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Gadducci A, Cosio S. Pharmacological Treatment of Patients with Metastatic, Recurrent or Persistent Cervical Cancer Not Amenable by Surgery or Radiotherapy: State of Art and Perspectives of Clinical Research. Cancers (Basel) 2020; 12:E2678. [PMID: 32961781 PMCID: PMC7565040 DOI: 10.3390/cancers12092678] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/04/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023] Open
Abstract
Cervical cancer patients with distant or loco-regional recurrences not amenable by surgery or radiotherapy have limited treatment options, and their 5-year overall survival (OS) rates range from 5% to 16%. The purpose of this paper is to assess the results obtained with chemotherapy and biological agents in this clinical setting. Several phase II trials of different cisplatin (CDDP)-based doublets and a phase III randomized trial showing a trend in response rate, progression-free survival, and OS in favor of CDDP + paclitaxel (PTX) compared with other CDDP-based doublets have been reviewed. The factors predictive of response to chemotherapy as well as the benefits and risks of the addition of bevacizumab to CDDP + PTX have been analyzed. The FDA has recently approved pembrolizumab for patients with recurrent or metastatic cervical cancer in progression on or after chemotherapy whose tumors were PD-L1 positive. Interesting perspectives of clinical research are represented by the use of immune checkpoint inhibitors alone or in addition to chemotherapy, whereas PARP inhibitors and PI3K inhibitors are still at the basic research phase, but promising.
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Affiliation(s)
- Angiolo Gadducci
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, 56127 Pisa, Italy;
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Tsuda N, Watari H, Ushijima K. Chemotherapy and molecular targeting therapy for recurrent cervical cancer. Chin J Cancer Res 2016; 28:241-53. [PMID: 27199523 PMCID: PMC4865618 DOI: 10.21147/j.issn.1000-9604.2016.02.14] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
For patients with primary stage ⅣB, persistent, or recurrent cervical cancer, chemotherapy remains the standard treatment, although it is neither curative nor associated with long-term disease control. In this review, we summarized the history of treatment of recurrent cervical cancer, and the current recommendation for chemotherapy and molecular targeted therapy. Eligible articles were identified by a search of the MEDLINE bibliographical database for the period up to November 30, 2014. The search strategy included the following any or all of the keywords: “uterine cervical cancer”, “chemotherapy”, and “targeted therapies”. Since cisplatin every 21 days was considered as the historical standard treatment for recurrent cervical cancer, subsequent trials have evaluated and demonstrated activity for other agents including paclitaxel, gemcitabine, topotecan and vinorelbine among others. Accordingly, promising agents were incorporated into phase Ⅲ trials. To examine the best agent to combine with cisplatin, several landmark phase Ⅲ clinical trials were conducted by Gynecologic Oncology Group (GOG) and Japan Clinical Oncology Group (JCOG). Through, GOG204 and JCOG0505, paclitaxel/cisplatin (TP) and paclitaxel/carboplatin (TC) are now considered to be the recommended therapies for recurrent cervical cancer patients. However, the prognosis of patients who are already resistant to chemotherapy, are very poor. Therefore new therapeutic strategies are urgently required. Molecular targeted therapy will be the most hopeful candidate of these strategies. From the results of GOG240, bevacizumab combined with TP reached its primary endpoint of improving overall survival (OS). Although, the prognosis for recurrent cervical cancer patients is still poor, the results of GOG240 shed light on the usefulness of molecular target agents to chemotherapy in cancer patients. Recurrent cervical cancer is generally considered incurable and current chemotherapy regiments offer only modest gains in OS, particularly for patients with multiple poor prognostic factors. Therefore, it is crucial to consider not only the survival benefit, but also the minimization of treatment toxicity, and maximization of quality of life (QOL).
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Affiliation(s)
- Naotake Tsuda
- 1Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Hidemichi Watari
- 2Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kimio Ushijima
- 1Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
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Abstract
PURPOSE The objective of this study was to report the results of in vitro chemoresponse analysis of primary, metastatic, and recurrent human cervical cancers. METHODS There were 557 tumor specimens submitted for testing from August 2006 to June 2010. Single agents tested were cisplatin, carboplatin, paclitaxel, docetaxel, epirubicin, fluorouracil, 4-hydroxy ifosfamide (active metabolite of ifosfamide), SN-38 (active metabolite of irinotecan), topotecan, and vinorelbine. Doublets tested were carboplatin/paclitaxel and cisplatin/topotecan. Tumor response was determined from dose-response curves. Results were scored as responsive, intermediate, or nonresponsive. Chemoresponse was reported as the combined responsive and intermediate results. RESULTS Three hundred fifty-three (63.4%) of 557 submitted specimens were successfully assayed. Confirmation of histology and tumor status (primary, metastatic, or recurrent) was available for 273 specimens. The chemoresponse of the most active agents in primary cancers (n = 151) was 75% for SN-38, 71% for 4-hydroxy ifosfamide, 62% for topotecan, and 73% for carboplatin/paclitaxel. The chemoresponse of metastatic cancers (n = 66) was 54% for SN-38, 51% for 4-hydroxy ifosfamide, 44% for epirubicin, and 53% for carboplatin/paclitaxel. The chemoresponse for recurrent cancers (n = 56) was 44% for epirubicin, 41% for 4-hydroxy ifosfamide, 39% for vinorelbine, 39% for paclitaxel, 36% for topotecan, 46% for carboplatin/paclitaxel, and 35% for cisplatin/topotecan. The overall chemoresponse was greater in primary cancers (58%) than in recurrent cancers (35%) (P < 0.0001). CONCLUSIONS In vitro chemoresponse analysis of cervical cancer biospecimens is feasible. Chemoresponse results are variable depending on tumor status. Clinical studies of assay-directed therapy should be developed.
