Cervical Cancer Flashcards
(137 cards)
1
Q
What does the Milan study show about WPRT+brachy vs surgery in early stage cervical cancer?
A
WPRT+brachy and surgery have similar overall survival (OS)
Surgery tends to have more morbidity, so radiation therapy (RT) becomes standard for many cases.
2
Q
What is the benefit of adding chemotherapy to RT for cervical cancer?
A
OS benefit in definitive treatment of cervical cancer
This is confirmed in meta-analysis.
3
Q
What did the Peters trial demonstrate regarding post-operative chemotherapy?
A
OS benefit with chemotherapy in post-op cervix with N+, +margin, or +parametria
4
Q
What was the finding of the Sedlis trials in post-operative cervical cancer?
A
PFS benefit with RT in post-op cervix with intermediate risk factors
5
Q
What does the EMBRACE trial refine in cervical cancer treatment?
A
Use of image-guided HDR brachytherapy
6
Q
What did the Tata Memorial and EORTC 55994 studies find regarding neoadjuvant chemotherapy?
A
Worse DFS with neoadjuvant chemotherapy prior to surgery vs definitive chemoRT
7
Q
What did the OUTBACK trial conclude about additional adjuvant chemotherapy?
A
No benefit to additional adjuvant chemotherapy after definitive chemoRT
8
Q
In the Landoni et al. study, what were the two treatment approaches compared?
A
Radical hysterectomy + LND + adjuvant RT vs. EBRT + LDR
9
Q
What were the 5-year OS and DFS rates in the Landoni study?
A
5-year OS 83%, DFS 74%
10
Q
What was the median time to relapse in the Landoni study?
A
13.5 months vs. 11.5 months (p=0.10)
11
Q
What were the late complications rates in the Landoni study?
A
20-year late complications 32% vs. 23%, worse with surgery
12
Q
What is the trend regarding OS benefit in cervical cancer treatment for tumors size ≥4 cm?
A
OS benefit trend with RT in size ≥4 cm
13
Q
What was the result of the EORTC 55994 study on neoadjuvant chemotherapy followed by surgery?
A
5-year OS not different, 72-76%
14
Q
What was the 5-year PFS in the EORTC 55994 study?
A
57% vs. 66%, p=0.010
15
Q
What conclusion was drawn regarding neoadjuvant chemotherapy followed by surgery?
A
Not superior to chemoradiation
16
Q
What were the findings of the Tata Memorial study on neoadjuvant chemotherapy?
A
No change in OS, worse DFS with neoadjuvant
17
Q
What were the delayed toxicity rates in the Tata Memorial study?
A
Rectal 2.2% vs. 3.5%, bladder 1.6% vs. 3.5%, vaginal 12.0% vs. 26%
18
Q
What was compared in GOG 71 study?
A
Definitive RT vs Neoadjuvant RT + surgery
19
Q
What were the 5-year LR rates in GOG 71 study?
A
27% vs. 14% for hysterectomy
20
Q
What was the conclusion regarding hysterectomy after definitive RT?
A
No overall benefit, but favored in larger tumors of size 4-6 cm
21
Q
What is the significance of tumor diameter, histology, age, and comorbidities in cervical cancer treatment?
A
Should be considered in treatment decisions
22
Q
What was the overall benefit of hysterectomy after definitive radiation therapy?
A
There was no overall benefit to hysterectomy after definitive RT.
23
Q
In which tumor size did hysterectomy seem to be favored according to unplanned subanalysis?
A
Hysterectomy seemed to be favored in larger tumors of size 4-6 cm.
24
Q
What caution did the authors of the trial emphasize regarding the subanalysis?
A
The authors acknowledged interpretation with caution.
25
What does the long-term follow-up of the Milan study (Landoni 2017) favor for larger tumors?
It favors definitive RT for larger tumors.
26
What was the comparison in the ENGOT-cx11/GOG-3047/KEYNOTE-A18 trial?
