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Horowitz NS, Deng W, Peterson I, Mannel RS, Thompson S, Lokich E, Myers T, Hanjani P, O'Malley DM, Chung KY, Miller DS, Ueland FR, Dizon DS, Miller A, Mayadev JS, Leath CA, Monk BJ. Phase II Trial of Cisplatin, Gemcitabine, and Intensity-Modulated Radiation Therapy for Locally Advanced Vulvar Squamous Cell Carcinoma: NRG Oncology/GOG Study 279. J Clin Oncol 2024; 42:1914-1921. [PMID: 38574312 DOI: 10.1200/jco.23.02235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/21/2023] [Accepted: 02/06/2024] [Indexed: 04/06/2024] Open
Abstract
PURPOSE To assess efficacy and toxicity of cisplatin (C) and gemcitabine (G) with intensity-modulated radiation therapy (IMRT) in patients with locally advanced vulvar cancer not amenable to surgery. METHODS Patients enrolled in a single-arm phase II study. Pretreatment inguinal-femoral nodal assessment was performed. Sixty-four Gy IMRT was prescribed to the vulva, with 50-64 Gy delivered to the groins/low pelvis. Radiation therapy (RT) plans were quality-reviewed pretreatment. C 40 mg/m2 and G 50 mg/m2 were administered once per week throughout IMRT. Complete pathologic response (CPR) was the primary end point. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and adverse events were assessed with Common Terminology Criteria for Adverse Events v 4.0. RESULTS Fifty-seven patients enrolled, of which 52 were evaluable. The median age was 58 years (range, 25-58), and 94% were White. Forty (77%) had stage II or III disease, and all had squamous histology. A median of six chemotherapy cycles (range, 1-8) were received. Eighty-five percent of RT plans were quality-reviewed with 100% compliance to protocol. Seven patients came off trial because of toxicity or patient withdrawal. Of 52 patients available for pathologic assessment, 38 (73% [90% CI, 61 to 83]) achieved CPR. No pelvic exenterations were performed. With a median follow-up of 51 months, the 12-month PFS was 74% (90% CI, 62.2 to 82.7) and the 24-month OS was 70% (90% CI, 57 to 79). The most common grade 3 or 4 adverse events were hematologic toxicity and radiation dermatitis. There was one grade 5 event unlikely related to treatment. CONCLUSION Weekly C and G concurrent with IMRT sufficiently improved CPR in women with locally advanced vulvar squamous cell carcinoma not amenable to surgical resection.
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Affiliation(s)
| | - Wei Deng
- NRG Oncology/Gynecologic Oncology Group Statistics & Data Center, Buffalo, NY
| | | | - Robert S Mannel
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Spencer Thompson
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | | | | | - David M O'Malley
- The James CCC & The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - David S Miller
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Austin Miller
- NRG Oncology/Gynecologic Oncology Group Statistics & Data Center, Buffalo, NY
| | - Jyoti S Mayadev
- University of California San Diego School of Medicine, La Jolla, CA
| | - Charles A Leath
- O'Neal Comprehensive Cancer Center at the University of Alabama Birmingham; Birmingham, AL
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Bejar FG, Oaknin A, Williamson C, Mayadev J, Peters PN, Secord AA, Wield AM, Coffman LG. Novel Therapies in Gynecologic Cancer. Am Soc Clin Oncol Educ Book 2022; 42:1-17. [PMID: 35594502 DOI: 10.1200/edbk_351294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
During the past decade, considerable strides have been made in the understanding and treatment of gynecologic cancers. The advent of PARP inhibitors, antiangiogenic therapies, immunotherapy combinations, and targeted agents have altered the standard of care in ovarian, endometrial, and cervical cancers. However, continued advancement in the treatment of gynecologic cancers is critical. Fortunately, exciting work defining new therapeutic targets and novel treatment strategies is on the horizon. Here, we discuss emerging treatments for gynecologic cancers, including endometrial, cervical, ovarian, and rare gynecologic cancers. We highlight research that has deepened our understanding of the unique biology and molecular underpinnings of these cancers and is being translated into powerful new treatment approaches. We particularly highlight the advent of immunotherapy in endometrial cancer; radiosensitizers in cervical, vaginal, and vulvar cancers; targeted therapies in ovarian cancer; and molecularly driven approaches to treat rare gynecologic cancers. Continued basic, translational, and clinical research holds the promise to change the landscape of gynecologic cancer and improve the lives of all women impacted by these diseases.
