Neoadjuvant chemotherapy for locally advanced cervix cancer

Dose-dense neoadjuvant chemotherapy before radical surgery in cervical cancer: a retrospective cohort study and systematic literature review

OBJECTIVE

To evaluate the role of dose-dense neoadjuvant chemotherapy followed by radical hysterectomy in reducing adjuvant radiotherapy in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB1-IB2/IIA1 cervical cancer with disrupted stromal ring and as an alternative to concurrent chemoradiotherapy in FIGO 2018 stages IB3/IIA2.

METHODS

This was a retrospective cohort study including patients with FIGO 2018 stage IB1-IIA2 cervical cancer undergoing dose-dense neoadjuvant chemotherapy at the European Institute of Oncology in Milan, Italy between July 2014 and December 2022. Weekly carboplatin (AUC2 or AUC2.7) plus paclitaxel (80 or 60 mg/m2, respectively) was administered for six to nine cycles. Radiological response was assessed by Response Evaluation Criteria in Solid Tumours (RECIST) v1.1 criteria. The optimal pathological response was defined as residual tumor ≤3 mm. Kaplan-Meier curves were used to estimate survival rates. A systematic literature review on dose-dense neoadjuvant chemotherapy before surgery for cervical cancer was also performed.

RESULTS

A total of 63 patients with a median age of 42.8 years (IQR 35.3-47.9) were included: 39.7% stage IB-IB2/IIA1 and 60.3% stage IB3/IIA2. The radiological response was as follows: 81% objective response rate (17.5% complete and 63.5% partial), 17.5% stable disease, and 1.6% progressive disease. The operability rate was 92.1%. The optimal pathological response rate was 27.6%. Adjuvant radiotherapy was administered in 25.8% of cases. The median follow-up for patients who underwent radical hysterectomy was 49.7 months (IQR 16.8-67.7). The 5-year progression-free survival and overall survival were 79% (95% CI 0.63 to 0.88) and 92% (95% CI 0.80 to 0.97), respectively. Fifteen studies including 697 patients met the eligibility criteria for the systematic review. The objective response rate, operability rate, and adjuvant radiotherapy rate across studies ranged between 52.6% and 100%, 64% and 100%, and 4% and 70.6%, respectively.

CONCLUSIONS

Dose-dense neoadjuvant chemotherapy before radical surgery could be a valid strategy to avoid radiotherapy in stage IB1-IIA2 cervical cancer, especially in young patients desiring to preserve overall quality of life. Prospective research is warranted to provide robust, high-quality evidence.

Neoadjuvant Chemotherapy Followed by Vaginal Radical Trachelectomy as Fertility-Preserving Treatment for Patients with FIGO 2018 Stage 1B2 Cervical Cancer

BACKGROUND

Standard treatment for International Federation of Gynecology and Obstetrics (FIGO) 2018 stage 1B2 cervical cancer (i.e., tumor size between 2 and 4 cm) is a radical hysterectomy (RH) with pelvic lymph node dissection (PLND). We evaluated the oncological and fertility outcomes treatment in patients receiving a fertility-sparing alternative consisting of neoadjuvant chemotherapy (NACT) followed by vaginal radical trachelectomy (VRT).

METHODS

Patients with stage 1B2 cervical cancer who wished to preserve fertility were included from September 2009 to September 2018. NACT consisted of 6-week cycles of cisplatin or carboplatin with paclitaxel. If tumor size decreased to 2 cm or smaller, NACT was followed by a robot-assisted PLND and VRT.

RESULTS

Eighteen patients were included. Median follow-up time was 49.7 months (range 11.4-110.8). Median tumor size was 32 mm (range 22-40 mm). Complete remission after NACT occurred in seven women. Four women had a poor response on NACT. Three underwent RH with PLND; one received chemoradiation after PLND instead of VRT because of positive lymph nodes. The remaining 14 patients received VRT 3-4 weeks after NACT. Four recurrences occurred: three after NACT and VRT and one after NACT and RH. Median time to recurrence was 20.8 months (range 17.0-105.7). Three recurrences occurred in women with adenocarcinoma with lymph vascular space invasion (LVSI). In four women fertility could not be preserved. To date, four women had six pregnancies, including three live births born at term, two first trimester miscarriages, and one currently ongoing pregnancy.

CONCLUSION

NACT and VRT in women with stage 1B2 cervical cancer showed promising results. In 78% fertility was preserved. However, patients with poor response on NACT and with adenocarcinoma and/or LVSI were possibly at risk for recurrence. Long-term results in relation to fertility and oncological outcome are needed to corroborate these findings.

