Fire Both Barrels

By Christine Gorman

For just the fourth time in the past 10 years, the National Cancer Institute last week called for an immediate change in the way doctors treat a particular type of cancer. The disease in question is cancer of the cervix, located at the opening of the uterus. Researchers at the institute recommended attacking moderately advanced cases with a combination of chemotherapy and radiation rather than the current standard of radiation alone. This new thinking is based on the results of five as-yet-unpublished studies of 1,900 women with cervical cancer, which show that simultaneous chemotherapy and radiation reduced the women's risk of dying from their tumors by 30% to 50%.

Three of the studies are scheduled to appear in the April 15 issue of the New England Journal of Medicine, but have already been released on the Web at www.nejm.org The new recommendation does not apply to women whose cervical abnormalities are detected at the earliest stages and can be treated by hysterectomy or biopsy. And women who have finished radiation treatment should not go back for chemotherapy.

Each year in the U.S. about 13,000 women develop cervical cancer and 4,800 die, making it the 11th leading cancer killer of American women. In 40% of newly diagnosed cases, the cancer has spread far enough that it requires treatment with radiation, says Dr. Edward Trimble, a gynecological oncologist at the NCI. "If all those women also received chemotherapy, we could probably save 1,000 to 2,000 lives" a year, he notes.

Researchers aren't sure why chemotherapy boosts the effectiveness of radiation, though they have an idea. Radiation damages the DNA found in cancer cells. But all cells, including cancer cells, contain enzymes that repair broken DNA. Perhaps the drugs used in chemotherapy block the cellular repairmen from doing their job. The damaged DNA never gets fixed, and the cancer cells die.

All five studies had the best results with a platinum-based drug, like cisplatin. Side effects of this treatment include nausea, vomiting and low red and white blood-cell counts, but not hair loss.

Still, an ounce of prevention--or at least early detection--is worth a gallon of cancer-fighting drugs. Ever since the introduction in the 1950s of the Pap-smear test, which allows doctors to detect changes in the cervix before the tissue becomes malignant, both the incidence of cervical cancer and its death rate have plummeted in industrialized countries. (One out of two American women who develop invasive cervical cancer have not had a Pap test in the preceding five years.) Unfortunately, cervical cancer is more common in poorer parts of the world, and among underinsured and uninsured Americans.

To reduce the risk of cervical cancer, all women should get a Pap smear annually, starting at 18 or whenever they first have sex. (More than 90% of cervical cancers are caused by a common virus that is sexually transmitted, although only a fraction of infected women develop the malignancy.) If you have normal tests three years in a row, you may, at your doctor's discretion, begin having them less frequently. But don't be fooled into thinking you no longer need a Pap smear after menopause. As long as you have a cervix, you need to get tested.

For more on the cervical-cancer studies, click on News at cancertrials.nci.nih.gov/ E-mail Christine at gorman@time.com