For cancer of the cervix, the National Cancer Institute published a clinical alert in 1999 after 5 trials evaluating cisplatin-based concurrent chemoradiotherapy demonstrated a marked improvement in overall survival.34,35 A patterns of care study performed in Canada demonstrated the rapid adoption of chemoradiotherapy.36 A meta-analysis confirmed the survival benefit of platinum-based chemoradiotherapy; however, it also showed a survival improvement for non–platinum-based chemoradiotherapy.31 This meta-analysis suggested a possible improvement in survival for patients receiving extended adjuvant chemotherapy, although the numbers of contributing studies and patients were small. The value of extended adjuvant chemotherapy after the concurrent radiation and chemotherapy course is currently being tested in multiple international phase 3 trials (Table 3).
The inconsistent quality of pathologic review is another major challenge in the effort to obtain generalizable conclusions from endometrial trials. After central pathologic review in the postoperative radiotherapy in endometrial cancer-1 trial, the percentage of patients with grade 1 disease increased to 21% from 69%. Similarly, the fraction of patients with grade 2 disease decreased from 68% at their home institution to 16% after central review. Nineteen percent of the patients in the postoperative radiotherapy in endometrial cancer-1 trial were ineligible because of the finding of grade 1 disease after central review.44 In this context, it has been very difficult to perform cross trial comparisons or to generalize the results of adjuvant radiotherapy trials because of these variations in surgical staging, central pathologic review, and eligibility criteria.
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