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Quimioterapia adyuvante después de quimiorradiación concurrente para el cáncer de cuello de útero localmente avanzado

Appendices

Appendix 1. CENTRAL

 #1  MeSH descriptor: [Uterine Cervical Neoplasms] this term only
#2  (cervi* near/5 (cancer* or neoplas* or carcinoma* or tumor* or tumour* or malignan*))
#3  #1 or #2
#4  Any MeSH descriptor with qualifier(s): [Radiotherapy ‐ RT]
#5  MeSH descriptor: [Radiotherapy] explode all trees
#6  MeSH descriptor: [Chemoradiotherapy] explode all trees
#7  (radiotherap* or radiat* or irradiat* or chemoradi* or radiochemo*)
#8  #4 or #5 or #6 or 7
#9  Any MeSH descriptor with qualifier(s): [Drug therapy ‐ DT]
#10 MeSH descriptor: [Antineoplastic Agents] explode all trees
#11 MeSH descriptor: [Antineoplastic Combined Chemotherapy Protocols] this term only
#12 MeSH descriptor: [Chemotherapy, Adjuvant] explode all trees
#13 chemo*
#14 #9 or #10 or #11 or #12 or #13
#15 #3 and #8 and #14

Appendix 2. MEDLINE search strategy

1.       Uterine Cervical Neoplasms/
2.       (cervi* adj5 (cancer* or neoplas* or carcinoma* or tumor* or tumour* or malignan*)).mp.
3.       1 or 2
4.       radiotherapy.fs.
5.       exp Radiotherapy/
6.       exp Chemoradiotherapy/
7.       (radiotherap* or radiat* or irradiat* or chemoradi* or radiochemo*).mp.
8.       4 or 5 or 6 or 7
9.       drug therapy.fs.
10.    exp Antineoplastic Agents/
11.    Antineoplastic Combined Chemotherapy Protocols/
12.    Chemotherapy, Adjuvant/
13.    chemo*.mp.
14.    9 or 10 or 11 or 12 or 13
15.    3 and 8 and 14
16.    randomized controlled trial.pt.
17.    controlled clinical trial.pt.
18.    randomized.ab.
19.    placebo.ab.
20.    clinical trials as topic.sh.
21.    randomly.ab.
22.    trial.ti.
23.    16 or 17 or 18 or 19 or 20 or 21 or 22
24.    15 and 23
25.    exp animals/ not humans.sh.
26.    24 not 25

key: mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier, pt=publication type, ab=abstract, ti=title, sh=subject heading, fs=floating subheading, exp=exploded term

Appendix 3. EMBASE

1.     exp uterine cervix tumor/
2.     (cervi* adj5 (cancer* or neoplas* or carcinoma* or tumor* or tumour* or malignan*)).mp.
3.     1 or 2
4.     rt.fs.
5.     exp radiotherapy/
6.     exp chemoradiotherapy/
7.     (radiotherap* or radiat* or irradiat* or chemoradi* or radiochemo*).mp.
8.     4 or 5 or 6 or 7
9.     dt.fs.
10.  exp antineoplastic agent/
11.  exp chemotherapy/
12.  chemo*.mp.
13.  9 or 10 or 11 or 12
14.  3 and 8 and 13
15.  crossover procedure/
16.  double‐blind procedure/
17.  randomized controlled trial/
18.  single‐blind procedure/
19.  random*.mp.
20.  factorial*.mp.
21.  (crossover* or cross over* or cross‐over*).mp.
22.  placebo*.mp.
23.  (double* adj blind*).mp.
24.  (singl* adj blind*).mp.
25.  assign*.mp.
26.  allocat*.mp.
27.  volunteer*.mp.
28.  15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27
29.  14 and 28
30.  (exp animal/ or nonhuman/ or exp animal experiment/) not human/
31.  29 not 30

 key: [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]

Appendix 4. The Cochrane Collaboration tool for assessing risk of bias in included studies

Random sequence generation

  • Low risk of bias: e.g. participants assigned to treatments on basis of a computer‐generated random sequence or a table of random numbers.

  • High risk of bias: e.g. participants assigned to treatments on basis of date of birth, clinic ID number or surname or no attempt to randomly assign participants.

  • Unclear risk of bias: e.g. not reported, information not available.

Allocation concealment

  • Low risk of bias: e.g. where the allocation sequence could not be foretold.

  • High risk of bias: e.g. allocation sequence could be foretold by participants, investigators or treatment providers.

  • Unclear risk of bias: e.g. not reported.

Blinding of participants and personnel (not applicable)

Blinding of outcomes assessors

  • Low risk of bias if outcome assessors were adequately blinded.

  • High risk of bias if outcome assessors were not blinded to the intervention that the participant received.

  • Unclear risk of bias if this was not reported or was unclear.