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Abstract
The use of taxanes in the treatment of gynecologic malignancies has expanded tremendously over the past 30 years. Both paclitaxel and docetaxel have unique microtubule stabilizing, antiangiogenic and radiation sensitizing properties that endow them with remarkable activity as chemotherapeutic agents. As research into the appropriate dose, timing, treatment interval, and response rates have been studied, they have emerged as one of the most active agents available in the treatment of gynecologic cancer. The body of research on taxanes continues to expand especially with regard to the use of taxanes in alternative formulations and in combination with newer treatments or routes of treatment. This review focuses on the development of taxanes as an effective therapy in the treatment of gynecologic cancers and data currently available in the literature regarding their efficacy. Future directions of taxane-based chemotherapy with regards to ovarian, uterine, and cervical cancers are also addressed. There is little doubt that taxane-based chemotherapy will remain an integral part of the treatment of gynecologic cancer for the foreseeable future.
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Kamura T, Ushijima K. Chemotherapy for advanced or recurrent cervical cancer. Taiwan J Obstet Gynecol 2014; 52:161-4. [PMID: 23915846 DOI: 10.1016/j.tjog.2013.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2013] [Indexed: 10/26/2022] Open
Abstract
The primary treatment options for cervical cancer are surgery and radiation for more than a century. However, over the last 40 years chemotherapy has been building up its reputation in the management of cervical cancer in various forms such as chemoradiation, neoadjuvant chemotherapy, and palliative chemotherapy for advanced or recurrent disease. Among these, in this review, chemotherapy for advanced or recurrent cervical cancer will be discussed.
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Affiliation(s)
- Toshiharu Kamura
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume-Shi, Japan.
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Elit LM, Hirte H. Management of advanced or recurrent cervical cancer: chemotherapy and beyond. Expert Rev Anticancer Ther 2014; 14:319-32. [DOI: 10.1586/14737140.2014.866041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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A pilot feasibility study for cisplatin plus S-1 for the treatment for advanced or recurrent cervical cancer. Cancer Chemother Pharmacol 2013; 71:1369-74. [DOI: 10.1007/s00280-013-2137-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 03/07/2013] [Indexed: 01/09/2023]
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Katsumata N, Hirai Y, Kamiura S, Sugiyama T, Kokawa K, Hatae M, Nishimura R, Ochiai K. Phase II study of S-1, an oral fluoropyrimidine, in patients with advanced or recurrent cervical cancer. Ann Oncol 2011; 22:1353-1357. [PMID: 21345941 PMCID: PMC3101364 DOI: 10.1093/annonc/mdq602] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: S-1 is an oral fluoropyrimidine. This phase II study was designed to evaluate the efficacy and safety of S-1 in patients with advanced or recurrent uterine cervical cancer. Patients and methods: S-1 35 mg/m2 was given twice daily for 28 days repeated every 6 weeks. Eligible patients were women aged 20–74 years, who had Eastern Cooperative Oncology Group performance status of zero or one, who had stage IVB or recurrent uterine cervical cancer, and who had received no more than one platinum-containing chemotherapy regimen for stage IVB or recurrent disease. The primary end point was overall response rate (ORR) determined by RECIST. Results: A total of 37 patients were enrolled in the trial and 36 were eligible. The median number of cycles administered was 4. The confirmed ORR was 30.6% (95% confidence interval 15.5% to 45.6%). The response rate for patients who had received platinum-based treatment including chemoradiotherapy was 31.8% (7 of 22). After a median follow-up duration of 25 months, the median time to progression and the median survival time were 5.2 and 15.4 months, respectively. The most frequent grade 3 or 4 adverse events were anemia (16%), anorexia (16%), and diarrhea (22%). Conclusions: This phase II study of S-1 in cervical cancer suggests a promising response rate and a contribution toward prolonging survival, with modest toxic effects. Phase III studies of S-1 in patients with advanced or recurrent cervical cancer are thus warranted.
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Affiliation(s)
- N Katsumata
- Department of Medical Oncology, National Cancer Center Hospital, Tokyo.
| | - Y Hirai
- Department of Gynecology, Cancer Institute Hospital Ariake, Tokyo
| | - S Kamiura
- Department of Gynecology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka
| | - T Sugiyama
- Department of Obstetrics and Gynecology, Iwate Medical University, Iwate
| | - K Kokawa
- Department of Obstetrics and Gynecology, Wakayama Medical University Hospital, Wakayama
| | - M Hatae
- Department of Obstetrics and Gynecology, Kagoshima City Hospital, Kagoshima
| | - R Nishimura
- Department of Gynecology, Hyogo Cancer Center, Hyogo
| | - K Ochiai
- Department of Obstetrics and Gynecology, The Jikei University, School of Medicine, Tokyo, Japan
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Legge F, Fuoco G, Lorusso D, Lucidi A, Borriello M, Pisconti S, Scambia G, Ferrandina G. Pharmacotherapy of cervical cancer. Expert Opin Pharmacother 2010; 11:2059-75. [PMID: 20642372 DOI: 10.1517/14656566.2010.493556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Cervical cancer (CC) remains an important health problem. It is the second most frequent malignancy in women worldwide, with one-third of patients dying from pharmacoresistant disease. AREAS COVERED IN THIS REVIEW We reviewed pharmacotherapy approaches in the medical and multidisciplinary management of CC and conducted a systematic search of Pubmed for clinical trials, reviews and meta-analysis published in the last 20 years. Abstracts of the American Society of Clinical Oncology, European Society of Gynecological Oncology and International Gynecologic Cancer Society were also searched, together with the US National Institutes of Health clinical trial database. WHAT THE READER WILL GAIN The state-of-the art of cytotoxic and biologically targeted therapies in early, locally advanced and metastatic/recurrent CC is discussed. TAKE HOME MESSAGE Until recently, the role of pharmacotherapy in CC was restricted to palliation of advanced/metastatic or recurrent disease. During the past two decades, this reluctant attitude towards chemotherapy has been modified after a series of randomized trials demonstrated its beneficial contribution as an adjunct to radiotherapy or surgery in early and locally advanced CC. Moreover, new combinations of cytotoxics, together with novel molecular target agents, open new perspectives in the treatment of primary and recurrent CC.