IMPLICATIONS FOR PRACTICE

Standard treatment for women with International Federation of Gynecology and Obstetrics (FIGO) 2018 stage 1B2 cervical cancer (tumor size 2-4 cm) is a radical hysterectomy and pelvic lymph node dissection (PLND). However, many of these women are young and wish to preserve fertility. Data on fertility-sparing treatment options are sparse, but neoadjuvant chemotherapy followed by a vaginal radical trachelectomy and PLND could be an alternative. Since 2009 we performed an observational cohort study in which 18 women opted for this treatment in our center. In 14 women fertility could be preserved. In four patients the tumor recurred. In four women six pregnancies occurred. After careful selection this treatment could be a good fertility-sparing treatment option.

Determining Optimal Routes to Surgery for Borderline Resectable Venous Pancreatic Cancer-Where Is the Least Harm and Most Benefit?

Surgery among patients with borderline resectable pancreatic cancer (BRPC) and venous disease has emerged as a viable strategy to achieve curative treatment. By definition, these patients are at increased risk of a positive resection margin, however, controversy exists with regards to necessity of radical surgery and optimum pathways with no consensus on definitive treatment. A surgery first approach is possible though outcomes vary but patients can have an efficient pathway to surgery, particularly if biliary drainage is avoided which limits overall complications. Neoadjuvant therapy (NAT) is emerging as a widely used strategy to improve oncological outcomes, including resection margin status. However, some patients progress on NAT whilst others suffer major complications whilst elderly patients are unlikely to be offered effective NAT limiting the widespread applicability of this therapy. In this article an overview of the entire pathway is presented along with assimilation of current best evidence to determine optimal routes to surgery for BRPC with venous involvement.

Neoadjuvant chemotherapy in woman with early or locally advanced cervical cancer

Cervical cancer is a major global health problem for women. Despite the screening and vaccines available today, it continues to be the fourth most common cancer in women worldwide with 85% of cases occurring in developing countries. Standard treatments for early or locally advanced cervical cancer are surgery (S) or concomitant chemo-radiotherapy (CT-RT). Neoadjuvant chemotherapy (NACT) prior to surgery or radiotherapy has been proposed and tested in clinical trials and has been included in clinical practice in some countries.In order to determine the true role of NACT either prior to S or RT in terms of achieving benefits in OS or DFS, randomized clinical trials and meta-analyses published from its beginnings to the present have been searched and analyzed in this study.The analysis of published clinical trials shows that NACT followed by S and NACT followed by RT have failed to demonstrate benefits in OS or DFS. Clinical trials comparing NACT followed by S versus exclusive RT have also been analyzed, where NACT followed by S could not show benefits for RT either.

CONCLUSION

Adding neoadjuvant chemotherapy to S or RT cannot be recommended outside the context of clinical trials.

Defining the Role of Neoadjuvant Chemotherapy Followed by Surgery in Locally Advanced Cancer Cervix: A Meta-analysis of Phase III Trials

STUDY OBJECTIVES

This meta-analysis was performed to compare the outcomes between NACT-S and RT for locally advanced cancer cervix. The primary end points were survival benefits.

SEARCHING METHOD

The data sources for the search included medline, national library of medicine, and the embase search engines. Inclusion criteria included studies published between 2000 and 2012, and FIGO stages IB2 to IVA. Studies had to be properly randomized, prospective, or retrospective and only phase III. Further, the studies had to be with two arms, including one arm for neoadjuvant chemotherapy then-surgery (NACT-S), and the other arm for radiotherapy (RT).

RESULTS

Data were collected from 1171 patients enrolled in seven phase III trials. The 5-year PFS (progression-free survival) for NACT-S and RT were 62 and 45.5 %, respectively. The 5-year OS for NACT-S and RT were 66 and 49 %, respectively. NACT-S was associated with better late toxicities compared to RT.

CONCLUSION

NACT-S is a reasonable treatment option for locally advanced cancer cervix. It achieved better results than RT, especially for stages from IB2 to IIB.

Neoadjuvant chemotherapy followed by surgery has no therapeutic advantages over concurrent chemoradiotherapy in International Federation of Gynecology and Obstetrics stage IB-IIB cervical cancer

Objective

We aimed to assess the efficacy of neoadjuvant chemotherapy followed by surgery (NACT+S), and compared the clinical outcome with that of concurrent chemoradiotherapy (CCRT) in patients with International Federation of Gynecology and Obstetrics (FIGO) IB–IIB cervical cancer.

