With the introduction of cervical screening, the incidence of cervical cancer has dropped dramatically around the world. The disease is expected to decrease further with the expansion of human papillomavirus (HPV) vaccine coverage . Although CT as primary adjuvant therapy for early-stage cervical cancer is not recommended by the National Comprehensive Cancer Network (NCCN) and FIGO, an overwhelming number of women with risk factors for recurrence have accepted postoperative CT in recent years. In this retrospective study, the median follow-up duration for surviving patients was 75 months, the 5-year OS and DFS rates were 86.6% and 90.0%, respectively. The 5-year OS were 85.5% and 87.7% in the CT and the RT/CRT group, respectively (p=0.727). There was also no significant difference in the 5-year DSS between the two arms (CT: 87.1%, RT/CRT: 90.8%; P=0.548). Our study indicated that CT for early-stage cervical cancer patients meeting Sedlis criteria is a good alternative to RT/CRT as there were no significant differences on rate of recurrence and fewer side effects.
Some studies found that in early-stage cervical cancer patients RS was equivalent to RT in terms of overall and disease-free 5-year survival rate [20, 21]. In other words, both the treatments were equally effective only in decreasing local recurrences. The main objective of adjuvant therapy after radical surgery, however, ought to be not only to reduce local recurrences but also extra-pelvic recurrences. A number of reports have reported that post-operative RT caused serious complications and relatively higher rate of mortality [22, 23]. Early leukopenia and gastrointestinal symptoms, late urinary side effects and vaginal shortening or atrophy may occur after RT and CCRT, which can lower the QOL to a considerable extent in cancer patients . Our study also revealed that RT/CRT might add to the spectrum of side effects compared to CT alone. These inferences led us to believe that adopting CT as postsurgical adjuvant therapy might improve the survival rate and QOL in cervical cancer patients. Takeshima et al. reported that a single chemotherapeutic regimen of BOMP (bleomycin, vincristine, mitomycin and cisplatin) improved the 5-year DFS to 93.3% in patients with intermediate-risk factors and 85.7% in patients with high-risk factors with adverse events within acceptable range . Lee et al. also revealed statistical difference in the OS between surgery only group and postoperative adjuvant CT group in stage IB cervical cancer with intermediate-risk factors (surgery alone: 81.8% vs. surgery + CT: 94.9%; P<0.05) . Lee et al. reported the 3-year DFS and 5-year OS were 94.6% and 90.6%, respectively rates in 101 patients meeting the Sedlis criteria receiving adjuvant CT alone after RS. This finding indicated that CT should be a rational choice for IB/IIA cervical cancer patients with risk of recurrence . Many studies have compared RT/CRT versus CT to determine better prognosis and fewer complications. A previous small sized phase III clinical study reveal that RT+CT was not superior to chemotherapy alone as adjuvant therapy for early-stage cervical cancer patients who are at higher-risk of recurrence after RH-PLND . There are several retrospective studies that concur with this view. Although Hosaka et al. did not indicate the superiority of postoperative CT with BOMP over RT; the authors speculated that using TP might have less adverse effects and confer a survival advantage after radical surgery [29, 30]. Takekuma et al. certified 4-year PFS and OS did not differ significantly between the CT arm and the CCRT arm in FIGO stage IB1/IIB cervical cancer with high-risk factors who were treated by RS . Similarly, Li et al. showed that 5-year OS and DFS in the CT group were slightly higher than that the group RT in FIGO IB/IIIB cervical cancer .
Cervical cancer is one of the most preventable and curable forms of cancer, as long as it is detected early and managed effectively. Given the increase of long-term survivors, the QOL have recently become a crucial issue in early-stage cervical cancer [33, 34]. Growing number of researchers began to pay more attention to the adhibition of chemotherapy in early-stage cervical cancer [35, 36, 37, 38]. Previous observations have shown that cervical cancer is moderately chemosensitive. The use of CT for cervical cancer was mainly carried out in recurrent and metastatic cervical cancer. Cisplatin is the most widely used drug; other drugs such as paclitaxel, fluorouracil, bleomycin and carboplatin also are effective in cervical cancer. Over the past decades, paclitaxel in combination with cisplatin has proved to be very effective in advanced cervical cancer [39, 40, 41]. An open-label randomized phase III trial JCOG0505 (Japan Clinical Oncology Group) also demonstrated TC was noninferior to TP, with long nonhospitalization periods and similar median OS and PFS . Similarly, Austrian Gynecologic Oncology Group (AGOG) conducted a randomized controlled trial (RCT) in high-risk cervical cancer after RH to evaluate the impact of chemotherapy . Nevertheless, the application of CT alone as an adjuvant therapy in patients with intermediate-risk cervical cancer has not been fully evaluated.
In 2014, NCCN Guidelines proposed sedlis criteria for external pelvic radiation after RH in node-negative, margin-negative, parametria-negative cases, and is widely accepted as a standard for radiotherapy in early-stage cervical cancer. At the same time, the guidelines pointed out that potentially important risk factors for recurrence may not be limited to the sedlis criteria. Ryu et al. (2014) identified a "four-factor model" (histology, tumour size, deep stromal invasion, and LVSI) in which the presence of any two factors may be useful for predicting recurrence . Other professors also suggested adenocarcinoma (AC) and adenosquamous carcinoma (ASC) are independent prognostic factors (poorer survival outcomes than those with SCC) for cervical cancer patients treated with definitive radiotherapy. In addition, a particular effectiveness of adjunvant RT was seen in reducing the recurrence rate of patients with AC/ ASC vs. squamous cervical tumors . Therefore, it is necessary to distinguish SCC from AC and ASC for discussion [46, 47]. Our study aim to provide a more targeted treatment strategy for SCC. There are also several limitations of this study. As this was a retrospective study, factors such as heterogeneity of the patients, selection bias and incomplete data may have influenced the results. Besides, absence of patients who met the third category in Sedlis criteria and sub-group analysis of RT and CRT separately may have affected the conclusions to some extent.