Incomplete outcome data

We recorded the proportions of participants whose outcomes were not reported at the end of the study. We coded a satisfactory level of loss to follow‐up for each outcome as follows.

  • Low risk of bias if less than 20% of participants were lost to follow‐up and reasons for loss to follow‐up were similar in both treatment arms.

  • High risk of bias if more than 20% of participants were lost to follow‐up or reasons for loss to follow‐up differed between treatment arms.

  • Unclear risk of bias if loss to follow‐up was not reported.

Selective reporting of outcomes

  • Low risk of bias: e.g. review reports all outcomes specified in the protocol.

  • High risk of bias: e.g. it is suspected that outcomes have been selectively reported.

  • Unclear risk of bias: e.g. it is unclear whether outcomes had been selectively reported.

Other bias

  • Low risk of bias if no source of bias is suspected and the trial appears to be methodologically sound.

  • High risk of bias if the trial is suspected to have an additional bias.

  • Unclear risk of bias if it is uncertain whether an additional bias may have been present.

Adopted from Higgins 2011.

Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

Forest plot of comparison: 1 Survival, outcome: 1.1 Progression‐free survival.
Figuras y tablas -
Figure 2

Forest plot of comparison: 1 Survival, outcome: 1.1 Progression‐free survival.

Forest plot of comparison: 1 Survival, outcome: 1.2 Overall survival.
Figuras y tablas -
Figure 3

Forest plot of comparison: 1 Survival, outcome: 1.2 Overall survival.

Forest plot of comparison: 2 Failure after treatment, outcome: 2.1 Total failure after treatment.
Figuras y tablas -
Figure 4

Forest plot of comparison: 2 Failure after treatment, outcome: 2.1 Total failure after treatment.

Forest plot of comparison: 2 Failure after treatment, outcome: 2.2 Local failure.
Figuras y tablas -
Figure 5

Forest plot of comparison: 2 Failure after treatment, outcome: 2.2 Local failure.

Forest plot of comparison: 2 Failure after treatment, outcome: 2.3 Distant failure.
Figuras y tablas -
Figure 6

Forest plot of comparison: 2 Failure after treatment, outcome: 2.3 Distant failure.

Forest plot of comparison: 3 Adverse events, outcome: 3.1 Anaemia.
Figuras y tablas -
Figure 7

Forest plot of comparison: 3 Adverse events, outcome: 3.1 Anaemia.

Forest plot of comparison: 3 Adverse events, outcome: 3.2 Thrombocytopenia.
Figuras y tablas -
Figure 8

Forest plot of comparison: 3 Adverse events, outcome: 3.2 Thrombocytopenia.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 9

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 10

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Survival, Outcome 1 Progression‐free survival.
Figuras y tablas -
Analysis 1.1

Comparison 1 Survival, Outcome 1 Progression‐free survival.

Comparison 1 Survival, Outcome 2 Overall survival.
Figuras y tablas -
Analysis 1.2

Comparison 1 Survival, Outcome 2 Overall survival.

Comparison 2 Failure after treatment, Outcome 1 Total failure after treatment.
Figuras y tablas -
Analysis 2.1

Comparison 2 Failure after treatment, Outcome 1 Total failure after treatment.

Comparison 2 Failure after treatment, Outcome 2 Local failure.
Figuras y tablas -
Analysis 2.2

Comparison 2 Failure after treatment, Outcome 2 Local failure.

Comparison 2 Failure after treatment, Outcome 3 Distant failure.
Figuras y tablas -
Analysis 2.3

Comparison 2 Failure after treatment, Outcome 3 Distant failure.

Comparison 3 Adverse events, Outcome 1 Anaemia.
Figuras y tablas -
Analysis 3.1

Comparison 3 Adverse events, Outcome 1 Anaemia.

Comparison 3 Adverse events, Outcome 2 Thrombocytopenia.
Figuras y tablas -
Analysis 3.2

Comparison 3 Adverse events, Outcome 2 Thrombocytopenia.

Table 1. Survival outcome

Study

Lordvithaya

Dueñas‐Gonzalez

N (CCRT versus CCRT/ACT)

233 versus 230

256 versus 259

FU

89 months

46.9 months

Outcomes (CCRT versus CCRT/ACT)

 

 

1.        OS

 

 

·         3‐year OS

85% versus 79% (estimated from graph), P value NS

HR 1.309, 95% CI 0.795 to 2.157 (by Parmar method)

69% versus 78% (estimated from graph)

HR 0.68, 95% CI 0.49 to 0.95, P value 0.0224

·         5‐year OS        

82.7% (79.0 to 86.4) versus 73.6 (67.1 to 80.1), P value NS

2.        PFS

 

 

·         3‐year PFS

68% versus 63% (estimated from graph), P value NS

HR 1.125, 95% CI 0.799 to 1.586 (by Parmar method)

