Adriamycin plus Bleomycin versus Cyclophosphamide plus Vincristine in Advanced Carcinoma of the Uterine Cervix

Chemotherapy for metastatic and recurrent cervical cancer

BACKGROUND

Cervical cancer is the second most common cancer among women up to 65 years of age and is the most frequent cause of death from gynaecological cancers worldwide. A woman's risk of developing cervical cancer by 65 years of age ranges from 0.69% in developed countries to 1.38% in developing countries. Although screening by Pap smear should mean early detection at a curable stage for most women, many still present with advanced or metastatic disease with a worse prognosis. The addition of platinum-based chemotherapy to radiotherapy has improved outcome compared to radiotherapy alone; however, 30% to 50% fail to respond to treatment or develop recurrent disease. There are no standard treatment options for these patients, although platinum-based chemotherapy is frequently used and trials are on-going.

OBJECTIVES

To compare different types and combinations of cytotoxic chemotherapy for the treatment of metastatic/recurrent cervical cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2012), MEDLINE (1950 to January 2012) and EMBASE (1980 to January 2012). The reference lists from these and those of review articles were also checked.

SELECTION CRITERIA

All randomised controlled trials (RCTs) involving chemotherapy for metastatic/recurrent cervical cancer. Trials involving radiotherapy, chemoradiotherapy, intra-arterial chemotherapy, biological agents or immunomodulators were excluded.

DATA COLLECTION AND ANALYSIS

Three review authors independently reviewed trials for inclusion and data extraction and assessed risk of bias.

MAIN RESULTS

There were no data comparing best supportive care with chemotherapy. Cisplatin-based regimens are the most widely used and therefore we have concentrated on these trials. In terms of response rates some non-platinum regimens are equivalent but toxicity is higher. The most common cisplatin regimen was 50 mg/m(2) day 1 q21days. Higher doses had similar survivals. There was no direct comparison between single-agent cisplatin and carboplatin. Overall survival (OS) and progression-free survival (PFS) were not adequately reported and quality of life (QoL) outcomes were incompletely documented. Combination regimens were more toxic than single agents, but in the limited reported data this did not appear to adversely affect QoL.No significant difference in response rate by site of recurrence was found, although there was a trend towards improved response when the main site of disease was beyond the previously irradiated pelvis.

AUTHORS' CONCLUSIONS

Combination cisplatin-based chemotherapy could be a viable option for patients of good performance status with recurrent/metastatic cervical cancer, but further trials that report adequate survival and QoL data are sought. Response rates and improvements in survival are low. Cisplatin-based combinations have significant toxicity. Outcomes are poor and novel cytotoxic/biological agents and optimal scheduling need further investigation. Future trials need to stratify for and perform planned subgroup analysis with respect to previous treatment and site of recurrence.

Effects of different chemotherapy regimens on survival for advanced cervical cancer: Systematic review and meta-analysis

BACKGROUND

A large number of trials have assessed various chemotherapy regimens for the treatment of advanced cervical cancer, but there is uncertainty about the magnitude of survival benefits.

METHODS

We searched (last update January 2006) for trials in women with locally advanced or disseminated cervical cancer that compared neo-adjuvant or concurrent chemotherapy plus radiotherapy versus radiotherapy alone; or different chemotherapy regimens among themselves (with or without background radiotherapy in both arms). Sixty-five trials were identified with survival data on 11,180 women. Results for survival were combined with fixed and random effects models and between-study heterogeneity was estimated. Separate results were obtained for different regimens, cycle length, and type of chemotherapy (neo-adjuvant, concurrent, without radiotherapy).

RESULTS

Twenty two comparisons had survival data on 3837 women randomized to receive chemotherapy plus radiotherapy versus radiotherapy alone; the summary relative hazard for mortality was 0.95, 95% CI, 0.83-1.08. Modest between-study heterogeneity (I2=38%) seemed to be due to contradictory results in early trials; trials published in the last decade had a summary relative hazard 0.89 (95% CI, 0.78-1.02) and no between-study heterogeneity (I2=0%). Results were similar for neo-adjuvant chemotherapy and for concurrent chemo-radiotherapy. Cisplatin or cisplatin-based combinations had no significant benefit overall, but a potential benefit was seen with short-length cycles (14 days) and a marginally significant harm with longer-length cycles (summary relative hazards 0.80, 95% CI, 0.66-0.99 and 1.18, 95% CI, 1.02-1.38, respectively). The summary relative hazard was 1.02, (95% CI, 0.84-1.24) for trials using neo-adjuvant chemotherapy and 0.85 (95% CI, 0.73-1.00) for trials using concurrent chemotherapy.

CONCLUSIONS

Evidence on chemotherapy in women with advanced cervical cancer is not encouraging for major survival benefits. However, small benefits have been observed in some trials, especially with short-length cycles of cisplatin-based regimens and concurrent chemotherapy and radiotherapy.

Cervix carcinoma: treatment with combination cisplatin and bleomycin

Thirty patients with metastatic carcinoma of the cervix were treated with a combination of cisplatin and bleomycin. Thirty patients were evaluable for toxicity and 24 were evaluable for response. Thirteen patients achieved a partial remission for an objective response rate of 54% with a median duration of 3.5 months. The response rate for extrapelvic disease without prior radiation was 57% while the response rate for disease recurring in the previously irradiated pelvic area was only 36%. Response rates were higher in tumors with nonsquamous histology. Survival times for responders and nonresponders were not significantly different. Significant toxicity was observed. It is concluded that the combination of high-dose cisplatin and bleomycin infusion in patients with recurrent cervix cancer has an improved response rate. However, these responses are of short duration and drug toxicity is significant. The role of this combination for adjuvant studies is discussed.

Chemotherapy for advanced recurrent carcinoma of the cervix. A report on the treatment of 22 patients

In 22 patients with advanced squamous-cell carcinoma of the cervix, chemotherapy with adriamycin and methotrexate was attempted. Remission occurred in five patients, being complete in two of these. The median duration of remission was 8 months. In eight patients, the course of the disease was stabilized for at least 3 months. The median survival time was 3 months for the group of "failures', 11.5 months for those with stable disease, and 21 months for patients in remission. The most favourable course of the disease was observed in the two patients with complete remission; they survived for 31 and 32 months, respectively, after the start of chemotherapy.