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Datta NR, Stutz E, Liu M, Rogers S, Klingbiel D, Siebenhüner A, Singh S, Bodis S. Concurrent chemoradiotherapy vs. radiotherapy alone in locally advanced cervix cancer: A systematic review and meta-analysis. Gynecol Oncol 2017; 145:374-385. [PMID: 28188016 DOI: 10.1016/j.ygyno.2017.01.033] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 12/20/2022]
Abstract
The efficacy of concurrent chemoradiotherapy (CTRT) in locally advanced cervix cancer (LACC, stages IIB-IVA) is contentious. This is due to the variable extent of therapeutic benefit reported in different randomized clinical trials and meta-analyses that usually include all stages of cervix cancer. A systematic review and meta-analysis was therefore conducted to evaluate the efficacy of concurrent CTRT over radiotherapy (RT) alone, predominantly in LACC for the key endpoints; complete response (CR), long-term loco-regional control (LRC), overall survival (OS), grade III/IV acute and late toxicities. Six databases namely - PubMed, EMBASE, SCOPUS, Web of Science, Google Scholar and Cochrane library were explored and supplemented by hand-searching. Only prospective randomized trials conducted in LACC between concurrent CTRT and RT alone with no surgical interventions were included. Fourteen English language articles from 1788 citations were shortlisted for the final analysis. Of the 2445 patients evaluated (CTRT: n=1217; RT: n=1228), 95.7% had LACC and 96% had a squamous cell histology. Eight studies used cisplatin alone, 4 had cisplatin-based combination chemotherapy (CT) while 2 used mitomycin-C, either alone or in combination. CTRT improved the CR (+10.2%, p=0.027), LRC (+8.4%, p<0.001) and OS (+7.5%, p<0.001) over RT alone. However a 10.4% higher incidence of grade III/IV acute toxicities (p<0.001) was also evident with CTRT. Late toxicities in both groups were equivalent. Subgroup analysis and meta-regression did not reveal any significant advantage in outcomes between the 3 CTRT regimens. Thus, although concurrent CTRT provides conclusive therapeutic benefit over RT alone in LACC, the choice of CT agents should be based on their cost-effectiveness and the anticipated expenses for the management of any associated acute toxicities. This assumes importance particularly in resource-constrained low-middle-income countries with the highest burden of LACC, where majority of the patients meet the treatment costs as out-of-pocket expenses.
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Affiliation(s)
- Niloy Ranjan Datta
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland.
| | - Emanuel Stutz
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Michael Liu
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Susanne Rogers
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Dirk Klingbiel
- Swiss Group for Clinical Cancer Research (SAKK), Coordinating Centre, Bern, Switzerland
| | | | - Shalini Singh
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Stephan Bodis
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland; Department of Radiation Oncology, University Hospital Zurich, Switzerland
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Basu P, Jenson AB, Majhi T, Choudhury P, Mandal R, Banerjee D, Biswas J, Pan J, Rai SN, Ghim SJ, Miller D. Phase 2 Randomized Controlled Trial of Radiation Therapy Plus Concurrent Interferon-Alpha and Retinoic Acid Versus Cisplatin for Stage III Cervical Carcinoma. Int J Radiat Oncol Biol Phys 2016; 94:102-110. [PMID: 26700705 DOI: 10.1016/j.ijrobp.2015.09.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 09/02/2015] [Accepted: 09/25/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Because a combination of retinoic acid, interferon-alpha, and radiation therapy demonstrated synergistic action and effectiveness to treat advanced cervical cancers in earlier studies, we designed this randomized phase 2 open-label trial to assess efficacy and safety of interferon alpha-2b (IFN) and 13-cis-retinoic acid (RA) administered concomitantly with radiation therapy (IFN-RA-radiation) to treat stage III cervical cancer. METHODS AND MATERIALS Stage III cervical cancer patients were randomized to study and control groups in a 1:1 ratio. All patients were treated with radiation therapy; study arm patients received IFN (3 × 10(6) IU subcutaneously) 3 times a week for 4 weeks and daily RA (40 mg orally) for 30 days starting on day 1 of radiation, whereas control arm patients received weekly cisplatinum (40 mg/m(2)) for 5 weeks during radiation. Patients were followed for 3 years. The primary endpoint was overall survival at 3 years. RESULTS Patients in the study (n=104) and control (n=105) groups were comparable for clinicopathological characteristics, radiation therapy-related variables and treatment response. Proportions of disease-free patients in the study and control groups were 38.5% and 44.8%, respectively, after median follow-up of 29.2 months. Hazard ratios were 0.67 (95% confidence interval [CI]: 0.44-1.01) and 0.69 (95% CI: 0.44-1.06) for overall and disease-fee survival, respectively, comparing the study group to control, and demonstrated an inferior outcome with RA-IFN-radiation, although differences were statistically nonsignificant. Kaplan-Meier curves of disease-free and overall survival probabilities also showed inferior survival in the study group compared to those in the control. Acute toxicities of chemoradiation were significantly higher with 2 acute toxicity-related deaths. CONCLUSIONS Treatment with RA-IFN-radiation did not demonstrate survival advantage over chemoradiation despite being less toxic. The trends predicted an inferior outcome with the RA-IFN combination.
