Concurrent Chemoradiotherapy for Stage IIIB Cervical Cancer

Of the 500 000 new cervical cancer cases annually, most (85%) locally advanced cervical cancer (LACC) occurs in low- and middle-income countries (LMICs), where sufficient resources are not always readily available for treatment. For almost 2 decades, the optimal management for all LACC in the United States has included concurrent chemoradiotherapy (CRT). A National Cancer Institute alert was released in 1999, after the publication of multiple randomized clinical trials demonstrated improved survival rates with concurrent CRT compared with radiotherapy (RT) alone. In particular, the Radiation Therapy Oncology Group (RTOG) 90-01 trial showed a 5-year absolute survival benefit of 21% for all stages of cervical cancer with CRT. However, an unplanned and inadequately powered subgroup analysis of patients with stage III to IVA disease showed an overall survival (OS) advantage of 14% (P = .06), disease-free survival (DFS) benefit of 17% (P = .05), and locoregional control benefit of 15% (P = .065). A 2010 meta-analysis demonstrated a 5-year absolute OS benefit of 6% for all stages of cervical cancer treated with concurrent CRT compared with RT alone; however, the survival benefit was only 3% for women with stage III to IVA cervical cancer. Nevertheless, due to the lack of statistical significance in the patient subgroup with stage IIIB to IVA disease in RTOG 90-01, combined with issues of cost and access, some LMICs chose not to standardize CRT for all patients with LACC.

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