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Affiliation(s)
- Francesco Legge
- Catholic University of Campobasso, Department of Oncology, Gynecologic Oncology Unit, 86100 Campobasso, Italy
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Cella D, Huang HQ, Monk BJ, Wenzel L, Benda J, McMeekin DS, Cohn D, Ramondetta L, Boardman CH. Health-related quality of life outcomes associated with four cisplatin-based doublet chemotherapy regimens for stage IVB recurrent or persistent cervical cancer: a Gynecologic Oncology Group study. Gynecol Oncol 2010; 119:531-7. [PMID: 20837359 DOI: 10.1016/j.ygyno.2010.08.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 08/01/2010] [Accepted: 08/16/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To assess the differences in health-related quality of life (HRQL) of 4 cisplatin containing doublet chemotherapy combinations in women with advanced/recurrent cervical carcinoma. METHODS Patients were randomized to three-week cycles of paclitaxel + cisplatin (PC); vinorelbine + C (VC); gemcitabine + C (GC); or topotecan + C (TC). We report HRQL results from data available on 434 eligible patients enrolled into this 513 patient trial. HRQL was assessed with the Functional Assessment of Cancer Therapy-Cervix (FACT-Cx) the FACT/Gynecologic Oncology Group (FACT/GOG) four-item neurotoxicity scale, and the 0-10 "worst pain" item from the Brief Pain Inventory, at baseline (pre-treatment), prior to beginning cycle 2, prior to beginning cycle 5, and at 9 months after enrollment. As reported by Monk et al. (2009) [13] VC, GC and TC were found not to be superior to PC with regard to progression-free survival or overall survival. RESULTS The trial was terminated early due to planned interim futility analysis, reducing power for HRQL analysis from 85% to 55%. Patients receiving VC, GC and TC doublets did not report significantly different HRQL, neuropathy, or pain from those who received the PC (control) doublet. Patients receiving PC tended to report worse neuropathy during treatment than patients who received other doublets (especially GC and TC), but the differences were not statistically significant. CONCLUSION None of the 3 experimental doublets was different from PC in terms of HRQL during treatment. Long-term toxicity data are inconclusive. Except where patients may wish to reduce their risk of worsening pre-treatment neuropathy, PC remains the standard of care for this disease.
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Affiliation(s)
- David Cella
- Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA.
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GADDUCCI ANGIOLO, TANA ROBERTA, COSIO STEFANIA, CIONINI LUCA. Treatment options in recurrent cervical cancer (Review). Oncol Lett 2010; 1:3-11. [PMID: 22966247 PMCID: PMC3436344 DOI: 10.3892/ol_00000001] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 09/15/2009] [Indexed: 11/06/2022] Open
Abstract
The management of recurrent cervical cancer depends mainly on previous treatment and on the site and extent of recurrence. Concurrent cisplatin-based chemo-radiation is the treatment of choice for patients with pelvic failure after radical hysterectomy alone. However, the safe delivery of high doses of radiotherapy is much more difficult in this clinical setting compared with primary radiotherapy. Pelvic exenteration usually represents the only therapeutic approach with curative intent for women with central pelvic relapse who have previously received irradiation. In a recent series, the 5-year overall survival and operative mortality after pelvic exenteration ranged from 21 to 61% and from 1 to 10%, respectively. Free surgical margins, negative lymph nodes, small tumour size and long disease-free interval were associated with a more favourable prognosis. Currently, pelvic reconstructive procedures (continent urinary conduit, low colorectal anastomosis, vaginal reconstruction with myocutaneous flaps) are strongly recommended after exenteration. Concurrent cisplatin-based chemo-radiation is the treatment of choice for isolated para-aortic lymph node failure, with satisfactory chances of a cure in asymptomatic patients. Chemotherapy is administered with palliative intent to women with distant or loco-regional recurrences not amenable by surgery or radiotherapy. Cisplatin is the most widely used drug, with a response rate of 17-38% and a median overall survival of 6.1-7.1 months. Cisplatin-based combination chemotherapy achieves higher response rates (22-68%) when compared with single-agent cisplatin, but median overall survival is usually less than one year. In a recent Gynecologic Oncology Group (GOG) trial the combination topotecan + cisplatin obtained a significantly longer overall survival than single-agent cisplatin in patients with metastatic or recurrent or persistent cervical cancer. A subsequent GOG study showed a trend in terms of longer overall survival and better quality of life for the doublet cisplatin + paclitaxel vs. the doublets cisplatin + topotecan, cisplatin + vinorelbine, and cisplatin + gemcitabine. Molecularly targeted therapy may represent a novel therapeutic tool, but its use alone or in combination with chemotherapy is still investigational.
