Primary Treatment for Locally Advanced Cervical Cancer: Concurrent Platinum-based Chemotherapy and Radiation pptx

Practice Guideline Report 4-5 IN REVIEW Primary Treatment for Locally Advanced Cervical Cancer: Concurrent Platinum-based Chemotherapy and Radiation H.. Primary Treatment for Locally A

Practice Guideline Report 4-5 IN REVIEW

Primary Treatment for Locally Advanced Cervical Cancer:

Concurrent Platinum-based Chemotherapy and Radiation

H Lukka, H Hirte, A Fyles, G Thomas, M Fung Kee Fung, M Johnston,

and members of the Gynecology Cancer Disease Site Group

Report Date: June 2004

An assessment conducted in September 2011 placed Practice Guideline Report (PG) 4-5

IN REVIEW, which means that it is undergoing assessment for currency and relevance The Gynecologic Cancer Disease Site Group has determined that it is still appropriate for this document to continue to be available while this updating process unfolds

This PG consists of a Summary and a Full Report and is available on the CCO website ( http://www.cancercare.on.ca )

PEBC Gynecologic Cancer Disease Site Group page at:

https://www.cancercare.on.ca/toolbox/qualityguidelines/diseasesite/gynecologic_cancer/

For information about the PEBC and the most current version of all reports,

please visit the CCO website at http://www.cancercare.on.ca/

or contact the PEBC office at:

Phone: 905-527-4322 ext 42822 Fax: 905-526-6775 E-mail: ccopgi@mcmaster.ca

Guideline Citation (Vancouver Style): Lukka H, Hirte H, Fyles A, Thomas G, Fung Kee Fung M,

Johnston M, et al Primary treatment for locally advanced cervical cancer: concurrent platinum-based chemotherapy and radiation Toronto (ON): Cancer Care Ontario; 2004 Jun [In review 2011] Program in Evidence-based Care Practice Guideline Report No.:4-5 IN REVIEW

Primary Treatment for Locally Advanced Cervical Cancer: Concurrent Platinum-based Chemotherapy and Radiation

Practice Guideline Report #4-5

H Lukka, H Hirte, A Fyles, G Thomas, M Fung Kee Fung, M Johnston, and members of the

Gynecology Cancer Disease Site Group

ORIGINAL GUIDELINE: August 26, 2002

MOST RECENT LITERATURE SEARCH: June 2004

NEW EVIDENCE ADDED TO GUIDELINE REPORT: June 2004

New evidence found by update searches since completion of the original guideline is consistent with the original recommendations

SUMMARY

Guideline Question

For women with cervical cancer in whom radiotherapy is considered appropriate, does the addition of concurrent platinum-based chemotherapy improve survival and quality of life with acceptable toxicity?

Target Population

These recommendations apply to women with cervical cancer for whom primary treatment with radiotherapy is being considered:

- those with locally advanced cervical cancer,

- those with bulky clinical stage IB (>4 cm) cervical cancer, who are treated with radiotherapy,

- those with high-risk early-stage cervical cancer (node-positive or margin-positive), who will be treated with radiotherapy following hysterectomy

Qualifying Statements

Despite this recommendation, other schedules and doses have been used; thus, there is

Methods

Entries to MEDLINE (1966 through June 2004), EMBASE (1980 through week 25, 2004), CANCERLIT (1975 through October 2002), and Cochrane Library (2004, Issue 2) databases and abstracts published in the proceedings of the annual meetings of the American Society of Clinical Oncology from 1999 to 2004 were systematically searched for evidence relevant to this practice guideline report

Evidence was selected and reviewed by members of the Practice Guidelines Initiative’s Gynecology Cancer Disease Site Group and methodologists This practice guideline report has been reviewed and approved by the Gynecology Cancer Disease Site Group, comprised of medical oncologists, radiation oncologists, a pathologist, an oncology nurse and patient representatives

External review by Ontario practitioners is obtained for all practice guideline reports through

a mailed survey Final approval of the practice guideline report is obtained from the Practice Guidelines Coordinating Committee

The Practice Guidelines Initiative has a formal standardized process to ensure the currency

of each guideline report This process consists of the periodic review and evaluation of the scientific literature and, where appropriate, integration of this literature with the original guideline information

