The cervical cancer treatment landscape is experiencing significant shifts in surgical approaches and therapy sequencing, with emerging data reshaping clinical practice patterns. Leading experts are adapting to these changes while evaluating new treatment strategies for optimal patient outcomes.
Surgical Approach Evolution
A notable paradigm shift has occurred in surgical management, with data supporting open surgical approaches over minimally invasive techniques for early-stage cervical cancer. Dr. Ritu Salani, Director of the Division of Gynecologic Oncology at UCLA Health, notes that this change stems from studies showing reduced recurrence and mortality rates with open procedures.
The phase 3 ROCC trial (NCT04831580) is currently challenging this paradigm by investigating minimally invasive surgery with enhanced safety measures. The study implements specific protocols including tumor containment systems and the elimination of uterine manipulators. Additionally, the trial maintains strict surgeon qualification requirements to ensure procedural standardization.
"Less radical surgery is a nice approach for patients who have early-stage disease and meet certain criteria where we can reduce morbidity from surgery," explains Dr. Salani. However, she emphasizes the critical importance of proper patient selection to avoid compromising oncologic outcomes.
Immunotherapy Sequencing Challenges
The integration of immune checkpoint inhibitors (ICIs) into standard treatment protocols has created new sequencing challenges. While pembrolizumab combined with chemotherapy (with or without bevacizumab) has received FDA approval for metastatic or recurrent disease, questions remain about its efficacy in patients previously treated with immunotherapy.
The field now faces a critical knowledge gap regarding the optimal use of ICIs in patients who received prior immunotherapy during chemoradiation for locally advanced disease. "Understanding the role of ICI therapy after ICI therapy remains a needs gap for us because we have not encountered that yet," Dr. Salani acknowledges.
Second-Line Treatment Evolution
The second-line treatment landscape has expanded with the introduction of targeted therapies. Tisotumab vedotin (Tivdak) has emerged as a standard second-line option following platinum-based therapy failure. For patients with HER2-positive disease, fam-trastuzumab deruxtecan-nxki (T-DXd) presents an additional option, though this applies to a smaller subset of patients with IHC 2+ or 3+ expression.
The recent addition of neratinib to NCCN guidelines for HER2-mutated cervical cancer provides another treatment option in the second-line setting or beyond. While neratinib targets somatic mutations rather than HER2 expression, management of side effects, particularly diarrhea, requires careful consideration.
Future Directions
Looking ahead, Dr. Salani highlights emerging opportunities in the field, particularly with TROP2 antibody-drug conjugates being evaluated in second-line settings for patients who have received platinum-based chemotherapy with immunotherapy. These ongoing investigations represent the field's continuous effort to improve treatment options and patient outcomes.