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Affiliation(s)
- Francisco Grau Bejar
- Gynaecologic Cancer Programme, Vall d'Hebron Institute of Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ana Oaknin
- Gynaecologic Cancer Programme, Vall d'Hebron Institute of Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Casey Williamson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Jyoti Mayadev
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Pamela N Peters
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Alyssa M Wield
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, Pittsburgh, PA
| | - Lan G Coffman
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, Pittsburgh, PA.,Division of Hematology/Oncology, Department of Medicine, Hillman Cancer Center, Magee-Womens Research Institute, Pittsburgh, PA
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Phase 1 Trial of Concurrent Gemcitabine and Cisplatin with Image Guided Intensity Modulated Radiation Therapy for Locoregionally Advanced Cervical Carcinoma. Int J Radiat Oncol Biol Phys 2020; 107:964-973. [PMID: 32334034 DOI: 10.1016/j.ijrobp.2020.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE The use of concurrent doublet chemotherapy with radiation for locoregionally advanced cervical cancer (LACC) is limited by gastrointestinal and hematologic toxicity. By reducing radiation dose to bowel and bone marrow, image guided intensity modulated radiation therapy (IG-IMRT) may improve chemotherapy tolerance. The goal of this study was to determine whether IG-IMRT could lead to improved tolerance to concurrent cisplatin and gemcitabine for LACC. METHODS AND MATERIALS We conducted an open-label, nonrandomized, prospective phase 1 dose escalation trial at a tertiary academic cancer center (ClinicalTrials.gov identifier: NCT01554410). We enrolled patients with stage IB-IVA cervical cancer, with either an intact cervix or posthysterectomy with residual/recurrent pelvic or paraortic nodal involvement, undergoing radical pelvic or extended field chemoradiation therapy. Treatment consisted of chemoradiation with IG-IMRT (45-47.6 Gy, 25-28 fractions to the pelvis ± paraortic nodes with simultaneous nodal boost to 53.2-59.4 Gy, 28 fractions) plus 5 cycles of concurrent weekly cisplatin 40 mg/m2 with escalating doses of gemcitabine (50, 75, 100, or 125 mg/m2). Cohorts were separated preregistration according to whether the patient received pelvic or extended field IG-IMRT and whether gemcitabine followed (CG) or preceded (GC) cisplatin delivery. Dose-limiting toxicity (DLT) events were monitored up to 30 days after chemoradiation therapy. The primary endpoint was maximum tolerated dose (MTD) resulting in DLT probability ≤20%. RESULTS Between February 2011 and June 2019, 35 patients were registered. Overall, 7 patients (20.0%) experienced DLTs. For the pelvic field cohort, the estimated MTD was 100 mg/m2 with GC sequencing, which is higher than the previously reported MTD for this regimen. The extended field cohort was closed after 2 of 3 patients experienced a DLT at the first dose level. CONCLUSIONS IG-IMRT can permit higher doses of concurrent gemcitabine with cisplatin and pelvic radiation for LACC. However, acute toxicity remains a factor with this regimen, depending on radiation volume and chemotherapy sequencing.
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Duenas-Gonzalez A, Gonzalez-Fierro A. Pharmacodynamics of current and emerging treatments for cervical cancer. Expert Opin Drug Metab Toxicol 2019; 15:671-682. [DOI: 10.1080/17425255.2019.1648431] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Alfonso Duenas-Gonzalez
- Unit of Biomedical Research on Cancer, Instituto de Investigaciones Biomédicas UNAM/Instituto Nacional de Cancerología, Mexico City, Mexico
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Gultekin M, Sari SY, Yazici G, Hurmuz P, Yildiz F, Ozyigit G. Gynecological Cancers. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-97145-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Mabuchi S, Isohashi F, Okazawa M, Kitada F, Maruoka S, Ogawa K, Kimura T. Chemoradiotherapy followed by consolidation chemotherapy involving paclitaxel and carboplatin and in FIGO stage IIIB/IVA cervical cancer patients. J Gynecol Oncol 2017; 28:e15. [PMID: 27958682 PMCID: PMC5165064 DOI: 10.3802/jgo.2017.28.e15] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/05/2016] [Accepted: 11/10/2016] [Indexed: 02/08/2023] Open
Abstract
Objective To evaluate the efficacy and toxicity of paclitaxel plus carboplatin (TC)-based concurrent chemoradiotherapy (CCRT) followed by consolidation chemotherapy in the International Federation of Gynecology and Obstetrics (FIGO) stage IIIB/IVA cervical cancer patients. Methods We reviewed the medical records of FIGO stage IIIB/IVA cervical cancer patients (n=30) who had been intended to be treated with TC-based CCRT followed by consolidation chemotherapy (TC-CCRT-group) from April 2012–May 2016. Patients who had been treated with CCRT involving a single platinum agent (CCRT-group; n=52) or definitive radiotherapy alone (RT-group; n=74) from January 1997–September 2012 were also identified and used as historical controls. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. Results Of the 30 patients included in the TC-CCRT-group, 22 patients (73.3%) completed the planned TC-based CCRT. The most frequently observed acute grade 3/4 hematological toxicities were leukopenia and neutropenia, and diarrhea was the most common acute grade 3/4 non-hematological toxicity. After a median follow-up of 35 months, 9 patients (30.0%) had developed recurrent disease. The patients’ estimated 3-year progression-free survival (PFS) and overall survival (OS) rates were 67.9% and 90.8%, respectively. In comparisons with historical control groups, the survival outcomes of TC-CCRT-group was significantly superior to CCRT-group in terms of OS (p=0.011) and significantly superior to RT-group in terms of both PFS (p=0.009) and OS (p<0.001). Conclusion TC-based CCRT followed by consolidation chemotherapy is safe and effective. A randomized controlled study needs to be conducted to further evaluate the efficacy of this multimodal approach in this patient population.
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Affiliation(s)
- Seiji Mabuchi
- Department of Obstetrics and Gynecology, Osaka University, Graduate School of Medicine, Osaka, Japan.