Methods

We reviewed 85 patients with FIGO IB–IIB cervical cancer who received NACT+S between 1989 and 2012, and compared them to 358 control patients who received CCRT. The clinical application of NACT was classified based on the following possible therapeutic benefits: increasing resectability after NACT by reducing tumor size or negative conversion of node metastasis; downstaging adenocarcinoma regarded as relatively radioresistant; and preservation of fertility through limited surgery after NACT.

Results

Of 85 patients in the NACT+S group, the pathologic downstaging and complete response rates were 68.2% and 22.6%, respectively. Only two young patients underwent limited surgery for preservation of fertility. Patients of the NACT+S group were younger, less likely to have node metastasis, and demonstrated a higher proportion of FIGO IB cases than those of the CCRT group (p≤0.001). The 5-year locoregional control, progression-free survival, and overall survival rates in the NACT+S group were 89.7%, 75.6%, and 92.1%, respectively, which were not significantly different from the rates of 92.5%, 74%, and 84.9% observed in the CCRT group, respectively (p>0.05).

Conclusion

NACT+S has no therapeutic advantages over CCRT, the standard treatment. Therefore, NACT+S should be considered only in selected patients through multidisciplinary discussion or clinical trial setting.

Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline

Purpose

To provide evidence-based, resource-stratified global recommendations to clinicians and policymakers on the management and palliative care of women diagnosed with invasive cervical cancer.

Methods

ASCO convened a multidisciplinary, multinational panel of cancer control, medical and radiation oncology, health economic, obstetric and gynecologic, and palliative care experts to produce recommendations reflecting resource-tiered settings. A systematic review of literature from 1966 to 2015 failed to yield sufficiently strong quality evidence to support basic- and limited-resource setting recommendations; a formal consensus-based process was used to develop recommendations. A modified ADAPTE process was also used to adapt recommendations from existing guidelines.

Results

Five existing sets of guidelines were identified and reviewed, and adapted recommendations form the evidence base. Eight systematic reviews, along with cost-effectiveness analyses, provided indirect evidence to inform the consensus process, which resulted in agreement of 75% or greater.

Recommendations

Clinicians and planners should strive to provide access to the most effective evidence-based antitumor and palliative care interventions. If a woman cannot access these within her own or neighboring country or region, she may need to be treated with lower-tier modalities, depending on capacity and resources for surgery, chemotherapy, radiation therapy, and supportive and palliative care. For women with early-stage cervical cancer in basic settings, cone biopsy or extrafascial hysterectomy may be performed. Fertility-sparing procedures or modified radical or radical hysterectomy may be additional options in nonbasic settings. Combinations of surgery, chemotherapy, and radiation therapy (including brachytherapy) should be used for women with stage IB to IVA disease, depending on available resources. Pain control is a vital component of palliative care. Additional information is available at www.asco.org/rs-cervical-cancer-treatment-guideline and www.asco.org/guidelineswiki. It is the view of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Efficacy and tolerability of paclitaxel, ifosfamide, and cisplatin as a neoadjuvant chemotherapy in locally advanced cervical carcinoma

OBJECTIVE

To evaluate the efficacy and tolerability of a neoadjuvant paclitaxel, ifosfamide, and cisplatin chemotherapy in patients with locally advanced cervical carcinoma.

METHODS

Patients with histologically confirmed locally advanced cervical carcinoma, aged ≥18 years, were treated with intravenous ifosfamide 5,000 mg/m² and mesna 5,000 mg/m², on day 1; intravenous paclitaxel 175 mg/m² and cisplatin 75 mg/m², on day 2; every 3 weeks for three cycles. Following chemotherapy, operable patients underwent radical hysterectomy and pelvic lymphadenectomy, and, if necessary, adjuvant radiotherapy.

RESULTS

One hundred fifty-two patients with median age 53 years (range, 24 to 79 years), FIGO stage IIB in 126 (89%), were treated with chemotherapy for median 3 cycles (range, 1 to 3). Treatment was delayed or withdrawn in 23 patients (15%). One hundred thirty-nine patients (91%) underwent surgery. Postchemotherapy pathological complete response rate was 18% (25 patients). Postoperative radiotherapy was administered in 100 patients (72%). The 5-year overall survival and progression-free survival were 87.3% (95% confidence interval [CI], 84.5 to 90.3) and 76.4% (95% CI, 73.5 to 79.5), respectively.

CONCLUSION

Neoadjuvant paclitaxel, ifosfamide, and cisplatin chemotherapy was feasible and effective in the treatment of locally advanced cervical carcinoma patients with older age and more advanced disease stage than reported in previous studies. Hematological and renal toxicity could be carefully prevented.