Definitive chemoRT vs. Definitive chemoRT + concurrent and adjuvant pembrolizumab.
27
What were the results of the 2-year OS in the trial comparing chemoRT with and without pembrolizumab?
2-yr OS 81% vs. 87%, not different.
28
What was the median PFS in both arms of the trial comparing chemoRT with and without pembrolizumab?
Median PFS not reached in either arm.
29
What does the addition of concurrent and adjuvant pembrolizumab improve in locally advanced cervical cancer?
It improves PFS.
30
What radiation planning report was recommended for brachytherapy?
ICRU/GEC ESTRO report 89.
31
What was the objective of the INTERLACE trial?
Induction chemo then chemoRT vs. chemo RT.
32
What was the 5-year OS comparison between neoadjuvant chemotherapy and definitive RT?
5-yr OS 72% vs. 80%.
33
What was the main finding regarding induction chemotherapy prior to definitive chemoradiation?
It improves OS and PFS.
34
What percentage of brachytherapy was prescribed to point A and HRCTV respectively?
70% prescribed to point A, and 30% to HRCTV.
35
What was the main conclusion regarding 5-FU and cisplatin in GOG 85/SWOG 8695?
5-FU and cisplatin added to definitive RT improves OS and PFS compared to hydroxyurea.
36
What did the GOG 120 trial establish regarding weekly cisplatin?
It established giving weekly cisplatin without 5FU or other chemo.
37
What was the comparison in the RTOG 9001 trial?
45 Gy EFRT + LDR to 85 Gy vs. WPRT + LDR to 85 Gy + cisplatin/5-FU.
38
What were the findings regarding late effects between EFRT and WPRT with chemotherapy in the RTOG 9001 trial?
Late effects unchanged.
39
What was the overall survival rate at 8 years for WPRT + LDR to 85 Gy + cisplatin/5-FU?
67%.
40
Fill in the blank: The addition of chemotherapy to definitive RT improves _______.
[overall survival, local recurrence, and distant metastasis].
41
True or False: The addition of chemotherapy to definitive RT improved PFS in the meta-analysis of 19 trials.
True.
42
What is the comparison made in RTOG 9001?
Definitive CRT: EFRT vs. WPRT/chemo
## Footnote
Eifel et al, JCO, 2004
43
What were the 8-year overall survival rates for EFRT and WPRT?
41% vs. 67%
## Footnote
EFRT had lower overall survival compared to WPRT.
44
What does the addition of chemotherapy to definitive RT improve?
OS, LR, and DM
## Footnote
OS: Overall Survival, LR: Local Recurrence, DM: Distant Metastasis.
45
What is the conclusion regarding EFRT in the EORTC trial?
EFRT does not improve LC, DFS, or DM
## Footnote
Haei et al, Radiother Oncol, 1988
46
What was the outcome of the RTOG 7920 trial comparing EFRT and WPRT?
Benefit in OS and DM with EFRT
## Footnote
Rotman et al, JAMA, 1995
47
What was the 10-year overall survival for EFRT compared to WPRT?
44% vs. 55%
## Footnote
EFRT showed improved survival over WPRT.
48
What did the meta-analysis by Sapienza et al. conclude about EFRT?
EFRT reduces PA failure and DM
## Footnote
CSM was unchanged.
49
What was the primary finding of the OUTBACK trial regarding adjuvant chemotherapy?
No benefit to adjuvant chemo
## Footnote
Mileshkin et al, Lancet Oncol, 2023
50
What was the 5-year overall survival rate in the OUTBACK trial?
72%, not different
## Footnote
No significant improvement with adjuvant chemotherapy.
51
What did the study by Duenas-Gonzalez et al. find regarding concurrent cis/gem?
Improved PFS with chemo, but increased toxicity
## Footnote
JCO, 2011
52
What were the 3-year PFS rates in the STARS trial for sequential vs. RT alone?