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Mika Okazawa
- Department of Obstetrics and Gynecology, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Fuminori Kitada
- Department of Obstetrics and Gynecology, Suita Tokusyukai Hospital, Osaka, Japan
| | - Shintaro Maruoka
- Department of Radiology, Suita Tokusyukai Hospital, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University, Graduate School of Medicine, Osaka, Japan
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Davis MA, Delaney JR, Patel CB, Storgard R, Stupack DG. Nelfinavir is effective against human cervical cancer cells in vivo: a potential treatment modality in resource-limited settings. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:1837-46. [PMID: 27330277 PMCID: PMC4898046 DOI: 10.2147/dddt.s102241] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective The standard treatment for cervical cancer in developed countries includes surgery and chemoradiation, with standard of care lagging in developing countries. Even in the former case, treatment frequently yields recalcitrant tumors and women succumb to disease. Here we examine the impact of nelfinavir, an off-patent viral protease inhibitor, which has shown promise as an antineoplastic agent. Methods We evaluated the morphological and proliferative effects of the autophagy-stressing drug nelfinavir in normal and cisplatin-resistant cervical cancer cells. Immunofluorescent validation of autophagy markers was performed and the impact of nelfinavir in an in vivo model of tumor growth was determined. Results Nelfinavir exhibits cytotoxicity against both cisplatin-sensitive and -resistant ME-180 human cervical cancer cells in vitro and in vivo. Immunoblotting and immunofluorescence showed an expression of the autophagy marker LC3-II in response to nelfinavir treatment. Conclusion Nelfinavir, now available as an inexpensive generic orally dosed agent (Nelvir), is cytotoxic against cervical cancer cells. It acts by burdening the autophagy pathway to impair tumor cell survival and a modest induction of apoptosis. While further studies are needed to elucidate the optimal method of application of nelfinavir, it may represent an appealing global option for the treatment of cervical cancer.
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Affiliation(s)
- Mitzie-Ann Davis
- Division of Gynecologic Oncology, Department of Reproductive Medicine, Rebecca and John UCSD Moores Cancer Center, La Jolla, CA, USA
| | - Joe R Delaney
- Division of Gynecologic Oncology, Department of Reproductive Medicine, Rebecca and John UCSD Moores Cancer Center, La Jolla, CA, USA
| | - Chandni B Patel
- Division of Gynecologic Oncology, Department of Reproductive Medicine, Rebecca and John UCSD Moores Cancer Center, La Jolla, CA, USA
| | - Ryan Storgard
- Division of Gynecologic Oncology, Department of Reproductive Medicine, Rebecca and John UCSD Moores Cancer Center, La Jolla, CA, USA
| | - Dwayne G Stupack
- Division of Gynecologic Oncology, Department of Reproductive Medicine, Rebecca and John UCSD Moores Cancer Center, La Jolla, CA, USA
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Mabuchi S, Isohashi F, Yokoi T, Takemura M, Yoshino K, Shiki Y, Ito K, Enomoto T, Ogawa K, Kimura T. A phase II study of postoperative concurrent carboplatin and paclitaxel combined with intensity-modulated pelvic radiotherapy followed by consolidation chemotherapy in surgically treated cervical cancer patients with positive pelvic lymph nodes. Gynecol Oncol 2016; 141:240-246. [DOI: 10.1016/j.ygyno.2016.02.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 11/16/2022]
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Moore KN, Rowland MR. Treatment Advances in Locoregionally Advanced and Stage IVB/Recurrent Cervical Cancer: Can We Agree That More Is Not Always Better? J Clin Oncol 2015; 33:2125-8. [PMID: 25987695 DOI: 10.1200/jco.2015.61.0998] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kathleen N Moore
- Stephenson Oklahoma Cancer Center, University of Oklahoma, Oklahoma City, OK
| | - Michelle R Rowland
- Stephenson Oklahoma Cancer Center, University of Oklahoma, Oklahoma City, OK
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Five years' experience treating locally advanced cervical cancer with concurrent chemoradiotherapy: results from a single institution. Arch Gynecol Obstet 2015; 292:1091-9. [PMID: 25914074 DOI: 10.1007/s00404-015-3712-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/01/2015] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cervical cancer is the second most common cause of female cancer death. In Morocco it is the second most common cancer, our department recruits more than 500 patients each year and proximally half of the cases are diagnosed at an advanced stage. PATIENTS AND METHODS Between January 2008 and December 2008, all patients with diagnosis of locally advanced cervical cancer referred to our department and treated with concurrent chemoradiotherapy were retrieved. We analyzed outcomes for this particular population; overall survival, local control, and toxicities, we also retrieved prognostic factors influencing outcomes for this population. RESULTS The overall survival rate for the cohort was 68 % at 2 years, and reached 47 % at 5 years. The overall LC rate was 71 % at 2 years and 58 % at 5 years. The most important prognostic factors for OS and LC were the pretreatment hemoglobin, the tumor size, total duration of treatment, and the use of brachytherapy. For OS, the presence of enlarged lymph nodes was also important. For LC, the number of chemotherapy's courses was important. Of the included patients, 20 % experienced late grade 3 or 4 toxicity. CONCLUSION The results of our study have shown that despite all the treatment strategies available, locally advanced cervical cancer is associated with bad outcomes. In this cohort, the most important prognostic factors were the pretreatment hemoglobin level and the tumor size.
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Wang CC, Chou HH, Yang LY, Lin H, Liou WS, Tseng CW, Liu FY, Liou JD, Huang KG, Huang HJ, Huang EY, Chen CH, Chang TC, Chang CJ, Hong JH, Lai CH. A randomized trial comparing concurrent chemoradiotherapy with single-agent cisplatin versus cisplatin plus gemcitabine in patients with advanced cervical cancer: An Asian Gynecologic Oncology Group study. Gynecol Oncol 2015; 137:462-7. [PMID: 25827291 DOI: 10.1016/j.ygyno.2015.03.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/22/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE A recent randomized trial demonstrated that concurrent chemoradiotherapy (CCRT) with weekly cisplatin and gemcitabine, followed by two adjuvant cycles of cisplatin and gemcitabine improved survival for advanced cervical cancer patients. An Asian Gynecologic Oncology Group (AGOG) study was designed to determine whether only adding gemcitabine in the chemoradiation phase without adjuvant chemotherapy could improve survival. METHODS Between March 2009 and March 2013, 74 eligible patients with International Federation of Obstetrics and Gynecology stage III/IVA cervical cancer or stage I/II with positive pelvic/para-aortic nodal metastasis were enrolled. Thirty-seven patients were randomized to arm C (weekly cisplatin 40mg/m(2)) and 37 patients were randomized to arm CG (weekly cisplatin 40mg/m(2) and gemcitabine 125mg/m(2)), for six cycles. Six eligible patients were excluded before the beginning of treatment. RESULTS An interim analysis showed superimposable progression-free (PFS) and overall survival (OS), a decision of closing accrual was made. A 3-year PFS was similar in both arms (arm C 65.1% vs. arm CG 71.0%, p=0.71), and a 3-year OS was 74.1% in arm C vs. 85.9% in arm CG (p=0.89), but crossed over at 5years. Grade 2-4 hematological toxicities, including neutropenia (p=0.028) and thrombocytopenia (p=0.001), were more frequent in arm CG than arm C. CONCLUSIONS Despite limitation in power, it suggests that only adding gemcitabine at the CCRT phase does not provide substantially superior results, but treatment toxicities could increase. Further studies are required to determine the role of post-CCRT adjuvant chemotherapy in advanced cervical cancer.
