[Comparison of the clinical efficacy of different treatments based on radical surgery in stage Ⅰ b2 and Ⅱa2 cervical cancer: a prospective randomized control study]

Debulking hysterectomy followed by chemoradiotherapy versus chemoradiotherapy for FIGO stage (2019) IB3/II cervical cancer

BACKGROUND

With an estimated 570,000 new cases reported globally in 2018, and increasing numbers of new cases in countries without established human papillomavirus (HPV) vaccination programmes, cervical cancer is the third most common cancer in women worldwide. The majority of global disease burden (around 85%) is in low-and middle-income countries (LMICs), with estimates of cervical cancer being the second most common cancer in women in such regions. As it commonly affects younger women, cervical cancer has the greatest impact on years of life lost (YLL) and adverse socioeconomic outcomes compared to all other cancers in women. Management of cervical cancer depends on tumour stage. Radical hysterectomy with lymphadenectomy is the standard primary treatment modality for International Federation of Gynecology and Obstetrics (FIGO) stage (2019) 1B1 to 1B3 disease. However, for larger primary tumours, radical hysterectomy is less commonly recommended. This is mainly due to a high incidence of unfavourable histopathological parameters, which require adjuvant concurrent chemoradiotherapy (CCRT) (chemotherapy given with radiotherapy treatment). CCRT is the standard of care and is widely used as first-line treatment for cervical cancer considered to be not curable with surgery alone (i.e.those with locally advanced disease). However, a sizable cohort of women managed with primary CCRT will have residual disease within the cervix following treatment. Debulking' hysterectomy to remove (debulk) the primary tumour in locally advanced disease, prior to CCRT, may be an alternative management strategy, avoiding the potential need for surgery for residual cervical disease following CCRT, which may be more extensive, or have increased morbidity due to CCRT. However, this strategy may subject more women to unnecessary surgery and its inherent risks.

OBJECTIVES

To assess the efficacy and harms of debulking hysterectomy (simple or radical) followed by chemoradiotherapy (CCRT) versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer.

SEARCH METHODS

We systematically searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 4), MEDLINE via Ovid (1946 to 12 April 2021) and Embase via Ovid (1980 to 12 April 2021). We also searched other registers of clinical trials, abstracts of scientific meetings and reference lists up to 12 April 2021.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs), quasi-RCTs or non-randomised studies (NRSs) comparing debulking hysterectomy followed by CCRT versus CCRT alone for locally advanced FIGO (2019) stage IB3/II cervical malignancy.

DATA COLLECTION AND ANALYSIS

We applied Cochrane methodology, with two review authors independently assessing whether potentially relevant studies met the inclusion criteria. We planned to apply standard Cochrane methodological procedures to analyse data and risk of bias.

MAIN RESULTS

We did not find any evidence for or against debulking hysterectomy followed by CCRT versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer. We did not identify any studies assessing the validity of debulking hysterectomy for these women.  AUTHORS' CONCLUSIONS: There was no evidence for or against debulking hysterectomy followed by CCRT versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer.

Neoadjuvant and Adjuvant Treatments Compared to Concurrent Chemoradiotherapy for Patients With Locally Advanced Cervical Cancer: A Bayesian Network Meta-Analysis

Aim

This study aimed to identify the most effective treatment mode for locally advanced cervical cancer (LACC) by adopting a network meta-analysis (NMA).

Methods

Randomized controlled trials about treatments were retrieved from PubMed, Medline and Embase. Odds ratios (OR) of overall survival (OS) and progression-free survival (PFS) were calculated by synthesizing direct and indirect evidence to rank the efficacy of nine treatments. Consistency was assessed by node-splitting method. Begg's test was performed to evaluate publication bias. The surface under cumulative ranking curve (SUCRA) was also used in this NMA.

Results

A total of 24 eligible randomized controlled trials with 6,636 patients were included in our NMA. These trials compared a total of nine different regimens: radiotherapy (RT) alone, surgery, RT plus adjuvant chemotherapy (CT), concurrent chemoradiotherapy (CCRT), neoadjuvant CT plus CCRT, CCRT plus adjuvant CT, neoadjuvant CT, RT, CCRT plus surgery. Among those therapeutic modalities, we found that the two interventions with the highest SUCRA for OS and PFS were CCRT and CCRT plus adjuvant CT, respectively. ORs and 95% confidence interval (CI) for the two best strategies were CCRT versus CCRT plus adjuvant CT (OR, 0.84; 95% CI, 0.53-1.31) for OS, CCRT plus adjuvant CT versus CCRT (OR, 0.60; 95% CI, 0.38-0.96) for PFS.

Conclusions

This NMA supported that CCRT and CCRT plus adjuvant CT are likely to be the most optimal treatments in terms of both OS and PFS for LACC. Future studies should focus on comparing CCRT and CCRT plus adjuvant CT in the treatment of LACC.

Systematic Review Registration

PROSPERO, CRD42019147920.

Assessment of local treatment modalities for FIGO stage IB-IIB cervical cancer: A propensity-score matched analysis based on SEER database

The aim of this study was to investigate the impact of local treatment modalities on the survival of patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB-IIB cervical cancer, including cancer-directed surgery (CDS) alone and CDS combined with radiotherapy (RT). A total of 8,357 patients with cervical cancer between 1988 and 2013 were included in the final study cohort, including 4,298 (51.4%) patients who underwent CDS alone and 4,059 (48.6%) patients who received combination therapy. Univariate and multivariate analyses showed that local treatment modalities were prognostic factors for cause-specific survival (CSS). Patients who received combination therapy had worse CSS (HR = 1.38; 95% CI = 1.20–1.59; P < 0.001). Subgroup analyses showed the prognostic effect of local treatment modalities was significantly influenced by FIGO stage. In the propensity-score matched (PSM) dataset, CDS was associated with better CSS (P < 0.001) for patients with IB-IIA cervical cancer; nevertheless, no differences were observed in CSS (P = 0.639) for patients with IIB cervical cancer. In conclusion, radical surgery was the preferred treatment for patients with IB-IIA cervical cancer, and there was no difference between radical surgery alone and combination therapy for patients with IIB cervical cancer.