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Affiliation(s)
- ANGIOLO GADDUCCI
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, Pisa 56127, Italy
| | - ROBERTA TANA
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, Pisa 56127, Italy
| | - STEFANIA COSIO
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, Pisa 56127, Italy
| | - LUCA CIONINI
- Department of Oncology, Division of Radiotherapy, University of Pisa, Pisa 56127, Italy
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Mountzios G, Dimopoulos M, Bamias A, Vourli G, Kalofonos H, Aravantinos G, Fountzilas G, Papadimitriou C. Randomized multicenter phase II trial of cisplatin and ifosfamide with or without paclitaxel in recurrent or metastatic carcinoma of the uterine cervix: a Hellenic Cooperative Oncology Group (HeCOG) study. Ann Oncol 2009; 20:1362-8. [DOI: 10.1093/annonc/mdn797] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Movva S, Rodriguez L, Arias-Pulido H, Verschraegen C. Novel chemotherapy approaches for cervical cancer. Cancer 2009; 115:3166-80. [DOI: 10.1002/cncr.24364] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chemotherapy for recurrent and metastatic cervical cancer. Gynecol Oncol 2008; 110:S67-71. [DOI: 10.1016/j.ygyno.2008.04.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 04/19/2008] [Indexed: 11/18/2022]
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Pectasides D, Kamposioras K, Papaxoinis G, Pectasides E. Chemotherapy for recurrent cervical cancer. Cancer Treat Rev 2008; 34:603-13. [PMID: 18657909 DOI: 10.1016/j.ctrv.2008.05.006] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Revised: 05/07/2008] [Accepted: 05/07/2008] [Indexed: 11/18/2022]
Abstract
PURPOSE Cervical cancer is the second most common cancer of women worldwide and one of the leading cause of death in relative young women. This review gives an outline of chemotherapy of advanced, persistent or recurrent cervical cancer. METHODS We performed a literature search in the PubMed of almost all relevant articles concerning chemotherapy of advanced, persistent or recurrent cervical cancer. RESULTS The available data from the literature is mainly composed of most recent reviews, phase II and randomized phase III clinical trials. CONCLUSION Single-agent cisplatin remains the current standard therapy for advanced, persistent or recurrent cervical cancer. Several single-agents have been tested, but none has been found to be superior compared to cisplatin. Both topotecan and paclitaxel in combination with cisplatin, have yielded superior response rates and progression-free survival without diminishing patient quality of life. However, only the combination of cisplatin and topotecan has improved overall survival. It is important to identify clinical and tumor-related factors predictive of response to cisplatin-based chemotherapy. Future trials are necessary, not only to compare combinations of existing agents, but to incorporate biological agents (monoclonal antibodies or small molecules) to chemotherapy in order to improve the treatment results of advanced, persistent or recurrent cervix cancer.
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Affiliation(s)
- D Pectasides
- Second Department of Internal Medicine, Propaedeutic, Oncology Section, University of Athens, Attikon University Hospital, Haidari, 1 Rimini, Athens, Greece.
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Homesley HD, Meltzer NP, Nieves L, Vaccarello L, Lowendowski GS, Elbendary AA. A phase II trial of weekly 1-hour paclitaxel as second-line therapy for endometrial and cervical cancer. Int J Clin Oncol 2008; 13:62-5. [PMID: 18307021 DOI: 10.1007/s10147-007-0731-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Accepted: 09/26/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND The efficacy of weekly paclitaxel has not been well characterized in either cervical or endometrial cancer. METHODS Eligible women had disseminated endometrial or squamous cell cancer of the cervix, one prior chemotherapy regimen, measurable disease, and a Gynecologic Oncology Group (GOG) performance status of 0-2. At entry, all laboratory results were within normal limits. Paclitaxel 80 mg/m(2) was administered by intravenous infusion over 1 h every 7 days. Response served as the endpoint of the trial. RESULTS Forty-four patients were registered, and 15 of 16 patients with endometrial cancer and 20 of 28 patients with cervical cancer were evaluable for response. Four of the 15 (26.7%) endometrial cancer patients responded to treatment, with one complete response of 22 weeks and three partial responses. Stable disease was present in 26.7%. Two of the 20 (10%) cervical cancer patients responded to treatment, with one complete response of 25 weeks and one partial response of 14 weeks. Stable disease was present in 35%. Adverse effects were minimal and easily managed with dose adjustments as needed. CONCLUSION Although confirmatory larger trials are needed, weekly paclitaxel appears promising for advanced endometrial carcinoma, and possibly for squamous cell carcinoma of the cervix.
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Affiliation(s)
- Howard D Homesley
- The Brody School of Medicine of East Carolina University, Greenville, NC 27834, USA.
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Goncalves A, Fabbro M, Lhommé C, Gladieff L, Extra JM, Floquet A, Chaigneau L, Carrasco AT, Viens P. A phase II trial to evaluate gefitinib as second- or third-line treatment in patients with recurring locoregionally advanced or metastatic cervical cancer. Gynecol Oncol 2008; 108:42-6. [DOI: 10.1016/j.ygyno.2007.07.057] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 07/11/2007] [Accepted: 07/16/2007] [Indexed: 10/22/2022]
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Cadron I, Van Gorp T, Amant F, Leunen K, Neven P, Vergote I. Chemotherapy for recurrent cervical cancer. Gynecol Oncol 2007; 107:S113-8. [PMID: 17804044 DOI: 10.1016/j.ygyno.2007.07.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 07/06/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To give an overview of chemotherapy schemes used in recurrent cervical cancer. METHODS A pubmed search was performed using chemotherapy and recurrent cervical cancer including articles until April 2007. RESULTS Most recent articles and articles of interest are discussed. CONCLUSION Single agent cisplatin (50 mg/m2) remains the current standard for recurrent cervical cancer. Numerous chemotherapeutic agents have been tested but did not show convincing evidence of improved survival rates, except for the GOG 179 study which showed an improved survival for the combination of cisplatin and topotecan compared with single agent cisplatin. However, nearly 60% of patients in both groups received prior cisplatinum therapy as a radiosensitizer, which could be responsible for the development of platinum resistance, causing lower response and survival rates in the single platinum group. Hence, the apparent benefit in the doublet group is maybe just a reflection from the change in primary therapy and patient population. It is hoped that current trials comparing standard therapy with other single or doublet chemotherapeutic regimens or that the use of molecular-targeted agents will give us promising therapeutic options in the future.
