Role of locoregional surgery in treating FIGO 2009 stage IVB cervical cancer patients: a population-based study

Redefining stage IVB cervical cancer: The unique prognosis of distant lymph node metastasis which is comparable to stage IIIC

OBJECTIVE

Current staging systems classify distant lymph node metastasis (DLM) in cervical cancer as stage IVB, typically treated with systemic therapy. We aim to assess if patients with DLM have different survival rates than those with other stage IVB cervical cancer forms.

METHODS

This study included patients diagnosed with metastatic cervical cancer from 2000 to 2021, divided into three groups: para-aortic lymph node metastasis (PaLM), DLM, and distant organ metastasis (DM). Kaplan-Meier analyses estimated cervical cancer-specific (CCSS) and overall survival (OS). A 1:1 propensity-score match between DLM and PaLM patients used logistic regression. Univariate and multivariate Cox analyses identified prognostic risk factors.

RESULTS

Of the included 6241 patients, 2079 (33.3 %) were diagnosed with PaLM only, 631 (10.1 %) with DLM only, and 3531 (56.6 %) had DM. Multivariate Cox regression analysis indicated that patients with DLM exhibited comparable CCSS (HR, 0.91; P = 0.28) and OS (HR, 0.93; P = 0.34) to those with PaLM. In contrast, compared to patients with DM, the DLM cohort demonstrated significantly improved CCSS (HR, 0.54; P < 0.001) and OS (HR, 0.58; P < 0.001). Following matching, the CCSS (HR, 0.96; P = 0.70) and OS (HR, 0.95; P = 0.61) of patients with DLM remained comparable to those with PaLM. Among the 632 patients with DLM, locoregional treatments such as total hysterectomy (HR, 0.46; P = 0.039) and radiotherapy (HR, 0.34; P = 0.046) were independently associated with improved OS.

CONCLUSION

In cervical cancer, metastasis confined to distant lymph nodes indicates a locoregionally advanced stage, distinct from other stage IVB forms, and can be treated curatively with intensive locoregional therapy.

Different surgical methods for FIGO stage IVB cervical cancer patients receiving chemotherapy: a population-based study

OBJECTIVE

To assess survival differences between non-extensive surgery (NES) and extensive surgery (ES) in International Federation of Gynecology and Obstetrics (FIGO) stage IVB cervical cancer patients receiving chemotherapy from a population-based database, the Surveillance, Epidemiology and End Results.

METHODS

Propensity matching was conducted to minimize heterogeneity. Survival analysis was performed by the Kaplan-Meier method, log-rank test, and Cox proportional hazards model.

RESULTS

A total of 154 patients met screening criteria, among whom 84 patients (84/154) underwent NES while 70 patients (70/154) underwent ES. After matching, no survival advantage was observed in ES group compared with NES group (p=0.066; hazard ratio [HR]=1.54; 95% confidence interval [CI]=0.97-2.42). Stratified analyses suggested ES prolonged overall survival in patients with histology other than squamous cell carcinoma and adenocarcinoma (p=0.028; HR=0.36; 95% CI=0.15-0.89) and American Joint Committee on Cancer (AJCC) T stage T1 (p=0.009; HR=0.18; 95% CI=0.05-0.66). Despite no survival benefit after regional lymph node surgery (p=0.629; HR=0.88; 95% CI=0.53-1.47), subgroup analyses demonstrated that patients younger than 50 (p=0.006; HR=0.21; 95% CI=0.07-0.64), with AJCC T stage T1 (p=0.002; HR=0.09; 95% CI=0.02-0.42), T3 (p=0.001; HR=0.02; 95% CI=0.00-0.21), hematogenous metastasis (p=0.036; HR=0.27; 95% CI=0.08-0.92) and without surgery of other sites (p=0.040; HR=0.01; 95% CI=0.00-0.79) might achieve longer survival after regional lymph node surgery.

CONCLUSION

In conclusion, ES or regional lymph node surgery may provide survival advantage for certain subgroup of FIGO IVB cervical cancer patients receiving chemotherapy. However, it deserves large scale prospective clinical trials to confirm.

