Our analysis of the NCI patterns of care data during the period 1997-2001 demonstrated several interesting trends over this relatively short time frame. The most dramatic observation was the significant rise in the percentage of women receiving both chemotherapy (34% to 85%) and chemoradiation (20% to 72%) for stage II to IVA disease from 1997 to 2001.
The most likely explanation for the change in therapy is the publication of 3 of the 5 clinical trials in the New England Journal of Medicine in 1999,2-4
timed with the NCI-issued Clinical Announcement.7
Shortly thereafter, the fourth and fifth trials were published in the Journal of Clinical Oncology.5,6
With the help of the American Society of Clinical Oncology, the American Society for Therapeutic Radiation Oncology, and the Society of Gynecologic Oncologists, the NCI Clinical Announcement was disseminated to those oncologists most likely to treat women with cervical cancer. A recently published population-based study reported by Barbera et al from the province of Ontario found a temporal impact of the NCI Clinical Announcement in Canada.10
In the Canadian study, the increase in the use of chemotherapy and radiation increased from <10% before the NCI Clinical Announcement to >67% in the period April 1999 through March 2001, after the announcement. This change was also reported in the patterns of care study by Eifel et al, where the use of chemoradiation for women with locally advanced disease rose from 19% in 1996 to 63% in 1999.11
The increase in chemotherapy was not seen before 1999. The NCI Clinical Announcement was issued February 22, 1999. The reports by Eifel et al and Barbera et al suggest that these clinicians responded rapidly.
It is disturbing that only 70% of patients diagnosed with stage II to IVA disease received brachytherapy/ICRT as part of their treatment management plan. On the basis of patterns of care studies by Eifel et al,11
we would expect that a larger percentage of women would receive ICRT. However, the lower percentage may reflect the finding that our data was population-based and included smaller community hospitals where, in the analysis by Eifel et al, patients were less likely to receive ICRT. The lower rates may also be because of several other factors, including lack of an appropriate facility to deliver ICRT in the community, distance to a facility offering ICRT, and patient compliance.
Finally, 11% and 5% of women with stage II to IVA disease did not receive radiation therapy in 2000 and 2001, respectively. Only 1% of patients in 2000 and 3.5% of patients in 2001 refused radiation therapy. We were not able to determine the explanation for this lack of therapy in the remaining patients.
Surgical therapies for women with FIGO stage I disease were 15% local destruction (including conization), 30% total hysterectomy, and 40% radical hysterectomy. These percentages were unchanged from 1997 to 2001. There was a much smaller increase in the use of chemotherapy and chemoradiation for women with early stage disease, and these results strongly suggest that surgical management remains the primary therapy for FIGO I cervical cancer.
In this study, we found that advancing age played a role in the therapeutic management of cervical cancer. Advancing age was associated with decreased receipt of concurrent chemoradiation and the combination of chemotherapy, EBRT, and ICRT. After adjusting for therapy, as well as other factors, the increased risk of all-causes mortality was higher in older women. However, there was no significant association between risk of death from cervical cancer and age after adjusting for race/ethnicity, insurance status, FIGO stage, grade, nodal status, treatment, and year of diagnosis. These results would suggest that older women, their families, and their healthcare providers need to be educated about the importance of screening for cervical cancer to find cervical cancer at an earlier stage. Furthermore, it may be essential to develop chemoradiation regimens that can be safely administered to older women with cervical cancer, particularly those with comorbidity.
At present there is no consensus in the developed world for the optimal pretreatment evaluation for cervical cancer. Despite efforts by FIGO to develop a standardized algorithm, physician- and institution-specific approaches remain in light of rapid technological developments in imaging modalities. Data from the joint ACRIN/GOG trial suggests that neither CT nor MRI provide reliable evaluation of cervical stromal involvement or lymph node involvement.12
Institutions with expertise in positron emission tomography consider that particular modality a more accurate predictor of lymph node involvement, but there is still no national consensus on the optimal imaging modality.13
In addition, our findings clearly suggest that many clinicians remain convinced that exam under anesthesia, as compared with imaging, remains the most reliable means to assess of local tumor size and extent of disease.
In conclusion, the analysis of these US population-based patterns of care data for cervical malignancies during the period 1997-2001 has demonstrated remarkable changes in the treatment management of this disease, consistent with earlier observations of Eifel et al11
and Barbera et al10
The most significant change observed was the rapid shift to the use of chemoradiation in the treatment of women diagnosed with stage II to IVA disease, after the dissemination of results from the 5 randomized trials addressing the issue of chemoradiation.