Focusing on locally advanced cervical cancer, experts elucidate the role of surgery and standard of care therapy.
Bradley Monk, MD, FACOG, FACS: It’s been an exciting journey understanding the biology, and trying to advocate for HPV [human papillomavirus] vaccinations in 2006—we’re not doing good enough, we need to do better—and now screening is all about testing for the virus on the cervix, but let’s evolve. There are still cervical cancers in this country, more than 10,000, and there are more than 4,000 deaths. Cervical cancer is among us and you are the leaders in treatment. Dr. Huh, you have a high-volume surgical practice in Alabama and when caught early, surgery can cure those patients. Where is the threshold for surgery in cervical cancer? And do you say, if it’s more than that I’m going to give chemotherapy and radiation?
Warner K. Huh, MD, FACOG, FACS:Yes. It’s a great question, Dr. Monk. In the last 15 years, at least at UAB [University of Alabama at Birmingham], we have modified our surgical approach for doing specifically a radical hysterectomy. The day in which we would do a bulky IB2 and the IIA is a relic of the past. We no longer do radical hysterectomy on those patients, we give them radiation therapy. The LACC [Laparoscopic Approach to Cervical Cancer] trial, demonstrated a worse survival in patients who were undergoing a minimally-invasive approach, and we’ve abandoned that because of that trial. It has greatly contracted the number of surgical candidates that can get a radical hysterectomy. It may be a IB1, IA disease. We’re giving a lot more RT [radiation therapy] than we ever have. To take it further, we no longer do exenterations.
Bradley Monk, MD, FACOG, FACS: Never.
Warner K. Huh, MD, FACOG, FACS:We’re doing maybe 1-2 exenterations a year. It’s a procedure you only read in a textbook now. My fellows have no idea how to do one.
Bradley Monk, MD, FACOG, FACS: An exenteration is after radiation and chemotherapy, removing the bladder, vagina, cervix, uterus, and all the genital organs and the rectum, and we no longer do pelvic exenterations because radiation and chemotherapy are better. It’s intended as a curative operation, and if there’s cancer in that central area, there’s metastatic disease. Dr. Pothuri, you work as a leadership position in the GOG [Gynecologic Oncology Group] Partners. There’s this study, the ROCC [Robotic Versus Open Hysterectomy Surgery in Cervix Cancer] trial, which is just starting. Tell us what the ROCC trial is.
Bhavana Pothuri, MD:This trial is looking at this question and trying to focus on populations where it may be acceptable to do a minimally invasive surgery. It’s a robotic radical hysterectomy versus open laparotomy. This is going to be a study within the United States. We’re going to standardize some of the processes that occur, especially in terms of tumor containment, which was a criticism of the LACC trial that was published.
Bradley Monk, MD, FACOG, FACS: Dr. Tewari, I was a fellow at your institution, and I remember doing radical hysterectomies like Dr. Huh said, pelvic exenterations. How do you train fellows these days when you’re not doing exenterations, and radical hysterectomies are becoming less common and less radical? Is there a challenge to training surgeons?
Krishnansu S. Tewari, MD:We still do a fair amount of exenterations. We probably do 4 a year amongst the 4 of us.
Bhavana Pothuri, MD:I did 6 exenterations my first month as a fellow.
Bradley Monk, MD, FACOG, FACS: Now they’re doing 1 a year.
Bhavana Pothuri, MD:We’re not doing that now.
Bradley Monk, MD, FACOG, FACS: Continue, Dr. Tewari.
Krishnansu S. Tewari, MD:It is challenging to train the fellows. The field has evolved and training fellows needs to focus on therapeutics because that’s how we cure patients these days.
Bradley Monk, MD, FACOG, FACS: Systemic therapy, yes. It’s challenging because half of our specialty doesn’t give systemic therapy, they’re still whetted to this surgical approach which is evolving. Particularly in ovarian cancer, where at least half of our advanced ovarian cancer patients start with chemotherapy and that big operation now becomes a smaller interval debulking operation.
Krishnansu S. Tewari, MD:Yes.
Bradley Monk, MD, FACOG, FACS: Dr. Thaker, surgery has a limited role, small tumors up to 4 centimeters, and then it’s chemotherapy and radiation. What is the standard for chemotherapy and radiation for this term which we call locally advanced cervical cancer, which is any cancer that’s too large for a radical operation? Tell us about the standard for locally advanced cervical cancer.
Premal H. Thaker, MD, MS:Cancer is getting smaller and smaller, so we’re giving radiation. It’s giving chemotherapy of cisplatin as a chemosensitizer, for a radiosensitizer, along with pelvic radiation. We must emphasize a brachytherapy component because there’s lots of places in the world, and even in the United States, patients don’t get their brachytherapy. They receive external beam radiation and chemotherapy, but aren’t introduced to centers that are specialized in brachytherapy. There’s overall survival disadvantage if you do not get your brachytherapy. It’s key that we emphasize that portion of the treatment plan, because whoever the oncologist is, we need to oversee that plan.
Bradley Monk, MD, FACOG, FACS: Yes. It’s critical. Now we look to see where the cancer is and give image-guided brachytherapy. You can place the implant where the cancer is, and the external beam has evolved. Dr. Huh, intensity-modulated radiation therapy, IMRT, that is the standard, correct?
Warner K. Huh, MD, FACOG, FACS:Yes. We have shifted to being IMRT-based at our institution. In Alabama, we’ve had radiation oncologists use IMRT to substitute the brachytherapy component, which is terrible. I think everyone would agree, that the brachytherapy is the backbone for curative therapy. We’re using a lot more IMRT. Time will tell what the recurrence pattern will look like, and if there’s one that’s different than traditional volume-based directed therapy. That’s the standard here.
Bradley Monk, MD, FACOG, FACS: Dr. Pothuri, remember when you’d have radiation bowel injuries? Small bowel obstructions. It doesn’t happen anymore, correct? Or does it still happen with IMRT and putting the radiation where the cancer is?
Bhavana Pothuri, MD:That’s exactly the point. We’re seeing fewer cases of radiation-induced bowel injury, and it’s because we’ve gotten smarter at delivering the radiation in a more targeted way and minimizing toxicity.
Transcript edited for clarity.