Stage IVA cervical cancer: outcomes of disease related complications and treatment

Introduction: Stage IVA cervical cancer is an uncommon diagnosis. The course of the disease and the complications of treatment are not well characterized. The goal of this study was to report treatment outcomes of patients with stage IVA cervical cancer.

Methods: A single institution retrospective review was carried out of all patients treated for stage IVA cervical cancer from January 2008 to July 2017. Patients were clinically staged using the International Federation of Gynecology and Obstetrics (FIGO) 2009 staging criteria for cervical cancer. Inclusion criteria were patients with stage IVA cervical cancer of any histologic subtype, including patients with evidence of para-aortic lymph node involvement, treated at the institution during this time period. Overall survival and progression free survival were calculated using the Kaplan-Meyer method. Comparisons between survival were done using the Cox proportional hazards regression model and the log rank test.

Results: We identified 25 patients with stage IVA cervical cancer. Mean age at diagnosis was 54 years (range 27-77). Squamous cell carcinoma was the histologic diagnosis in 24 of 25 patients (96%), with 1 case of small cell carcinoma (4%). 21 patients completed a full course of radiation. The median overall survival for patients who completed their treatment was 60 months (range 3-136), with a 2 year overall survival of 63%. The median progression free survival was 27 months (range 0-125), with a 2 year progression free survival of 40%. 11 of 25 patients (44%) developed fistulas during the course of their disease, and 55% of these were complex fistulas. 19 of 25 (76%) patients had a percutaneous nephrostomy for either hydronephrosis or diversion of vesicovaginal fistula. 111 unplanned admissions occurred among the 25 patients, and infections of the urinary tract was implicated in 46 (41%) of these. The cohort had a total of 92 emergency department visits, with pain control (36%) and medication refills (15%) being the most common presentations.

Discussion: Patients with stage IVA cervical cancer may have substantial long term survival, although the sequelae of disease and treatment is associated with significant morbidity. Symptoms of fistula, percutaneous nephrostomy complications, and chronic pain present unique issues that require extensive supportive care.

Keywords: cervical cancer; intestinal fistula; quality of life (PRO)/palliative care; urinary bladder fistula; vaginal fistula.