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Affiliation(s)
- Isabelle Cadron
- Division of Gynecological Oncology, Department of Obstetrics and Gynecology, University Hospitals Leuven, Gasthuisberg, B-3000 Leuven, Katholieke Universiteit Leuven, Belgium
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Abstract
This article reviews the English-language literature concerning chemotherapy for advanced, recurrent, or metastatic cervix carcinoma. Specifically, it reviews the available literature for active single agents, doublets, triplets, and multiple drug combination chemotherapy. Until recently, single-agent cisplatin was the drug of choice in metastatic cervix cancer. Various doublets, triplets, and quartlets have been reported to have higher objective response rates than single-agent cisplatin when compared in phase III clinical trials. Some have demonstrated improvements in progression-free survival, but only topotecan plus cisplatin has demonstrated an improvement in overall survival. This benefit is most apparent in patients who have a long disease-free interval from primary therapy and who have not received prior cisplatin as a radiosensitizer.
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Affiliation(s)
- Harry J Long
- Department of Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Goedhals L, van Wiyk AL, Smith BL, Fourie SJ. Pemetrexed (Alimta, LY231514) demonstrates clinical activity in chemonaive patients with cervical cancer in a phase II single-agent trial. Int J Gynecol Cancer 2007; 16:1172-8. [PMID: 16803502 DOI: 10.1111/j.1525-1438.2006.00451.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to determine the response rate in chemonaive patients with inoperable, locally advanced, recurrent, or metastatic cervical cancer treated with pemetrexed (Alimta, LY231514), a multitargeted antifolate. The patients were treated with either 500 mg/m(2) (11 patients) or 600 mg/m(2) (24 patients) of pemetrexed, administered as a 10-min infusion on day 1 of a 21-day cycle. Patients receiving 500 mg/m(2) dose also received 5 mg/day oral folic acid supplementation beginning 2 days prior and ending on day 3 of each cycle. Of the 34 patients evaluable for efficacy, six patients (18%) had partial response, with median response duration of 3.8 months (range, 3.3-6.6 months). Twenty-four patients (71%) had stable disease, one patient (3%) had progressive disease, and three patients could not be assessed. Median overall survival was 15.2 months (range, 2.9-35.3+ months). Grade 4 hematologic toxicities consisted of neutropenia (37%), leukopenia (9%), anemia (6%), and thrombocytopenia (3%). One patient died of hypotensive shock associated with frank rectal hemorrhage that was considered to be related to the study drug. We conclude that pemetrexed therapy showed moderate activity, similar to other active agents, in the treatment of locally advanced or metastatic cervical cancer.
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Affiliation(s)
- L Goedhals
- Department of Oncotherapy, National Hospital, Private Bay, Bloemfontein X20598, South Africa.
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Abstract
PURPOSE OF REVIEW If chemotherapy becomes the only treatment option for cervical cancer, the prognosis has traditionally been regarded as dismal. Data from several recent trials have demonstrated significant improvements in outcome with specific cisplatin-containing combinations. The purpose of this review is to highlight the evolution of phase III trials leading to current treatment standards. RECENT FINDINGS Given the modest activity of single-agent cisplatin, devoid of any meaningful impact on survival, prospective studies focused on other drugs that might prove either more effective than, or could be used in combination with, cisplatin. Both paclitaxel and topotecan, in combination with cisplatin, yielded superior response rates and progression-free survival without diminishing patient-reported quality of life; however, only cisplatin plus topotecan also improved overall survival. Furthermore, patient-reported quality of life is not diminished despite the greater acute toxicity of combination regimens. SUMMARY Despite these chemotherapeutic advances, median survival is still less than one year and most patients do not respond to treatment. It is important that investigators identify those patients who should participate in investigational trials of non-platinum-containing regimens. The next generation of clinical trials should explore emerging biological therapies.
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Affiliation(s)
- David H Moore
- Gynecologic Oncology of Indiana, Indianapolis, Indiana 46237, USA.
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Tewari KS, Monk BJ. Gynecologic oncology group trials of chemotherapy for metastatic and recurrent cervical cancer. Curr Oncol Rep 2005; 7:419-34. [PMID: 16221379 DOI: 10.1007/s11912-005-0007-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Because only 16% of patients with metastatic cervical cancer are alive 5 years after diagnosis, the Gynecologic Oncology Group (GOG) has carefully designed and conducted many phase II studies to identify promising drugs. Cisplatin has emerged as the most active single agent with overall response rates of 19%. Recent phase III trials have documented response rates of 27% and 39% when cisplatin has been combined with either paclitaxel or topotecan, respectively. The comparison of cisplatin to cisplatin plus topotecan in GOG-179 has yielded the first study to show a statistically significant impact on the overall response rate, median progression-free survival, and median survival, with all outcome measures favoring the two-drug regimen. Despite these encouraging results, however, most of the responses are partial and of short duration. The need for novel combinations and the implementation of active biologic agents is implicit. The accumulated data in this disease setting, as evidenced by the experience of the GOG, are presented in this review.
