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Treating CIN Treating Cervical Cancer Follow-up care Treating CIN Hearing that your Pap test is abnormal can be upsetting, but remember that, when detected early, most abnormalities can be treated successfully. Your doctor considers several factors when making treatment recommendations. These include the type of cancer, the size of the tumor, the stage of disease, evidence of cancer in the lymph nodes, risk for anesthesia and surgery, and your preferences. In general, cancer affecting only the surface layer tissue (intraepithelial lesions) is treated with superficial techniques aimed at ablating or destroying only the affected tissue. Microinvasive cancers that have affected only the tissue immediately next to the original tumor are treated with limited surgery. This may include cervical conization (removal of a portion of the cervix) or simple hysterectomy (removal of uterus, cervix, and selected surrounding tissues). More invasive cancers are treated with either extensive surgery or radiation therapy; and locally advanced cancers are managed with radiation therapy. For patients with cervical cancer that involves the lymph nodes outside the pelvis, chemotherapy is recommended. For women who have recurrence of cervical cancer in the pelvis, radiation therapy, surgery, or chemotherapy may be recommended depending on previous treatments. Observation One treatment option for mild dysplasia (CIN I) is a "watch and wait" approach. Almost half of mild dysplasia cases will return to normal without further treatment. Close follow-up with frequent Pap tests may be all your physician recommends to monitor mild dysplasia. Be sure to follow through on this recommendation. A common follow-up schedule is listed below:
Moderate or severe dysplasia (carcinoma in situ) needs treatment that either destroys or removes the abnormal cells. There are several treatments available for early stage, noninvasive cervical cancer. These include cryotherapy, also known as cryosurgery, carbon dioxide (CO2) laser vaporization, loop electrosurgical excision procedure (LEEP), and electrocoagulation diathermy or electrocautery. Because of the superficial nature of these treatments, there is usually no effect on a woman's fertility. Cryotherapy or cryosurgery - Cryotherapy involves freezing the cancerous lesion with a metal probe that is cooled with refrigerants. The probe is applied to the tissue and kept in contact with the tissue until an ice "ball" forms. The effect of cryotherapy can be "patchy." Therefore after the tissue has visibly thawed, it is usually frozen a second time to assure a thorough treatment. The area treated by cryosurgery can be difficult to control. This can result in the destruction of either too much or not enough tissue. No specimens are generated from this treatment, so it would not be recommended for microinvasive or invasive cancer or adenocarcinoma in situ. Side effects can include cramping, swelling, and a light discharge. CO2 laser vaporization - Laser beams are directed at the lesion to vaporize (destroy) the cancerous tissues. An iodine solution is applied to the cervix to reveal the outline of the lesions, which are then treated with the laser. Laser surgery is slightly more likely than cryosurgery to destroy the diseased tissue the first time, but often is more expensive. Other benefits of laser treatment include its precision and reach; it only destroys diseased tissue and can be directed at abnormalities farther inside in the cervix that may be inaccessible by cryosurgery or electrocautery. No specimens are generated from this treatment. A discharge is often present after this procedure. Loop electrosurgical excision procedure (LEEP) - LEEP uses a wire loop to remove the entire transformation zone (the area where the squamous cells meet the glandular cells and most cervical cancers start) and a portion of the canal and surface of the cervix. This procedure is performed under local anesthesia. Complications include bleeding, cervical stenosis (narrowing of the canal), and rarely, infections such as cellulitis or an abscess (collection of pus). When microinvasive or invasive cancer is suspected or adenocarcinoma in situ is present, LEEP is not as adequate of a therapy as cervical conization is. Because the electrocautery process distorts and destroys the tissue along the edges of the specimen, it may make it difficult to determine if all of the disease was removed. Electrocoagulation diathermy - Electrocoagulation diathermy or electrocautery uses electricity to destroy the cervical lesion. No specimens are generated and a discharge is often present after this procedure. Follow-up - After electrocautery, cryosurgery, laser treatment, or LEEP, nothing should be inserted into the vagina for several weeks. This means no tampons, douching, or sexual intercourse. Pap smear and colposcopy should be performed in four months to determine whether the treatments were successful. Pap smears may not return to normal for some time following these treatments because of the trauma to the