90% vs. 82%
## Footnote
Sequential chemotherapy showed superior outcomes.
53
What is the ongoing study RTOG 0724 focusing on?
DFS with additional carbo/paclitaxel vs. none
## Footnote
Protocol ongoing for high-risk early-stage cervical cancer.
54
What is the purpose of the nomogram developed in the GOG post-op analysis?
Determine the risk of recurrence after surgery in Stage I cervical cancer
## Footnote
Levinson et al, Gynecol Oncol, 2021.
55
What factors were identified as leading to the highest risk of recurrence for SCC?
DOI
## Footnote
For ACC, tumor size and LVI were significant factors.
56
What is the purpose of the nomogram developed for Stage I cervical cancer?
To determine the risk of recurrence after surgery.
57
Which factors led to the most risk in SCC according to the nomogram?
DOI.
58
For ACC, which factors were identified as the biggest risk factors?
Tumor size and LVI.
59
What criteria do the new nomograms replace for indications for radiation therapy?
The Sedlis criteria.
60
What was the primary endpoint of the Sedlis trial?
PFS.
61
In the Sedlis trial, what were the 10-year local recurrence rates for adjuvant RT versus observation?
14% vs. 21%.
62
What does adjuvant RT improve in intermediate-risk IB cervical cancer?
PFS and LR.
63
What was the outcome of adjuvant chemotherapy and RT compared to RT alone in Peters trial?
Improved OS and PFS in resected cervical cancer with + nodes, margin, or parametrial involvement.
64
What was the dose of WPRT in the Peters trial?
49.3 Gy/29 fx.
65
What was the 4-year OS in the Peters trial for concurrent chemotherapy versus RT alone?
71% vs. 81%.
66
What is the significance of PET detected nodes in cervical cancer prognosis?
They help predict DSS.
67
What are the 5-year OS rates for N- and Stage I+II patients in the EMBRACE study?
82%.
68
What are the suggested dose constraints for the rectum in brachytherapy?
D2cc <69.5 Gy had <10% grade 2+ toxicity.
69
What is the relationship between HRCTV size and local control rates in the EMBRACE study?
HRCTV size ≤30 cm had 96% LC rates.
70
True or False: In the EMBRACE study, interstitial brachytherapy has better local control in size ≥30 cc.
True.
71
Fill in the blank: The nomograms predicting PFS, OS, and pelvic recurrence in locally advanced cervical cancer were developed from an analysis of identifiable _______.
Prognostic factors.
72
What was the outcome of the study regarding late adverse effects in the Sedlis trial?
Late adverse effects were not recorded.
73
What was the overall 5-year OS reported in the EMBRACE study?
67%.
74
List three factors that were significant for recurrence risk in the context of cervical cancer.
* Tumor size
* LVI
* DOI
75
What is the significance of the study by Kidd et al. regarding PET in cervical cancer?
It shows the value of PET in staging and predicting long-term DSS.
76
What are the factors for which dose-effect relationships were analyzed in the EMBRACE study?
* Bladder
* Rectum
* Small bowel
* Rectovaginal point
77
What was the key finding regarding the frequency of lymph node metastases in the study?
Similar to historic surgical series.
78
What is the focus of the EMBRACE II protocol?
Prospective validation of EMBRACE findings including DVH constraints with IMRT and image guided brachytherapy
## Footnote
ICRU rectovaginal point <65, ICRU R-V point EBRT dose <45, WPRT PTV of 5 mm with IGRT, SIB to nodes during WPRT.
79
What are the endpoints of the EMBRACE II study?
LC, Pelvic control, DM, toxicity, OS, CSS
## Footnote
LC: Local Control, DM: Distant Metastasis, OS: Overall Survival, CSS: Cause-Specific Survival.
80
What was the outcome of the French STIC study regarding 3D brachytherapy?
