16. Cervix cancer - The GEC-ESTRO Handbook of Brachytherapy

Cervix cancer

21

THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 01/09/2023

TABLE 5 SELECTED PUBLISHED REPORTS OF 5-YEAR OVERALL SURVIVAL AND PELVIC CONTROL BY DISEASE STAGE. RT = X-ray based EBRT + X-ray based BT CRT = Chemoradiotherapy

a 10-year survival and local control rates given. b separate figures given for IB1 and IB2 patients SERIES

Patients Treatment

I

IIB

IIIB

S

PC

S

PC

S

PC

Fletcher 1967 [57, 58]

1705

RT

91%

93%

67%

82%

36%

67%

Horiot 1988 [59]

1383

RT

89%

93%

76%

80%

50%

57%

Perez 1998 [60]

1499

RT

82%

88%

68%

84%

45%

63%

CRT + IGABT CRT + IGABT

Sturdza 2016 [62]

731

90%

96%

77%

87%

53%

67%

Pötter 2021 [63]

1461

83%/73% 95%/84% 78%

88%

59%

86%

The 5-year locoregional control ratee were 93% for Stage I, 80% for Stage IIB, and 57% for Stage IIIB. Perez et al. [60] from Washington University reported the outcome of 1499 patients treated with radiotherapy alone between 1959 and 1993. The actuarial 10-year disease-free survival rates according to the UICC/FIGO 1975 classification were 82% for Stage IB, 62% for Stages IIA and IIB, and 36% for Stage III. The pelvic control rate was 88% for Stage I, 80% for Stages IIA and IIB, and 59% for Stage III. Chemo-radiotherapy rapidly became standard of care for the treatment of cervical cancer after a National Cancer Institute (NCI) clinical alert was issued in 1999. Vale and colleagues from the Chemo-radiotherapy for Cervical Cancer Meta-Analysis Collaboration [61] analysed the events in 3128 patients treated within 13 randomised trials of chemo-radiotherapy + conventional BT. The addition of chemotherapy improved absolute disease-free survival by 8% at 5 years (from 50% to 58%) and locoregional disease-free survival by 9%. The benefit of chemotherapy on survival appeared to be greater in early-stage disease. Retro-EMBRACE [62] was a retrospective observational study of chemo-radiotherapy + MRI or CT-based IGABT involving 731 patients treated in 12 institutions worldwide. The actuarial 5-year cancer-specific survival rates according to the FIGO 2009 classification were 90% for Stage IB, 77% for Stage IIB, and 53% for Stage III. Actuarial local control at 5 years for IB, IIB, IIIB was 98%, 91% and 75%. The 5-year pelvic control rate was 84% across all stages (IB 96%, IIB 87%, IIIB 67%) with a crude pelvic control rate of 87%. These results compare favourably with the Vale meta-analysis where the crude pelvic control rate was 77%. The improvement in pelvic control in Retro-EMBRACE was larger in advanced stage disease (absolute differences: stage I/IIA 7-10%, IIB 9-12%, IIIB 16-24%, IVA 59%). Pötter et al. [63] recently published the results of EMBRACE-I, a prospective observational multi-centre cohort study of chemo

Studies of patient-reported outcomes [55, 56] have shown that while global health-related quality of life scores tended to improve 3-6 months after completing treatment, there can nevertheless be substantial treatment-related physical, psychosexual and emotional sequelae. The role of multi-disciplinary late effects clinics for patient rehabilitation is crucial.

12. RESULTS

There is vast literature on the results of cervical cancer treated with definitive radiotherapy +/- concomitant chemotherapy. Most of the reports are retrospective mono-institutional series often with relatively small numbers and results are difficult to compare because of differences in classification used and treatment schedules. A summary of the results of selected published large cohorts is provided in table 5. In 1967, GH Fletcher from the MD Anderson Hospital (MDAH) [57] presented the outcome of one of the earliest large cohort of patients treated with definitive radiotherapy according to modern principles (EBRT + BT). Between 1954 and 1963, 1705 patients received radiotherapy alone for invasive squamous cell carcinoma of the intact uterine cervix. The survival rates at 5 years according to the MDAH 1955 classification were 91% for Stage I (many of these patients were treated with BT alone), 67% for Stage IIB, and 36% for Stage IIIB. The pelvic control rates of 916 patients reported in a subsequent paper [58] were Stage I, 93%; Stage IIB, 82%; and Stage IIIB, 67%. Horiot et al. [59] reported the results of a French cooperative study of 1383 patients treated with radiotherapy alone according to Fletcher principles between 1970 and 1993. The 5-year disease free survival rates according to the UICC/FIGO 1975 classification were 89% for Stage I, 76% for Stage IIB, and 50% for Stage IIIB.