65.0% (58.5 to 70.7) versus 74.4 % (68 to 79.8)

HR 0.68, 95% CI 0.49 to 0.95), P value 0.0227

·         5‐year PFS

64.5% (60.6 to 68.0) versus 59.7% (53.6 to 65.8), P value NS

Figuras y tablas -
Table 1. Survival outcome
Table 2. Recurrence

Study

Lordvithaya

Dueñas‐Gonzalez

N (CCRT versus CCRT/ ACT)

233 versus 230

256 versus 259

·         Local (with or without DR)

31 (14.3%) versus 36 (17.6%), P value NS

16.4% versus 11.2%, P value 0.097

·         Distant (with or without LR)

38 (17.7%) versus 40 (19.5%), P value NS

16.4% versus 8.1%, P value 0.005

·         Local and/ or distant

63 (29.0%) versus 64 (31.2%), P value NS

 ‐

Figuras y tablas -
Table 2. Recurrence
Table 3. Response rate

Study

Lordvithaya

Dueñas‐Gonzalez

Response rate

NA

93.4 (89.6 to 96.1) in CCRT arm versus 95.8 (92.5 to 97.9) in CCRT + ACT arm, P value 0.249

Figuras y tablas -
Table 3. Response rate
Table 4. Acute adverse event

Adverse events/Study

Lordvithaya

n (%)

Dueñas‐Gonzalez

n (%)

CCRT

(N = 218)

CCRT + ACT

(N = 211)

CCRT

(N = 255)

CCRT + ACT

(N = 260)

Acute adverse event (grade 1 to 2)

1. Haematological

  • Leucopenia

110 (50.4)

139 (65.8)

NA

  • Anaemia

137 (62.8)

142 (67.3)

86 (33.8)

128 (49.3)

  • Neutropenia

NA

62 (24.3)

80 (30.8)

  • Febrile neutropenia

NA

0

1 (0.4)

  • Thrombocytopenia

56 (25.7)

70 (33.5)

26 (10.2)

58 (32.4)

  • Haemorrhage

NA

NA

2. Gastrointestinal

  • Nausea

NA

148 (58.0)

153 (58.8)

  • Vomiting

NA

116 (45.5)

129 (49.6)

  • Anorexia

NA

37 (14.5)

46 (17.7)

  • Diarrhoea

NA

119 (46.7)

121 (46.5)

  • Liver

NA

6 (1.6)

33 (12.6)

  • Proctitis

NA

20 (7.9)

29 (11.2)

3. Genitourinary (increased Cr level)

NA

2 (0.8)

5 (1.9)

4. Skin

NA

40 (15.7)

45 (17.3)

5. Neurological

NA

NA

6. Pulmonary

NA

NA

Acute adverse event (grade 3 to 4)

1. Haematological

  • Leucopenia

9 (4.1)

6 (2.9)

NA

  • Anaemia

0

5 (2.0)

24 (9.2)

  • Neutropenia

NA

15 (5.9)

133 (51.2)

  • Febrile neutropenia

NA

1 (0.4)

6 (2.3)

  • Thrombocytopenia

5 (2.3)

3 (1.5)

3 (1.2)

16 (6.2)

  • Haemorrhage

NA

NA

2. Gastrointestinal

  • Nausea

NA

7 (2.7)

11 (4.2)

  • Vomiting

NA

7 (2.8)

20 (7.7)

  • Anorexia

NA

0

1 (0.4)

  • Diarrhoea

NA

12 (4.7)

46 (17.7)

  • Liver

NA

0

4 (1.6)

  • proctitis

NA

1 (0.4)

9 (3.5)

3. Genitourinary (increased Cr level)

NA

2 (0.8)

4 (1.5)

4. Skin

NA

27 (10.6)

29 (11.2)

5. Neurological

NA

NA

6. Pulmonary

NA

NA

Figuras y tablas -
Table 4. Acute adverse event
Table 5. Late adverse event

Study

Lordvithaya

n (%)

Dueñas‐Gonzalez

n (%)

Late adverse event (grade 3 to 4)

1. Bowel

3.1% vs 5.8%

1 (0.5) vs 5 (2.3)

2. Bladder

1 (0.5) vs 3 (1.4)

3. Mucous membrane

NA

1 (0.5%) vs 1 (0.5)

4. Subcutaneous

0 vs 1 (0.5)

Figuras y tablas -
Table 5. Late adverse event
Comparison 1. Survival

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Progression‐free survival Show forest plot

2

Hazard Ratio (Fixed, 95% CI)

Totals not selected

2 Overall survival Show forest plot

2

Hazard Ratio (Fixed, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 1. Survival
Comparison 2. Failure after treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total failure after treatment Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Local failure Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

3 Distant failure Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 2. Failure after treatment
Comparison 3. Adverse events

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Anaemia Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Thrombocytopenia Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 3. Adverse events