Advances in the Treatment of Gynecologic Malignancies

The article by Kim et al is a comprehensive summary of several decades of research in the management of cervical and vulvar cancer. It describes the current status of treatment and possible future trials. Surgical Staging For the management of cervical cancer, two issues need to be further addressed. The first is surgical staging of cervical cancer. For decades it has been known that nodal metastasis to the pelvic and para-aortic regions is common in cervical cancer including clinical stage I disease. Moreover, nodal metastasis is a well-documented indicator of poor prognosis, particularly in apparent early-localized disease. Identification of microscopic nodal disease may alter the treatment plan, especially if the para-aortic nodes are involved. Despite the poor accuracy of currently available imaging modalities in detecting pelvic and para-aortic metastasis, cervical cancer continues to be clinically staged in most institutions in the United States. The use of clinical staging may be justified in the absence of technology to accurately determine disease status, particularly in developing nations with limited medical resources. However, with the advent of minimally invasive surgical approaches, surgical staging of apparent local cervical cancer can be adequately performed through transperitoneal or extraperitoneal laparoscopic pelvic and bilateral para-aortic lymph node dissection with minimal morbidity and delay in treatment. The laparoscopic approach has been used for the past decade by many national and international investigators with excellent lymph node yield, limited operative time, short hospital stay, and a very low overall complication rate.[1-4] Pathologic evaluation of retroperitoneal lymph nodes remains the gold standard for detecting metastasis. Until accurate imaging techniques are commonly available, surgical staging should be offered to women with cervical cancer who have access to minimally invasive surgery and are at risk for para-aortic nodal metastasis as well as to those for whom identification of retroperitoneal nodal metastasis will modify the treatment plan. The results of randomized trials in cervical cancer are most informative when the protocol mandates pretreatment surgical staging. Compliance Issues The second issue of concern in the application of results from phase III chemoradiation trials is compliance with treatment, particularly in the indigent population. Indigent, uninsured, and minority women in the United States continue to share a large burden of cancer, and cervical cancer is among the most common gynecologic cancers in these patients. The addition of chemotherapy to radiation substantially increases the complexity of treatment. Chemotherapy and radiation are commonly delivered in separate areas by independent services, so that problems in patient orientation, staff integration, and coordination of schedules are exacerbated. Indigent, minority women have difficulty complying with standard radiation protocols for cervical cancer, and different cultural models of cancers prevalent in indigent and minority communities may compound obstacles, including lack of transportation, child care, and time off from work. Epidemiologists have distinguished between the efficacy of therapy, as demonstrated in the controlled and carefully prepared setting of clinical trials at academic centers, and the effectiveness of therapy, as delivered in ordinary conditions to unselected patients in disparate environments. Recently, reports on chemoradiation in this setting indicated that nearly one-third of the indigent women treated with chemoradiation for cervical cancer did not fully complete the prescribed treatment.[5] Although the efficacy of chemoradiation for cervical cancer has been demonstrated, its