The treatment of cervical cancer is mainly surgery and radiation therapy. In advanced cases, chemotherapy is used before and after surgery or radiotherapy.
For stage I and II cervical cancer, surgical resection and radiation therapy have the same efficacy. For younger patients and those in good health, hysterectomy is preferred to avoid vaginal atrophy and sclerosis caused by radiation therapy, which may affect sex life in the future; however, ovaries are preserved to maintain endocrine function. The procedure is usually a total hysterectomy, where the uterus, vagina and nearby lymph nodes are removed. The decision to preserve the ovaries is based on the age of the patient. For more advanced patients, radiation therapy is the primary treatment. Chemotherapy is sometimes chosen to complement radiation therapy to increase its effectiveness.
I. Surgical treatment
Radical hysterectomy and pelvic lymph node dissection should be performed except for in situ cervical cancer and very early stage microscopic invasive cancer which can be treated with radical hysterectomy. In recent years, some experts have performed colposcopic vaginal cervical cone resection for cervical carcinoma in situ, which is less invasive, more effective and easily accepted by patients, and is of great significance to improve patients’ survival quality.
1. Pre-surgery preparation ① Pay attention to keep the vulva clean and report to the doctor in time if menstruation comes. ②Prevent infection and perform vaginal douching daily 1 week before surgery. ③Prepare the diet well, both for nutrition and to create conditions for surgery. You should have a high protein and high calorie diet with less residue 2 days before surgery, semi-liquid 2 days before surgery, liquid 1 day before surgery, fasting after 12:00 pm the night before surgery and drinking 4 hours before surgery. ④ Take a bath 1 day before surgery, and pay attention to scrubbing the skin of the surgical field with soap; those who are too sick to take a bath should take a bed bath. ⑤ Vaginal irrigation in the morning after the operation to leave a urinary catheter.
2, post-operative precautions ① change to semi-sitting position after general anesthesia awake. ②The normal flow of drainage tube after surgery is 50~100ml for 24 hours. if the drainage flow is large and fast, there may be postoperative bleeding. ③Generally, a small amount of liquid food can be eaten after anal venting, and the next day, semi-liquid and gradually transition to general food. Pay attention to eating more fruits and vegetables and drinking more water to prevent constipation. Turn over regularly in bed and get out of bed as early as possible to promote gastrointestinal motility and prevent postoperative intestinal adhesions. ④ Keep the vulva clean: flush the vagina twice a day and disinfect the urethral opening to prevent infection. Do not hold urine for 2 weeks after surgery to avoid excessive bladder distension. ⑤The length of time the urinary catheter is left in place is related to the scope of surgery. Sometimes the urinary catheter can be left in place for several weeks, and bladder gymnastics, which alternates between intermittent clamping and relaxation of the urinary catheter, is usually started 10 days after surgery. The catheter can be removed 14 days after surgery. Patients are instructed to urinate regularly, with or without the need to urinate. Urination can be combined with abdominal hot compresses and acupuncture treatment. If you cannot insist on exercising, you can extend the time of indwelling urinary catheter, and at the same time, you should drink more water to ensure the daily urine output exceeds 2000ml to prevent infection.
3. Patients with surgical complications may have difficulty urinating, but will recover on their own after a period of time. A small number of patients may have lower limb edema and slight paralysis of the thighs. Or lymphatic cysts may be caused by the accumulation of lymphatic fluid in the pelvis, followed by infection and constipation. Other complications include vaginal bleeding or blood accumulation, incisional infection, etc.
4.Prevention of complications
(1) Pelvic lymphatic cyst: mainly due to the dead cavity behind the peritoneum after the removal of pelvic lymphatic tissue, resulting in the retention of refluxed lymphatic fluid in this part to form a cyst and produce compression symptoms. Extraperitoneal or vaginal drainage for 3~5 days to prevent.
(2) Bladder paralysis: manifests as difficulty in urination, urinary retention, and even secondary urinary tract infection. Generally, the urinary catheter is routinely left in place for 2 weeks after surgery, and patients are encouraged to urinate themselves as much as possible after the catheter is removed. The amount of residual urine in the bladder should be measured by ultrasound before removal of the catheter. If the residual urine volume in the bladder is less than 200m, the bladder function will generally recover on its own; if it is more than 200ml, it is necessary to continue to keep the urinary catheter in place and assist in physical therapy.
(4) Vaginal shortening: caused by self-involvement of the vagina. The surgeon usually lengthens the upper end of the vagina through surgical techniques to improve the patient’s quality of survival.
II. Radiotherapy
Radiotherapy can be used for all stages of cervical cancer, and radiotherapy should be the first choice for stage IIIB and all subsequent stages. Radiotherapy is divided into two kinds: external irradiation and intracavitary radiotherapy.
