Title Surgery in locally advanced and in residual disease post concurrent chemoradiotherapy - Greta Dreyer.pdf ✅

SURGERY in LOCALLY ADVANCED and RESIDUAL DISEASE after CONCURRENT CHEMORADIATION Prof Greta Dreyer Gynaecologic Oncologist University of Pretoria
What is the role of primary surgical treatment in Locally Advanced Cervical Cancer? Standard global approach? Surgery (PST) vs CRT NACT debate... Caveats... Statue of Nelson Mandela overlooking Pretoria
The “standard” global approach is CRT?? • The most frequently employed primary treatment modality for stage IB2 in Korea is RH or NACT + RH(1) • Followed by CCRT, RT and/or extrafascial hysterectomy • Radiation very scarce resource in Africa and LMIC • And very few patients in LMIC will receive “optimal” RT or CRT • Interest in NAC to increase operable patients • Interest in reduced radicality in smaller tumours • Interest in cost efficacy • Rethinking of this paradigm is urgently needed • Reduced surgical expertise / experience • Not accurate to assume same outcomes today Rye et al. Gyn Cancer 2007; 17
Surgery (PST) in bulky early stage • RCT shows no difference in survival between surgery and RT (1) • RH followed by tailored adjuvant therapy has better survival outcomes compared to primary CRT in retrospective trials (2, 3, 4) • At least 30% of patients with tumors >4 cm do not need RT, others: 37-50% (4) • RH possibly the most cost-effective for bulky early-stage cervical cancer (5, 6) • RH continues to play a significant role in patients with bulky early-stage cervical cancer. 1 Landoni F, et al. Lancet 1997;350:535-40.6. 2 Zivanovic O et al. Gynecol Oncol 2008;111: 265-70.7. 3 Kim et al. Gynecol Obstet Invest 2011;71:19-23. 4 Ryu et al. Int J Gyn Cancer 2007; 17 5 Rocconi et al Gynecol Oncol 2005;97:387-94. 6 Jewell EL et al Gynecol Oncol 2007;107:532-40.12
What were the true reasons for accepting this “standard”? • “EQUAL OUTCOME” but “HIGHER MORBIDITY” in dual therapy • Subjective perceptions of severity of SAE • Assumption of equal resources across the globe • Power struggle between surgeons and radiation therapists • Bias and resistance against patient preference • Bias due to poor outcomes of node positive early stage • Variable quality of surgery, loss of skills • Surgeon’s fear of litigation View of city from Union buildings hill