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Critical Reviews in Oncology/Hematology 79 (2011) 24–30

Treatment for advanced cervical cancer: Impact on quality of lifeSusan Davidson ∗

The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK

Accepted 6 July 2010

ontents

. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

. Treatment options for cervical cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252.1. Single-agent chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252.2. Combination chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

. Importance of measuring quality of life in the assessment of combination regimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273.1. Combination chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273.2. Chemoradiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Biography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

bstract

Cisplatin-based combinations can potentially improve response rates in patients with cervical cancer, but unacceptable toxicity must bevoided. Quality of life (QoL) measures are increasingly used to assess the benefits versus limitations of chemotherapy regimens. A MEDLINEearch of English language publications from January 2000 to December 2008 was conducted using the search terms: ‘quality of life’ ORQoL’ OR ‘HRQoL’ AND ‘cervical cancer’. Abstracts from the Association of Clinical Oncology meeting, 2008, were also searched. Articlenclusion was based on abstract content. Several cervical cancer therapies have shown response rate improvements in combination withisplatin, including topotecan and paclitaxel. However, only topotecan/cisplatin demonstrates a significant overall survival advantage overisplatin monotherapy, while both topotecan/cisplatin and paclitaxel/cisplatin demonstrate comparable impact on QoL to cisplatin alone.

ew trials of combination chemotherapy for cervical cancer have directly assessed QoL. The combination of topotecan/cisplatin significantly

ncreases overall survival rates without reducing patient QoL.2010 Elsevier Ireland Ltd. All rights reserved.

eywords: Cervical cancer; Chemotherapy; Quality of life; Topotecan

wdm

. Introduction

Cervical cancer is a worldwide health concern. The diag-

osis and treatment of this disease can have a profound impactn the quality of patients’ lives [1]. Maintenance of qualityf life (QoL) is, therefore, extremely important in women

∗ Tel.: +44 0161 446 3330; fax: +44 0161 446 3180.E-mail address: Susan.Davidson@christie.nhs.uk.

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040-8428/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.critrevonc.2010.07.002

ith cervical cancer, especially in those with advanced stageisease [2]. The median survival for patients with advancedetastatic or recurrent carcinoma of the cervix is reported

o be less than 6 months, with fewer than 20% surviving 1ear [3]. Women with advanced cervical cancer are known

o experience pain and QoL deficits as a result of diseaserogression, and QoL has been reported as poor and gener-lly lower than published norms in patients with advancedervical cancer [2].

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The modalities most commonly used to treat cervicalancer are surgery, radiotherapy and chemotherapy. Thesereatment options frequently have significant adverse effectsn physical comfort, body image, sexual function and fer-ility, and can have a profound impact on overall QoL [4].ompared with other gynaecological cancers, cervical can-er often affects younger women, at a mean age of 50 years.f cured, these women may have an additional life expectancyf 25–30 years; thus, it is important to ascertain the long-termmpact of treatment on QoL [5].

Inclusion of QoL as an outcome in clinical trials is impor-ant for assessing the full impact of cancer therapies onatients’ well-being. An understanding of the impact of aew therapy on patient QoL provides insight into whetherny survival benefit is justifiable when balanced against lim-tations of the therapy, such as adverse events. However, toate, few clinical trials have reported the impact of novelreatments on QoL for patients with gynaecological cancers2,4,6–11]. Protocol 204, reported by Wenzel et al. [12], wasnly the third Gynaecological Oncology Group (GOG) studyn cervical cancer to include QoL measures in a randomizedhemotherapy trial.

Awareness of the importance of health-related qualityf life (HRQoL) investigations is increasing and HRQoLeasures are now a key part of many cancer clinical

rial research programmes [6]. Tools used to measure QoLnclude self-assessment questionnaires, such as the Euro-ean Organization for Research and Treatment of CancerEORTC) QLQ-CX24 cervical cancer-specific QoL ques-ionnaire designed for use with EORTC C-30 [13]. Theseelf-assessment questionnaires usually include items onhysical, psychological and social function [8].

Measurement of QoL is associated with a variety of prob-ems. For example, some of the methodology is complicated;QoL tool may contain dozens of questions that can placeconsiderable burden on patients, particularly frail patients,nd this burden may even influence QoL outcomes [14]. Inddition, interpretation of QoL data is often inaccurate andebatable [15]. Quality of life is not directly linked to a par-icular level of tissue or organ damage caused by cancer, ands influenced by a range of factors, many of which are notonnected to any treatment modality, such as age, education,ime since diagnosis, extent of disease, marital status, copingtyle and patient expectations [15]. The majority of studies doot correct for such confounding variables. The experience ofisease often leads to a response shift over time: patients mayhange the evaluation of their QoL as a result of a shift in theirnternal criteria and values [5,16]. There is also controversys to what constitutes a clinically significant effect [14].

