ABSTRACT
BACKGROUND: Immune markers have been correlated with prognosis in a variety of solid tumors, including cervical cancer. OBJECTIVE: To review the literature on hematologic and immune markers and their association with recurrence and survival among patients with cervical cancer treated with chemoradiation. EVIDENCE REVIEW: This systematic review was conducted in accordance with PRISMA guidelines via searches of Ovid MEDLINE, Ovid Embase, and the Cochrane Library using keywords regarding cervical cancer, immune markers, and HIV. Studies involving patients treated with cisplatin-based chemoradiotherapy were selected and reviewed by at least two independent reviewers, with disagreements resolved by a third reviewer. FINDINGS: A total of 737 studies were identified, of which 314 assessed immune biomarkers in immunocompetent patients (30 included in the final analysis) and 327 studies in immunosuppressed patients (5 included in the final analysis). The strongest prognostic indicators were lymphopenia and elevated neutrophil-to-lymphocyte ratio. Other potential markers included HPV-specific lymphocyte response, cytokine profile, expression of immune-blocking antigens on cell surfaces, and tumor-associated lymphocyte, macrophage, and neutrophil infiltration. Studies of immunosuppressed patients described more severe cytopenic changes overall and concluded that viral suppression led to improved outcomes. CONCLUSIONS: The immunologic interplay at work in cervical cancer development, progression, and treatment is complex. Strong evidence was found in favor of lymphopenia and elevated neutrophil-to-lymphocyte ratio being prognostic for worse outcomes with other markers showing potential associations as well. Although the interpretation of immune status with regard to treatment approach remains unclear, future studies should aim to tailor treatment that minimizes possible detrimental immune effects.
Subject(s)
Chemoradiotherapy , Neoplasm Recurrence, Local/immunology , Uterine Cervical Neoplasms/immunology , Uterine Cervical Neoplasms/therapy , Antineoplastic Agents/therapeutic use , Biomarkers, Tumor/immunology , Cisplatin/therapeutic use , Female , HIV Infections/immunology , Humans , Immunocompetence , Immunocompromised Host , Lymphocytes/cytology , Lymphocytes/immunology , Lymphopenia/mortality , Monitoring, Immunologic , Neoplasm Recurrence, Local/mortality , Neutrophils/cytology , Neutrophils/immunology , Prognosis , Radiation-Sensitizing Agents/therapeutic use , Treatment Outcome , Tumor Microenvironment/immunology , Uterine Cervical Neoplasms/mortalityABSTRACT
Cervical cancer incidence and mortality rates are significantly higher in low- and middle-income countries compared with the United States and other developed countries. This disparity is caused by decreased access to screening, often coupled with low numbers of trained providers offering cancer prevention and treatment services. However, similar disparities are also found in underserved areas of the United States, such as the Texas-Mexico border, where cervical cancer mortality rates are 30% higher than in the rest of Texas. To address these issues, we have adopted the Project ECHO (Extension for Community Healthcare Outcomes) program, a low-cost telementoring model previously proven to be successful in increasing local capacity, improving patient management skills, and ultimately improving patient outcomes in rural and underserved areas. We use the Project ECHO model to educate local providers in the management of cervical dysplasia in a low-resource region of Texas and have adapted it to inform strategies for the management of advanced cervical and breast cancer in Latin America and sub-Saharan Africa. This innovative approach, using ECHO, is part of a larger strategy to enhance clinical skills and develop collaborative projects between academic centers and partners in low-resource regions.