Immuno-Molecular Targeted Therapy Use and Survival Benefit in Patients with Stage IVB Cervical Carcinoma in Commission on Cancer®-Accredited Facilities in the United States

PURPOSE

To investigate IMT use and survival in real-world stage IVB cervical cancer patients outside randomized clinical trials.

METHODS

Patients diagnosed with stage IVB cervical cancer during 2013-2019 in the National Cancer Database and treated with chemotherapy (CT) ± external beam radiation (EBRT) ± intracavitary brachytherapy (ICBT) ± IMT were studied. The adjusted hazard ratio (AHR) and 95% confidence interval (CI) for risk of death were estimated in patients treated with vs. without IMT after applying propensity score analysis to balance the clinical covariates.

RESULTS

There were 3164 evaluable patients, including 969 (31%) who were treated with IMT. The use of IMT increased from 11% in 2013 to 46% in 2019. Age, insurance, facility type, sites of distant metastasis, and type of first-line treatment were independently associated with using IMT. In propensity-score-balanced patients, the median survival was 18.6 vs. 13.1 months for with vs. without IMT (p < 0.001). The AHR was 0.72 (95% CI = 0.64-0.80) for adding IMT overall, 0.72 for IMT + CT, 0.66 for IMT + CT + EBRT, and 0.69 for IMT + CT + EBRT + ICBT. IMT-associated survival improvements were suggested in all subgroups by age, race/ethnicity, comorbidity score, facility type, tumor grade, tumor size, and site of metastasis.

CONCLUSIONS

IMT was associated with a consistent survival benefit in real-world patients with stage IVB cervical cancer.

Directed acyclic graphs in perioperative observational research-A systematic review and critique against best practice recommendations

The Directed Acyclic Graph (DAG) is a graph representing causal pathways for informing the conduct of an observational study. The use of DAGs allows transparent communication of a causal model between researchers and can prevent over-adjustment biases when conducting causal inference, permitting greater confidence and transparency in reported causal estimates. In the era of 'big data' and increasing number of observational studies, the role of the DAG is becoming more important. Recent best-practice guidance for constructing a DAG with reference to the literature has been published in the 'Evidence synthesis for constructing DAGs' (ESC-DAG) protocol. We aimed to assess adherence to these principles for DAGs constructed within perioperative literature. Following registration on the International Prospective Register of Systematic Reviews (PROSPERO) and with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting framework for systematic reviews, we searched the Excerpta Medica dataBASE (Embase), the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cochrane databases for perioperative observational research incorporating a DAG. Nineteen studies were included in the final synthesis. No studies demonstrated any evidence of following the mapping stage of the protocol. Fifteen (79%) fulfilled over half of the translation and integration one stages of the protocol. Adherence with one stage did not guarantee fulfilment of the other. Two studies (11%) undertook the integration two stage. Unmeasured variables were handled inconsistently between studies. Only three (16%) studies included unmeasured variables within their DAG and acknowledged their implication within the main text. Overall, DAGs that were constructed for use in perioperative observational literature did not consistently adhere to best practice, potentially limiting the benefits of subsequent causal inference. Further work should focus on exploring reasons for this deviation and increasing methodological transparency around DAG construction.

Combined modality management of advanced cervical cancer including novel sensitizers

The management of advanced cervical cancer has evolved with time. Combined modality treatments for cervical cancer have been shown to improve clinical outcomes for these patients. The role of surgery is reviewed in this article for specific situations such as the treatment of bulky lymph nodes and even in the metastatic setting. External beam radiotherapy and brachytherapy techniques have improved which has decreased patient toxicity. Systemic therapy such as chemotherapy, immunotherapy, and novel sensitizing agents have been extensively studied and have shown promising results. The combination of these three different modalities of treatment can be tailored to each specific patient to achieve the best outcomes. We review the recent advances and various international guidelines for the management of cervical cancer in this article.