Terapi Kanker Serviks Stadium Lanjut: Standar Baru CCRT + Imunoterapi Pembrolizumab

by Dr. dr. Brahmana Askandar, Sp.OG (K) 

Cervical cancer is divided into several stages. Simply put:

• Early stage: The cancer is still very small and confined to the cervix.
• Locally advanced stage: The cancer has enlarged or begun to spread to surrounding tissue, but has not spread far. This is the most common stage in Indonesia.
• Advanced stage: The cancer has spread to distant organs.

In the early stages, surgery is still possible. However, in the locally advanced and advanced stages, surgery is no longer an option because the cancer has spread too widely.

How is locally advanced cervical cancer treated?

In the past, patients at this stage only received radiation. Even in the past, gynecologists manually administered radium—a practice no longer used today.

Today, the modern and best treatment standard is a combination of three therapies:

1. External radiation
2. Weekly chemotherapy with low-dose cisplatin, given 5–6 times
3. Brachytherapy (internal radiation)

This combination of three therapies is called CCRT (Concurrent Chemoradiotherapy). It is the international standard for locally advanced cancer.

The addition of weekly cisplatin has been shown to provide significant benefits:

• Increases survival by 10–15%
• Reduces the risk of cancer recurrence, both in the pelvis and distantly related to the initial site.

Newest Therapy: Combination of CCRT + Pembrolizumab Immunotherapy

The latest development in medicine is the addition of an immunotherapy called pembrolizumab alongside CCRT.

A large study, Keynote A-18, showed that:

• Patients receiving pembrolizumab plus CCRT had a longer progression-free survival (progression-free survival) than patients receiving CCRT alone.
• The risk of disease progression decreased by 30%.
• The risk of death decreased by 33%.

Due to strong research results, this combination is now considered the new standard of care for locally advanced stage disease.

Who can receive pembrolizumab therapy?

• Locally advanced stage IB3, IIB-IVA

Dosage Scheme:

1. During CCRT: Pembrolizumab 200 mg every 3 weeks, 5 times a day.
2. After CCRT (maintenance): Pembrolizumab 400 mg every 6 weeks, 15 times a day.

Pembrolizumab Availability & Cost

• Already available in Indonesia
• Not yet covered by BPJS
• Some private insurance plans cover it
• Price at one online pharmacy: approximately IDR 68 million per 100 mg
  This translates to:
  200 mg = approximately IDR 136 million per infusion
  400 mg = approximately IDR 272 million per infusion

Time is a key factor.

Besides the type of therapy, the speed at which the therapy is completed is crucial for treatment outcomes.

• If the total duration of therapy is longer than 9–10 weeks, the risk of cancer recurrence in the pelvic area is significantly higher.
• Ideally, the total course of external radiation therapy plus brachytherapy should be completed within 6–7 weeks, with a maximum of 8 weeks.

The sooner the completion, the better the results.

Conclusion: Current Standards for Treatment of Locally Advanced Cervical Cancer

1. External Radiation
2. Weekly Cisplatin 40 mg/m² for 5–6 weeks
3. Brachytherapy (internal radiation)
4. Pembrolizumab
   200 mg every 3 weeks × 5 times during CCRT
   400 mg every 6 weeks × 15 times as maintenance

This is a snapshot of the latest treatment options for advanced cervical cancer worldwide.
The challenge lies in the disparity in access and cost between developed and developing countries. Without funding solutions, the gap in treatment outcomes will widen.

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