OS 74% with CT planning vs 65% with point A
## Footnote
Grade 3/4 toxicity 23% vs 3%. 3D brachytherapy is feasible and safe.
81
What advantage does bone marrow sparing IMRT have over typical IMRT?
Less neutropenia
## Footnote
Grade 3+ neutropenia 54% vs. 19%.
82
What was the result comparing IMRT and 3DCRT in the PARCER trial?
IMRT improves physician and patient reported adverse events, especially late GI, compared to 3DCRT.
## Footnote
3-yr late GI grade 2+ toxicity 42% vs. 21%.
83
What were the findings of the TIME-C (NRG RTOG 1203) study regarding IMRT?
IMRT improves patient reported GI adverse events compared to 3DCRT.
## Footnote
Clinicians under reported adverse events compared to patients.
84
What is the significance of the GOG 249 study?
VCB/C not superior to WPRT. Acute toxicity was worse with VCB/C. Late toxicity was similar.
## Footnote
WPRT remains an appropriate treatment option.
85
Fill in the blank: The GOG 249 study defined HIR patients as those with age ≥70 + 1 risk factor, age ≥50 + 2 risk factors, or age ≥18 + 3 risk factors, where risk factors include _______.
grade 2 or 3, LVI, >50% myometrium.
86
What key conclusion was drawn from the PORTEC studies regarding WPRT?
The benefit with WPRT is in high intermediate risk groups. Most recurrences in vaginal cuff.
## Footnote
VC brachy is noninferior to WPRT in high intermediate risk.
87
True or False: The addition of chemotherapy to WPRT in the PORTEC 3 study showed a significant benefit.
False
## Footnote
There was no benefit to the addition of chemotherapy.
88
What is the recommended dose constraint for the small bowel in radiation therapy?
V40 <30%, Max <46 Gy
## Footnote
Recommended constraints help minimize toxicity.
89
What is the primary focus of the PORTEC-3 trial?
The trial investigates the benefit of chemotherapy added to whole pelvic radiotherapy (WPRT) for women with high-risk endometrial cancer.
## Footnote
The trial began the transition to the molecular subtype era in post-operative endometrial cancer.
90
What were the significant outcomes of the PORTEC-3 trial in Stage III patients?
The trial showed a 5-year overall survival (OS) benefit of 79% vs. 69% and a 5-year freedom from survival (FFS) benefit of 71% vs. 58% in Stage III patients.
## Footnote
Benefits were only observed in Stage III on subanalysis.
91
What does the acronym p53abn refer to in the context of endometrial cancer?
p53abn refers to tumors with abnormal p53 protein expression.
## Footnote
This molecular subtype showed benefits from chemotherapy in the PORTEC-3 trial.
92
True or False: There was no benefit in overall survival for Stage I-II patients in the PORTEC-3 trial.
True
## Footnote
The benefit in OS was only present in Stage III patients.
93
What is the significance of POLEmut in endometrial cancer treatment?
POLEmut indicates a lower risk group, where outcomes were outstanding in the PORTEC trials, suggesting no adjuvant therapy may be necessary.
## Footnote
Omission of any adjuvant treatment should be considered for Stage I-II POLEmut patients.
94
Fill in the blank: The 5-year isolated distant metastasis (DM) rate was _____ in the PORTEC-3 trial.
21% vs. 29%
## Footnote
This indicates the effectiveness of the treatment in reducing distant metastasis.
95
What treatment comparison was made in the context of toxicity in the PORTEC-3 trial?
3DCRT vs. IMRT showed that 3DCRT had higher rates of grade 2+ diarrhea (15% vs. 4%) and grade 2+ hematologic toxicity (26% vs. 13%).
## Footnote
IMRT was associated with less toxicity than 3DCRT.
96
What are the primary endpoints of the RAINBO study?
3-year recurrence-free survival (RFS) for NSMP, MMRd, p53abn and 3-year locoregional recurrence (LRR) for POLEmut.