Intracavitary radiotherapy (also called post-mounted therapy) refers to the placement of radiation source in the vagina and uterine cavity, which is mainly used for the primary foci of cervical cancer and the adjacent affected areas. In recent years, intracavitary afterloading therapy is mainly used, that is, a container without radiation source is placed into the uterine cavity and vagina first, and then the tube is connected with the container, and the radiation source is sent from the storage tank to the container through the tube by remote control transmission device. Intracavitary radiotherapy can be performed 2 weeks after the end of external irradiation, usually 2 times a week, with the uterine cavity and vagina crossed, or intracavitary treatment can be performed simultaneously with external irradiation. A total of 5 times per week, i.e. 2 times for intracavitary treatment and 3 times for extracorporeal irradiation. No external irradiation is done at the same time of intracavitary treatment.
2, the importance of intracavitary and extracorporeal irradiation with high radiation tolerance of the cervix and vagina, after the radiation source is directly close to the tumor, it can form an effective radiation zone centered on the primary tumor of the cervix, thus increasing the radiation dose in the tumor area, reducing the irradiation of the surrounding tissues and organs of the human body, and reducing the complications of radiotherapy. In order to reduce the disadvantage of uneven dose of intracavitary radiotherapy, the treatment dose of vaginal and uterine cavity can be adjusted in order to reduce complications. However, because the parametrial and pelvic metastases and pelvic lymphatic drainage areas can only be solved by extracorporeal irradiation, it is necessary to coordinate intracavitary and extracorporeal irradiation.
3.Examination and laboratory tests before radiotherapy
(1) First of all, gynecological examination should be performed to determine the diagnosis and stage. Regardless of whether the local tumor is obvious or not in clinical examination, cervical biopsy should be taken for pathological examination, and corresponding radiotherapy plan should be formulated according to the cancer cell type and clinical stage.
(2) Ultrasound examination of pelvic cavity can understand the extent of tumor invasion in pelvic cavity and bladder and whether it is accompanied by ascites, etc. If necessary, CT and MRI can be done.
(3) In the process of radiotherapy, tumor necrosis is caused by the destruction of tumor by radiation, and some metabolites produced by the decomposition of tumor tissues, such as the increase of blood uric acid, will increase the burden of kidney in the process of excretion, so it is necessary to understand the kidney function before radiotherapy; and because the lower ureter is compressed by pelvic tumor, the kidney excretory function can be decreased to different degrees, so isotope renal chart analysis should be done.
(4) For those who are found to have heavy anemia in routine blood test, they should correct the anemia before radiotherapy; for elderly patients over 55 years old, they should do electrocardiogram examination; if the heart function is not normal, they should be closely observed in radiotherapy; for those who are suspected of lung metastasis, they should do chest X-ray and other examinations.
4.Prepare for vaginal douching and keep the vulva clean before radiotherapy.
5.Precautions in radiotherapy ①Strengthen nutrition, more high-protein, easy-to-digest diet. ②If the patient’s body temperature exceeds 37.5℃, radiotherapy should be suspended. ③Rinse the vulva daily during radiotherapy to clean the area and prevent vaginal adhesions and stenosis.
6. Precautions for endovenous radiotherapy ①Empty the stool on the night before or the morning of the day of treatment and give an enema to reduce the amount of rectal exposure. ②Measure the morning temperature and stop treatment if it exceeds 37.5℃. ③Shave the pubic hair, do vaginal douching, and fill sterile gauze after douching, and do not remove the gauze by yourself. ④Empty urine before treatment. ⑤Take the bladder truncal position, pay attention to relax as much as possible and cooperate well with the doctor to make the operation go smoothly. ⑥Rest in bed after treatment, turn over and move your limbs, but avoid sitting up to keep the position of the radiation source. After urination and defecation, you should pay attention to check whether the radioactive source is dislodged to prevent loss. (7) If you have difficulty in urination, report to the doctor in time. ⑧ Pay attention to whether there is bleeding or not, and report to the doctor in time if there is more blood leakage. ⑨ After 10 minutes of treatment, remove the radioactive source, perform vaginal irrigation and remove the gauze in the vagina. ①Patients should drink more water. If the body temperature is high and accompanied by abdominal pain, especially restricted pain, you should report to the doctor in time.
7.The main side effects and complications of radiotherapy radiation therapy may lead to acute or chronic adverse reactions. Acute ones include diarrhea and fatigue; chronic ones include bleeding from the bladder or rectum within 1 year after radiotherapy and vaginal contraction in about 5% of patients; more rarely, there are abnormal channels between the bladder or rectum and the vagina, called vesico-vaginal fistula and recto-vaginal fistula.
(1) Recent radiotherapy reactions: occurring during or within 3 months after treatment.