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Affiliation(s)
- Chun-Chieh Wang
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung-Hsueh Chou
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lan-Yan Yang
- Clinical Trial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Data Management and Biostatistical Core, Asian Gynecologic Oncology Group, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hao Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Shiung Liou
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Wen Tseng
- Department of Obstetrics and Gynecology, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Feng-Yuan Liu
- Department of Nuclear Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jui-Der Liou
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kuan-Gen Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Huei-Jean Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Hsun Chen
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ting-Chang Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chee-Jen Chang
- Data Management and Biostatistical Core, Asian Gynecologic Oncology Group, Taiwan; Research Center of Clinical Informatics and Medical Statistics, Chang Gung University, Taoyuan, Taiwan
| | - Ji-Hong Hong
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Chyong-Huey Lai
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
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Dizon DS, Mackay HJ, Thomas GM, Werner TL, Kohn EC, Hess D, Rose PG, Covens AL. State of the science in cervical cancer: where we are today and where we need to go. Cancer 2014; 120:2282-8. [PMID: 24737608 DOI: 10.1002/cncr.28722] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/05/2014] [Accepted: 03/10/2014] [Indexed: 12/27/2022]
Abstract
Invasive cervical cancer remains an important global cause of death, despite the declining prevalence within the United States. Definitive therapies, including surgical resection of early-stage disease and chemoradiation for locally advanced disease, can be curative. For women who experience local or distant recurrences, the prognosis remains poor and better treatments are required. On July 18, 2013, The Gynecologic Oncology Group sponsored a State of the Science in Cervical Cancer Symposium with experts, researchers, clinicians, and interested stakeholders. This article summarize the progress that has been made, questions that require further investigation, and contemporary genomic findings and innovative treatments that may help inform the next generation of clinical trials for patients with cervical cancer.
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Affiliation(s)
- Don S Dizon
- Gillette Center for Gynecologic Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Abstract
OBJECTIVES To review nursing science history within the Gynecology Oncology Group (GOG); to discuss challenges of nursing science in the cooperative group (CG) using a current nurse-led protocol (GOG-0259) as an exemplar; and to propose recommendations to advance nursing science in the CG setting. DATA SOURCES Indexed citations and personal experience. CONCLUSION Benefits of CG research include opportunities for inter-disciplinary collaboration and ability to rapidly accrue large national samples. Challenges include limited resources to support non-treatment trials, a burdensome protocol approval process, and lack of experience with nursing/quality-of-life intervention studies. Formal GOG structures need to evolve to encourage nurse scientists to become active members; promote collaboration between experienced GOG advanced practice nurses and nurse scientists to identify nursing research priorities; and consider new funding sources to support pilot intervention studies. IMPLICATIONS FOR NURSING PRACTICE Understanding the CG research process is critical for nurse scientists. A multi-disciplinary team of CG leaders can help investigators navigate a complex research environment and increase awareness of the value of nursing research.
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Outcomes of cervical cancer and positive para-aortic lymph nodes in the modern era of chemoradiation. Int J Gynecol Cancer 2014; 24:564-9. [PMID: 24552890 DOI: 10.1097/igc.0000000000000093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Patients with cervical cancer with positive para-aortic lymph nodes have a poor prognosis. Our primary aim was to describe outcomes among this subgroup in the era of modern chemoradiation. METHODS Patients with histologically confirmed cervical cancer metastatic to their para-aortic lymph nodes diagnosed between 1998 and 2011 and treated with curative intent were included in this analysis. Surgicopathologic, demographic, and outcome data were collected. Descriptive and survival statistics were generated to evaluate overall survival (OS) and progression-free survival (PFS) and to compare outcomes by treatment. P values were generated using both Wilcoxon and log-rank methods and listed respectively. RESULTS The median PFS was 19 months. The median OS was 23.4 months. The median PFS for radiation only was 14 months and for chemoradiation was 20 months (P = 0.27 and 0.60, respectively). There was no difference in median OS for the radiation-only group versus chemoradiation. The median OS stratified by stage was 32 months (stage I), 21 months (stage II), 19.4 months (stage III), and 19.8 months (stage IV; P = 0.17 and 0.22). CONCLUSIONS Our study shows a median OS of 23 months, which is less than what was documented in the literature. Despite the use of modern chemoradiation therapy, most of the cohort died within 3 years. The low OS presented in our study highlights the limitations of the current treatment regimens and the need for identification of for more effective therapy.