Neoadjuvant chemotherapy in locally advanced cervical carcinoma: which is better, intravenous or intra-arterial?

Purpose

The aim of our study is to investigate the differences in therapeutic effects and clinical significance between intravenous systematic chemotherapy and intra-arterial interventional chemotherapy in stage Ib2–IIb cervical carcinomas.

Methods

A retrospective analysis was performed on 93 cases of intravenous and 118 cases of intra-arterial neoadjuvant chemotherapy for stage Ib2–IIb cervical carcinomas treated in Peking Union Medical College Hospital from the year 2001 to 2010.

Results

After neoadjuvant chemotherapy, the overall response rate was 84.9% versus (vs) 88.2% and the operability rate was 77.4% vs 81.4%, for intravenous vs intra-arterial (P>0.05). There were no significant differences in toxicities, surgical duration, perioperative blood loss, and operative complications between these two groups. Postoperative pathological examination revealed a significantly lower parametrial infiltration in the intra-arterial group (12.5% vs 38.1%, P<0.05), while the positive vaginal margin, lymph node metastasis, and intravascular tumor embolus showed no significant differences. The intravenous group and the intra-arterial group had similar recurrence rate (16.0% vs 12.3%), distant metastasis rate (9.1% vs 8.5%), and 5 year survival rate (79.5% vs 84.9%), without significant differences.

Conclusion

Neoadjuvant chemotherapy with cisplatin and 5-fluorouracil are safe and effective for patients with locally advanced cervical carcinomas. The intravenous and the intra-arterial approaches present with similar chemotherapy efficacy and clinical outcome. Since it is more simple and economical, the intravenous systematic approach shows greater value in clinical application.

The Effect of Extrafascial Hysterectomy After Completion of External Beam Radiotherapy for Treatment of Locally Advanced Stages (IIB-III) of Cervical Cancer

Background:

Worldwide, cervical cancer is one of the most challenging gynecologic cancers in treatment.

Objectives:

This study was designed with the aim of comparing patients treated with External Beam Radiotherapy (EBRT) and Interactivity Brachytherapy (ICBT) with EBRT and extrafascial hysterectomy in locally advanced stages of cervical cancer (IIB-III).

Patients and Methods:

The present study was designed as a case-control which was performed on the patients with cervical cancer in locally advanced stages (IIB-III) admitted to Namazi and Faghihi hospitals (university hospitals in Shiraz) between 2008-2011. 51 patients were included in two distinct groups: 25 patients were treated with EBRT and Interactivity Brachytherapy (group A). 26 patients were treated with EBRT and extrafascial hysterectomy group B.

Results:

In group A, the number of patients with FIGO stage IIb and III were 16 and 9, respectively, and 17 and 9 in group B. The median duration of follow-up was 24 months. There were no significant differences between two groups in metastasis and recurrence rate (P > 0.05). 5-years overall survival rate was 54.8% [95% CI: 39-70.9] in group A and in group B was 50.9% [95% CI: 41.5-60] and The LOG-rank test which controls the effect of treatment modalities on overall survival rate, did not show any significant difference between two groups (P = 0.407).

Conclusion:

The results of our study showed that the trend of treatment using EBRT along with intracavity brachytherapy may have the same outcome as the method of using EBRT and extrafascial hysterectomy. Overall, it seems that external beam radiation followed by extrafascial hysterectomy could be a proper substitute for brachytherapy.

The efficacy and safety of neoadjuvant chemotherapy in treatment of locally advanced carcinoma cervix

OBJECTIVE

A prospective cohort study in a teaching hospital to assess the efficacy and safety of neoadjuvant chemotherapy in the treatment of locally advanced carcinoma cervix.

METHOD

Neoadjuvant chemotherapy in the form of cisplatin 75 mg/m(2) and paclitaxel 135 mg/m(2) on day 1 and repeated at 14 days' interval for up to a maximum of three courses.

RESULTS

Neoadjuvant chemotherapy in cervical cancer was effective in the downstaging of the disease. Downstaging was observed in 19.23 % of patients after two cycles and in 50 % of patients after three cycle of NACT. Operability increases to 33.3 and 38.4 % after two and three cycles of NACT, respectively. Complete pathological response was observed in 37.5 % of patients after NACT. No significant adverse effect in the feasibility of surgery was observed.

CONCLUSION

The present study showed that neoadjuvant chemotherapy was an effective and well-tolerated mode of therapy with significantly less morbidity and mortality.

