Chemotherapy in cervical cancer: is cisplatin alone still the standard of care?

Editorial Chemotherapy in cervical cancer: Is cisplatin alone still the standard of care? Recent reports of trials of combined chemo-radiation in patients with localized cervical cancer have led to a change in the standard of care. Many clinicians have taken the pragmatic approach that chemo-radiation with weekly cisplatin 40 mg/m 2 during pelvic radiation should be preferred over radiation alone in all circumstances where previously radiation alone was the standard approach. It remains to be seen whether the wide adoption of this policy in environments where locally advanced cervical cancer is prevalent will translate into improved survival rates. Cisplatin was first reported to cause tumour response in cervical cancer patients in the early 1980s. Soon after several groups reported tumour response rates in the range of 40%-70% using different cisplatin-containing chemotherapy regimens, and some patients had prolonged disease control. These encouraging reports prompted trials of neoadjuvant chemotherapy using a variety of cisplatin containing regimens. Tumour response following chemotherapy was reported in ~ 50%, and subsequent surgery or radiotherapy or both was not complicated by deferring local therapy for six to nine weeks. However the expected improved outcomes after radiation were not confirmed in several randomized trials, although surgery after neoadjuvant chemother-apy seemed to have a better outcome than treatment by radiation alone. Nevertheless the climate of opinion concerning the treatment of locally advanced cervical cancer has drifted away from neoadjuvant chemotherapy, and combined chemo-radiation is widely preferred. The UK Medical Research Council is undertaking a meta-analysis of neoadjuvant chemotherapy trials in cervical cancer patients, and the results will guide the standard of care. Should cisplatin alone be the standard chemotherapy in cervical cancer management both in chemo-radiation, in neoadjuvant settings and in metastatic disease? If so, what cisplatin regimen/schedule is most active? Few clinical trials have investigated this last question directly. Nevertheless the similar results of different cisplatin-containing chemo-radiation protocols compared to radiation alone have persuaded most clinicians to adopt the simplest schedule, i.e., cisplatin 40 mg/m" weekly during radiation. However, this regimen has not been widely used in the metastatic disease setting. The Gynecologic Oncology Group phase III trial of cisplatin alone versus cisplatin + dibromodulcitol, versus cisplatin + ifosfamide reported a significantly higher tumour response rate with cisplatin + ifosfamide compared to cisplatin alone (31% vs. 18%, P = 0.004) and regression-free survival (4.6 vs. 3.2 months, P = 0.003). In this issue of the Journal, Vermorken et …