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Prospective study of symptom assessment among patients with cervical cancer during concurrent chemoradiotherapy with weekly cisplatin or every-3-week cisplatin and 5-fluorouracil. Int J Gynecol Cancer 2013; 23:1520-7. [PMID: 24257567 DOI: 10.1097/igc.0b013e3182a0c0e5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE In this prospective study, symptoms were assessed in patients with locally advanced cervical cancer undergoing concurrent chemoradiotherapy (CTRT) with either weekly cisplatin (WP) or every-3-week cisplatin/5-fluorouracil (PF). MATERIALS AND METHODS Patients with 1994 International Federation of Gynecology and Obstetrics stage IIB to IVA disease, biopsy-proven involved pelvic nodes, or gross tumor size greater than 5 cm were eligible. Patients requiring paraaortic radiotherapy were excluded. With the use of a modified Edmonton Symptom Assessment Scale, patients reported symptom severity on an 11-point scale 3 times per week during CTRT and at the first follow-up. The Wilcoxon rank sum test and multilevel mixed-effects linear regression were used to assess the effect of chemotherapy regimen on symptoms. RESULTS Among the 52 patients included in the final analysis, 37 received WP, 13 received PF, and 2 received 1 cycle of PF followed by WP. Overall compliance with completion of Edmonton Symptom Assessment Scale questionnaires was 75%. There were significant differences in symptom scores for well-being, anorexia, fatigue, diarrhea, and stomatitis favoring the WP regimen. All symptoms except diarrhea were stable and of low intensity in the WP group. In the PF group, symptoms had a cyclical pattern with an initial rise followed by a gradual fall during the 3-week period after chemotherapy. For the 29 patients (56%) who completed the follow-up surveys, scores for all symptoms improved to baseline levels 4 to 6 weeks after treatment. CONCLUSIONS This analysis provides important patient-reported data regarding the rates and timing of acute symptoms during CTRT that can help clinicians better manage symptoms that impact patients' quality of life.
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Markman M. Chemoradiation in the Management of Cervix Cancer: Current Status and Future Directions. Oncology 2013; 84:246-50. [DOI: 10.1159/000346804] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 11/19/2022]
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Moore KN, Sill MW, Miller DS, McCourt C, De Geest K, Rose PG, Cardenes HR, Mannel RS, Farley JH, Schilder RJ, Fracasso PM. A phase I trial of tailored radiation therapy with concomitant cetuximab and cisplatin in the treatment of patients with cervical cancer: A gynecologic oncology group study. Gynecol Oncol 2012; 127:456-61. [DOI: 10.1016/j.ygyno.2012.08.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 08/13/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
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Phippen NT, Leath CA, Chino JP, Jewell EL, Havrilesky LJ, Barnett JC. Cost effectiveness of concurrent gemcitabine and cisplatin with radiation followed by adjuvant gemcitabine and cisplatin in patients with stages IIB to IVA carcinoma of the cervix. Gynecol Oncol 2012; 127:267-72. [DOI: 10.1016/j.ygyno.2012.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 08/01/2012] [Accepted: 08/05/2012] [Indexed: 11/26/2022]
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Hodge LS, Downs LS, Chura JC, Thomas SG, Callery PS, Soisson AP, Kramer P, Wolfe SS, Tracy TS. Localized delivery of chemotherapy to the cervix for radiosensitization. Gynecol Oncol 2012; 127:121-5. [PMID: 22796462 DOI: 10.1016/j.ygyno.2012.07.097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 07/01/2012] [Accepted: 07/04/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Chemoradiation is the mainstay of therapy for advanced cervical cancer, with the most effective treatment regimens involving combinations of radiosensitizing agents. However, administration of radiosensitizing chemotherapeutics concurrently with pelvic radiation is not without side effects. The aim of this study was to examine the utility of localized drug delivery as a means of improving drug targeting of radiosensitizing chemotherapeutics to the cervix while limiting systemic toxicities. METHODS An initial proof-of-concept study was performed in 14 healthy women following local administration of diazepam utilizing a novel cervical delivery device (CerviPrep™). Uterine vein and peripheral blood samples were collected and diazepam was measured using a GC-MS method. In the follow-up study, gemcitabine was applied to the cervix in 17 women undergoing hysterectomy for various gynecological malignancies. Cervical tissue, uterine vein blood samples, and peripheral plasma were collected, and gemcitabine and its deaminated metabolite 2',2'-difluorodeoxyuridine (dFdU) were measured using HPLC-UV and LC/MS methods. RESULTS Targeted delivery of diazepam to the cervix was consistent with parent drug detectable in the uterine vein of 13 of 14 women. In the second study, pharmacologically relevant concentrations of gemcitabine (0.01-6.6 nmol/g tissue) were detected in the cervical tissue of 11 of 16 available specimens with dFdU measureable in 15 samples (0.04-8.8 nmol/g tissue). Neither gemcitabine nor its metabolites were detected in the peripheral plasma of any subject. CONCLUSIONS Localized drug delivery to the cervix is possible and may be useful in limiting toxicity associated with intravenous administration of chemotherapeutics for radiosensitization.