In view of the negative impact that treatment may have onoL, patients should be given high-quality information to aid

heir decision making and choice of treatment. It is important

hat QoL information is presented to patients and clinicians inays that are clearly understood. Measuring patients’ expe-

ience could be a mechanism for improving the quality ofervice.

stnT

gy/Hematology 79 (2011) 24–30 25

. Treatment options for cervical cancer

The majority of patients with early-stage invasive diseasestages IA2, IB1, and small stage IIA with no parametrialnvolvement) are treated with surgery, alone or with radiother-py. However, advanced disease (stages IIB2–IV) is seldomanaged surgically due to regional involvement and a high

elapse rate. Instead, these patients are treated with radiother-py, alone or in combination with chemotherapy [17,18]. Thisggressive early approach makes the treatment of relapsedisease problematic, as prior radiation treatment is knowno reduce the overall response rate (ORR) to subsequenthemotherapy. In one study, the response of cervical cancerying outside irradiated areas was nearly five times that of can-er within the previously irradiated area. Several explanationsre put forward to explain the difference in responses betweenn-field and metastatic relapse sites. Firstly, radiotherapy mayelect out drug-resistant as well as radiation-resistant clones.econdly, the severe disruption of blood vessels by high dosesf radiation may lead to reduced perfusion of relapsed can-er and, therefore, reduced concentrations of cytotoxic drugsithin the tumour [17].Chemotherapy is recommended for patients with

xtrapelvic metastases or recurrent disease who are not can-idates for radiotherapy or exenterative surgery [19]. Thentensity of the chemotherapy regimen used is largely depen-ent on the patient’s expected survival. Median survival foratients with advanced cervical cancer is reported as less thanmonths, with fewer than 20% surviving a year [3]. Thus,more aggressive approach may be used if chemotherapy is

ikely to improve survival. However, this increases the poten-ial for side effects that can have a severe negative impact onoL. It is, therefore, important to develop treatment strate-ies that minimize toxicity and maximize QoL [2]. Althoughmprovement in survival is desirable, palliative treatment,hich aims to improve QoL through early detection and

elief of distressing symptoms and psychosocial problems,s usually recommended for patients with terminal cancer20].

.1. Single-agent chemotherapy

Cisplatin has been considered the standard chemother-py regimen for the treatment of advanced/recurrent andetastatic cervical cancer for several decades [21]. It is also

he only single agent that demonstrates significant activ-ty in advanced cervical cancer [22,23]. When administeredntravenously at a dose of 50 mg/m2, multicentre trials haveeported ORRs ranging between 17.0 and 31%; however,hese responses are partial and short-lived, with a medianverall survival of 6–7 months [22,24].

A variety of other chemotherapeutic agents have shown

ignificant activity in patients with cervical cancer, includingopotecan, paclitaxel, vinorelbine and ifosfamide, althoughone have demonstrated survival advantages over cisplatin.he activities of single chemotherapeutic agents commonly

26 S. Davidson / Critical Reviews in Oncology/Hematology 79 (2011) 24–30

Table 1Single-agent activities of chemotherapy for the treatment of recurrent cervical cancer [adapted from [34]].

Drug Dosage n RR (%) Survival (months) PFS (months) Reference

Alkylating agentsCisplatin 50 mg/m2, q3w 164 17 6.2 – [24]

50 mg/m2/24 h, q3w 156 18 6.4 – [24]50 mg/m2, q3w 150 21 7.1 3.7 [22]100 mg/m2, q3w 166 31 7.0 4.6 [22]

Carboplatin 20 mg/m2, days 1–5, q3w 128 25 6.1 3.9 [22]Iproplatin 270 mg/m2/day, q4w 177 11 5.5 3 [25]

Topoisomerase inhibitorsTopotecan 1.5 mg/m2, days 1–5, q3w 43 19 6.4 2.4 [26]

1.5 mg/m2, days 1–5, q3w 41 12.5 6.6 2.1 [27]Irinotecan 125 mg/m2/week × 4 weeks, q6w 42 21 6.4 3 [28]Etoposide 37.5 mg/m2/day × 21 days, q4w 44 9.1 7.7 – [29]

AntimetabolitesGemcitabine 800 mg/m2, days 1, 8, 15, q4w 25 8 4.9 1.9 [30]

Antimicrotubule agentsVinorelbine 30 mg/m2/20 min/week 41 17 – – [31]

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R: response rate; PFS: progression-free survival; q3w: every 3 weeks; q4w

sed in the treatment of recurrent cervical cancer are reviewedn Table 1.

