervical cancer:

1. Surgical treatment of cervical cancer is used in the early stages of the disease and involves removing the tumour together with part or all of the cervix, as well as  removing the pelvic lymph nodes where necessary.

Surgical treatment options for cervical cancer include:

• conisation of the cervix;
• radical trachelectomy — a modern, unique surgical procedure that allows young patients to preserve their reproductive function and have a child later on. During the procedure the cervix, part of the vagina and the pelvic lymph nodes are removed, while the uterus and ovaries are preserved;
• simple hysterectomy — the cervix and the uterus are removed;
• radical hysterectomy — removal of the uterus, cervix, surrounding tissue and lymph nodes.

2. High-dose radiotherapy can be used either as a stand-alone treatment or in addition to surgery for cervical cancer. This method is often combined with chemotherapy.

3. Chemotherapy may be used either concurrently in combination with radiotherapy or separately, after surgical treatment and the rehabilitation period have been completed. In some cases, when the cancer is detected at an early stage in a patient who wishes to preserve her reproductive function, chemotherapy is given before surgery.

Clinical staging is based on biopsy findings, examination and chest X-ray. If the stage is > IB1, CT or MRI of the abdomen and pelvis is performed to look for metastases, although the findings are not used for staging. PET/CT is increasingly used to check for spread beyond the cervix. If PET/CT, MRI or CT is not available, cystoscopy, sigmoidoscopy and intravenous urography are used.

The staging system is designed to build an extensive database for clinical research through the use of uniform diagnostic criteria worldwide. The system excludes the results of investigations that may not be universally available (for example MRI), because most cases of cervical cancer occur in developing countries. Because such tests are not used, features such as parametrial invasion and lymph node metastases may go undetected, which can lead to incorrect staging.

If imaging suggests significant enlargement of the pelvic or para-aortic lymph nodes (> 2 cm), diagnostic surgery is sometimes performed, usually via a retroperitoneal approach. Its sole purpose is to remove the enlarged lymph nodes so that radiotherapy can be delivered more precisely and effectively.

In squamous cell carcinoma, distant metastases usually appear only at an advanced stage or in the event of recurrence. Five-year survival:

• stage I: 80–90%

• stage II: 60–75%

• stage III: 30–40%

• stage IV: 0–15%

About 80% of recurrences occur within 2 years. Unfavourable prognostic factors are lymph node involvement, large tumour size and volume, deep cervical stromal invasion, parametrial invasion, vascular invasion and poor tumour cell differentiation.

• urgent appointments with leading German oncology experts;

• diagnosis and treatment exclusively at certified university cancer centres;

• innovative diagnostic techniques;

• accurate pathological diagnosis at certified institutes of pathology;

• an immediate start of treatment once the diagnostic work-up is complete;

• selection of the optimal individual therapy by a multidisciplinary tumour board (surgeons, uro-oncologists, radiologists, haematologists, chemotherapists, pathologists, nuclear medicine specialists);

• adherence to international treatment protocols;

• innovative methods of treating cancer;

• use of minimally invasive surgical techniques wherever possible;

• treatment with genuine, latest-generation cytostatic drugs;

• implantation of a port system for chemotherapy to avoid damage to the peripheral veins;

• supportive therapy to minimise the side effects of chemotherapy and radiotherapy;

• an individually tailored radiotherapy plan