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Affiliation(s)
- Lucy S Hodge
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
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Kunos C, Radivoyevitch T, Abdul-Karim FW, Fanning J, Abulafia O, Bonebrake AJ, Usha L. Ribonucleotide reductase inhibition restores platinum-sensitivity in platinum-resistant ovarian cancer: a Gynecologic Oncology Group Study. J Transl Med 2012; 10:79. [PMID: 22541066 PMCID: PMC3403898 DOI: 10.1186/1479-5876-10-79] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 04/27/2012] [Indexed: 01/26/2023] Open
Abstract
Background The potent ribonucleotide reductase (RNR) inhibitor 3-aminopyridine-2-carboxyaldehyde-thiosemicarbazone (3-AP) was tested as a chemosensitizer for restored cisplatin-mediated cytotoxicity in platinum-resistant ovarian cancer. Methods Preclinical in vitro platinum-resistant ovarian cancer cell survival, RNR activity, and DNA damage assays were done after cisplatin or cisplatin plus 3-AP treatments. Six women with platinum-resistant ovarian cancer underwent four-day 3-AP (96 mg/m2, day one to four) and cisplatin (25 mg/m2, day two and three) infusions every 21 days until disease progression or adverse effects prohibited further therapy. Pre-therapy ovarian cancer tissues were analyzed by immunohistochemistry for RNR subunit expression as an indicator of cisplatin plus 3-AP treatment response. Results 3-AP preceding cisplatin exposure in platinum-resistant ovarian cancer cells was not as effective as sequencing cisplatin plus 3-AP together in cell survival assays. Platinum-mediated DNA damage (i.e., γH2AX foci) resolved quickly after cisplatin-alone or 3-AP preceding cisplatin exposure, but persisted after a cisplatin plus 3-AP sequence. On trial, 25 four-day overlapping 3-AP and cisplatin cycles were administered to six women (median 4.2 cycles per patient). 3-AP-related methemoglobinemia (range seven to 10%) occurred in two (33%) of six women, halting trial accrual. Conclusions When sequenced cisplatin plus 3-AP, RNR inhibition restored platinum-sensitivity in platinum-resistant ovarian cancers. 3-AP (96 mg/m2) infusions produced modest methemoglobinemia, the expected consequence of ribonucleotide reductase inhibitors disrupting collateral proteins containing iron. Trial registry ClinicalTrials.gov NCT00081276
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Affiliation(s)
- Charles Kunos
- Department of Radiation Oncology, University Hospitals of Cleveland, Cleveland, OH 44106, USA.
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Rose PG, Sill MW, McMeekin DS, Ahmed A, Salani R, Yamada SD, Wolfson AH, Fusco N, Fracasso PM. A phase I study of concurrent weekly topotecan and cisplatin chemotherapy with whole pelvic radiation therapy in locally advanced cervical cancer: a gynecologic oncology group study. Gynecol Oncol 2012; 125:158-62. [PMID: 22198338 PMCID: PMC4533103 DOI: 10.1016/j.ygyno.2011.12.431] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 12/08/2011] [Accepted: 12/09/2011] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the maximum tolerated dose (MTD) and acute dose-limiting toxicities (DLT) of intravenous topotecan administered with weekly cisplatin during pelvic radiation therapy in patients with locally advanced cervical cancer. METHODS Patients were treated at one of two dose levels receiving intravenous topotecan at 0.5mg/m(2) and cisplatin at either 30 or 40 mg/m(2) given weekly for 6 weeks concurrently with pelvic radiation and intracavitary brachytherapy. The primary endpoint for the escalation study was acute dose-limiting toxicities occurring within 30 days of completing radiation therapy. RESULTS Eleven patients were enrolled. Dose-limiting toxicity consisting of Grade 3 nausea and vomiting lasting >24h in one patient and grade 3 febrile neutropenia in another patient occurred at the first dose level of weekly topotecan 0.5mg/m(2) and cisplatin 40 mg/m(2). This necessitated de-escalation to weekly cisplatin 30 mg/m(2) in combination with topotecan 0.5mg/m(2) and pelvic radiation. This dose level was tolerable in 6 evaluable patients with only one DLT consisting of grade 4 thrombocytopenia, grade 3 abdominal pain and grade 3 elevated gamma glutamyl transpeptidase (GGT). CONCLUSIONS In women with locally advanced cervical cancer, intravenous topotecan 0.5mg/m(2) and cisplatin 30 mg/m(2) given weekly for 6 weeks with concurrent pelvic radiation and intracavitary brachytherapy were tolerable. Further expansion of the feasibility cohort of this study was suspended based on the results of a phase 3 trial comparing the efficacy of platinum combinations in advanced and recurrent cervical cancer.
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Affiliation(s)
- Peter G Rose
- Case Western Reserve University, Cleveland, OH 44195, USA.
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Kunos CA, Radivoyevitch T. Molecular Strategies of Deoxynucleotide Triphosphate Supply Inhibition Used in the Treatment of Gynecologic Malignancies. ACTA ACUST UNITED AC 2012; Suppl 4:001. [PMID: 25392744 DOI: 10.4172/2161-0932.s4-001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chemotherapies targeting deoxynucleotide triphosphate synthesis are of high medical interest in the treatment of gynecologic malignancies. In this article, we focus on targeted inhibitors of ribonucleotide reductase, an enzyme in charge of ribonucleotide reduction to their corresponding deoxyribonucleotide to be used as the building blocks of DNA. We also discuss human clinical trials have utilized ribonucleotide reductase subunit-specific inhibitors, particularly trials for women with cervical cancer.
