Oncologic outcomes of neoadjuvant chemotherapy followed by radical hysterectomy for locally advanced cervical cancer (311)

Abstract

Objectives: To investigate the utilization and oncologic outcomes of neoadjuvant chemotherapy followed by radical hysterectomy for patients with locally advanced cervical cancer. Methods: Patients diagnosed between 2004-2015 with FIGO 2009 stage IB2-II squamous cell, adenocarcinoma, or adenosquamous cervical carcinoma with at least one month of follow-up with no history of another tumor were selected from the National Cancer Database. Patients who received neoadjuvant chemotherapy (defined as receipt of chemotherapy without radiation up to six months prior to surgery) followed by radical hysterectomy and those who received definitive chemoradiation (defined as external beam radiation therapy of at least 45 Gy, with same day concurrent chemotherapy and without adjuvant hysterectomy) were identified. Clinical-pathologic and demographic characteristics were compared. Overall survival (OS) was estimated following the generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for a priori selected confounders. Results: A total of 182 patients who received NACT followed by radical hysterectomy and 3859 patients who had definitive chemoradiation were identified. For patients who had a radical hysterectomy, the rate of positive margins was 7%, median hospital stay was 3 days and rate of unplanned re-admission within 30 days from discharge was 5.1% while most of them (90.1%) received adjuvant radiation, with 85 (46.7%) of them receiving brachytherapy. Compared to patients who received chemoradiation, those who had NACT/radical hysterectomy were younger (median 47 vs 50 years, p=0.001), and more likely to have stage IB2 disease (40.1% vs 23.2%, p<0.001) and adenocarcinoma (30.8% vs 13.9%, p<0.001). There was no difference in OS between the NACT/radical hysterectomy and chemoradiation groups (p=0.91); 5-year OS rates were 70.2% and 68.5%. There was no difference in OS for patients with stage IB2 (p=0.73) or stage II disease (p=0.39). After controlling for patient age, race, presence of comorbid conditions, tumor histology, and stage, NACT/radical hysterectomy was not associated with better OS (HR: 1.05, 95% CI: 0.80, 1.38). Conclusions: Neoadjuvant chemotherapy followed by radical hysterectomy is rarely utilized in the United States. Overall survival appears to be comparable to primary chemoradiation. Given no survival advantage and potentially increased morbidity, primary chemoradiation should remain the preferred treatment modality in a high- resource setting. Objectives: To investigate the utilization and oncologic outcomes of neoadjuvant chemotherapy followed by radical hysterectomy for patients with locally advanced cervical cancer. Methods: Patients diagnosed between 2004-2015 with FIGO 2009 stage IB2-II squamous cell, adenocarcinoma, or adenosquamous cervical carcinoma with at least one month of follow-up with no history of another tumor were selected from the National Cancer Database. Patients who received neoadjuvant chemotherapy (defined as receipt of chemotherapy without radiation up to six months prior to surgery) followed by radical hysterectomy and those who received definitive chemoradiation (defined as external beam radiation therapy of at least 45 Gy, with same day concurrent chemotherapy and without adjuvant hysterectomy) were identified. Clinical-pathologic and demographic characteristics were compared. Overall survival (OS) was estimated following the generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for a priori selected confounders. Results: A total of 182 patients who received NACT followed by radical hysterectomy and 3859 patients who had definitive chemoradiation were identified. For patients who had a radical hysterectomy, the rate of positive margins was 7%, median hospital stay was 3 days and rate of unplanned re-admission within 30 days from discharge was 5.1% while most of them (90.1%) received adjuvant radiation, with 85 (46.7%) of them receiving brachytherapy. Compared to patients who received chemoradiation, those who had NACT/radical hysterectomy were younger (median 47 vs 50 years, p=0.001), and more likely to have stage IB2 disease (40.1% vs 23.2%, p<0.001) and adenocarcinoma (30.8% vs 13.9%, p<0.001). There was no difference in OS between the NACT/radical hysterectomy and chemoradiation groups (p=0.91); 5-year OS rates were 70.2% and 68.5%. There was no difference in OS for patients with stage IB2 (p=0.73) or stage II disease (p=0.39). After controlling for patient age, race, presence of comorbid conditions, tumor histology, and stage, NACT/radical hysterectomy was not associated with better OS (HR: 1.05, 95% CI: 0.80, 1.38). Conclusions: Neoadjuvant chemotherapy followed by radical hysterectomy is rarely utilized in the United States. Overall survival appears to be comparable to primary chemoradiation. Given no survival advantage and potentially increased morbidity, primary chemoradiation should remain the preferred treatment modality in a high- resource setting.