Postoperative Adjuvant Therapy for Cervical Cancer

Treatment for most patients with early-stage cervical cancer involves radical hysterectomy and pelvic lymph node dissection. Indications for postoperative adjuvant therapy are determined by evaluating prognostic risk factors for recurrence in each individual case. Several clinicopathological factors, such as tumor size, lymphovascular space involvement, deep stromal invasion, parametrial involvement, and lymph node metastasis, have been identified as having prognostic significance in early-stage cervical cancer. However, these indicators remain controversial because there is substantial heterogeneity among patients after radical hysterectomy and lymphadenectomy and it is difficult to define clear risk groups. There is thus an unmet need to develop more accurate criteria to define risk groups and treat accordingly. According to the currently available evidence, there remains the question of whether CCRT-P delivers a survival benefit superior to radiotherapy (RT) alone for patients with high-risk factors after radical surgery. In addition to this issue, patients with high-risk factors have a high incidence of distant metastasis, for whom systemic chemotherapy might be the key to improving overall survival. Results from the pivotal study GOG092, that investigated the role of RT alone for patients with intermediate-risk factors after hysterectomy, also failed to resolve this issue. That trial did not show that postoperative RT significantly improved overall survival relative to no further treatment, even though a reduction in the risk of recurrence after RT was documented. However, the study did indicate that patients allocated to the RT group experienced an increase in severe toxicities compared with the NFT group. This could be why many physicians are reluctant to treat patients using this approach, although the guidelines recommend RT for patients with intermediate-risk factors. Further improvement in adjuvant therapy will depend on more robust definition of prognostic risk factors, better patient selection, and refinements in both local and systemic therapies.