Comparison of adjuvant therapy for node-positive clinical stage IB-IIB cervical cancer: Systemic chemotherapyversuspelvic irradiation
This was a nation-wide retrospective study in Japan examining women who underwent radical hysterectomy for clinical stage IB–IIB cervical cancer with pelvic and/or para-aortic lymph node metastasis between 2004 and 2008. Time to recurrence or death and patterns of disease recurrence were compared based upon the adjuvant treatment pattern: whole pelvic radiotherapy alone (n = 253), concurrent chemoradiotherapy (CCRT,n = 502) and chemotherapy alone (n = 319). Women who received chemotherapy alone had similar recurrence (5-year rates, 36.6%vs. 34.1%, adjusted-hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.70–1.28,P = 0.72) and cervical cancer mortality (24.7%vs. 21.8%, adjusted-HR 0.96, 95% CI 0.67–1.38,P = 0.83) rates compared to those who received CCRT on multivariate analysis. However, when recurrence patterns were stratified, chemotherapy treatment was independently associated with decreased risk of distant recurrence (5-year cumulative rates, 19.2%vs. 24.6%, adjusted-HR 0.47, 95% CI 0.31–0.71,P < 0.001) but increased risk of local recurrence (23.9%vs. 14.3%, adjusted-HR 2.03, 95% CI 1.34–3.08,P = 0.001) compared to CCRT. Non-squamous histology, parametrial involvement and high lymph node ratio were independent predictors for local recurrence, and presence of multiple risk factors was associated with high 5-year cumulative local recurrence rate in the chemotherapy group: no risk factor 3.9%, single factor 14.2–22.1%, and multiple risk factors 27.8–71.9% (P < 0.001). In conclusion, while exhibiting different recurrence patterns, systemic chemotherapy may be as effective a postoperative treatment as radiation-based therapy in node-positive high-risk stage IB–IIB cervical cancer. When tumor exhibits certain risk factors, chemotherapy alone is likely insufficient for local control and adding pelvic irradiation to systemic chemotherapy is recommended in this subgroup.