cervical cells. Pap testing should continue at six-month intervals until your physician is comfortable with the status of your Pap reports. Conservative Surgery Excision - This is both a treatment method (it removes damaged tissue) and a diagnostic tool. Removed tissue can be examined and evaluated for abnormalities. The edges or margins of the tissue area also can be evaluated to ensure that all the abnormal cells have been removed. The edges are more difficult to assess with methods such as electrocautery and vaporization that destroy the tissue. Cervical conization (cone biopsy) - Cervical conization is performed for microinvasive cervical cancer in women who wish to retain their fertility. Additional indications for conization include inability to see the area where the glandular and squamous cells meet on colposcopic exam, a positive endocervical curettage for high-grade dysplasia, appearance of possible invasion on colposcopic exam even if target biopsies only show CIN 3, adenocarcinoma in situ, and microinvasion on the punch biopsy. Conization may be performed with a scalpel or with the CO2 laser under general or spinal anesthesia. Cervical conization involves removal of a cone-shaped piece of the cervix. The tip of the cone extends into the cervical canal, and the bottom flares out onto the surface of the cervix. The width and depth of the cone is tailored to the size of the cancer to produce the least amount of injury while providing clear surgical margins.  Further treatment may be necessary if the cancer extends close to or up to the cut surfaces of the cone. In some instances, this may involve a re-excision of the cervix, but treatment that is more aggressive may be needed if indicated by the findings. Complications of cervical conization include bleeding, infection, infertility, stenosis (narrowing of the canal), and cervical incompetence which could result in premature dilation during pregnancy. Hysterectomy - This operation is sometimes recommended to treat CIN III. However, with other treatment options available, hysterectomy may not be the first choice for most women, especially if they are still interested in having children. This operation is a major surgery with specific risks and benefits. It should be discussed carefully with your physician. (For more detail on this procedure, see surgery section under treating cervical cancer.) Treating Cervical Cancer Carcinoma in situ cervical cancers (CIS) can be treated with the same procedures described for cervical dysplasia. However, conization and hysterectomy are more frequently recommended to prevent the disease from spreading. Without treatment, carcinoma in situ can develop into invasive cancer. Untreated, invasive cervical cancer will travel to other areas in the pelvis. From there it can invade the lymph nodes located in the groin and spread into the lungs, liver, and bones. Your doctor may refer to cancer that has spread beyond the pelvis as metastatic disease. Surgery and radiation therapy are equally successful treatment options for early invasive cervical cancer. Chemotherapy is sometimes used with radiation therapy to improve treatment outcomes. In addition, chemotherapy can be used when cervical cancer recurs or has metastasized. Surgery Surgery is used to treat cancer when the disease is confined to the cervix. If a woman wants to preserve her fertility, conization may be an option for microinvasive cancer. Otherwise, hysterectomy, which is the removal of the uterus, cervix, and selected surrounding tissues within the pelvis, may be recommended. There are three types of hysterectomy commonly used to cure cervical cancer: simple, modified radical, and radical hysterectomy. The choice of procedure depends on a woman's age and overall health as well as the size of the tumor. The removal of the ovaries may or may not be done with a hysterectomy, depending on a woman's situation. More treatment may be recommended following surgery, depending upon what is found at the time of the surgery and in the specimens that are removed. Simple Hysterectomy - In a simple hysterectomy, the uterus, cervix, a small portion of the upper vagina, and part of the adjacent muscles, ligaments, and tissues are removed. The pelvic lymph nodes are generally not removed. A simple hysterectomy is a treatment option for women with stage IA1 cervical cancer who do not wish to retain their fertility. Sometimes cervical cancer might first be discovered following a simple hysterectomy that was done for another reason. Depending upon what was found, further treatment might be necessary. Modified radical hysterectomy - A modified radical hysterectomy involves removal of the uterus, the cervix, the upper quarter of the vagina, and the ligaments and tissues surrounding these organs. The removal of the pelvic lymph nodes (lymphadenectomy) is also usually performed. A modified radical hysterectomy is a treatment option for women with stage IA1 cervical cancer who do not wish to retain their fertility. Radical hysterectomy - A radical hysterectomy involves the removal of the uterus, the cervix, the