## Footnote
This ongoing study evaluates the benefit of new agents based on molecular profiles.
97
What is the main focus of the PORTEC-4a trial?
The trial compares molecular profile-based adjuvant treatment versus standard adjuvant radiotherapy in high-intermediate risk endometrial cancer.
## Footnote
It assesses whether tailoring treatment based on molecular characteristics improves outcomes.
98
What is the significance of NSMP in the context of endometrial cancer treatment?
NSMP refers to tumors with no specific molecular profile that showed no benefit from chemotherapy in the PORTEC-3 trial.
## Footnote
Progestin evaluation is ongoing in NSMP patients.
99
What treatment options were compared for MMRd Stage II and III patients?
WPRT vs. WPRT plus durvalumab.
## Footnote
This is part of the ongoing RAINBO study evaluating MMRd patients.
100
What was the reported 5-year OS for patients with serous histology in the PORTEC-3 trial?
71% vs. 53%
## Footnote
Serous histology had the highest risk of recurrence.
101
What were the secondary endpoints of the RAINBO study?
3-year and 5-year VCRFS, DMFS, CSS, OS, toxicity, quality of life (QOL).
## Footnote
These endpoints will help assess the overall effectiveness and impact of treatments.
102
What is the main focus of the PORTEC-4a trial?
Molecular profile-based adjuvant treatment for women with high-intermediate risk endometrial cancer.
## Footnote
The trial aims to evaluate treatment based on molecular profiling to improve outcomes.
103
What are the high-intermediate risk (HIR) criteria for endometrial cancer?
Age >60 and IC grade 1-2, or IB grade 3; Stage IIA any age (grade 3 and >1/2 invasion excluded).
## Footnote
IC refers to invasion characteristics.
104
What is the treatment comparison in the PORTEC-2 trial?
VCB vs. WPRT.
## Footnote
VCB stands for vaginal cuff brachytherapy, and WPRT stands for whole pelvic radiotherapy.
105
What was the noninferiority threshold for WPRT in the trial?
WPRT 46 Gy vs. VCB to proximal 1/2 of vagina, HDR 7 Gy x 3 or LDR 30 Gy Rx to 5mm depth.
106
What were the 5-year vaginal recurrence rates for WPRT and VCB?
5-yr VR 1.6% WPRT vs. 1.8% VCB, noninferior.
## Footnote
VR refers to vaginal recurrence.
107
What were the 10-year pelvic recurrence rates for WPRT and VCB?
10-yr pelvic recurrence 1% vs. 6%.
108
What is the overall survival (OS) rate at 5 and 10 years for the treatments?
5-yr OS ~84%, 10-yr OS ~68%.
109
What molecular subtypes were analyzed in the PORTEC studies?
* POLEmut
* MMRd
* p53abn
* NSMP
## Footnote
These subtypes provide insight into treatment outcomes and recurrence rates.
110
What is the LRRFS for POLEmut in the PORTEC studies?
100% in all.
## Footnote
LRRFS stands for locoregional recurrence-free survival.
111
What were the findings regarding toxicity with VBT vs. WPRT?
QOL better with VBT; WPRT had higher rates of fecal leakage and bowel complications.
112
What was concluded about VCB in HIR patients?
VCB is noninferior to WPRT and has less toxicity.
113
What is the recommendation for Stage I-II POLEmut patients?
Omission of any adjuvant treatment should be considered.
114
What was the result of chemotherapy in NSMP patients according to PORTEC 3?
No benefit with chemotherapy, RFS p=0.246 and OS p=0.434.
115
What is the suggested treatment for MMRd patients?
Immunotherapy may be better, as there appears to be no benefit from chemotherapy or radiation.
116
What is the significance of the p53abn subtype?
Benefits from WPRT in early stage, but not in advanced stage.
117
What was the 5-year local recurrence rate for WPRT vs. observation in the PORTEC-1 trial?
