Evolution in the management of locally advanced cervical cancer: the experience of Cancer Institute (WIA), Chennai, India.

Objective: To conduct a retrospective analysis of disease free survival (DFS) of locally advanced cervical cancer (LACC) in relation to evolution of treatment and related factors.
Methods: A total of 3,892 cases of LACC treated at the Cancer Institute (WIA), Chennai, India, during 1990-1999 were analyzed. Management of LACC including concurrent chemo-radiation (CCRT) has evolved through trials conducted at the institute. DFS and risk of second cancer were elicited using actuarial and Kaplan-Meier methods, respectively.
Results: A majority belonged to stage III (54%) and complete follow-up at 5-years was 90%. DFS at 5, 10 and 15-years were 58%, 49% and 42% for stage IIB and 43%, 35% and 31% for stage III, respectively. External beam radiotherapy (EBRT) alone as treatment modality reported the poorest 5-year DFS (37%). Addition of chemotherapy to EBRT resulted in marginal increase in survival (41%) but inclusion of brachytherapy to EBRT enhanced survival (58%) significantly (p<0.001). CCRT with brachytherapy as a planned component resulted in the best DFS (69%), irrespective of disease stage. In a carefully selected group of patients who were suitable for salvage surgery, the long-term DFS was 71%, 63% and 63% at 5, 10 and 15 years, respectively, for stages IIB and III together. Complete response was achieved in 67% and 15% of them recurred. Remote metastasis occurred in 13%. The cumulative risk of developing any second cancer was 0.5% at 5 years, 1.9% at 10 years and 2.8% at 15 years of follow up.
Conclusion: Our data indicates satisfactory treatment outcome even in advanced disease and with the present state of knowledge, the recommended standard treatment for LACC is careful pre-treatment evaluation followed by CCRT which includes brachytherapy.