upper quarter of the vagina, and a wide area of the ligaments and tissues surrounding these organs. In addition, most of the pelvic lymph nodes are removed. Some of the paraaortic lymph nodes, which are located near the main artery of the body (the aorta), may also be removed. This surgery is performed for stage I and IIA cervical cancers. Radical hysterectomies are complex because the tissues removed are close to other vital structures such as the bowel, bladder, ureters, and blood vessels of the pelvis. The blood loss associated with this surgery, which may be around a pint and a half, is typically more than that associated with less complicated hysterectomies. Ovarian preservation vs. removal - The ovaries are 2 organs that sit on either side of the uterus. They produce female hormones and reproductive eggs. When having a hysterectomy, a woman and her physician may decide to leave the ovaries, move them, or remove them. This decision is influenced by the woman's age, reproductive and hormone considerations, and cervical cancer stage. For example, since the risk of metastasis to the ovaries is very low in women with early stage disease, the ovaries may be left behind if she is younger than 40 to 45 years of age. If it looks like she might need radiation therapy, the ovaries might be moved out of the pelvis in a procedure called oophoropexy. This helps limit the amount of radiation that they will receive and reduces the risk that they will stop functioning. Hospitalization - Routine tests to prepare for surgery may include: 
Time spent in the hospital for any of these surgeries varies depending on the individual's overall health and postoperative recovery. Follow up after radical hysterectomy and lymph node dissection involves examination with Pap smears every 3-6 months during the first 2 years, then every 6 months for 3 to 5 years, and annually thereafter. Additional studies may also be performed. Side effects of surgery - Hysterectomy can have significant side effects and potential complications. For the woman who is premenopausal, removal of the uterus ends menstruation. If the ovaries are left intact, they continue to produce hormones until natural menopause occurs. However, if they are removed during hysterectomy, menopausal symptoms such as hot flashes, vaginal dryness, and night sweats can begin. Hormone replacement therapy can prevent or minimize these symptoms. Although sexual function should not be impaired, some women experience changes in sexual sensation following a hysterectomy. In some cases, the vagina is slightly shortened. Hysterectomy can be an emotional issue for some women. Regardless of whether a woman still wants to, or is able to have children, removal of the uterus can affect her identity as a woman. This is an important issue to consider and to come to terms with when deciding whether to have a hysterectomy. Recovery from hysterectomy takes between four and six weeks, although many women may feel fatigued for longer periods. Common postoperative side effects - Some amount of pain, nausea and vomiting, difficulty urinating or having a bowel movement, fatigue, and anxiety is normal after hysterectomy. Most of these side effects are due to the general anesthesia used during surgery and the stress of the surgical procedure on the body. Medications can be used to relieve pain, nausea and vomiting, and constipation as needed. A catheter placed in the bladder during surgery will be used to drain the urine until you are able to urinate on your own. Fatigue and anxiety usually resolve with recovery from surgery. Each individual's experience and recovery process will vary. Some patients have difficulty regaining their bowel function. Often, these symptoms can be relieved by slowing or stopping foods and oral fluids and switching to intravenous (I.V.) fluids temporarily. Rarely is additional surgery required to relieve the obstruction so that bowel function can return. About one-third of women who have a radical hysterectomy experience temporary bladder difficulties that may last for several weeks after surgery. This is due to a loss of nerve signals to urinate and an inability to completely empty the bladder. Although most women learn to compensate for the bladder difficulties and return to near normal functioning, some occasionally need intermittent self-catheterization (placement of a thin plastic tube into the bladder to drain the urine). In some patients (about 3%), these bladder problems persist. Allergic reaction to anesthesia - A body-wide (systemic) reaction to the general anesthesia used during surgery can occur. This is usually an allergic type of reaction and is treated with medications. In most cases, the medication effectively reverses the reaction and symptoms. Bleeding or hemorrhage - Bleeding, also called "hemorrhage," can occur during or after surgery when a blood vessel is damaged or when the clotting system is not working normally. Bleeding during surgery is managed carefully to minimize blood loss in an attempt to avoid the need for transfusion. Some vaginal bleeding and discharge