Ghent University. Faculty of Medicine and Health Sciences
Abstract
Over the past decades cervical cancer has become significantly less common in those countries where screening has been introduced, nevertheless it is still the second most common cancer in developing countries. Worldwide it is responsible for about 266,000 deaths each year. The International Federation of Gynecology and Obstetrics (FIGO)-staging system is the principal instrument in the staging of cervical cancer. Although it is used for almost a century no data on the accuracy of this staging system are available. Therefore, in order to investigate its reliability and reproducibility, we performed a prospective study to evaluate the interobserver agreement of the examination under anesthesia on which FIGO staging mainly is based. In addition we evaluated possible confounding factors of FIGO staging. The interobserver agreement among experienced investigators is only moderate. This could indicate possible limitations for sharing and comparing results based on this staging system. Our data demonstrated a significant better agreement between experienced investigators compared to the agreement between an experienced and an inexperienced investigator. This implies that clinical gynecological examination is a skill that can be improved by training.
A close look to the disagreement patterns on FIGO stage showed that in case of discrepancy the inexperienced investigator tended to underestimate the disease stage (by rating the FIGO stage lower than the rating of the experienced examiner) and consequently recommended surgery in patients that were considered inoperable by the experienced examiner. This could result in a suboptimal treatment with an increased risk of morbidity and higher medical costs. Multivariate analysis could not demonstrate any patient or tumor related characteristics with a significant impact on the interobserver agreement of FIGO staging. In conclusion we could say that our data, demonstrating the importance of experience of the investigators in staging of cervical malignancies, are strong additional arguments for centralization of care in cervical cancer patients. Since the addition of chemotherapy to radiotherapy, the survival rates of locally advanced cervical cancer (LACC) have improved but are still disappointing. Therefore, the idea of surgery after chemoradiation in case of LACC or bulky disease was adopted. The rationale for this idea is to obtain a better local control that might translate into a better overall survival. One of the concerns regarding surgery following chemoradiotherapy is surgery-related morbidity. The implementation of advanced radiotherapy techniques with a higher radiation dose on the target volume and less damage to the organs at risk creates opportunities to safely perform radical hysterectomy and a tailored lymphadenectomy. Our data demonstrated complication rates of type II hysterectomy after intensity modulated arc therapy (IMAT) with concomitant chemotherapy to be acceptable and comparable to complication rates of radical surgery for low-stage cervical cancer.
In order to reduce the overall toxicity of the treatment in patients with LACC it would be opportune to be able to select patients with residual disease after the initial chemo radiation therapy that would benefit adjuvant treatment. Consequently this would mean that one would be able to avoid additional brachytherapy and/or surgery in patients without residual disease. This could minimalize the treatment toxicity without deteriorating the prognosis. We evaluated the value of cervical biopsy in predicting residual disease after initial chemo radiation therapy. Only in half of the patients with residual disease (sensitivity of 50%) cervical biopsies could prove malignancy. This indicates it is not reliable for evaluating treatment response. We therefore can not recommend routine application of this technique for selecting LACC patients for additional treatment