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Affiliation(s)
- Krishnansu S Tewari
- Division of Gynecologic Oncology, The Chao Family Comprehensive Cancer Center, University of California, Irvine Medical Center, 101 The City Drive, Building 56, Room 262, Orange, CA 92868-3298, USA
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Tambaro R, Scambia G, Di Maio M, Pisano C, Barletta E, Iaffaioli VR, Pignata S. The role of chemotherapy in locally advanced, metastatic and recurrent cervical cancer. Crit Rev Oncol Hematol 2004; 52:33-44. [PMID: 15363465 DOI: 10.1016/j.critrevonc.2004.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2004] [Indexed: 11/25/2022] Open
Abstract
Cervical cancer is among the major health problems world-wide although advances in screening programs. Surgery and radiotherapy are the treatment modalities of choice for early and locally advanced cervical cancer. However, the role of chemotherapy in this setting has been better investigated in the latest years. To improve loco-regional control in locally advanced disease, authors have tested both neo-adjuvant chemotherapy and concurrent chemoradiotherapy. From 1999 NCI clinical announcement, concurrent cisplatin-based chemoradiation is considered the treatment of choice for cervical cancer patients requiring radiation therapy. Neo-adjuvant chemotherapy is reaching encouraging results in IB bulky-IIA cervical cancer, but further investigation are ongoing in locally advanced cervical setting. The optimal treatment for patients with metastatic or recurrent cervical cancer is still undefined and chemotherapy is used with palliation intent. Cisplatin remains the most active cytotoxic agents, although combinations of cisplatin with paclitaxel, topotecan, vinorelbine, have shown encouraging results in phase II and in early phase III studies. This paper reviews the role of chemotherapy in the management of patients with locally advanced, metastatic and recurrent cervical cancer. Studies discussed in this paper were selected trough a search in the med-line database performed in October 2003.
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Affiliation(s)
- Rosa Tambaro
- Department of Oncology, Catholic University of the Sacred Heart-Campobasso, Napoli, Italy
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Morris M, Blessing JA, Monk BJ, McGehee R, Moore DH. Phase II study of cisplatin and vinorelbine in squamous cell carcinoma of the cervix: a gynecologic oncology group study. J Clin Oncol 2004; 22:3340-4. [PMID: 15310778 DOI: 10.1200/jco.2004.12.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the efficacy and toxicity of intravenous cisplatin and vinorelbine as combination chemotherapy in patients with advanced or recurrent squamous cell carcinoma of the cervix. PATIENTS AND METHODS Between August 1997 and January 2001, 73 patients with advanced or recurrent squamous cell carcinoma of the cervix were entered onto this study. Eligible patients had received no prior therapeutic chemotherapy, except when administered concurrent with primary radiation therapy. The initial doses administered were cisplatin 75 mg/m(2) every 4 weeks and vinorelbine 30 mg/m(2) weekly. Subsequent doses were unchanged, reduced, escalated, or omitted according to observed toxicity and protocol guidelines. Patients were evaluated for response and toxicity using standard Gynecologic Oncology Group criteria. RESULTS Of 73 patients, 67 were eligible and assessable. The overall response rate was 30% (five complete and 15 partial responses). The overall median response duration was 5.5+ months. The major toxicity was neutropenia, with 16% grade 3 and 67% grade 4 reported. Gastrointestinal and neurotoxicity were infrequent and mild. CONCLUSION The combination of cisplatin and vinorelbine has moderate activity in advanced or recurrent squamous cell carcinoma of the cervix. Additional study of this regimen in a phase III setting is justified in this patient population.
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Affiliation(s)
- Mitchell Morris
- Department of Gynecologic Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Mundt AJ, Rotmensch J, Waggoner SE, Yamada SD, Fleming GF. Phase I trial of concomitant vinorelbine, cisplatin, and pelvic irradiation in cervical carcinoma and other advanced pelvic malignancies. Gynecol Oncol 2004; 92:801-5. [PMID: 14984944 DOI: 10.1016/j.ygyno.2003.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2003] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the maximum tolerated dose (MTD) of vinorelbine in combination with weekly cisplatin and pelvic radiation therapy (RT). METHODS Eligible patients included those with bulky or locally advanced cervical cancer. Women with other advanced gynecologic malignancies were also eligible. All patients received cisplatin 40 mg/m(-2)/week (maximum dose, 70 mg) during pelvic RT. Vinorelbine was administered on the same day as cisplatin at a starting dose of 10 mg/m(-2)/week and escalated in 5 mg/m(-2)/week increments. Dose-limiting toxicity (DLT) was defined as: grade 3-4 non-hematologic toxicity, grade 4 hematologic toxicity, or any toxicity which required > or =1 week delay in RT or an omission of >1 dose of chemotherapy. RESULTS Between April 2001 and September 2002, 12 women with pelvic malignancies (11 cervical, 1 recurrent ovarian) were enrolled. Cohorts of 3, 6, and 3 patients were treated at 10, 15, and 20 mg/m(-2)/week dose levels of vinorelbine. At the 20 mg/m2 level, DLT was observed. Two of three patients missed >1 cycle of chemotherapy secondary to predominantly hematologic toxicity. One patient at the 20 mg level developed a creatinine clearance <50 ml/min and missed 1 dose of cisplatin. Another developed transient grade 3 diarrhea. No grade 4 toxicities were observed. CONCLUSIONS The MTD of vinorelbine in combination with cisplatin and pelvic RT in patients with cervical cancer is 15 mg/m(-2)/week.
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Affiliation(s)
- Arno J Mundt
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, Chicago, IL 60647, USA.
