Present Status of Treatment for Invasive Cervical Carcinoma

The results are presented of a retrospective clinical study carried out on 341 patients affected with cancer of the uterine cervix, with lymphography in the pretreatment diagnostic work-up, treated in our Institute from January 1961 to December 1976. The clinical classification of the patients studied was: 157 cases in Stage I (46.0%), 95 cases in Stage II (27.9%), and 89 cases in Stages III and IV (26.1%). During the period considered, the therapeutic approach for carcinoma of the cervix was practically constant and in line with the therapeutic policy most frequently followed for these neoplasms. For the early stages (9/341 patients or 27.6%) preference was given to a radical surgery and postoperative radiotherapy combination; for borderline cases and « bulky » and « barrel-shaped » lesions, radiotherapy usually preceded surgical treatment to enlarge its indications and improve its results (36/341 patients or 10.5%). The cases that were more developed locally or that presented contraindications to surgery received radiological treatment alone (211/341 patients or 61.9%). Radiotherapy treatment consisted of radium therapy performed with a single application of 226Ra conventional sources, followed by percutaneous irradiation with 60Co-teletherapy in the more developed cases and/or in the presence of lymph node metastases. All the patients were submitted to diagnostic lymphography at the onset of the treatment and 92 (26.9%) had lymph node metastases. In the framework of this clinical review, the 5-year disease-free survival from onset of the treatment varied from 88.2% for the cases at Stage Ib occult, 72.5% for the cases at Stage Ib, 63.8% for the Stage II cases, to 40.5% for the cases at Stages III and IV. The presence of a pathologic report at lymphography makes a considerable difference in terms of disease-free, long-term survival after treatment.

A randomised, prospective, phase III clinical trial of primary bleomycin, ifosfamide and cisplatin (BIP) chemotherapy followed by radiotherapy versus radiotherapy alone in inoperable cancer of the cervix

BACKGROUND

Phase II studies have shown primary (neo-adjuvant) chemotherapy with bleomycin, ifosfamide and cisplatin (BIP) is active against inoperable cervical cancer. We present here results of a randomised phase III multicentre trial comparing radical radiotherapy with neo-adjuvant BIP chemotherapy followed by radical radiotherapy in patients with inoperable cervical cancer, designed to discover whether this combination might improve survival.

PATIENTS AND METHODS

Patients with inoperable cervical carcinoma were randomised to pelvic radiotherapy alone [RT] or two to three cycles of bleomycin 30 units/24-hour infusion, ifosfamide 5 g/m2/24 hours, and cisplatin 50 mg/m2) chemotherapy followed by pelvic radiotherapy (BIP + RT). Randomisation was stratified by stage and radiotherapy centre.

RESULTS

One hundred seventy-two eligible women were randomised into this trial; eighty-six to RT and eighty-six to BIP + RT. A total of 190 cycles of chemotherapy were given. Median follow-up for the 47 patients still alive is 9 years with a minimum follow-up of 3 years. Complete or partial response occurred in 51 of 86 (59%) of those randomised to RT and 60 of 86 (69%) of those randomised to BIP + RT. The difference between response rates does not reach statistical significance (chi2 = 2.06, P = 0.15). Median survival is two years with an actuarial survival at five years of 32% (95% confidence interval (95% CI): 25%-39%). There is no significant difference between the treatment groups (chi2log-rank = 0.11, P = 0.74).

CONCLUSIONS

This study does not show any survival benefit from the use of neo-adjuvant BIP chemotherapy in advanced cervical cancer.

Phase II studies of ifosfamide alone and in combination in cancer of the cervix

A series of phase II studies using ifosfamide (IFX) as a single agent and in combination with cisplatin and bleomycin (BIP) in advanced and recurrent cervical cancer have been coordinated at the West Midlands CRC Clinical Trials Unit (Birmingham, UK). The aims of these studies were to identify single agents and combination regimens that may be of value for palliation and have potential for use as neoadjuvant and adjuvant therapy at the time of primary treatment. A total of 79 patients with disease non-amenable to radical local therapy were treated with single-agent IFX or the BIP combination. In 30 patients treated with single-agent IFX, 10 objective responses (30%) were seen, with 1 complete response. In 49 patients treated with BIP, 34 objective responses (69%) were seen, with 10 complete responses (20%). Toxicity included alopecia, nausea and vomiting, myelosuppression, infection, reduction in renal function and disturbance of consciousness. These data indicate that IFX is highly active in cervix cancer and, in combination with bleomycin and cisplatin, can be used for effective palliation and cytoreduction in greater than 70% of patients. IFX-containing regimens have potential for use as neoadjuvant and adjuvant therapy in patients at high risk of recurrence with conventional treatment. These hypotheses are currently being tested in prospective randomised trials.

Treatment of recurrent and metastatic carcinoma of cervix: a comparison of low dose methotrexate with adriamycin plus methotrexate

Sixty-six patients with recurrent or metastatic cervical cancer were treated with two different chemotherapy regimens in the last 11 years. Thirty-three patients received weekly low-dose methotrexate (MTX) regimen A and the other 33 patients were treated with a combination of adriamycin and MTX, regimen B. Response rates were 15.2% and 42.4% with regimens A and B respectively (P = 0.014). Symptomatic relief, duration of response and median survival were similar in both groups. General and haematological toxicities were higher including one toxic death with regimen B. Considering the quality of remaining life of the patient low dose MTX is preferred for the treatment of symptomatic recurrent and metastatic cervical cancer.

Phase II studies of bleomycin, ifosfamide and cis-platinum in advanced and recurrent cervical carcinoma

We report the results of phase II studies using a combination of ifosfamide, cis-platinum and bleomycin (BIP) in advanced and recurrent cervical cancer. Fifty-one patients have been studied. In 37 patients with disease not amenable to radical local therapy 27 objective responses (73%) were seen with 7 complete responses. Eleven of 14 patients (79%) with primary inoperable disease had at least a 50% reduction in tumour bulk prior to radical local radiotherapy. All patients experienced alopecia, nausea and vomiting. Other toxicity included myelosuppression, infection, reduction in renal function and disturbance of consciousness. There was no evidence that primary chemotherapy enhanced the acute toxic effects of pelvic radiotherapy. These data indicate that BIP is highly active in cervical cancer and can be used for effective palliation and cytoreduction in more than 70% of patients.

Continuous-infusion vinblastine in refractory carcinoma of the cervix: a phase II trial

Twenty patients with recurrent or metastatic squamous cell carcinoma of the cervix were treated with continuous-infusion vinblastine sulfate. Two patients (10%) had partial responses of 4 and 7 months' duration. Neutropenia was dose limiting. Vinblastine sulfate given by continuous infusion has limited activity in this malignancy.