ESGO/ESTRO/ESP Guidelines for the management of patients with cervical cancer - Update 2023

Key guideline recommendations

1. Treatment planning should be multidisciplinary (usually at a tumour board meeting) and based on comprehensive and precise knowledge of the prognostic and predictive factors for oncological outcome, morbidity and quality of life.

   IV, A

2. In T1b1, T1b2 and T2a1 tumours without nodal involvement on imaging, radical surgery by a gynaecological oncologist is the preferred approach. Laparotomy is the standard approach for all surgery that includes radical parametrectomy.

   I, A

3. A minimally invasive approach may be considered only for low-risk tumours (less than 2 cm and clear margins after conisation), in high-volume centres experienced in minimally invasive radical hysterectomy that meet ESGO quality criteria, and if the patient agrees after a thorough discussion of the current evidence.

   IV, C

4. Sentinel lymph node biopsy should be performed before pelvic lymphadenectomy; indocyanine green (ICG) is the preferred technique.

   III, A

5. Fertility-sparing treatment is an oncologically valid alternative to radical hysterectomy in young patients with cancer less than 2 cm (squamous and HPV-associated adenocarcinoma) who wish to preserve the possibility of having children; before starting, counselling at an oncofertility centre and discussion at a multidisciplinary tumour board are recommended.

   III, B

6. In locally advanced cervical cancer (T1b3–T4a), definitive radiotherapy should be combined with concurrent chemotherapy whenever possible. Weekly cisplatin (40 mg/m²) is standard.

   I, A

7. Image-guided brachytherapy (IGBT) is an essential component of definitive radiotherapy and should not be replaced by an external boost (photon or proton); if brachytherapy is not available, the patient should be referred to a centre that performs it.

   III, B

8. In recurrent/metastatic disease in fit patients without prior chemotherapy, platinum-based chemotherapy ± bevacizumab is recommended; carboplatin/paclitaxel and cisplatin/paclitaxel are the preferred regimens. Adding bevacizumab is recommended after careful assessment and discussion of the risk of significant gastrointestinal/genitourinary toxicity.

   I, A

9. Adding pembrolizumab to platinum-based chemotherapy ± bevacizumab is recommended in patients with PD-L1-positive tumours (CPS of 1 or more).

   I, A

10. Patients who have progressed after first-line platinum-based chemotherapy and have not previously received immunotherapy should receive the anti-PD-1 drug cemiplimab, regardless of PD-L1 status.

    I, A

Study population

Clinical significance and place in guidelines

Limitations