.2. Combination chemotherapy

Combination therapy with two or more agents is becom-ng an increasingly attractive option for cervical cancer, as itan produce higher ORRs and longer periods of remissionhan single agents [17]. Numerous combination regimensave been tested; however, few randomized controlled tri-ls have been performed that compared two- or three-drugombinations [17,34].

Cisplatin has been combined with a number of differenthemotherapeutic agents in Phase II trials of patients withervical cancer. In general, the addition of an active singlegent to cisplatin doubles the response rate but minimallyrolongs survival [35]. Reported response rates vary consid-rably, depending upon the treatment history of the patient:atients with no prior therapy have higher response rates com-ared with those with prior radiation therapy or chemotherapy35].

Several doublets have been evaluated in Phase III clin-cal trials, including bleomycin plus cisplatin, fluorouracillus cisplatin, paclitaxel plus cisplatin, ifosfamide plus cis-latin, gemcitabine plus cisplatin and topotecan plus cisplatinTable 2). When compared with single-agent cisplatin, theajority of doublets showed a response advantage over

isplatin alone. The combination of cisplatin with eitherfosfamide [3,36] or paclitaxel [37] is associated with

mprovements in both ORR and progression-free survivalPFS), but not overall survival. Ifosfamide plus cisplatin [3]esulted in a significantly greater ORR (31.1%) comparedith cisplatin monotherapy (17.8%; P = 0.004). Median PFS

omv

– 4.8 [32]7.3 – [33]

4 weeks; q6w: every 6 weeks.

mproved from 3.1 with cisplatin monotherapy to 6.4 monthsith the combination (P = 0.003). A subsequent compari-

on of ifosfamide plus cisplatin compared with a bleomycin,fosfamide, and cisplatin regimen confirmed the results forfosfamide plus cisplatin; however, it did not demonstrate andvantage in adding bleomycin to the doublet. In both clin-cal trials, the combination of ifosfamide and cisplatin wasssociated with unacceptable toxicity, including leucopenia,enal toxicity, peripheral neurotoxicity and central nervousystem toxicity [3,36]. The combination of paclitaxel plusisplatin also demonstrated significant improvements in ORRnd PFS: ORR was 36 and 19% for the combination regimennd cisplatin monotherapy, respectively (P = 0.002); medianFS improved from 2.8 to 4.8 months with the combinationP < 0.001).

Topotecan plus cisplatin is the only combination to showdvantages in terms of ORR, PFS and overall survival [38].n the GOG 179 Phase III study of patients with advancedr recurrent cervical cancer, median PFS with topotecan plusisplatin combination was 4.6 months, compared with 2.9onths for cisplatin monotherapy (relative risk [RR]: 0.76;= 0.014); this survival benefit was maintained even after

djusting for covariates, such as performance status, age andisease status, at entry. Overall response rate with topotecanlus cisplatin combination was 27%, compared with 13% forisplatin monotherapy (P = 0.004) in patients with advancedr recurrent cervical cancer; median survival was 9.4 versus.5 months, respectively (RR: 0.76; P = 0.017) [38]. On theasis of this activity, topotecan plus cisplatin was includedn GOG 204, a Phase III study in patients with advanced

r recurrent cervical cancer that attempted to find the opti-al cisplatin doublet. In the GOG 204 protocol, doublets of

inorelbine, gemcitabine and topotecan plus cisplatin were

S. Davidson / Critical Reviews in Oncology/Hematology 79 (2011) 24–30 27

Table 2Randomized Phase III trials of combination chemotherapy in recurrent cervical cancer [adapted from [34]].

Drugs Dosage n RR (%) Survival (months) PFS (months) Reference

P P: 50 mg/m2 iv, q3w 140 17.8 8 3.2 [3]versus P + MI P: 50 mg/m2 iv, day 1 147 21.1 7.3 3.3

MI: 180 mg/m2 po, days 2–6, q3wversus P + I P: 50 mg/m2 iv, day 1 151 31.1 8.3 4.6

I: 5 g/m2/24 h iv, day 1, q3w

P + I P: 50 mg/m2/h iv, day 1, q3w 146 31.2 8.5 4.6 [36]I: 5 g/m2/24 h iv, day 1, q3w

versus BIP B: 30 �g/24 h iv, day 1, q3w 141 31.2 8.4 5.1I: 5 g/m2/24 h iv, day 2, q3wP: 50 mg/m2 iv, day 1, q3w