Key Evidence

Eight randomized controlled trials were eligible for the evidence review: six compared cisplatin-based chemotherapy plus radiotherapy to radiotherapy alone (in one of those trials, para-aortic radiotherapy was added to pelvic radiotherapy in the control arm) and two compared cisplatin-based chemotherapy plus radiotherapy to radiotherapy plus hydroxyurea

The guideline authors pooled survival data from published reports Pooled survival rates detected a statistically significant effect in favour of cisplatin-based chemotherapy plus radiotherapy compared with radiotherapy alone or with hydroxyurea (relative risk of death, 0.74; 95% confidence interval, 0.64 to 0.86)

The pooled relative risk of death among the six trials that enrolled only women with locally advanced cervical cancer was 0.78 (95% confidence interval, 0.67 to 0.90) in favour of cisplatin-based chemotherapy and radiotherapy

The pooled relative risk for the two trials in high-risk early-stage disease also demonstrated

a significant benefit for the addition of cisplatin-based chemotherapy to radiotherapy (relative risk, 0.56; 95% confidence interval, 0.41 to 0.77)

Rates of serious hematologic, gastrointestinal and genitourinary acute adverse effects are higher with cisplatin-based chemotherapy plus radiotherapy than with radiotherapy alone

For further information about this practice guideline, please contact: Dr Michael Fung Kee Fung, Chair, Gynecology Disease Site Group; Ottawa General Hospital, 501 Smyth Road,

Ottawa, Ontario; Telephone: 613-737-8560, FAX: 613-737-8828

The Practice Guidelines Initiative is sponsored by:

Cancer Care Ontario & the Ontario Ministry of Health and Long-term Care

Visit http://www.cancercare.on.ca/.htm for all additional Practice Guidelines Initiative reports

PREAMBLE: About Our Practice Guideline Reports

The Practice Guidelines Initiative (PGI) is a project supported by Cancer Care Ontario (CCO) and the Ontario Ministry of Health and Long-Term Care, as part of the Program in Evidence-based Care The purpose of the Program is to improve outcomes for cancer patients,

to assist practitioners to apply the best available research evidence to clinical decisions, and to promote responsible use of health care resources The core activity of the Program is the development of practice guidelines by multidisciplinary Disease Site Groups of the PGI using the methodology of the Practice Guidelines Development Cycle.1 The resulting practice guideline reports are convenient and up-to-date sources of the best available evidence on clinical topics, developed through systematic reviews, evidence synthesis, and input from a broad community of practitioners They are intended to promote evidence-based practice

This practice guideline report has been formally approved by the Practice Guidelines Coordinating Committee, whose membership includes oncologists, other health providers, patient representatives, and CCO executives Formal approval of a practice guideline by the Coordinating Committee does not necessarily mean that the practice guideline has been adopted as a practice policy of CCO The decision to adopt a practice guideline as a practice policy rests with each regional cancer network that is expected to consult with relevant stakeholders, including CCO

Reference:

1 Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, et al The practice guidelines development cycle: a conceptual tool for practice guidelines development

and implementation J Clin Oncol 1995;13(2):502-12

For information about the PEBC and the most current version of all reports,

please visit the CCO website at http://www.cancercare.on.ca/

or contact the PEBC office at:

Phone: 905-527-4322 ext 42822 Fax: 905-526-6775 E-mail: ccopgi@mcmaster.ca

Copyright

This guideline is copyrighted by Cancer Care Ontario; the guideline and the illustrations herein may not be reproduced without the express written permission of Cancer Care Ontario Cancer Care Ontario reserves the right at any time, and at its sole discretion, to change or revoke this authorization

Disclaimer

Care has been taken in the preparation of the information contained in this document Nonetheless, any person seeking to apply or consult the practice guideline is expected to use independent medical judgment in the context of individual clinical circumstances or seek out the supervision of a qualified clinician Cancer Care Ontario makes no representation or warranties

of any kind whatsoever regarding their content or use or application and disclaims any responsibility for their application or use in any way

FULL REPORT

I QUESTION

For women with cervical cancer in whom radiotherapy is considered appropriate does the addition of concurrent platinum-based chemotherapy improve survival and quality of life with acceptable toxicity?