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Affiliation(s)
- Charles A Kunos
- Department of Radiation Oncology, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
| | - Tomas Radivoyevitch
- Department of Epidemiology and Biostatistics, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
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Dueñas-Gonzalez A, Coronel J, Cetina L. Pharmacokinetic evaluation of gemcitabine hydrochloride for the treatment of cervical cancer. Expert Opin Drug Metab Toxicol 2011; 7:1601-12. [PMID: 21955161 DOI: 10.1517/17425255.2011.625012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Cervical cancer is the third most prevalent cancer in females worldwide. When advanced, the disease requires primary radiation concurrent with chemotherapy. However, chemotherapy alone is the standard treatment for recurrent/persistent/metastatic disease. AREAS COVERED Areas covered in this review include the treatment of advanced cervical cancer with gemcitabine as radiosensitizer, either alone or in combination with cisplatin. The use of gemcitabine for recurrent/persistent/metastatic cervical cancer is also reviewed. EXPERT OPINION Statistically significantly better survival rates are achieved with cisplatin doublets against cisplatin alone, in the management of recurrent/persistent/metastatic cervical cancer. The choice of the cisplatin doublet with paclitaxel, vinorelbine, gemcitabine and topotecan arms should be based on physician preference, pre-existing morbidity and patient-related factors. In advanced disease, a recently reported Phase III trial establishes the novel regimen of concurrent gemcitabine plus cisplatin and external radiation, followed by brachytherapy and two adjuvant 21-day cycles of gemcitabine plus cisplatin, as significantly improving survival outcomes when compared with the current standard of care. The increased acute toxicity of this regimen is clear; however, this should not deter its incorporation into clinical practice, in that the toxicity is predictable and manageable; nevertheless, the occurrence of late toxicity and survival at longer follow-up time are reasonable concerns in this regimen.
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Rose PG. Combination therapy: New treatment paradigm for locally advanced cervical cancer? Nat Rev Clin Oncol 2011; 8:388-90. [PMID: 21629215 DOI: 10.1038/nrclinonc.2011.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Dueñas-González A, Zarbá JJ, Patel F, Alcedo JC, Beslija S, Casanova L, Pattaranutaporn P, Hameed S, Blair JM, Barraclough H, Orlando M. Phase III, Open-Label, Randomized Study Comparing Concurrent Gemcitabine Plus Cisplatin and Radiation Followed by Adjuvant Gemcitabine and Cisplatin Versus Concurrent Cisplatin and Radiation in Patients With Stage IIB to IVA Carcinoma of the Cervix. J Clin Oncol 2011; 29:1678-85. [DOI: 10.1200/jco.2009.25.9663] [Citation(s) in RCA: 338] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose To determine whether addition of gemcitabine to concurrent cisplatin chemoradiotherapy and as adjuvant chemotherapy with cisplatin improves progression-free survival (PFS) at 3 years compared with current standard of care in locally advanced cervical cancer. Patients and Methods Eligible chemotherapy- and radiotherapy-naive patients with stage IIB to IVA disease and Karnofsky performance score ≥ 70 were randomly assigned to arm A (cisplatin 40 mg/m2 and gemcitabine 125 mg/m2 weekly for 6 weeks with concurrent external-beam radiotherapy [XRT] 50.4 Gy in 28 fractions, followed by brachytherapy [BCT] 30 to 35 Gy in 96 hours, and then two adjuvant 21-day cycles of cisplatin, 50 mg/m2 on day 1, plus gemcitabine, 1,000 mg/m2 on days 1 and 8) or to arm B (cisplatin and concurrent XRT followed by BCT only; dosing same as for arm A). Results Between May 2002 and March 2004, 515 patients were enrolled (arm A, n = 259; arm B, n = 256). PFS at 3 years was significantly improved in arm A versus arm B (74.4% v 65.0%, respectively; P = .029), as were overall PFS (log-rank P = .0227; hazard ratio [HR], 0.68; 95% CI, 0.49 to 0.95), overall survival (log-rank P = .0224; HR, 0.68; 95% CI, 0.49 to 0.95), and time to progressive disease (log-rank P = .0012; HR, 0.54; 95% CI, 0.37 to 0.79). Grade 3 and 4 toxicities were more frequent in arm A than in arm B (86.5% v 46.3%, respectively; P < .001), including two deaths possibly related to treatment toxicity in arm A. Conclusion Gemcitabine plus cisplatin chemoradiotherapy followed by BCT and adjuvant gemcitabine/cisplatin chemotherapy improved survival outcomes with increased but clinically manageable toxicity when compared with standard treatment.
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Affiliation(s)
- Alfonso Dueñas-González
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Juan J. Zarbá
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Firuza Patel
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Juan C. Alcedo
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Semir Beslija
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Luis Casanova
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Pittayapoom Pattaranutaporn
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Shahid Hameed
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Julie M. Blair
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Helen Barraclough
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
| | - Mauro Orlando
- From the National Cancer Institute/Institute of Biomedical Research, Universidad Nacional Autónoma de México, México City, México; Medical Center, San Roque, Tucumán; Eli Lilly Interamerica, Buenos Aires, Argentina; Post Graduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Oncology, Panamá, Panamá; Institute of Oncology, Clinical Centre of Sarajevo University, Sarajevo, Bosnia and Herzegovina; Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru; Siriraj
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Al-Mansour Z, Verschraegen C. Locally advanced cervical cancer: what is the standard of care? Curr Opin Oncol 2010; 22:503-12. [PMID: 20473164 DOI: 10.1097/cco.0b013e32833af426] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW Carcinoma of the cervix remains a significant health problem for women worldwide. Locally advanced cervical cancer (LACC) is a common presentation that has been extensively studied in the last three decades. This article reviews the standard of care and discusses current topics of clinical research. RECENT FINDINGS A multidisciplinary approach to the treatment of cervical cancer has led to marked improvement in outcome. Main advances are with neoadjuvant chemotherapy, chemoradiation, and preventive vaccination. Concurrent chemoradiation with a platinum-based agent is the recommended treatment for LACC. Palliation with platinum agent remains the standard of care for inoperable patients who have metastatic or recurrent disease. SUMMARY This is a review of published and ongoing studies testing multidisciplinary and medical management of LACC, with a focus on newer chemotherapeutic approaches. Optimal multidisciplinary treatment planning improves the outcome of each patient diagnosed with cervical cancer.