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Muggia FM, Blessing JA, Method M, Miller DS, Johnson GA, Lee RB, Menzin A. Evaluation of vinorelbine in persistent or recurrent squamous cell carcinoma of the cervix: a Gynecologic Oncology Group study. Gynecol Oncol 2004; 92:639-43. [PMID: 14766259 DOI: 10.1016/j.ygyno.2003.10.045] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2003] [Indexed: 11/16/2022]
Abstract
PURPOSE Vinorelbine is being explored by the Gynecologic Oncology Group (GOG) for its possible use in advanced or recurrent squamous cell carcinoma of the uterine cervix. The objective of this Phase II trial was to evaluate a days 1 and 8 every-21-days schedule and determine its activity in patients who had failed standard chemotherapy. PATIENTS AND METHODS Eligible patients with measurable disease and satisfactory baseline bone marrow, liver, and kidney functions were treated with vinorelbine 30 mg/m(2) given on days 1 and 8 every 21 days. A two-stage sampling design was used, proceeding to a second stage accrual if sufficient activity was documented in the first 25 patients. RESULTS The study did proceed to the second stage and accrued 44 patients. There were six objective responses (one complete, five partial) for a response rate of 13.7% (95% confidence interval: 5.2-27.4%). There were three patients with response in extra-pelvic sites (including the complete response) and three with response in the pelvis. The overall frequency of grades 3 and 4 neutropenia was 41%, whereas neuropathy was reported in 27% and was severe in three. Treatment-related pain, very severe in two instances, was also reported in 27%. CONCLUSION Vinorelbine has moderate activity in a pretreated population with squamous cell carcinoma of the cervix. Accordingly, vinorelbine in this days 1 and 8 schedule is being studied further in combination with cisplatin by the GOG.
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Affiliation(s)
- Franco M Muggia
- Division of Medical Oncology, Department of Medicine, Kaplan Cancer Center, New York University Medical Center, New York, NY 10016, USA.
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Stehman FB, Rose PG, Greer BE, Roy M, Plante M, Penalver M, Jhingran A, Eifel P, Montz F, Wharton JT. Innovations in the treatment of invasive cervical cancer. Cancer 2003; 98:2052-63. [PMID: 14603542 DOI: 10.1002/cncr.11676] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Invasive cervical cancer is characterized by basement membrane-invading lesions capable of metastasizing through the lymphatic and vascular systems. Treatment methods were reviewed by panelists at the Second International Conference on Cervical Cancer (Houston, TX, April 11-14, 2002), and new opportunities for translational research were discussed. Reviews encompassed hysterectomy with or without lymph node dissection or cervical conization in cases with microinvasion and radical trachelectomy with or without lymph node dissection as fertility-sparing surgery. Chemoradiation is used to treat advanced cervical malignancies, and the risks and benefits of radiotherapy are significant. Pelvic exenteration is used to treat certain types of recurrences. Use of the Miami pouch for continent urinary diversion was highlighted. Gynecologic oncologists expect novel in vivo imaging techniques currently being developed to help guide therapy choices within the next decade. The most significant research priorities are large group-randomized trials involving fertility-sparing procedures and the management of microinvasive carcinoma (MICA); better identification of candidates for chemoradiation; and the development of innovative approaches to exenteration. Improving diagnostic technologies, refining the criteria by which therapies are chosen, and preserving fertility remain challenges in selecting the most appropriate treatment for invasive cervical cancer. Research advances in both diagnosis and treatment are expected to improve therapy and outcomes.
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Affiliation(s)
- Frederick B Stehman
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana 46202-5274, USA.
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Savarese A, Cognetti F. New drugs in the treatment of recurrent or metastatic cervical cancer. Crit Rev Oncol Hematol 2003; 48:323-7. [PMID: 14693346 DOI: 10.1016/s1040-8428(03)00131-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Cervical cancer is the second major cause of death in women. In locally-advanced or refractory cervical cancer, cisplatin-based chemotherapy still represents the best chance of cure, although chemotherapy in these patients usually results in excessive toxicity and short duration of response. Newly developed chemotherapy agents, widely used in other cancers, have been employed as single agents and in combination with cisplatin in the treatment of locally advanced or recurrent cervical cancer. Several phase II-studies have been performed in order to assess the effectiveness of gemcitabine, paclitaxel, vinorelbine and camptothecines in cervical cancer. When used as single agents, these compounds have an overall response rate (ORR) of 8-25%. Cisplatin-combined regimens may offer improved efficacy, with a ORR between 41 and 60%. Toxicity remains the more limiting factor in the treatment of irradiated or pretreated patients. New targets must be identified for innovative therapeutic approaches that could improve the response rate and survival of cervical cancer patients.
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Affiliation(s)
- Antonella Savarese
- Department of Medical Oncology, Regina Elena Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
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Abstract
Cervical cancer is a preventable disease that is curable when it is detected early. For advanced-stage cancer, the prognosis is worse. Over the years, much progress has been made in radiation therapy and in chemotherapy, but it took three decades for the arrival of concurrent chemoradiation therapy, which significantly improved the survival among women with advanced cervical cancer. This fact underscores the need and the importance for continuing efforts in clinical research. While current standards of therapy are being fine-tuned as more information is being gathered, great strides are being made in the areas of molecular and cancer biology. Novel treatments for cervical cancer appear to be imminent in the near future.
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Affiliation(s)
- Samuel S Im
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center; Chao Family Comprehensive Cancer Center, 101 The City Drive, Building 23, Room 107, Orange, CA 92868, USA
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Aapro MS, Harper P, Johnson SA, Vermorken JB. Developments in cytotoxic chemotherapy: advances in treatment utilising vinorelbine. Crit Rev Oncol Hematol 2001; 40:251-63. [PMID: 11738948 DOI: 10.1016/s1040-8428(01)00167-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Vinorelbine is a third generation vinca alkaloid which has been in clinical development for 15 years. Recent exploration of its pre-clinical activity has revealed unexpected evidence of potential synergy with taxane compounds and early clinical results support the suggestion of enhanced efficacy particularly in breast cancer. The initial studies establishing the clinical activity of vinorelbine in breast cancer and non-small cell lung cancer have been extended to encompass a thorough evaluation of its contribution to combination chemotherapy for these disorders. In the treatment of breast cancer useful activity has been established for vinorelbine in combination with anthracyclines, anthracenediones, antimetabolites and the taxanes; additive toxicity is not a limiting factor. The activity of vinorelbine in the treatment of non-small cell lung cancer is significantly extended by incorporation into schedules utilising cisplatin and other agents. Vinorelbine has also demonstrated useful activity in the treatment of a wide range of other malignancies including prostatic carcinoma, multiple myeloma, cancer of the ovary, cervix and head and neck and malignant lymphomas.