II CHOICE OF TOPIC AND RATIONALE

Cancer of the cervix is the second most common gynecological malignancy worldwide Between 1992 and 1996, 2,897 women in Ontario were diagnosed with cervical cancer and 821 women died of this disease (1) The use of cervical screening has greatly reduced the incidence

of invasive cervical cancer in Western countries, but it continues to pose a significant health

problem in the rest of the world (2)

Women with early cervical cancer can be treated successfully with either radical surgery or radical radiotherapy Patients with large cervical tumours, extension to pelvic tissues or pelvic lymph-node involvement are sometimes treated with a combination of external beam radiotherapy and intracavitary treatment

In an attempt to enhance the effectiveness of treatment with radiotherapy (RT), investigators have explored the use of concurrent chemotherapy and radiotherapy The aim of such approaches has been to improve the therapeutic index by sensitizing tumour cells to radiation and to eradicate micrometastases while limiting damage to normal tissue

Results from five randomized controlled trials of radiotherapy plus cisplatin-based chemotherapy were published in 1999 (3-7) This new evidence prompted many clinicians in Ontario to offer concurrent cisplatin-based chemotherapy plus radiotherapy to women who require radiotherapy for the treatment of locally advanced cervical cancer Results of a trial by the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) were presented at the

2000 meeting of the American Society of Clinical Oncology (ASCO) (8) Of the recently reported trials, all but the NCIC CTG trial showed a significant benefit when cisplatin-containing chemotherapy was added to radiation therapy Because of this discrepancy, the provincial Gynecology Disease Site Group (DSG) felt that it would be timely to conduct a comprehensive literature review and meta-analysis to assess the role of concurrent platinum with radiotherapy for the treatment of cervical cancer

III METHODS

Guideline Development

This practice guideline report was developed by the Practice Guidelines Initiative (PGI) of Cancer Care Ontario’s Program in Evidence-based Care (PEBC), using the methods of the Practice Guidelines Development Cycle (9) Evidence was selected and reviewed by members

of the Gynecology Cancer Disease Site Group (Gynecology DSG) and methodologists Members of the Gynecology DSG disclosed potential conflict of interest information

The practice guideline report is a convenient and up-to-date source of the best available evidence on concurrent platinum-based chemotherapy plus radiotherapy as a primary treatment for cervical cancer developed through systematic reviews, evidence synthesis and input from practitioners in Ontario The body of evidence in this report is primarily comprised of mature randomized controlled trial data; therefore, recommendations by the DSG are offered The report is intended to promote evidence-based practice The PGI is editorially independent of Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care

External review by Ontario practitioners is obtained through a mailed survey consisting of items that address the quality of the draft practice guideline report and recommendations, and whether the recommendations should serve as a practice guideline Final approval of the

original guideline report is obtained from the Practice Guidelines Coordinating Committee (PGCC)

The PGI has a formal standardized process to ensure the currency of each guideline report This consists of periodic review and evaluation of the scientific literature and, where appropriate, integration of this literature with the original guideline information

Literature Search Strategy

The MEDLINE database was searched from 1966 to March 2002 using the strategy described in Appendix 1 The same search strategy was used to find additional citations in the CANCERLIT (1975 to October 2001) and HealthStar (1975 to January 2002) databases The Cochrane Library (Issue 1, 2002) was also searched for randomized trials and systematic reviews The reference lists of papers and review articles identified by these sources were scanned as a source of additional citations All searches were restricted to English-language publications The proceedings of the 1999, 2000 and 2001 ASCO meetings were scanned for abstracts reporting recent clinical trial results The Canadian Medical Association (CMA) Infobase (http://www.cma.ca/cpgs/index.asp), the National Guidelines Clearinghouse (http://www.guideline.gov/index.asp) and other Web sites were searched for existing evidence-based practice guidelines

Update

The original literature search has been updated using MEDLINE (through June 2004), EMBASE (through week 25 2004), CANCERLIT (through October 2002), the Cochrane Library (Issue 2, 2004), and the 2002-2004 proceedings of the annual meeting of the American Society