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Affiliation(s)
- Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France.
| | | | - Tapas Majhi
- Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Prabir Choudhury
- Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Ranajit Mandal
- Department of Gynecological Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Dipanwita Banerjee
- Department of Gynecological Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Jaydip Biswas
- Department of Surgical Oncology, Chittaranjan National Cancer Institute, Kolkata, India
| | - Jianmin Pan
- James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky
| | - Shesh Nath Rai
- James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky
| | - Shin Je Ghim
- James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky
| | - Donald Miller
- James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky
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Naghavi AO, Johnstone PAS, Kim S. Clinical trials exploring the benefit of immunotherapy and radiation in cancer treatment: A review of the past and a look into the future. Curr Probl Cancer 2015; 40:38-67. [PMID: 26656977 DOI: 10.1016/j.currproblcancer.2015.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cancer immunotherapy is rapidly redefining the standard of cancer care. The role of radiation therapy in eliciting antitumoral immune response is also being actively investigated in combination with various immunotherapeutic agents to exploit potential synergy between the 2 modalities. In this review, we summarize the rationale and results of past and ongoing clinical trials that combined the use of radiation therapy and immunogenic agents such as vaccines, cytokines, immune checkpoint inhibitors, costimulatory agonists, and myeloid activators.
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Roy S, Goswami S, Bose A, Goswami KK, Sarkar K, Chakraborty K, Chakraborty T, Pal S, Haldar A, Basu P, Biswas J, Baral R. Defective dendritic cell generation from monocytes is a potential reason for poor therapeutic efficacy of interferon α2b (IFNα2b) in cervical cancer. Transl Res 2011; 158:200-13. [PMID: 21925117 DOI: 10.1016/j.trsl.2011.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Revised: 03/01/2011] [Accepted: 03/10/2011] [Indexed: 11/28/2022]
Abstract
Despite being a pleiotropic cytokine, the therapeutic potential of interferon α2b (IFNα2b) is debatable. Thus, the need for identifying predictive marker(s) for patients who are most likely to benefit from the treatment is pivotal for avoiding the exposure of nonresponsive patients to the toxicity of the treatment. To account for the attenuated efficacy of the drug, we have verified its dendritic cell (DC) maturating ability from monocytes of cervical cancer stage IIIB (CaCx-IIIB) patients. First, we evaluated the status of monocytes from CaCx-IIIB and healthy women by conducting flow cytometric studies of various activation markers and a cytokine analysis by enzyme-linked immunosorbent assay (ELISA) and flow cytometry. Immature DCs were then generated from these monocytes and matured with low-dose IFNα2b (1500 units/mL). A functional and phenotypic comparative analysis of these matured DCs was performed by flow cytometric, proliferative, cytotoxic, and enzyme-linked immunosorbent assays. Our study shows that monocytes isolated from CaCx-IIIB are impaired, and in vitro maturation with IFNα2b did not significantly improve the functional repertoire of DCs generated from these monocytes in comparison with healthy controls. This impairment of monocytes might be a plausible reason for the attenuated efficacy of this drug alone in treating CaCx-IIIB patients, and this imbalance of immune parameters associated with the stage of malignancy might be considered an effective marker to design a proper therapeutic regimen.
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Affiliation(s)
- Soumyabrata Roy
- Department of Immunoregulation and Immunodiagnostics, Chittaranjan National Cancer Institute, Kolkata 700026, India
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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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Radiochemotherapy versus radiotherapy in locally advanced cervical cancer: a meta-analysis. Arch Gynecol Obstet 2010; 283:103-8. [DOI: 10.1007/s00404-010-1385-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 01/26/2010] [Indexed: 10/19/2022]
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Candelaria M, Garcia-Arias A, Cetina L, Dueñas-Gonzalez A. Radiosensitizers in cervical cancer. Cisplatin and beyond. Radiat Oncol 2006; 1:15. [PMID: 16722549 PMCID: PMC1479830 DOI: 10.1186/1748-717x-1-15] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 05/08/2006] [Indexed: 01/01/2023] Open
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 therapeutical modality. Currently, the value of adding cisplatin or cisplatin-based chemotherapy to radiation for 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 assayed. A strategy currently being investigated is the use of newer radiosensitizers alone or in combination with platinum compounds. In the present work, we present preclinical information on known and newer cytotoxic agents as radiosensitizers on cervical cancer models, as well as the clinical information emanating from early phase trials that incorporate them to the cervical cancer management. In addition, we present the perspectives on the combined approach of radiation therapy and molecular target-based drugs with proven radiosensitizing capacity.
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Affiliation(s)
- Myrna Candelaria
- Division of Clinical Research, Instituto Nacional de Cancerología, Mexico
| | | | - Lucely Cetina
- Division of Clinical Research, Instituto Nacional de Cancerología, Mexico
| | - Alfonso Dueñas-Gonzalez
- Unidad de Investigación Biomédica en Cancer, Instituto Nacional de Cancerología/Instituto de Investigaciones Biomedicas, UNAM, Mexico
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