P P: 50 mg/m2 iv, day 1, q3w 134 19 8.8 2.8 [37]versus P + T P: 50 mg/m2 iv, day 1, q3w 130 36 9.7 4.8

T: 135 mg/m2/24 h iv, day 1, q3w

P P: 50 mg/m2 iv, day 1, q3w 146 13 6.5 2.9 [38]versus P + Top P: 50 mg/m2 iv, day 1, q3w 147 27 9.4 4.6

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R: response rate; PFS: progression-free survival; P: cisplatin; iv = intravenoop: topotecan.

ompared with the paclitaxel plus cisplatin combination. Theesults of an interim analysis found that none of the doubletsemonstrated superiority in terms of overall survival com-ared with paclitaxel plus cisplatin; consequently, the studyas terminated early [39]. A replacement study for GOG 204as recently been proposed. The GOG 240 protocol, whichas a 2 × 2 factorial design, will compare the efficacy of cis-latin plus paclitaxel with or without bevacizumab versusopotecan plus paclitaxel with or without bevacizumab in 450atients with advanced cervical cancer.

. Importance of measuring quality of life in thessessment of combination regimens

.1. Combination chemotherapy

Combination therapy with two or more agents is becom-ng an increasingly attractive option for cervical cancer,s it can produce higher overall response rates than singlegents. However, combination therapy is often associatedith increased toxicity, which can have a significant impactn patient QoL [18]. In a recent systematic review, signifi-ant increases in Grade 3/4 adverse events, particularly severeaematological toxicities, were reported among patientsreated with combination chemotherapy [40].

Only three randomized controlled Phase III trials haveirectly assessed the impact of increased toxicity associ-ted with combination chemotherapy on patient QoL. Therst study, GOG 169, assessed cisplatin monotherapy versusaclitaxel plus cisplatin in patients with advanced cervicalancer. Myelotoxicity was reported to be increased in the

ombination arm; despite this, QoL scores were not signifi-antly affected [37].

The second study, GOG 179, compared cisplatinonotherapy with topotecan plus cisplatin in patients with

fo

: every 3 weeks; MI: mitolactol; I: ifosfamide; B: bleomycin; T: paclitaxel;

dvanced disease [2,23,38]. Topotecan is currently licensedor the treatment of ovarian cancer and is well tolerated;ssociated haematological toxicity is predictable, generallyanageable, reversible and non-cumulative. The dose-

imiting toxicity of intravenous topotecan, as established inarly dose-finding studies, is haematological (largely neu-ropenia) [21]. Significant toxicity was reported for theombination of topotecan and cisplatin in the GOG 179tudy; 70% of patients experienced Grade 3/4 neutropenia,8% febrile neutropenia and 46% Grade 3/4 thrombocy-openia [23,35]. Despite the significantly higher incidencef haematological events in patients treated with combina-ion therapy, QoL did not differ between this group and theisplatin monotherapy group. The mean Functional Assess-ent of Cancer Therapy–General (FACT-G) score 9 months

fter randomization was 74.4 with cisplatin plus topotecan,ompared with 74.5 with cisplatin monotherapy; the QoLssessment used in this study was reliable in terms of sensi-ivity to detect clinically significant differences in QoL overime [23].

The third Phase III study to directly assess the impact ofombination therapy on patient QoL was GOG 204. Thistudy compared vinorelbine, gemcitabine and topotecan plusisplatin doublets with paclitaxel plus cisplatin in patientsith advanced cervical cancer [12,39]. The results of an

nterim analysis recently reported at the American Society oflinical Oncology annual meeting, indicate that QoL scores

or all three doublets were not statistically different fromaclitaxel plus cisplatin [12].

.2. Chemoradiotherapy

Chemoradiotherapy has been a standard treatment optionor advanced cervical cancer for over a decade on the basisf evidence from five separate studies [41–45]. A number of

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eta-analyses of such trials have since confirmed the ben-fits of combining treatment modalities showing increasedurvival with chemoradiotherapy versus control with bothlatinum- and non-platinum-based agents [46,47]. Signifi-ant reductions in local tumour recurrence were confirmedut meta-analyses also revealed a highly significant reduc-ion in the rate of distant metastases that was not evident inhe individual trials [47,48]. Chemoradiotherapy was associ-ted with greater toxicity with significant increases in grade 3nd 4 haematological and gastrointestinal events [49]. Radio-herapy is known to compromise bone marrow reserves, ashe radiotherapy fields in the pelvis cover marrow-containingone. Consequently, haematological toxicity may be morerequent in these patients, which may have a serious impactn QoL.