2 Included patients with cervical cancer (please see Appendix 2 for staging information);

3 Reported data on survival for each intervention group

Clinical trial results reported in either full papers or abstracts were eligible Clinical practice guidelines from other guideline-development groups were also eligible for inclusion

Synthesizing the Evidence

Two of the authors independently reviewed the eligible papers and extracted data regarding the number of patients randomized, disease stage, type of systemic therapy, radiation dose and

To estimate the overall effect on survival of the addition of chemotherapy, mortality data (the number of patients who had died by the end of the study and the number of patients included in the survival analysis by the investigators) were abstracted from the published reports of individual RCTs and pooled using the Review Manager software (RevMan 4.1)provided by the Cochrane Collaboration (Metaview © Update Software) Combining data in this manner assumes a constant hazard ratio of risks for the groups being compared Results are expressed

as relative risks (also know as risk ratios) with 95% confidence intervals (CI), where a relative risk (RR) for mortality less than one indicates that the experimental treatment (platinum-based chemotherapy plus radiotherapy) improved survival compared with the control treatment Conversely, a relative risk greater than one suggests that patients in the control group experienced lower mortality The relative risk is calculated by taking the ratio of the proportion of patients who have died in the experimental treatment group to the proportion of patients who have died in the control group The random-effects model was used for pooling across studies

in preference to the fixed-effects model, as the more conservative estimate of effect (10) Six sets of studies were identified for subgroup analyses: 1) those that enrolled women with locally advanced disease 2) those that enrolled women with high-risk early-stage (stages IB and IIA) disease, 3) those that administered radiotherapy alone in the control group, 4) those where hydroxyurea was added to radiotherapy in the control group, 5) those where cisplatin was given

as a single agent with radiotherapy and 6) those where cisplatin plus 5-fluorouracil was used with radiotherapy

IV RESULTS

Literature Search Results

No existing evidence-based clinical practice guidelines were found

The National Health Service Centre for Reviews and Dissemination at the University of York has completed a review of the evidence on the management of gynecologic cancers that includes a brief summary of evidence from randomized controlled trials of platinum-based chemotherapy plus radiotherapy versus radiotherapy alone (11) The York review includes five

of the nine reports discussed below and was completed before results of the NCIC CTG trial became available Survival data were described in the review but were not pooled When the Gynecology DSG started developing this practice guideline, a Cochrane review on concomitant chemotherapy and radiotherapy for cancer of the cervix, based on published data, was underway Published in September 2001 (12), it is discussed below

Nine reports of randomized trials of concurrent cisplatin-based chemoradiotherapy met the eligibility criteria (3-8,13-15) Results of two of these trials were reported in abstract form (8,13), while the others were reported in journal articles According to an abstract prepared for the 1991 meeting of the American Society of Clinical Oncology, only 18 of 47 patients allocated to chemoradiotherapy were evaluable in the study by Mickiewicz et al (13) Because the results reported in this abstract are likely to be biased, they have not been included in this review of the evidence

Update

Since the completion of the guideline, the RCT by Pearcey et al that was originally presented in abstract form (8) has now been published in full (1u) Another article reporting long term follow-up results from a previously reported trial (Morris, 1999 RTOG 90-01 (3)) has also been published (2u) Finally, one new RCT comparing cisplatin and radiation therapy to radiation therapy alone has been published (3u)

Outcomes

In September 2001, Green et al published a systematic review and meta-analysis based on the methods used by the Cochrane Collaboration (12) Randomized trials were eligible for inclusion if they compared concomitant cytotoxic chemotherapy plus radiotherapy (with or without surgery) to radiotherapy (with or without surgery) Trials that also included hydroxyurea

in the control group were eligible because the authors of the systematic review judged it to be

an inactive agent Seven trials of non-cisplatin-containing chemotherapy, that were not eligible for this practice guideline report, were included Ten randomized trials of cisplatin-containing chemotherapy were eligible for the review by Green et al: the eight studies eligible for this practice guideline report plus two unpublished studies

