Let’s move on to the larger carcinomas of the cervix, stage IB and stage IIA. Here we have basically two treatment options; the treatment of choice in cervical cancer as a disease as a whole as you know, is radiation therapy. In these particular stages, there may be a choice in selective cases between radical hysterectomy and bilateral pelvic lymphadenectomy, this can be done vaginally or abdominally, and radiation therapy with external radiation of the whole pelvis and brachy therapy. The bottom line is simple, they are comparable local control and survival rates with both modalities. So how does one choose? Well it’s basically based, and I try to sympathize it here on a number of points such as institutional preference, physician preference and training, tumor characteristics and here, the size of the tumor appears to be an important determinant, what is the growth pattern, is it an exophytically growing tumor, is it an endophytic growing tumor which involves the endocervical canal predominantly, what is the general condition and the age of the patient, is the patient a surgical candidate, what is our concern about possibly preserving ovarian function which is also of concern in young women which is often proposed to be better with surgery than with radiation therapy. And then basically we know that there are different patterns of adverse effects with radiation therapy or radical hysterectomy. With hysterectomy, the side effects tend to be either immediate, or to occur in the short term, and surgically related. Fistula rates are lower, between 1 and 2%, urinary tract fistulas are more common with radical surgery as opposed to with radiation therapy where the intestinal fistulas tend to be more common. ‘
With radiation therapy, adverse effects can occur within six months, from six months to a year or after a year, in which case they are called late adverse effects which are of concern in young patients and include intestinal dysfunction which can be protracted fistulas. In patient’s who undergo a radical hysterectomy, we have learned there are a number of factors that can be found that will affect prognosis, and they are, the presence of positive pelvic lymph nodes, positive margins, parametrial extension of the tumor, deep stromal invasion, large tumor volume, lymphovascular space invasion is less consistently shown to be an adverse prognostic factor. This is just a compilation of a number of studies where patient’s who had a radical hysterectomy were treated with adjuvant radiation through the whole pelvis because of the presence of one of these poor prognostic factors, and you can see there is a range here of patient’s between 9% all the way up to 38%, 35% of patient’s who had a radical hysterectomy and then went on to have pelvic radiation therapy.
The problem here is that you can see there is also a significant rate of complications, and I should point out that those are severe complications, those are not just minor complications occurring anywhere from 3 to 30% in those patient’s. The message I want to share with you here is that if at all possible, we would prefer to stay out of this kind of situation where patient’s are subjected to two radical treatment modalities; one is surgery, another radiation therapy, which means that I would be an advocate of trying to do either one but not both, so selection of the patient’s will be important. It has traditionally not been shown beyond any doubt that adding radiation therapy after radical hysterectomy when lymph nodes were involved really added to survival. Last year, a study was reported where 243 patient’s were accrued, they had radical hysterectomy and pelvic lymphadenectomy for stage IAII, IB and IIA carcinoma of the cervix, they have negative paraortic nodes and they were randomized between two treatment regimens; regimen one was radiation to the pelvis with concurrent cisplatin and IV 5FU given every three weeks for intended course of four cycles, and regiment two was radiation therapy to the pelvis alone.