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Affiliation(s)
- Zeina Al-Mansour
- The University of New Mexico Cancer Center, 1201 Camino de Salud, Albuquerque, NM 87131, USA
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Difluorodeoxyuridine plasma concentrations after low-dose gemcitabine during chemoradiation in head and neck cancer patients. Cancer Chemother Pharmacol 2010; 68:185-91. [PMID: 20882386 DOI: 10.1007/s00280-010-1471-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/13/2010] [Indexed: 12/21/2022]
Abstract
PURPOSE The aim of this study was to investigate whether relevant plasma levels of dFdU could be detected during concurrent chemoradiation (CRT) with low doses of dFdC administered in patients with head and neck cancer and to assess the toxicity related to dose. METHODS dFdC was administered at doses of 5 mg/m² twice weekly or 10, 50, or 100 mg/m² weekly. Plasma concentrations of dFdU were determined daily for 7 days after the first administration and before each administration, thereafter. A high-performance liquid chromatographic method was used. During CRT, skin and mucosal toxicity were scored weekly according to the RTOG toxicity scoring system. RESULTS Eight patients were sampled at the 10-50 mg/m² dose and nine at the 5-100 mg/m² dose. dFdU levels were in the micromolar range, inducing RS in vitro. There was a strong correlation between the area under the curve of dFdU and the dose of dFdC (r = 0.803, P < 0.001) and a weak correlation between trough concentrations and total dose of dFdC (r = 0.408, P = 0.017). Duration of severe mucositis correlated with dFdC dose. CONCLUSIONS During CRT with 10-100 mg/m(2) of dFdC weekly or 5 mg/m(2) twice weekly, dFdU remains detectable at potentially radiosensitizing concentrations.
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Dueñas-González A, Cetina L, Coronel J, Martínez-Baños D. Pharmacotherapy options for locally advanced and advanced cervical cancer. Drugs 2010; 70:403-32. [PMID: 20205484 DOI: 10.2165/11534370-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Cervical cancer continues to be a significant health burden worldwide. Globally, the majority of cancers are locally advanced at diagnosis; hence, radiation remains the most frequently used therapeutic modality. Currently, the value of adding cisplatin or cisplatin-based chemotherapy to radiation for the treatment of locally advanced cervical cancer is strongly supported by randomized studies and meta-analyses. Nevertheless, despite these significant achievements, therapeutic results are far from optimal; thus, novel therapies need to be investigated. A recent, randomized, phase III trial has shown for the first time that combination chemotherapy with cisplatin and gemcitabine concurrently with radiation improves parameters of survival over cisplatin alone and establishes a new standard for the management of locally advanced cervical cancer. On the other hand, advanced disease, presenting either as an International Federation of Gynecology and Obstetrics (FIGO) stage IVB or as persistent or recurrent to primary therapy without local curative options, remains a devastating group of diseases with no options other than palliative chemotherapy. Recent results from the GOG (Gynecologic and Oncologic Group)-204 study demonstrate that cisplatin-doublets with paclitaxel, vinorelbine, gemcitabine or topotecan only produce small improvements in survival, although with different toxicity patterns; hence, patient-related factors are important when choosing any one of these regimens. The role of targeted therapies both in locally advanced and advanced disease is promising, but still at an investigational stage.
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Affiliation(s)
- Alfonso Dueñas-González
- Unidad de Investigación Biomédica en Cáncer, Instituto Nacional de Cancerología/Instituto de Investigaciones Biomédicas (INCan/IIBM), Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico.
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Verma AK, Arya AK, Kumar M, Kumar A, Gupta S, Sharma D, Rath G. Weekly cisplatin or gemcitabine concomitant with radiation in the management of locally advanced carcinoma cervix: results from an observational study. J Gynecol Oncol 2009; 20:221-6. [PMID: 20041098 PMCID: PMC2799020 DOI: 10.3802/jgo.2009.20.4.221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 10/10/2009] [Accepted: 10/22/2009] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The use of non-platinum drugs in concurrent chemoradiation in carcinoma cervix has not been well explored and hence a two arm study was planned to compare the outcome of concomitant cisplatin or gemcitabine in locally advanced carcinoma cervix. METHODS Thirty six patients were evaluated in this study for response rates and complications. These patients were divided into two arms, sixteen patients in the cisplatin arm and twenty patients in the gemcitabine arm. Cisplatin and gemcitabine were given as i.v. infusion at doses of 40 mg/m(2) and 150 mg/m(2) respectively for five weeks concomitant with radiotherapy. All patients had received pelvic radiotherapy to a dose of 50 Gy/25 fraction/5 weeks by four field box technique followed by high-dose-rate brachytherapy (3 sessions, each of 7.5 Gy to point A). RESULTS Median follow up was of 10.4 months (range, 3 to 36 months) and 10.9 months (range, 2 to 49 months) in the cisplatin and gemcitabine arms, respectively. At first follow up, 68.8% in the cisplatin arm and 70% in the gemcitabine arm had achieved complete response (p=0.93). Similar response rates were noted in different stages in both arms. None of the patients except one developed grade 4 toxicity. Similar toxicity profiles were observed in both arms. Local disease control, distant disease free survival and overall survival was 68.8% vs. 70%, 93.8% vs. 85%, 68.8% vs. 60% in the cisplatin and gemcitabine arms, respectively. CONCLUSION Weekly gemcitabine had similar disease control and tolerable toxicity profile with cisplatin. Gemcitabine may be used as an alternative to cisplatin in patients with compromised renal function.
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Affiliation(s)
- Arun K Verma
- Department of Radiotherapy, S.N. Medical College and Hospital, Agra, India
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