For the published trials, Green et al based their meta-analysis on data available from published reports For overall or progression-free survival, hazard ratios and associated variances were abstracted from reports or were estimated based on other information available

in the reports, such as survival curves Numbers of recurrences and adverse events were also abstracted Fixed-effect models were used for all meta-analyses Green et al conducted subgroup analyses to explore potential sources of variance One of these restricted the meta-analysis to trials of cisplatin-based chemotherapy plus radiotherapy versus control, the group of studies of interest for this practice guideline

The conclusions of the published meta-analysis (12) were consistent with those already reached by the PGI guideline authors, who had completed their review and meta-analysis by September 2001 Green et al were able to obtain hazard ratios for survival for eight trials: seven

of those described below under 'Evidence from Randomized Trials' (3-8,15) and one unpublished trial by Leborgne Green et al detected a significant improvement in survival when cisplatin-based chemotherapy was added to radiotherapy, demonstrated by a pooled hazard ratio for death of 0.70 (95% CI, 0.61 to 0.80; p<0.0001) They also calculated the overall hazard ratio for progression-free survival and odds ratio for distant recurrence, using data from all eight published trials (3-8,14,15) plus the unpublished study The pooled hazard ratio for death or progression was 0.63 (95% CI, 0.56 to 0.72; p=0.003) and the pooled odds ratio for distant recurrence was 0.60 (95% CI, 0.46 to 0.77; p<0.0001), both in favour of cisplatin-based chemotherapy They also pooled toxicity data across all trials, including two that used non-platinum-based chemotherapy in the experimental arm, and detected statistically significantly higher rates of hematologic and gastrointestinal adverse effects when concomitant chemotherapy was added to radiotherapy

Evidence from Randomized Trials

Eight randomized trials included in this systematic review are listed in Table 1 None were double-blind Six trial reports gave descriptions of sample size calculations (3-7,15) Only one trial included all randomized patients in the survival analysis (15) All eligible patients were counted in the denominator for the survival analysis, except for the trials by Morris et al and Whitney et al (3,5) where small numbers of patients were lost to follow-up (Table 1) None of the trial reports described the method used to conceal allocation up to the time of randomization All

of the full reports of RCTs included detailed descriptions of eligibility criteria and three described the number of patients lost to follow-up (3,14,15)

Table 1 Randomized trials of cisplatin-based chemotherapy plus radiotherapy versus radiotherapy

Wong, 1989 (14) IIB-IIIB XRT + weekly CP† XRT 64 range:

42 to 72§ Tseng, 1997 (15) IIB-IIIB XRT + CP/bleo/VCR XRT 122 47 Morris, 1999 (3)

Hysterectomy + pelvic lymphadenectomy + XRT

bleo= bleomycin; CP= cisplatin; FIGO= International Federation of Obstetrics and Gynecology; GOG= Gynecologic Oncology Group; HU= hydoxyurea; NCIC CTG= National Cancer Institute of Canada Clinical Trials Group; RTOG= Radiation Therapy Oncology Group; SWOG= Southwest Oncology Group; VCR = vincristine; XRT = radiotherapy; 5FU = 5-fluorouracil;

* Pelvic + para-aortic radiotherapy; all other XRT regimens consisted of pelvic radiotherapy

† Study included a second treatment arm of XRT + cisplatin twice weekly

‡ Study included a second treatment arm of XRT + cisplatin/fluorouracil/hydroxyurea

§ Value for all 3 treatment groups

Some authors (2,16) have commented on the relatively low doses of radiation used in the study by Keys et al (6) and the low total dose of radiotherapy and protracted treatment time in the study by Rose et al (4). A beneficial effect of using concurrent cisplatin-based chemotherapy with standard doses of radiotherapy was also observed in the RTOG study (3) Even though the use of cisplatin with radiotherapy appeared to be beneficial, doubt remains about the potential magnitude of benefit associated with concurrent cisplatin when an optimum radiotherapy regimen is given

