Expert Point of View: Markus Joerger, MD, PhD, and Domenica Lorusso, MD, PhD


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Markus Joerger, MD, PhD

Markus Joerger, MD, PhD

PRESS CONFERENCE MODERATOR Markus Joerger, MD, PhD, of St. Gallen Cancer Center, Switzerland, indicated that prior to the current study, it was unclear whether chemotherapy followed by surgery would be superior to chemoradiotherapy. “I think we all agree that it has been confirmed as the standard of care at the moment,” he commented. 

Study discussant Domenica Lorusso, MD, PhD, of the Gynecology Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori in Milan, Italy, commented that the study offers the “first level 1 evidence comparing these strategies” and that the primary endpoint, disease-free survival, was not met with neoadjuvant chemotherapy followed by surgery. 

Domenica Lorusso, MD, PhD

Domenica Lorusso, MD, PhD

She emphasized that the burden of cervical cancer is greatest in the developing world—in sites that often lack the option for chemoradiotherapy. Therefore, the resource-stratified guidelines of the National Comprehensive Cancer Network® (NCCN®) have listed neoadjuvant chemotherapy plus radical hysterectomy as an acceptable option to the preferred approach of pelvic external-beam radiotherapy plus concurrent cisplatin-based chemotherapy plus brachytherapy. 

Cautious About the Findings 

ACCORDING TO DR. LORUSSO, the slow accrual rate and the early stopping of the current trial limit interpretation of its results, and there are other reasons to be cautious with the findings. 

It is possible, she said, that chemoradiotherapy “overperformed” in comparison with the surgical approach, which employed what could be seen as suboptimal neoadjuvant chemotherapy. A recent Japanese study found that in patients who were chemotherapy-naive, paclitaxel plus cisplatin increased disease-free survival odds by 57% over paclitaxel/cisplatin, which was given neoadjuvantly to patients in this trial.1 Other more effective neoadjuvant treatments also include the addition of bevacizumab (Avastin) or pembrolizumab (Keytruda), according to other recent studies. 

Dr. Lorusso further maintained that progression-free survival may not be a valid endpoint for the upfront treatment of locally advanced cervical cancer. “Postprogression survival in recurrent cervical cancer is not so long to justify the use of surrogate endpoints,” she said, “and it is also a time-dependent and investigator-dependent endpoint.” 

She concluded that concurrent chemoradiotherapy remains the standard of care, but she emphasized the need to wait for the European Organisation for Research and Treatment of Cancer trial results “before putting the tombstone” on neoadjuvant chemotherapy followed by surgery, which remains an important option for certain indications and in resource-restricted countries. 

DISCLOSURE: Drs. Joerger and Lorusso reported no conflicts of interest. 

REFERENCE 

1. Kitagawa R, Katsumata N, Shibata T, et al: Paclitaxel plus carboplatin versus paclitaxel plus cisplatin in metastatic or recurrent cervical cancer: The open-label randomized phase III trial JCOG0505. J Clin Oncol 33:2129-2135, 2015.


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Standard of Care Upheld for Locally Advanced Cervical Cancer


“Chemotherapy followed by surgery is not superior to radiotherapy and simultaneous chemotherapy in patients with locally advanced cervical cancer...and should not be routinely practiced.”
— Sudeep Gupta, MD, DM

THE FIRST FORMAL comparison of two acceptable approaches...


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