Five randomized phase III trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy,[1-6] while one trial examining this regimen demonstrated no benefit.[7] The patient populations in these studies included women with Federation Internationale de Gynecologie et d'Obstetrique (FIGO) stages IB2 to IVA cervical cancer treated with primary radiation therapy and women with FIGO stages I to IIA disease found to have poor prognostic factors (metastatic disease in pelvic lymph nodes, parametrial disease, or positive surgical margins) at the time of primary surgery. Although the positive trials vary in terms of the stage of disease, dose of radiation, and schedule of cisplatin and radiation, the trials demonstrate significant survival benefit for this combined approach. The risk of death from cervical cancer was decreased by 30% to 50% with the use of concurrent chemoradiation therapy. Based on these results, strong consideration should be given to the incorporation of concurrent cisplatin-based chemotherapy with radiation therapy in women who require radiation therapy for treatment of cervical cancer.[1-8]

Pretreatment surgical staging is the most accurate method to determine extent of disease. Because there is little evidence to demonstrate overall improved survival with routine surgical staging, it usually should be performed only as part of a clinical trial. Pretreatment surgical staging in bulky but locally curable disease may be indicated in select cases when a nonsurgical search for metastatic disease is negative. If abnormal nodes are detected by computed tomography scan or lymphangiography, fine-needle aspiration should be negative before a surgical staging procedure is performed. Surgery and radiation therapy are equally effective for early-stage small-volume disease.[9] Younger patients may benefit from surgery in regard to ovarian preservation and avoidance of vaginal atrophy and stenosis.

Patterns of care studies clearly demonstrate the negative prognostic effect of increasing tumor volume. Treatment, therefore, may vary within each stage as currently defined by FIGO and will depend on tumor bulk and spread pattern.[10]

Therapy of patients with cancer of the cervical stump is effective, yielding results comparable to those seen in patients with an intact uterus.[11]

During pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, though expert colposcopy is recommended to exclude invasive cancer. Treatment of invasive cervical cancer during pregnancy depends on the stage of the cancer and gestational age at diagnosis. The traditional approach is to recommend immediate therapy appropriate for the disease stage when the cancer is diagnosed before fetal maturity and to delay therapy only if the cancer is detected in the final trimester.[12,13] However, other reports suggest that deliberate delay of treatment to allow improved fetal outcome may be a reasonable option for patients with stage IA and early IB cervical cancer.[14-16]

References

1. Whitney CW, Sause W, Bundy BN, et al.: Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: a Gynecologic Oncology Group and Southwest Oncology Group study. J Clin Oncol 17 (5): 1339-48, 1999.  [PUBMED Abstract]
   
   
2. Morris M, Eifel PJ, Lu J, et al.: Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer. N Engl J Med 340 (15): 1137-43, 1999.  [PUBMED Abstract]
   
   
3. Rose PG, Bundy BN, Watkins EB, et al.: Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med 340 (15): 1144-53, 1999.  [PUBMED Abstract]
   
   
4. Keys HM, Bundy BN, Stehman FB, et al.: Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J Med 340 (15): 1154-61, 1999.  [PUBMED Abstract]
   
   
5. Peters WA 3rd, Liu PY, Barrett RJ 2nd, et al.: Concurrent chemotherapy and pelvic radiation therapy compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early-stage cancer of the cervix. J Clin Oncol 18 (8): 1606-13, 2000.  [PUBMED Abstract]
   
   
6. Thomas GM: Improved treatment for cervical cancer--concurrent chemotherapy and radiotherapy. N Engl J Med 340 (15): 1198-200, 1999.  [PUBMED Abstract]
   
   
7. Pearcey R, Brundage M, Drouin P, et al.: Phase III trial comparing radical radiotherapy with and without cisplatin chemotherapy in patients with advanced squamous cell cancer of the cervix. J Clin Oncol 20 (4): 966-72, 2002.  [PUBMED Abstract]
   
   
8. Rose PG, Bundy BN: Chemoradiation for locally advanced cervical cancer: does it help? J Clin Oncol 20 (4): 891-3, 2002.  [PUBMED Abstract]
   
   
9. Eifel PJ, Burke TW, Delclos L, et al.: Early stage I adenocarcinoma of the uterine cervix: treatment results in patients with tumors less than or equal to 4 cm in diameter. Gynecol Oncol 41 (3): 199-205, 1991.  [PUBMED Abstract]
   
   
10. Lanciano RM, Won M, Hanks GE: A reappraisal of the International Federation of Gynecology and Obstetrics staging system for cervical cancer. A study of patterns of care. Cancer 69 (2): 482-7, 1992.  [PUBMED Abstract]
    
    
11. Kovalic JJ, Grigsby PW, Perez CA, et al.: Cervical stump carcinoma. Int J Radiat Oncol Biol Phys 20 (5): 933-8, 1991.  [PUBMED Abstract]
    
    
12. Monk BJ, Montz FJ: Invasive cervical cancer complicating intrauterine pregnancy: treatment with radical hysterectomy. Obstet Gynecol 80 (2): 199-203, 1992.  [PUBMED Abstract]
    
    
13. Hopkins MP, Morley GW: The prognosis and management of cervical cancer associated with pregnancy. Obstet Gynecol 80 (1): 9-13, 1992.  [PUBMED Abstract]
    
    
14. Greer BE, Easterling TR, McLennan DA, et al.: Fetal and maternal considerations in the management of stage I-B cervical cancer during pregnancy. Gynecol Oncol 34 (1): 61-5, 1989.  [PUBMED Abstract]
    
    
15. Duggan B, Muderspach LI, Roman LD, et al.: Cervical cancer in pregnancy: reporting on planned delay in therapy. Obstet Gynecol 82 (4 Pt 1): 598-602, 1993.  [PUBMED Abstract]
    
    
16. Sood AK, Sorosky JI, Krogman S, et al.: Surgical management of cervical cancer complicating pregnancy: a case-control study. Gynecol Oncol 63 (3): 294-8, 1996.  [PUBMED Abstract]
    
    

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