Details about participants and treatments are given in Tables 2 and 3 Women with bulky stage IB disease were included in two of the trials in locally advanced cervical cancer (3,8) Chemotherapy was administered in the control arm for two of the trials (4,5); the others used radiotherapy alone as the control treatment The interventions used in the control arms of the six

published studies in locally advanced cervical cancer were usually based on previous studies conducted by the individual co-operative clinical trial groups Based on the published results of the RTOG-79-20 trial (17), the Radiation Therapy Oncology Group (RTOG) added para-aortic lymph-node irradiation to pelvic irradiation in the control group of the RTOG 90-01 (3) For this study, patients were required to have negative para-aortic lymph nodes on lymphadenectomy following para-aortic lymph-node dissection The Gynecologic Oncology Group (GOG) has traditionally used hydroxyurea in combination with radiotherapy as the standard treatment, because of the results from their placebo-controlled randomized trial of the addition of hydroxyurea to pelvic irradiation (GOG-4) (18) Patients treated with hydroxyurea had a significantly better response than those treated with the placebo The GOG-4 trial has been

criticized because data from only 51% of the patients randomized were included in the survival

analysis (18)

Two studies had a control arm and two active treatment arms (4,14) In both cases, survival results from the two active treatments were very similar The active treatment that was most consistent with the treatments used in the other eligible trials (i.e., weekly cisplatin as a single agent) was chosen for inclusion in the meta-analysis of survival data Details of the second treatment arm in both trials are described below

The trial by Wong et al was a three arm study Patients in two arms of the study received cisplatin and radiotherapy The third arm was a control arm in which patients received radiotherapy only The first treatment group received weekly administration of cisplatin and the other treatment group was given twice-weekly administration (14) A dose of 25 mg/m2 was used in both treatment groups The study by Wong et al is described as a randomized trial; whether all patients were randomized is unclear from the published reports Survival curves were not published, but at the last follow-up 11 of 22 patients in the weekly cisplatin group and

11 of 17 in the twice-weekly group were alive (14) Only data from the radiotherapy and the radiotherapy-alone groups were included in the meta-analysis of survival data described below

weekly-cisplatin-plus-The trial by Rose et al also included three treatment groups (4) Patients were randomized

to weekly cisplatin (40 mg/m2) plus radiotherapy, cisplatin/fluorouracil/hydroxyurea (50 mg/m2cisplatin on days 1 and 29, 4 g/m2 fluorouracil as a 96-hour infusion, 2 g/m2 hydroxyurea orally twice weekly) plus radiotherapy, or radiotherapy plus hydroxyurea Survival curves for the two cisplatin groups were almost identical and were both significantly different from the survival experience among the radiotherapy plus hydroxyurea group The relative risk of death, adjusted for clinical stage of disease, was 0.61 (95% CI, 0.44 to 0.85) for weekly cisplatin plus radiotherapy and 0.58 (95% CI, 0.41 to 0.81) for cisplatin/fluorouracil/hydroxyurea plus radiotherapy, compared with radiotherapy plus hydroxyurea Data from the weekly cisplatin-plus-radiotherapy active treatment group and the radiotherapy-plus-hydroxyurea control group have been included in the meta-analysis

Two studies were restricted to patients with high-risk early-stage disease (6,7) In the study reported by Keys et al (GOG-123), patients underwent hysterectomy three to six weeks after completing radiotherapy (6) Only women without evidence of para-aortic lymph-node involvement were eligible Women participating in the Southwest Oncology Group (SWOG) study were randomized to chemoradiotherapy or radiotherapy after radical hysterectomy and pelvic lymphadenectomy (7) Patients with positive pelvic lymph nodes, positive margins or microscopic involvement of the parametrium were eligible

Table 2 Randomized trials of cisplatin-based chemotherapy plus radiotherapy versus radiotherapy: patient

characteristics.

Study # randomized/

#eligible/

# analyzed

Histology Method of Staging Stage of disease - number of patients (%)

Locally advanced cervical cancer, radiotherapy alone as a control

259/253/253 squamous cell (100%) clinical, FIGO stages IB, IIA, IIB > 5 cm, III or IVA; number of patients with each stage not reported

Locally advanced cervical cancer, radiotherapy plus hydroxyurea as a control

* no follow-up data for 2 patients; †no follow-up data for 6 patients; FIGO = International Federation of Obstetrics and Gynecology

Histology Method of Staging Stage of disease - number of patients (%)