Adjuvant chemotherapy for endometrial cancer after hysterectomy

BACKGROUND

Endometrial adenocarcinoma (womb cancer) is a malignant growth of the lining (endometrium) of the womb (uterus). It is distinct from sarcomas (tumours of the uterine muscle). Survival depends the risk of microscopic metastases after surgery. Adjuvant (postoperative) chemotherapy improves survival from some other adenocarcinomas, and there is evidence that endometrial cancer is sensitive to cytotoxic therapy. This systematic review examines the effect of chemotherapy on survival after hysterectomy for endometrial cancer.

OBJECTIVES

To assess efficacy of adjuvant (postoperative) chemotherapy for endometrial cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 3), MEDLINE and EMBASE up to August 2010, registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant chemotherapy with any other adjuvant treatment or no other treatment.

DATA COLLECTION AND ANALYSIS

We used a random-effects meta-analysis to assess hazard ratios (HR) for overall and progression-free survival and risk ratios (RR) to compare death rates and site of initial relapse.

MAIN RESULTS

Five RCTs compared no additional treatment with additional chemotherapy after hysterectomy and radiotherapy. Four trials compared platinum based combination chemotherapy directly with radiotherapy. Indiscriminate pooling of survival data from 2197 women shows a significant overall survival advantage from adjuvant chemotherapy (RR (95% CI) = 0.88 (0.79 to 0.99)). Sensitivity analysis focused on trials of modern platinum based chemotherapy regimens and found the relative risk of death to be 0.85 ((0.76 to 0.96); number needed to treat for an additional beneficial outcome (NNT) = 25; absolute risk reduction = 4% (1% to 8%)). The HR for overall survival is 0.74 (0.64 to 0.89), significantly favouring the addition of postoperative platinum based chemotherapy. The HR for progression-free survival is 0.75 (0.64 to 0.89). This means that chemotherapy reduces the risk of being dead at any censorship by a quarter. Chemotherapy reduces the risk of developing the first recurrence outside the pelvis (RR = 0.79 (0.68 to 0.92), 5% absolute risk reduction; NNT = 20). The analysis of pelvic recurrence rates is underpowered but the trend suggests that chemotherapy may be less effective than radiotherapy in a direct comparison (RR = 1.28 (0.97 to 1.68)) but it may have added value when used with radiotherapy (RR = 0.48 (0.20 to 1.18)).

AUTHORS' CONCLUSIONS

Postoperative platinum based chemotherapy is associated with a small benefit in progression-free survival and overall survival irrespective of radiotherapy treatment. It reduces the risk of developing a metastasis, could be an alternative to radiotherapy and has added value when used with radiotherapy.

Guidelines on chemotherapy in advanced stage gynecological malignancies: an evaluation of 224 professional societies and organizations

Background

Clinical practice guidelines are important for guiding practice, but it is unclear if they are commensurate with the available evidence.

Methods

We examined guidelines produced by cancer and gynecological societies and organizations and evaluated their coverage of and stance towards chemotherapy for advanced stage disease among 4 gynecological malignancies (breast, ovarian, cervical, endometrial cancer) where the evidence for the use of chemotherapy is very different (substantial and conclusive for breast and ovarian cancer, limited and suggesting no major benefit for cervical and endometrial cancer). Eligible societies and organizations were identified through systematic internet searches (last update June 2009). Pertinent websites were scrutinized for presence of clinical practice guidelines, and relative guidelines were analyzed.

Results

Among 224 identified eligible societies and organizations, 69 (31%) provided any sort of guidelines, while recommendations for chemotherapy on advanced stage gynecological malignancies were available in 20 of them. Only 14 had developed their own guideline, and only 5 had developed guidelines for all 4 malignancies. Use of levels of evidence and grades of recommendations, and aspects of the production, implementation, and timeliness of the guidelines did not differ significantly across malignancies. Guidelines on breast and ovarian cancer utilized significantly more randomized trials and meta-analyses. Guidelines differed across malignancies on their coverage of disease-free survival (p = 0.033), response rates (p = 0.024), symptoms relief (p = 0.005), quality of life (p = 0.001) and toxicity (p = 0.039), with breast and ovarian cancer guidelines typically covering more frequently these outcomes. All guidelines explicitly or implicitly endorsed the use of chemotherapy.

Conclusions

Clinical practice guidelines are provided by the minority of professional societies and organizations. Available guidelines tend to recommend chemotherapy even for diseases where the effect of chemotherapy is controversial and recommendations are based on scant evidence.