after surgery is common, but heavy bleeding is rare. In the event of heavy vaginal bleeding, your doctor should be contacted immediately and physical activity should be restricted to bedrest until you are evaluated. Bleeding can also occur into the tissues around the other surgical sites, but again, excessive bleeding is rare. On the surface, this will appear as a bruise, or "hematoma." An area of firmness may be felt under the bruise. Although the color may spread, the firm area should not grow. Blood tests may be used to monitor for blood loss, particularly if there is concern about potential postoperative bleeding. The measurements may fall somewhat due to dilution of the blood by I.V. fluids that are given with and after surgery, but should not fall dramatically. If there is a large change in the blood test results, further investigation may be needed. Blood clots (thromboembolic events) - A blood clot, or "thrombus," is a solid or semisolid mass of blood. Blood clots play an important role in healing as they help stop bleeding. However, clots can also form in blood that is allowed to pool, as can occur in the legs due inactivity after surgery. This can cause swelling, pain, and redness. Patients who have a history of similar problems, or who have severe varicose veins, are at particular risk of developing blood clots in their legs after surgery. Special stockings, massaging devices, and medications may be used to help reduce this risk. Occasionally, a piece of clot can break free (called a thromboembolic event) from where it formed and travel through the blood stream to another part of the body, often the lungs. If you experience shortness of breath or chest pain, notify your nurse or call your doctor immediately. When your doctor permits, leg and foot exercises and walking as soon as possible after surgery can decrease the risk of blood clots. Breathing problems - The lungs are composed of millions of tiny air sacs where oxygen exchange occurs. It is normal for some air sacs to be collapsed at any moment in time, but the bedrest and shallow breathing that occur following surgery can lead to collapse of a larger number of air sacs than usual. This can lead to difficulty breathing and an increase in the risk of lung infections. In order to prevent this from happening, women are typically instructed to do breathing exercises after surgery. Walking, once it is okay to do so, also helps keep the air sacs open. Fistula formation - In rare instances, damage to the bladder, vagina, rectum, ureters, or blood vessels can result in fistulas (abnormal openings or passages). Fistulas may require surgical repair or the use of hyperbaric oxygen therapy. Lower leg swelling - As a result of lymph node dissection, swelling in the legs can occur. The use of elastic stockings or support hose can help minimize the swelling (edema). Women need to be careful about preventing infections or injury to the legs when edema is present. Surgical wound complications - An infection of the surgical wound can occur after any surgery, while in the hospital or after discharge. Such an infection can delay healing of the tissues and recovery. Signs and symptoms to look for are fever, new or increased pain, tenderness, redness, swelling, warmth or heat in the area, or yellow-green drainage (pus) from the incision. In rare instances, the wound may unexpectedly reopen (dehisce). Risk factors for this include obesity, diabetes, and poor nutritional status. If this rare complication occurs, it usually happens about 10 to 14 days after surgery. Infection or dehiscence should be reported to your doctor immediately. Radiation therapy Radiation therapy (RT) uses high-intensity x-rays to destroy the ability of cells to grow and divide. Radiation can be used alone or in combination with surgery, chemotherapy, or both to treat cervical cancer that is stage IA2 or higher. Two forms of radiation therapy are used: brachytherapy (internal radiation), in which radioactive implants are placed next to the cancerous site, and external radiation, in which a machine directs radiation to the diseased tissue. Brachytherapy destroys less of the healthy tissue around the cancer and causes fewer side effects than external radiation. Radioactive implants are inserted through the vagina, into the cervix and the uterus. Internal radiation is not always possible if the cancer or previous surgery has changed the shape of the vagina. Internal radiation usually requires a short hospital stay; the implant is left in place for one to two days. External radiation can be administered as an outpatient and is usually given five days a week for five to six weeks. Both forms of radiation therapy may be used depending on many factors including the type of cancer, the size of the tumor, the stage of disease, and evidence of cancer in the lymph nodes. Pelvic radiation therapy - Pelvic radiation therapy is a treatment for cervical cancer and may be given alone or following a hysterectomy. Radiation therapy is given by external beam therapy to the cancerous site in the body. Individual treatment plans depend