Adjuvant treatment after radical surgery for cervical cancer with intermediate risk factors: is it time for an update? Int J Gynecol Cancer.
Viveros-Carreño D 3/10/2022
Abstract
Cervical cancer is the fourth most common cancer in women worldwide. The preferred treatment for early stage cervical cancer is radical hysterectomy with pelvic lymph node assessment, and adjuvant therapy is suggested according to histopathological risk factors. A landmark study was published in 1999 that established 'intermediate risk' criteria for relapse, showing a benefit in recurrence free rate in patients that received pelvic radiotherapy. Furthermore, in the presence of parametrial, nodal, or vaginal margin involvement, another key study found that the addition of concurrent cisplatin based chemotherapy to radiation therapy improved progression free and overall survival for 'high risk' early cervical cancer. With the advancement in treatment modalities in surgery and radiotherapy, and the improved identification of prognostic histopathological factors, several authors have reconsidered the role of adjuvant therapy after radical hysterectomy in the presence of intermediate risk criteria. Here we review the literature on the evolution of adjuvant therapy for intermediate risk factors.
Conclusions
To date, recommendations for the management of early cervical cancer are that adjuvant radiotherapy should be considered in the presence of a combination of risk factors at final pathology, such as tumor size, lymphovascular space invasion, and depth of stromal invasion. However, the only evidence supporting adjuvant treatment in intermediate risk is the GOG92 study, with the potential limitations described given the evolution of cervical cancer diagnosis and management in recent decades. It is pertinent to establish new management alternatives, with adequately controlled clinical trials and standardization of imaging, histopathological factor evaluation, and radiotherapy techniques to assess the oncological benefit of different types of adjuvant treatment, including observation. The associated morbidity and quality of life should be considered as outcomes (Figure 1). Until new evidence is published, adjuvant therapy should continue to be individualized in the intermediate risk clinical setting.