What impacts your decision to use PET vs CT for radiographic staging of clinically locally advanced cervical cancer?

The quick of it: stage, histology, and availability are the major factors impacting my decision on PETCT vs. CT scan.

In most cases of stage IB1-IVA (FIGO 2018 staging, Bhatla et al., PMID 30656645), any histology, I prefer a PETCT when possible to ensure that no distant disease as well as to evaluate for lymph node involvement. I also will get a PETCT for stage IA high risk histology (neuroendocrine, clear cell, serous, undifferentiated). This preference correlates with NCCN guidelines (Cervical Cancer Version 1.2021, page CERV-B 1-4) and is in line with what our tumor board recommends.

While this is my preference, ultimately the biggest factor impacting my decision to use a PETCT versus CT is availability to the patient. We know that a larg...

It's a valuable tool to know if nodal or pulmonary mets and pretty essential for locally advanced disease. Not always able to get insurance to cover despite its ability to identify mets not visible on CT.

At our institution, PETCT vs CT is also largely dependent on insurance status/availability with PETCT often favored. However, the newly published SENTIREC trial was alarming (at least to me!) in that "the sensitivity of FDG-PET/CT was 14.8%". The authors then reference several previous studies that have found wide-ranging FDG-PET/CT sensitivities of 0–68.0% in women with early-stage cervical cancer. So if the goal is to choose between a CT or PET/CT to "rule out" nodal mets in clinically early stage cervical cancer, it doesn't seem any modality is sufficient to reassure yourself or the patient that there's no advanced disease with a negative scan.