Locally advanced cervical cancer, radiotherapy alone as a control

96/84/84 squamous cell (100%) clinical 53 (63%) 3 (4%) 28 (33%)

* no follow-up data for 2 patients; †no follow-up data for 6 patients

Table 3 Randomized trials of cisplatin-based chemotherapy plus radiotherapy (RT) versus radiotherapy: description of management

Study Chemotherapy (Cisplatin group) External radiation-whole pelvis Intracavitary radiation

Locally advanced cervical cancer, radiotherapy alone as a control

Wong, 1989

(14)

cisplatin

- 25 mg/m2 weekly

2.5 G/day 4X week to a total dose of 40 Gy stage II: 3500 mg/hour 1 week after

completion of external beam radiotherapy, followed by 2500-3000 mg/hour 7-10 days later

stage III: 4000 mg/hour in 1 application Tseng, 1997

(15)

cisplatin

- 50 mg/m2 on day 1 of 3-week cycle + vincristine (1 mg/m2) on day 2 + bleomycin (25 mg/m2) on days 2,3,4

2 Gy/day to a total dose of 44 Gy in 22 fractions over 30-35 days

25.8 Gy to point A in 6 courses (4.3 Gy each) starting 1-2 weeks after completing external beam radiotherapy

1.8 Gy/day to a total dose of 45 Gy* total cumulative dose at point A of at least

85 Gy, in 3 applications after completing external beam radiotherapy

1.8 Gy/day (5X week) to a total dose of 45 Gy total cumulative dose at point A of 24-35 Gy,

within 2 weeks after completing external beam radiotherapy

Locally advanced cervical cancer, radiotherapy plus hydroxyurea as a control

RT (low-dose) Whitney, 1999

(5)

(GOG-85)

cisplatin

- 50 mg/m2 on days 1 and 29 + fluorouracil (4 g/m2) as a 96-hour infusion

stage IIB:

total dose of 40.8 Gy in 24 fractions + parametrial

+ boost to bring total dose at point B to 55 Gy**

stage III or IVa:

total dose of 51 Gy in 30 fractions + boost to bring total dose at point B to 60 Gy**

30-40 Gy in 1 or 2 applications 1-3 weeks after completing external beam RT (low- dose)

Bulky stage IB cervical cancer

Update

Table 3a Randomized trials of cisplatin-based chemotherapy plus radiotherapy (RT) versus radiotherapy: description

of management

Study Chemotherapy (cisplatin group) External radiation-whole pelvis Intracavitary radiation

Locally advanced cervical cancer, radiotherapy alone as a control

1.8 Gy/day (5X week) to a total dose of 45 Gy total cumulative dose at point A of 24-35 Gy,

within 2 weeks after completing external beam radiotherapy

1.8 Gy/day to a total dose of 45 Gy* total cumulative dose at point A of at least

85 Gy, in 3 applications after completing external beam radiotherapy

2.0 Gy/day to a total dose of 50 Gy total cumulative dose at point A of 23-25 Gy,

1-2 weeks after completing external beam radiotherapy

* chemoradiotherapy group also received radiation to the para-aortic lymph nodes

Survival

Figure 1 shows the relative risk of death for the individual trials and overall The data is based, on the number of deaths by the end of the study At the time of the published reports, all trials had followed at least half of the patients enrolled for three years or more There was no significant heterogeneity detected among the study results (QHET=9.87) The meta-analysis involving a total of 2141 patients detected a statistically significant effect in favour of cisplatin-based chemotherapy plus radiotherapy compared with control (RR, 0.74; 95% CI, 0.64 to 0.86; p< 0.01) This translates into an absolute reduction in the risk of death of 11% (95% CI, 7% to 15%) with cisplatin-based chemotherapy

Figure 1 Pooled analysis of eight randomized trials of cisplatin-based chemotherapy plus RT versus RT: risk ratio (relative risk) for death

NB, the following data were used for this meta-analysis:

- 3-year mortality data for the Pearcey et al trial,

- data from the weekly cisplatin treatment arm of three-armed trials by Wong et al and Rose et al

RR = relative risk; CI = confidence interval; CT = chemotherapy; RT = radiotherapy; HU = hydroxyurea