on the stage of disease. Radiation therapy is directed to the cervical cancer as well as to the potential sites where the cancer may spread. If x-rays or surgical findings reveal spread (metastases) of the cancer to the paraaortic lymph nodes, "extended field" radiation therapy may be given. Extended field radiation therapy treats the entire pelvis as well as the region around the aorta where the paraaortic lymph nodes are found. External beam radiation therapy is usually given over a period of five to six weeks. Every effort is made to complete the entire treatment in less than seven to eight weeks because longer courses of treatment may result in poorer control of the disease. Brachytherapy - Brachytherapy refers to the technique of placing the radiation source close to or within an organ or tissue. Patients are usually treated with a combination of external-beam radiation therapy to the pelvis and brachytherapy. Brachytherapy is used to treat the cervix and the surrounding tissues, while minimizing the radiation dose to the bladder and rectum. The radiation source contained in a tube is temporarily inserted into the uterine cavity and vagina to provide a localized dose of radiation. Two consecutive implants scheduled one week apart may be used. The combination of vaginal and uterine implants is frequently used. In some instances, a vaginal cylinder (slightly larger in width than a tampon) or needles are used. Overnight hospitalization is required unless the length of treatment is just a few hours. Length of treatment can last from a few hours up to a few days depending on the technique used and the dose prescribed by the radiation oncologist. Prior to brachytherapy, a special applicator system is placed in the vagina. Vaginal packing is used to hold the applicator in place and to increase the distance between the radioactive sources and nearby bladder and rectum. X-rays are taken to ensure the applicator is in position. The slender metal containers or "seeds" of radioactive sources are inserted into the applicators after the patient has returned to her hospital bed. This reduces the exposure of the hospital staff during the applicator placement. Some facilities have a "remote after-loading" brachytherapy machine that allows the radiation oncologist to deliver the radioactive isotope mechanically from a position outside the patient's room. This helps to further decrease the exposure of the medical personnel to radiation. If a vaginal cylinder applicator is used, the procedure can be done in the hospital room. Bandages, elastic underwear, or straps are used to secure the vaginal cylinder in place. Radiation therapy combined with chemotherapy - Radiation therapy is frequently used with chemotherapy for patients with locally advanced cervical cancer (stages IB2-IVA). Chemotherapy may also be used in some women with lower stage cervical cancer to reduce the risk of recurrence. This is particularly true for patients following surgery if cancer is found in the lymph nodes, in the tissues that surround the cervix and uterus, or at the edges of the tissues removed. The chemotherapy can help sensitize the cancer cells to the radiation therapy as well as treat potential cancer cells in other parts of the body. Side effects of radiation therapy - The side effects of external beam radiation therapy generally occur in the organs within the pelvis. Some side effects occur during the course of treatment whereas others occur months to years after the completion of treatment. The radiation affects the rapidly dividing cells of the body such as the mucous membranes lining the intestines, rectum, bladder and vagina, and the reproductive tissues such as the ovaries. Each individual will vary in her experience of these side effects. Allergic reaction to anesthesia - Anesthesia is commonly used for placement of the applicator for brachytherapy. It is possible to have a body-wide (systemic) reaction to that anesthesia. This is usually an allergic type of reaction and is treated with medications, which in most cases effectively reverses the reaction and symptoms. This is not a common complication. Blood clots (thromboembolic events) - A blood clot, or "thrombus," is a solid or semisolid mass of blood. Blood clots play an important role in healing as they help stop bleeding. However, clots can also form in blood that is allowed to pool, as can occur in the legs due inactivity during brachytherapy. Occasionally, a piece of clot can break free (called a thromboembolic event) from where it formed and travel through the blood stream to another part of the body, often the lungs. Compression elastic stockings may be worn during the procedure and for several days after to ensure good blood circulation in the legs. Non-vigorous leg and foot exercises should be performed while on bed-rest as directed by your radiation oncologist to decrease the risk of this complication. Patients who have a history of similar problems, or who have severe varicose veins, are at particular risk of developing blood clots. To help reduce this risk, a blood thinning medication (heparin) may be given before and after the procedure. Blood clot-related complications are rare with brachytherapy. Symptoms that should be reported to your nurse or doctor immediately include chest pain; dizziness; pain, redness, or swelling of the legs or arms; one-sided weakness; shortness of breath; speech problems; sudden, severe headache; or sudden vision changes. Bladder and bowel changes - The bladder and the bowel can be affected by radiation therapy because they are near the treated area. The bladder is in front of the vagina and uterus, and the rectum, the last segment of the colon, is behind them. Some radiation is able to reach these organs during brachytherapy, even though vaginal packing is used to help protect them. Some temporary changes in bowel and bladder function may occur the first few days after the implant. These can include constipation or diarrhea and frequent urination. The treatment field with external beam radiation therapy is larger, so it can affect a larger portion of the colon and small bowel. If the fields are extended to include the paraaortic lymph nodes or larger fields are used, nausea and vomiting and stomach upset (gastritis) may occur. Your doctor can prescribe medications to control these symptoms. Bone marrow depression - Bone marrow depression may occur with some types of radiation treatments. This involves a reduction in the numbers of blood cells produced in the bone marrow (inside the bones). These cells include red blood cells, white blood cells, and platelets. Red blood cells carry oxygen through the body, white blood cells fight infections, and platelets help clot the blood when there is an injury. A blood test called a complete blood count (CBC) is usually ordered by the doctor to determine the amount of each cell in the blood. If any of the cell levels are diminished, special precautions may need to be followed until the body makes new cells and the level return to normal. Sometimes special medications may be used to help increase the number of blood cells, or a blood transfusion may be necessary to treat anemia. Early menopause or loss of fertility - Unless the ovaries have been transposed (moved out of the treatment area during surgery), radiation therapy will lead to loss of ovarian function in all premenopausal women. These women may then experience menopausal symptoms such as hot flashes, vaginal dryness, and night sweats. The number and severity of symptoms can vary among women experiencing early menopause. Hormone replacement therapy can prevent or minimize these symptoms. Fatigue - Fatigue is a feeling of being tired, exhausted, weary, or energy-depleted. Patients may also feel weak and dizzy. It is associated with a desire for rest or sleep. Some patients report difficulty thinking, forgetfulness, and an inability to concentrate. There are no medical tests to measure fatigue. Skin changes - When external beam radiation therapy is given, the therapy beam must go through the skin. The skin may be irritated by this. Redness, warmth, swelling, tenderness, dry or moist ("weepy") peeling, itching, ulceration, or hair follicle irritation may result. These symptoms are often only in the treatment area. Some discomfort may occur, but it typically resolves once treatment is completed and the skin has had time to heal. Special skin care products and instructions will be provided by the radiation physician or nurse. It is important to discuss skin care even before skin irritation develops, as some everyday skin-care products can contribute to the skin irritation. Vaginal changes - A small to moderate amount of vaginal discharge is normal following brachytherapy. A late effect of brachytherapy can be vaginal narrowing and loss of elasticity (called stenosis or fibrosis). If this occurs, vaginal dilation and estrogen medications and creams can help. Late effects of radiation therapy - Some women experience side effects of radiation therapy months to years after completion of the treatment. These effects are thought to be due to the damage of the tiny blood vessels that surround tissues and organs. The decreased blood supply can lead to scarring (fibrosis) of the tissue. Potential late effects of radiation therapy include fibrosis of the bladder or vagina, decrease in the size of the opening (stricture) of the rectum, and formation of an abnormal passage (fistula) from the bladder, vagina, bowel, or rectum. Surgery may be needed to repair fistulas. An increase in risk for fractures of the hip or pelvis may be a late effect of radiation therapy for cervical cancer. A 2005 study suggested that this occurs in about 8% of women within 5 years of pelvic radiation therapy (as compared to almost 6% of women who did not receive radiation therapy). It may be affected by menopausal status, smoking history, body mass index, ethnicity, and age at the time of radiation. Monitoring of bone density and the use of bone-building medications as appropriate may be recommended. Chemotherapy Chemotherapy (sometimes referred to as "chemo") uses anticancer drugs to destroy cancer cells wherever they may