Metastatic cervical cancer responds moderately to chemotherapy and it can provide palliation. One guideline writes: “It is recommended that all patients, particularly those who have been previously treated with cisplatin as a radiosensitizer, be offered the opportunity to participate in randomized trials, if available, that evaluate the efficacy and toxicity of other single-agent or combination chemotherapy regimens.
Until further evidence becomes available, it is recommended that cisplatin in combination with topotecan should be offered to patients on the basis of improvements in response and survival outcomes when compared with single-agent cisplatin alone.” However NCCN is more liberal, listing in addition carboplatin and cisplatin/paclitaxel, cisplatin/gemcitabine and a variety of single agents.
There was a recent study of single agent Avastin. To evaluate Avastin in the treatment of recurrent squamous cell carcinoma of the cervix, researchers conducted a Phase II clinical trial among 46 women. Study participants received intravenous Avastin every three weeks until cancer progression or the development of severe side effects.
24% of patients survived progression-free for at least six months.
11% of patients had a partial response.
Median response duration was 6.2 months.
Median overall survival was 7.3 months.
Median progression-free survival was 3.4 months.
There was one infection-related death that was possibly due to treatment.
Side effects included hypertension and thromboembolism
These researchers concluded that Avastin was generally well tolerated and appeared to have anticancer activity in women with previously treated recurrent cervical cancer. They note that the role of Avastin in this population merits further study in Phase III clinical trials. A combination phase II trial with topotecan reported as an abstract concluded: “Combination bevacizumab and topotecan administered in a weekly fashion demonstrate good activity in platinum refractory OC with acceptable toxicity.” There were also trials with 5FU or capecitbine.
For second line therapy, NCCN on page Papillae CER V – be recommence Avastin, docetaxel, 5-FU, gemcitabine, ifosfamide, irinotecan, mitomycin, topotecan. This is a category 2B recmmendation. Premetrexed and vinorelbine are recommended as category 3.
There are no FDA approved chemotherapy drugs specifically for cervical cancer.
For second line therapy, NCCN on page CER V –recommended Avastin, docetaxel, 5-FU, gemcitabine, ifosfamide, irinotecan, mitomycin, topotecan. There are no recommendations after line 2. This is a category 2B recmmendation. Premetrexed and vinorelbine are recommended as category 3. The most recent 2016 review says the following: Additional treatment options outside of platinum-based therapy are limited. Ifosfamide, paclitaxel, topotecan, irinotecan, capecitabine, pemetrexed, vinorelbine, and nab-paclitaxel are among the most active single agents, while docetaxel, gemcit abine, and ixabepilone were found to have minimal activity -
Hirte H, Strychowsky J, Oliver T, Fung-Kee-Fung M, Elit L, Oza A, Gynecology Cancer Disease Site Group. Chemotherapy for recurrent, metastatic, or persistent cervical cancer: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2006 Jul 5. 21 p. (Evidence-based series; no. 4-20). [27 references]
nccn.org, cervical cancer, CERV-B 2016
K. F. McGonigle, H. G. Muntz, J. L. Vuky, P. J. Paley, D. S. Veljovich, H. J. Gray, T. W. Malpass Phase II prospective study of weekly topotecan and bevacizumab in platinum refractory ovarian cancer or peritoneal cancer (OC). J Clin Oncol 26: 2008 (May 20 suppl; abstr 5551)
Alejandra Fuentes, MD, and Agustin A. Garcia, MD, Advancements in Cervical Cancer Prevention and Management of Persistent, Recurrent, and Metastatic Disease: 2016 Update. AJHO. 2