At the 2023 Society of Gynecological Oncology’s Annual Meeting on Women’s Cancer in Tampa, FL, Jyoti Mayadev, MD, University of California - San Diego, CA, discusses best practices for treating patients with IB3 cervical cancer, focusing on chemoradiation treatment.

Dr Mayadev discussed the importance of multidisciplinary treatment strategies for patients, and noted the benefits of chemoradiation, such as decreased toxicity, both in the short- and long-term.

Transcript

Hi, I'm Jyoti Mayadev, professor of Radiation Medicine at University of California San Diego. I'm really excited to be here at the 2023 Society of Gynecological Oncology’s Annual Meeting on Women’s Cancer. Today, we talked about a controversial topic, which is how to treat patients with 1B3 cervical cancer. We had a patient case presented in one of the sessions who was 45 years old and had a PET scan and CT scan, which were negative for lymph node disease. Her MRI showed us about a 6 centimeter tumor. The debate was should this patient be treated with primary chemoradiation and brachytherapy versus radical surgery. We talked about the pros and cons. I think this patient in particular should follow a multidisciplinary approach where she has 2 options.

Looking back at the data, however, we have level 1 evidence data from Landoni et al. Now, granted that was in 1997, but that showed that patients treated with bulky disease, 1B3, and randomized to radiation therapy versus radical hysterectomy showed no difference in progression-free survivals or overall survivals. However, almost two-thirds of patients in the surgery arm required adjuvant radiation. This increased toxicity. About 27% in the surgery arm versus 12% in the radiation arm. With the advances of radiation therapy in terms of image guidance and intensity-modulated radiation therapy we're better able to safely treat patients with radiation and chemotherapy.

The benefits of chemoradiation are that you can potentially decrease the toxicity if a patient goes to surgery and then needs adjuvant therapy. With chemoradiation and image guidance, image guided brachytherapy, we have data from several institutions, including the EMBRACE prospective studies that show that the low control and a woman with 1B3 disease or tumors greater than 4 centimeters without lymph node disease, should be greater than 95%. Also, in terms of long-term toxicities, we have randomized data from the PARCER trial published in the Journal of Clinical Oncology in 2022 that showed that the long-term gastrointestinal toxicity in the adjuvant setting is about 3%. If you look at the EMBRACE studies in terms of chemoradiation in the definitive setting with technologically advanced radiation and brachytherapy, the long-term genitourinary toxicities are about 6% to 8%, vaginal toxicities is 5%, and the rate of fistula, less than 2%.

We continued to talk in a multidisciplinary team about 1B3 cervical cancer, and that over time, strides in radiation therapy with image guidance, image guided brachytherapy, and even new novel trials looking at adaptive radiation therapy or ongoing to further decrease the toxicities and continue to have increasing cure rates for these patients. The implications of this strategy would increase the cure rates for patients and decrease toxicity.

In terms of strategies moving forward for 1B3 cervical cancer and the definitive chemoradiation space, we have ongoing trials looking at novel therapeutics. In addition, we have an adaptive radiation therapy trial that I'm honored to be PI on the ARTIA Cervical Trial. And this is a multi-institutional trial in the United States and hopefully opening it up to across the globe, looking at women with 1B3 and above cervical cancers, treating them with adaptive radiation. And that is that during radiation therapy, the cervical cancer can shrink and decrease in size, and therefore adaptive radiation takes motion management as well as decreasing the tumor size into account by doing a daily adaptive radiation plan while the patient is on the radiation table. This we're hoping will decrease further gastrointestinal toxicities, decreasing genitourinary toxicities, and we're also collecting patient reported outcomes.

Source:

Mayadev J. “Chemoradiation for stage IB3 cervical cancer” Presented at: SGO Annual Meeting on Women's Cancer; March 25-28, 2023; Tampa, FL

Landoni F, Maneo A, Colombo A, et al. Randomised study of radical surgery versus radiotherapy for stage IB–IIA cervical cancer. Lancet Oncol 1997;350:535–540. doi:10.1016/S0140-6736(97)02250-2

Chopra S, Gupta S, Kannan S, et al: Late toxicity after adjuvant conventional radiation versus image-guided intensity-modulated radiotherapy for cervical cancer (PARCER): A randomized controlled trial. J Clin Oncol. 2021;39:3682-3692. doi:10.1200/JCO/20.02530