be in the body. In most cases, chemotherapy is injected through the vein (intravenous) in the doctor's office or hospital clinic. Treatments are followed by rest periods to allow the body to build back new cells and gain strength. After the rest period, the cycle begins again. Three to six cycles of chemotherapy are usually given. Chemotherapy is combined with radiation therapy may be used to treat women with locally advanced cervical cancer (stages IB2-IVA). Chemotherapy may also be used in some women with lower stage cervical cancer to reduce the risk of recurrence. This is particularly true for patients following surgery if cancer is found in the lymph nodes, in the tissues that surround the cervix and uterus, or at the edges of the tissues removed. Chemotherapy helps sensitize the cancer cells to the radiation therapy and treats potential cancer cells in other parts of the body. With combination therapy, the dose of chemotherapy is usually very low. As a result, the chemotherapy is well tolerated and few side effects occur. Chemotherapy can also be used for treating metastatic or recurrent disease. Several different chemotherapy drugs may be used to treat cervical cancer. Typically, a woman is started on a combination of carboplatin and paclitaxel or a combination of cisplatin and paclitaxel, topotecan, or gemcitabine. Alternatively, she may be started on any one of these drugs as single agent therapy. If these medications are not effective, or the cancer returns, other drugs that might be used include bevacizumab, docetaxel, epirubicin, 5-fluorouracil (5-FU), ifosfamide, irinotecan, liposomal doxorubicin, mitomycin, pemetrexed, or vinorelbine. Additional medications may be available through clinical trials. Chemotherapy side effects - The side effects associated with chemotherapy depend on the specific medication used. Some side effects of several chemotherapy medications include hair loss (alopecia), loss of appetite (anorexia), fatigue, mouth sores (stomatitis), nausea and vomiting, and diarrhea. Each patient will vary in how she experiences these effects. Frequency and severity of the side effects will depend on the chemotherapy drug(s) and doses received. Very effective medications are available to prevent or minimize side effects from chemotherapy, especially nausea and vomiting. Your doctor will discuss this with you, as well as strategies for managing any other side effect you may experience. Allergic reaction to chemotherapy - Some chemotherapy drugs can cause allergic reactions and the patient may experience low blood pressure, shortness of breath, wheezing, chills, fever, itching, facial flushing, dizziness, rapid heartbeat, and hives or rash. This is not always predictable and usually occurs within the first 15 to 30 minutes of drug administration. When the drug is given, a nurse will monitor your blood pressure, temperature, pulse, and breathing for any signs of an allergic reaction. Should this occur, the drug would be stopped and medications given to reverse the reaction and relieve the symptoms. Some chemotherapy drugs require "premedications" which are given before the chemotherapy to reduce or prevent an allergic reaction. Premedications are routinely given with paclitaxel (Taxol®). These include dexamethasone (a steroid), diphenhydramine (an antihistamine), and cimetidine or ranitidine (antihistamines that protect the stomach and upper intestines). Bone marrow depression - Bone marrow depression commonly occurs with many chemotherapy drugs. This involves a reduction in the numbers of blood cells produced in the bone marrow (inside the bones). These cells include red blood cells, white blood cells, and platelets. Red blood cells carry oxygen through the body, white blood cells fight infections, and platelets help clot the blood when there is an injury. A blood test called a complete blood count (CBC) is usually ordered to determine the amount of each cell in the blood. If any of the cell levels are low, special precautions may need to be followed until the body makes new cells and the levels return to normal. Treatments may need to be delayed if the levels do not improve in time for the next scheduled cycle. Sometimes special medications may be used to help increase the number of blood cells, or a blood transfusion may be necessary to treat anemia. Cardiotoxicity - Most chemotherapy drugs do not affect the heart. However, some chemotherapy drugs such as paclitaxel (Taxol®) and doxorubicin (Adriamycin®, Doxil®) can irritate or damage the heart and can interfere with heart function. In the short-term, this may result in changes in the heart rate and rhythm and in the blood pressure. An electrocardiogram (ECG) may be completed before starting therapy. The nurse administering the drug will be monitoring your pulse and blood pressure. If any irregularities occur while it is being given, another ECG may be taken. Over the long-term, heart failure can develop. A heart function test (MUGA scan) may be performed before treatment begins to get a baseline look at your heart's function. Repeat scans can be used to