Locally Advanced

Question 1

Discuss use of adjuvant chemo following Chemo/RT

Answer 1

OUTBACK

Randomized phase III trial

Inclusion: FIGO 2008 stage IB1 and node positive, IB2, II, IIIB or IVA) that was suitable for primary treatment with chemo-radiation with curative intent.

Methods: cisplatin-based chemo-radiation (control) or standard cisplatin-based chemo-radiation followed by adjuvant chemotherapy (ACT) with 4 cycles of carboplatin and paclitaxel
- Primary endpoint 5y OS

Results: OS at 5 years was similar in those assigned ACT versus control (72% vs 71%, difference <1%, 95% CI -6 to +7; P = 0.91). The hazard ratio for OS was 0·91, (95% CI 0.70 to 1.18). PFS at 5 years was similar in those assigned ACT versus control (63% vs 61%, difference 2%, 95% CI -5 to +9; P = 0.61). The hazard ratio for PFS was 0·87, (95% CI 0.70 to 1.08). AE of grade 3-5 within a year of randomisation occurred in 81% who were assigned and received ACT versus 62% assigned control.

Question 2

Do you recommend oophorectomy with early stage ovarian

Answer 2

Shimada multi institutional retrospective cohort of 3500 patients: Study results indicate that ovaries can be preserved in patients with stage Ib-IIa squamous cell carcinoma but removed in all patients with adenocarcinoma.

The incidence of ovarian metastasis in patients with cervical cancer was 0.22% for stage Ib, 0.75% for stage IIa, and 2.17% for stage IIb with squamous cell carcinoma

IB 3.72%, IIA 5.26%, and IIB 9.85% in adenocarcinoma

Ovarian metastasis occurred more frequently among patients with adenocarcinoma than among those with squamous cell carcinoma (5.31% vs. 0.79%)

Outcome for patients with ovarian metastasis was very poor and not related to FIGO stage and histological type. The presence of ovarian metastasis did not correlate with lymph node involvement or parametrial invasion.

Question 3

5 things to properly stage (limited resource)

Answer 3

Exam
CXR
Cysto
Procto
IVP

Question 4

What is locally advanced cervical cancer

Answer 4

IB3 - IVA

Question 5

What is the mainstay of treatment for LACC

Answer 5

Chemo RT

30-50% decrease in risk of death with CDDP/RT vs RT

Cochrane Review 2010 HR 0.8 - absolute improvement in survival of 6% at 5 years no role for adjuvant chemo, more G3-4 toxicities for chemoRT

Question 6

Can you give carbo instead of cis for chemo/RT?

Answer 6

Only for patients who cannot tolerate CDDP

No randomized trials for this

Question 7

GOG 92

Answer 7

46% reduction in regional recurrence

Patients in RT arm with adenocarcinoma (8.8% LR vs 44% observation)

Trend to improved OS with RT - 30% risk reduction of death (p=0.07)

Rotman IJROBP 2006

Question 8

Discuss GOG 263

Answer 8

Role of adjucant chemo RT in early stage who meet sedlis criteria
S/p

Get 50.4Gy (standard post op dose)vs 50.4 with weekly cis

Brachy is excluded

Question 9

Discuss PARCER Study

Answer 9

Assessed 3D vs IG-IMRT (SOC) for postop cervix

Using IG-IMRT reduced high grade toxicities over G2 thus toxicity profile is different with high quality surgery