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Affiliation(s)
- M S Aapro
- Clinique de Genolier, 1272 Genolier, Switzerland
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Mundt AJ, Rotmensch J, Waggoner SE, Yamada D, Langhauser C, Fleming GF. Phase I trial of concomitant vinorelbine, paclitaxel, and pelvic irradiation in cervical carcinoma and other advanced pelvic malignancies. Gynecol Oncol 2001; 82:333-7. [PMID: 11531289 DOI: 10.1006/gyno.2001.6101] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to determine the feasibility and toxicity of concomitant vinorelbine, paclitaxel, and pelvic radiation therapy (RT) in patients with advanced cervical cancer and other pelvic malignancies. METHODS Eligible patients included those with large or locally advanced cervical cancer. In addition, patients with other advanced gynecologic malignancies were eligible. In part I, vinorelbine was administered as a single agent during pelvic RT at a starting dose of 10 mg/m(2)/week with subsequent cohorts being escalated in 5 mg/m(2)/week increments. In part II, paclitaxel was added to vinorelbine (20 mg/m(2)/week) and pelvic RT at a starting dose of 20 mg/m(2)/week. RESULTS Thirty-three women with pelvic malignancies (22 cervix, 6 vagina, 3 endometrium, 2 vulva) were enrolled. Twenty-seven received vinorelbine and 6 received both paclitaxel and vinorelbine in combination with pelvic RT. Escalating vinorelbine doses to 25 mg/m(2)/week were well tolerated, with the primary toxicity being hematologic. RT was delayed in only 1 patient due to acute hematologic toxicity. In contrast, the combination of paclitaxel, vinorelbine, and pelvic RT was not well tolerated. Five of 6 patients (83%) experienced grade > or = 2 leukopenia, with 2 patients missing > 1 cycle of chemotherapy. Moreover, RT was delayed for 1 week in 2 of 6 patients (33%). CONCLUSIONS Concomitant pelvic RT and vinorelbine with doses to 25 mg/m(2)/week is well tolerated. The addition of paclitaxel to this combination is associated with significant hematologic toxicity and is thus not a feasible approach.
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Affiliation(s)
- A J Mundt
- Department of Radiation and Cellular Oncology, Section of Gynecologic Oncology, Chicago, Illinois 60637, USA.
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Vermorken JB, Zanetta G, De Oliveira CF, van der Burg ME, Lacave AJ, Teodorovic I, Boes GH, Colombo N. Randomized phase III trial of bleomycin, vindesine, mitomycin-C, and cisplatin (BEMP) versus cisplatin (P) in disseminated squamous-cell carcinoma of the uterine cervix: an EORTC Gynecological Cancer Cooperative Group study. Ann Oncol 2001; 12:967-74. [PMID: 11521804 DOI: 10.1023/a:1011165115426] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Three previous mitomycin-cisplatin-based chemotherapy trials conducted within the EORTC Gynecological Cancer Cooperative Group (GCCG) in patients with disseminated squamous-cell carcinoma of the uterine cervix (SCCUC) suggested that with such regimens a higher overall response rate and a higher complete response rate could be obtained compared to what might have been expected from cisplatin alone. In that respect the combination of bleomycin, vindesine (Eldesine), mitomycin C and cisplatin (BEMP) was the most promising. In the present study BEMP has been compared with the best single agent, cisplatin (P) in the expectation that improved response rates might translate into a better survival. PATIENTS AND METHODS Eligible patients were those with SCCUC and disseminated measurable disease outside previously irradiated areas, aged < or = 75 years, with a WHO performance status < or = 2 and adequate bone marrow, renal, hepatic and pulmonary function, who gave consent according to regulations followed in individual institutions. Patients were randomized to BEMP: E 3 mg/m2 day 1, P 50 mg/m2 day 1, B 15 mg (24-hour infusion) day 2-4 and M 8 mg/m2 (at alternate cycles), or P 50 mg/m2. The first four cycles were given every 3 weeks (induction phase). Subsequent cycles were given every four weeks (maintenance phase), during which B was deleted from BEMP (MEP). Patients failing on P could be treated with BEM. Of the 287 patients entered, 235 were eligible and 201 evaluable for response. RESULTS BEMP induced a significantly higher response rate than P (42% vs. 25%, P = 0.006). There was no difference in complete response rate (11% vs. 7%). BEMP was significantly more toxic than P (+/- BEM), both with respect to hematologic and nonhematologic toxicities. After a median follow-up of 6.1 years, survival curves were not significantly different. Median progression-free survival and overall survival were 5.3 and 10.1 months with BEMP and 4.5 and 9.3 months with P (+/- BEM), respectively. In a multivariate analysis of prognostic factors for survival, a lower age (P = 0.003), a lower performance status (P = 0.0001) and a short (<1 year) interval since diagnosis (P = 0.0152) were all associated with an increased risk of dying. For progression-free survival, lower age, prior radiotherapy, locoregional involvement and no prior surgery were associated with a high risk. Treatment with BEMP or P had no significant impact on survival, but for progression-free survival there was a trend in favor of BEMP (P = 0.0893). Adjusting for prognostic factors did not change the effect of treatment. CONCLUSIONS Combination chemotherapy with BEMP produces more toxicity and more responses compared with cisplatin alone in patients with disseminated SCCUC, but this does not translate into a better survival. Therefore, in the palliative setting single-agent cisplatin should remain the standard therapy for these patients.
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Affiliation(s)
- J B Vermorken
- Department of Oncology, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands
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