However, very few studies have evaluated QoL withhemoradiotherapy in patients with cervical cancer to date.agy et al. compared two chemoradiotherapy regimens thatiffered in their use of cisplatin (20 mg/m2 q5 every 21 daysarm A) versus weekly 40 mg/m2 (arm B)) in 335 patientsith locally advanced cervical carcinoma over 5 weeks [50].uality of life was measured by the European Organisation

or Research and Treatment of Cancer (EORTC) quality ofife questionnaire (C30; version 3.0). While global health sta-us improved in arm A, emotional functioning deterioratednd the incidence of stress and depression were higher inoth arms. Fatigue was significantly higher with weekly cis-latin compared with the cyclical delivery, possibly due tosignificantly higher rate of anaemia with the weekly reg-

men. Kobayashi et al. reported on an evaluation of QoL inomen with cervical cancer (Stage 0–IV) who had undergone

adiotherapy (n = 33), chemoradiotherapy (n = 18) or postop-rative radiotherapy (n = 9) [51]. Mean duration of follow-upince treatment initiation was 33 months (range 6.3–129.2onths). Assessment by FACT-G and the Hospital Anxiety

nd Depression Scale showed revealed a trend towards pooreroL and increased depression with chemoradiation, but theseifferences were not clinically or statistically significant.

Further study of QoL in large-scale, randomized trialss required to determine the true impact of chemoradiationn women with cervical cancer. Longitudinal data are alsoequired since it is well known that late complications ofadiotherapy increase with time and are difficult to man-ge [47]; therefore, the impact of chemoradiation on qualityf life may be delayed. Strategies that could potentiallymprove the quality of life of patients include the selection ofhemotherapeutic agents with an improved safety profile [52]r pelvic bone marrow-sparing radiotherapy techniques thatould reduce associated haematological toxicity [53,54].

. Conclusion

Single-agent cisplatin has remained the stan-ard chemotherapeutic agent for the treatment ofdvanced/recurrent cervical cancer for several decades.

gy/Hematology 79 (2011) 24–30

owever, there is increasing interest in new chemotherapygents and combinations, as well as combined radio- andhemotherapy to improve response rates in patients withdvanced/recurrent disease. A variety of combinations haveeen investigated, and it has become clear that the increasedesponse rates observed are frequently accompanied byncreased treatment-related toxicities.

Maintenance of QoL is very important in patients with cer-ical cancer, and particularly those with advanced disease, somproved response rates with newer agents/combination ther-pies should not come at the expense of unacceptable toxicity.o date, few clinical trials of combination chemotherapy for

reatment of cervical cancer have directly assessed QoL, andhose that have assessed this endpoint have found no sig-ificant difference between regimens. One combination thatas produced encouraging results in Phase III trials is topote-an combined with cisplatin. This combination demonstratedncreased ORR, PFS and overall survival compared with cis-latin alone. Although significant toxicity was reported forhis combination, there was again no significant impact onoL.The issues of tolerability and patients’ HRQoL need

o be considered when selecting chemotherapy regimensor patients with advanced cervical cancer. In view ofhe increased potential for toxicity when chemotherapeuticgents are combined, future clinical trials of combinationherapy should include assessment of patient QoL.

onflict of interest statement

The author has no conflict of interest to declare.

eviewers

Dr. R.P. Symonds, Reader Consultant in Clinical Oncol-gy, Leicester Royal Infirmary, Dept. of Clinical Oncology,sborne Building, Leicester, LE1 5WW United Kingdom.Dr. Jane Orton, Consultant Clinical Oncologist, St James’

niversity Hospital, Oncology Department, Bexley Wing,ecket Street Leeds, LS9 7TF United Kingdom.

cknowledgements

The author would like to thank Dr Melanie Down, Medicusnternational, for her editorial assistance. GlaxoSmithKlinerovided funding for editorial assistance.

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iography

Susan Davidson obtained her M.D. on prognostic indi-ators for radiotherapy outcome in cervix cancer. She hasorked at the Christie Hospital in Manchester as a clini-

al oncologist since 1990, specializing in the treatment ofynaecological cancers. Current research involves outcomeeasures of cancer treatment and establishing a clinical tool

or treatment effects and clinical trials in gynaecological can-er. She is a member of the NCRI Clinical Study Groups

gynaecology and cross-cutting) and a member of the Lateffects Working Group of the National Cancer Survivorship

nitiative led by NHS Improvement.