watch for any evidence of accumulated damage. If evidence of heart damage is found, the treatment may need to be stopped. Heart effects are usually dependent on the dose and duration of treatment. Doxorubicin may be avoided in patients who already have significant heart problems. If you have a history of heart disease or experience any unusual or new symptoms (such as shortness of breath, having to sit up to breathe, palpitations, swelling of the lower legs and feet, or sudden weight gain) notify your nurse or doctor promptly. Hearing loss or ringing in the ears - Hearing changes can be a side effect of cisplatin, a chemotherapy drug sometimes used to treat cervical cancer. This occurs due to damage to the nerves that supply the inner ear. Ringing in the ears (called tinnitus) and hearing loss, especially high frequency hearing loss, can result. Usually, normal conversational tones are not affected. Hearing changes typically occur after long periods of drug therapy and may be temporary or permanent. You should report any ringing or decreased hearing to your doctor. Irritation at the IV site - Some chemotherapy drugs can cause irritation at the intravenous site where they are given. Reactions may include discomfort or pain, redness, fluid accumulation in the tissues around the IV site, inflammation of the surrounding skin of the vein itself, and ulceration. The leaking of IV fluids into the surrounding area usually causes these reactions. For some drugs (such as doxorubicin), a special IV catheter may be inserted to prevent or minimize this complication. Symptoms are usually temporary but can sometimes be more severe. If you notice any discomfort or pain, stinging, or burning during or after the infusion, contact your nurse or doctor immediately. Kidney problems - Some chemotherapy drugs may cause temporary or permanent kidney damage. Kidney function can be evaluated by blood tests. If you are receiving a drug that may cause this complication, your doctor will likely order these tests from time to time to check for any abnormalities. Extra intravenous fluids, and/or special medications may be given with the chemotherapy to prevent or minimize any damage. In addition, your doctor may recommend that you drink extra fluids before and after your chemotherapy. In some cases, adjusting the dose of chemotherapy is made or if necessary, the drug is discontinued. Muscle or joint aches and pains - Some chemotherapy drugs cause muscle or joint aches, pains, weakness, and soreness for several days (usually three to five days) after infusion. This is usually felt in the legs, but any area of the body may be affected. This temporary reaction will go away on its own. If these symptoms become bothersome or interfere with your daily activities, notify your doctor or nurse so they can assist you. Nerve damage (neuropathy) - Some chemotherapy drugs such as cisplatin and paclitaxel can irritate or damage nerves. One way this may be experienced is as numbness, tingling ("pins and needles"), burning, or weakness in the hands and/or feet. It may feel like your hands or feet are asleep. You may have difficulty picking up a coin or buttoning your shirt or blouse. Since the nerves that go to internal organs can also be affected, you may also experience this as constipation or other changes in your bowel or bladder function. These symptoms normally go away after completing treatment and usually require no medication. However, if you experience any of these symptoms and they interfere with your comfort or daily activities, let your doctor or nurse know so they can assist you. Urine discoloration - Some chemotherapy drugs will turn the urine a different color for the first 24 to 48 hours after infusion. This is a harmless drug effect. In a few days, the urine will clear on its own. The discoloration occurs because the drug itself is colored and it colors the urine as it leaves the body. Doxorubicin is sometimes used to treat cervical cancer and is reddish-orange in color when prepared for administration. Follow-up care After treatment for cervical cancer, careful follow-up, or surveillance, is necessary to make sure that the cancer does not return, and if it does return, to catch it early and treat it promptly. Follow-up includes regular history and physical exams with Pap smears of the retained cervix or the vaginal cuff every 3 to 6 months for the first 2 years. This is followed by Pap smears every 6 months for 3 to 5 years, and annually thereafter. Additionally, blood counts and kidney function tests may be done every 6 months. Annual chest x-rays and other imaging studies may also be done. Other tests may be done based on the treatments that were used. Pap tests can be inconclusive or inaccurate if a woman has received radiation therapy because radiation causes changes in cellular structure. For these women, a biopsy may be a better test. Three months after the tissue damage from treatment has healed, a biopsy should reveal only normal cells.  This content is reviewed regularly. Last Updated 1/4/2010
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