(1) Rectal reactions: manifesting as urgency, painful stool, mucus stool, diarrhea, blood in stool, etc. In severe cases, stop radiotherapy, treat symptomatically and continue treatment after improvement.
②Bladder reaction: manifested as urinary urgency, urinary frequency, urinary pain, hematuria, and difficulty in urination. Generally, the symptoms will gradually disappear after symptomatic treatment such as anti-infection and hemostasis, and stop radiotherapy if necessary.
(2) Long-term complications: they occur after 3 months of treatment.
(1) Intestinal complications: sigmoiditis, rectovaginal fistula, intestinal adhesion, intestinal obstruction, intestinal perforation, etc. Proctitis is the most common, mostly occurring within six months to one year after radiotherapy. It can be divided into three degrees.
Mild degree: mainly manifested as small amount of blood in stool and intra-abdominal discomfort, no special treatment is needed. Patients should pay attention to rest, avoid eating rough and irritating food, drink more water, eat more fruits, and keep the stool unobstructed.
Moderate: repeated blood in the stool, mucus and blood in the stool, with urgency, must be given anti-inflammatory, analgesic and antispasmodic treatment. Those with significant rectal drop can take medicine or retain enema as prescribed by the doctor.
Severe: intestinal stricture, intestinal obstruction, intestinal perforation or the emergence of rectovaginal fistula, etc.
②Radiation cystitis: mostly occurs more than 1 year after radiotherapy.
Mild: urinary urgency and frequency, painful urination, due to bladder mucosa congestion and edema.
Moderate: Sudden hematuria, which can recur. Caused by dilated capillaries of bladder mucosa and ulceration of bladder wall. It is usually treated with anti-infection, hemostasis and symptomatic treatment. Patients should urinate promptly to avoid excessive bladder distention.
Severe: vesicovaginal fistula formation, general treatment is bladder irrigation and surgery if necessary
③Vaginal stenosis of different degrees can occur due to fibrosis at the irradiated site, and older women are prone to vaginal atresia, which can be relieved by moderate sexual intercourse.
④Pelvic fibrosis: ureteral obstruction occurs in severe cases or due to lymphatic vessel obstruction, causing lower limb edema. Chinese herbs that activate blood circulation and remove blood stasis can be taken orally, together with physical therapy to improve local blood flow.
III. Chemotherapy
It is an adjuvant treatment for cervical cancer and is suitable for advanced and recurrent cases. It can reduce pain and prolong life for advanced patients. Generally, a combination treatment plan based on platinum is used.
Treatment for recurrence of cervical cancer after treatment
For patients who have not received radiation therapy, radiation therapy can be used.
If patients have received radiation therapy but the recurrence foci are still confined to the pelvic cavity, pelvic organ debridement surgery can be considered. For patients who can no longer tolerate radiation or surgery, chemotherapy can be given to relieve symptoms and discomfort.
Rehabilitation after cervical cancer treatment
1. Pay attention to the nutritional intake, and choose high-calorie and high-protein meals in small amounts and multiple meals. For some patients with nausea and vomiting, it is appropriate to eat more dry and salty foods, such as cookies, toast, steamed bread, etc. Avoid overly sweet and greasy foods. Some patients with radiotherapy and chemotherapy may have diarrhea and constipation. Those with diarrhea can take antidiarrheal agents, high protein, high vitamin, potassium-rich foods such as fruits, vegetables, fresh orange juice, mushrooms, etc., and increase water intake, but need to be careful with milk and dairy products. Constipated people should increase vitamin intake, such as fruits, vegetables, bread and cereals, and drink more water.
2. Keep a happy mood. Cancer patients have a heavy psychological burden and should try to keep enough confidence. Those with stable disease or early cure can continue to work, and even if they have retired, they should participate in some social activities to get rid of the disease and overcome it as soon as possible to prolong their lives.
3. Sexual life can be continued. Almost all cervical cancer patients and their husbands think that they have lost their sexual function after treatment and can never have sex again, so they are afraid of sex life. In fact, as long as the patient’s mental condition and physical condition recover well, sex can be continued 4-6 months after radiotherapy. The timely resumption of sexual life is also helpful to improve the narrowing of the vagina and maintain the width and length of the vagina due to vaginal fibrosis after endovenous treatment. After radical cervical cancer surgery, especially after removal of bilateral ovaries, vaginal dryness and vaginal shortening can cause painful intercourse and affect the quality of sexual life. This discomfort can be relieved by changing the position of intercourse, elevating the hips and using lubricants.
4. Keep the vulva clean: insist on vaginal douching for a long time, and choose 1:5000 potassium permanganate solution as the douching solution.
5.Prohibit smoking and alcohol, and eat less raw onion and leek.
6.Review: generally review once in 1-3 months in the first year after discharge, once in 3-6 months in the second year, once every six months in the third year, and once every year after 6 years.