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Optimal Therapy for Relapsed Carcinoma of the Cervix After Primary Chemoradiation

Beatson Oncology Centre, Glasgow, Scotland, United Kingdom

To the Editor:

We refer to the Gynecologic Oncology Group (GOG) phase III trial comparing single-agent cisplatin with the doublet cisplatin-paclitaxel in patients with stage IVB recurrent or persistent squamous cell carcinoma of the cervix, which was published in the August 1, 2004 issue of the Journal of Clinical Oncology.¹ Compared with single-agent therapy, the authors report a significant gain with combination chemotherapy in terms of response rate (RR; 19% v 36%, respectively; P = .002) and progression-free survival (2.8 v 4.8 months, respectively; P < .001), although both overall survival (8.8 v 9.7 months, respectively) and quality of life were not different.

The authors suggest that the combination of cisplatin and paclitaxel should be used as comparator for future palliative chemotherapy trials in this setting. The results reported in this trial are actually similar to those of a previous GOG three-arm trial comparing combination chemotherapy (ifosfamide or mitolactol) to single-agent cisplatin, with the difference perhaps being that the combination arm was less toxic in the current study compared with cisplatin-ifosfamide, which was the most active arm in that trial.² Interestingly, at that time, the results were considered insufficient evidence to consider combination chemotherapy as standard treatment for patients with metastatic or inoperable carcinoma of the cervix.

However, one of the most interesting findings in the current GOG study, which may have been insufficiently stressed in the discussion, was the poor activity recorded with single-agent cisplatin in patients who had received previous chemoradiotherapy (RR, 5%, n = 40 in the single-agent arm compared with 32%, n = 31 in the combination arm), even if cisplatin was not always the agent previously used as radiosensitizer (the actual figures are not mentioned in the article). These results suggest that single-agent cisplatin may have a limited role in this subgroup of patients, who may perhaps derive the highest benefit from combination chemotherapy. Although this trial was certainly not powered for this comparison, in the subgroup of patients without prior chemoradiotherapy, the difference of RR between the single-agent and combination study arms seemed to be less impressive (26% v 37%, respectively), although a better progression-free survival (3.0 v 4.9 months, respectively) was still reported with combination chemotherapy in this subgroup. We point out that, although by the time this trial was performed less than one third of the patients had actually received upfront chemoradiotherapy, in the year 2004, most patients seem to be doing so. Therefore, instead of relying on complicated retrospective analyses, future palliative chemotherapy trials may need to address these highly different populations separately.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Moore DH, Blessing JA, McQuellon RP, et al: Phase III study of cisplatin with or without paclitaxel in stage IVB, recurrent, or persistent squamous cell carcinoma of the cervix: A Gynecologic Oncology Group study. J Clin Oncol 22:3113-3119, 2004[Abstract/Free Full Text]

2. Omura GA, Blessing JA, Vaccarello L, et al: Randomized trial of cisplatin versus cisplatin plus mitolactol versus cisplatin plus ifosfamide in advanced squamous carcinoma of the cervix: A Gynecologic Oncology Group study. Clin Oncol 15:165-171, 1997

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• Phase III Study of Cisplatin With or Without Paclitaxel in Stage IVB, Recurrent, or Persistent Squamous Cell Carcinoma of the Cervix: A Gynecologic Oncology Group Study
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  David H. Moore
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