Authors’ reply

Dear Editor, We would like to thank Lowe-Zinola and co-authors for their interest in our article and for the opportunity to respond to the queries raised. We respond to them directly below. Interestingly, you have highlighted the area of treatment for women in pregnancy that we too identified as challenging, i.e. FIGO stage IIA and IB3 (FIGO 2018). It goes without saying that counselling cancer patients in various stages of pregnancy regarding their management decisions is never easy. The paucity of evidence for treatment of all cancers in pregnancy contributes to a distinct lack of guidance and hence leaves treatment options open to discussion, but, most importantly, also allows for individualised care. The randomised controlled trial (RCT) performed by Gupta et al. concluded thatCisplatin-based concomitant chemoradiation resulted in superior disease-free survival (DFS) compared with neoadjuvant chemotherapy followed by radical surgery in locally advanced cervical cancer. This study was designed on the presumption that neoadjuvant chemotherapy would substantially reduce the risk of distant recurrence and facilitate local control when compared with local chemo-radiation. The difference in DFS did not reach statistical significance. Furthermore, the study results did not suggest a difference in Overall Survival between the two groups (OS). As one armof the study includes full pelvic radiotherapy (associated with spontaneous abortion, congenital malformations and paediatric malignancy in pregnancy), extrapolating these results to a pregnant population with locally advanced disease would not be suitable. By the authors’ admission, this study was not powered to definitively assess differences in treatment strategies in operable cervical cancer i.e stage 1B2, 1B3 and stage 2A, which perhaps would have been more relevant to our own practice in the UK. The Uterus-11 Trial group excluded pregnant and lactating women from their study. For this reason, once again, it is very difficult to extrapolate the results to the pregnant population. Surgical staging for locally advanced cervical cancer has always been a contentious topic. However, the recent editorial in the International Journal of Gynaecological Cancer reaffirms that surgical staging for locally advanced disease offers no benefit to patients. Once again, we thank you for the interest in our article.