5-yr LRR 4% WPRT vs. 14% obs.
118
True or False: The addition of radiotherapy decreases pelvic recurrence rates.
True.
119
What does the acronym GOG stand for in the context of clinical trials?
Gynecologic Oncology Group.
120
What did the Witlink analysis find regarding second cancers after radiotherapy?
No increase in second cancers after RT in PORTEC 1 and 2.
121
Fill in the blank: The recommended radiation dosage for WPRT in the trial was _____ Gy.
46.
122
What were the late complications associated with WPRT?
Higher rates of GI and GU toxicity, and worse physical function.
123
What is the preferred treatment for NSMP patients in early stages according to PORTEC 1&2?
VCB is preferred.
124
What does the acronym PORTEC stand for?
Post Operative Radiation Therapy in Endometrial Carcinoma
## Footnote
PORTEC trials focus on the role of radiotherapy after surgery for endometrial cancer.
125
What was the primary finding of the study by Wiltink et al. regarding second cancers after radiotherapy?
No Increased Risk of Second Cancer After Radiotherapy in Patients Treated for Rectal or Endometrial Cancer
## Footnote
This finding was based on data from the randomized TME, PORTEC-1, and PORTEC-2 trials.
126
What were the main treatment arms compared in the ASTEC/EN.5 trials?
WPRT (whole pelvic radiotherapy) vs. observation
## Footnote
WPRT was administered at a median dose of 45 Gy.
127
What was the observed effect of adjuvant WPRT on local control (LC) in endometrial cancer?
Adjuvant WPRT improved LC by a small amount compared to observation, but increased toxicity
## Footnote
Toxicity rates were higher in the WPRT group.
128
What was the 2-year local recurrence (LR) rate for WPRT compared to observation in the GOG 99 trial?
2-year LR: 3% WPRT vs. 12% observation
## Footnote
WPRT showed significant improvement in local control compared to observation.
129
What factors were considered in defining high-intermediate risk (HIR) patients in the GOG 99 trial?
Age ≥70 with 1 risk factor, ≥50 with 2 risk factors, or any age with 3 risk factors
## Footnote
Risk factors include grade 2-3, LVI (lymphovascular invasion), or IC (invasive cancer).
130
What was the primary endpoint of the GOG 99 trial?
Overall survival (OS) was not the primary endpoint
## Footnote
The trial primarily focused on local recurrence rates.
131
What did the later PORTEC 2 trial find regarding vaginal brachytherapy (VCB) compared to WPRT?
VCB is as effective as WPRT with less adverse effects
## Footnote
This finding supports VCB as a viable alternative for patients.
132
What was the significance of pelvic lymph node dissection (LND) in the ASTEC trial?
Positive pelvic nodes were allowed in ASTEC, but not in EN.5
## Footnote
This distinction affected the trial outcomes and patient eligibility.
133
What was the late toxicity rate associated with WPRT in the ASTEC trial?
Late toxicity rate: 8% for WPRT vs. 3% for observation
## Footnote
Indicates a higher risk of long-term complications with WPRT.
134
What was the compliance rate for external beam radiotherapy (EBRT) in the ASTEC trial?
EBRT compliance rate was 82%
## Footnote
High compliance indicates adherence to the treatment protocol among participants.
135
True or False: The ASTEC trial showed that adjuvant therapy is beneficial for high-intermediate risk patients.
True
## Footnote
The trial results indicated a benefit in local recurrence rates for HIR patients receiving adjuvant therapy.
136
Fill in the blank: The study by Horeweg et al. found that molecular classification predicts response to _______ in endometrial cancer.
radiotherapy
## Footnote
This suggests that molecular characteristics can guide treatment decisions.
137
What is the primary focus of the ESGO/ESTRO/ESP guidelines?
Management of patients with endometrial carcinoma
## Footnote
These guidelines provide recommendations for treatment based on current evidence.
