Cervical cancer — structured oral station (12 minutes)

Opening prompt — "Stage this tumour using FIGO 2018 and tell me why."

Model response — assign the stage with the verbatim definitions: ^[1]

• "This is Stage IIIC1 (r) — a 3.5 cm tumour with parametrial invasion and an enlarged right external iliac lymph node on MRI."
• "Under FIGO 2018, the tumour alone would be Stage IIB (parametrial invasion); the pelvic nodal disease upstages it to IIIC1, which is pelvic lymph node metastasis only. IIIC2 would be para-aortic."
• "The 'r' notation records that the nodal status was determined by imaging — radiological — rather than surgical pathology ('p')."^[1]

Probe 1 — "What is the standard treatment for this stage?"

• "Concurrent chemoradiotherapy. EBRT 45 to 50 Gy to the pelvis in 25 to 28 fractions, with para-aortic field extension if nodes were involved; intracavitary brachytherapy boost to a total equivalent dose of at least 80 Gy; plus cisplatin 40 mg per square metre intravenously weekly during EBRT — typically 5 to 6 cycles — as a radiosensitiser." ^[2]
• "The CCCMAC meta-analysis of 18 randomised trials showed a 6 percent absolute 5-year survival benefit over radiotherapy alone. Surgery is not appropriate for Stage IIIC disease."

Probe 2 — "She is 38 and asks whether surgery could be offered to preserve her ovaries. How do you answer?"

• "For Stage IIIC1, surgery is not the treatment — chemoradiotherapy is curative-intent and superior to surgery for this stage. However, because the ovaries would be in the radiation field, I would offer laparoscopic ovarian transposition before chemoradiotherapy to move them out of the field and preserve ovarian function, given her young age."^[1][2]

Probe 3 — "If instead her tumour were 1.5 cm Stage IB1 and she wished to preserve fertility, what would change?"

• "For a 1.5 cm Stage IB1 tumour, radical trachelectomy with pelvic lymphadenectomy is the fertility-sparing option of choice. The cervix, parametrium and upper vagina are removed with pelvic lymphadenectomy; the uterine body and ovaries are preserved and a permanent cervical cerclage is placed."
• "Live-birth rates are 60 to 70 percent thereafter, with deliveries usually by caesarean; the principal obstetric risks are prematurity and second-trimester loss." ^[4]
• "For the radical hysterectomy candidate with early disease, the open abdominal approach is now the standard after LACC, which showed minimally-invasive radical hysterectomy had lower disease-free survival (86 vs 97 percent at 4.5 years) and higher recurrence." ^[3]

Probe 4 — Communication probe: "She asks what her chances are. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[1]

• "I would be honest and precise, and sit at her eye level: 'Stage IIIC1 cervical cancer is serious but treatable with curative intent. With chemoradiotherapy, the 5-year survival for Stage IIIC is approximately 30 to 45 percent — meaning that 1 in 3 to nearly 1 in 2 women are alive and well 5 years later. The treatment is demanding — about 6 weeks of daily radiotherapy plus weekly chemotherapy — but it gives you the best chance of cure. I will support you through every step, and we will have a dedicated team including a cancer nurse, a dietitian, and a counsellor.'"^[1]

Probe 5 — "Two years later she has a central pelvic recurrence. What are the options?"

• "Investigate with imaging (MRI pelvis, PET-CT) and biopsy to confirm recurrence and exclude distant disease."^[1]
• "For an isolated central pelvic recurrence after chemoradiotherapy in a fit patient, pelvic exenteration (anterior, posterior, or total) may be curative. This is a major undertaking and requires careful selection, counselling, and a multidisciplinary approach."
• "For recurrent disease not amenable to exenteration, systemic therapy with the GOG-240 triplet (cisplatin, paclitaxel, bevacizumab) plus pembrolizumab for PD-L1-positive disease is the standard."