Neoadjuvant immune checkpoint blockade before chemoradiation for cervical squamous carcinoma (GINECO window-of-opportunity COLIBRI study): a phase II trial

Domain: biology
Published: 2026-01-05
Editorial outcome: minor_revision

Abstract
Combining immunotherapy with chemoradiation is effective in locally advanced cervical cancer. However, the impact of induction combination immunotherapy on immune modulation and treatment response is poorly understood. In this phase II trial (NCT04256213), 40 females with locally advanced cervical carcinoma received one cycle of nivolumab-plus-ipilimumab immunotherapy before standard chemoradiation, followed by maintenance nivolumab. We show, using multiplex-immunofluorescence tissue imaging, a significantly increased CD8+/FOXP3+ cell ratio (primary endpoint; increase of 0.87 cells/mm², P = 0.0164) and proliferative CD8+ T-cell density after one cycle of combination immunotherapy. HOT score (27-gene-based signature identifying immunologically active tumors) also increased significantly (exploratory analysis; 0.17, P < 0.0001). Objective response rates (secondary endpoint) were 13% immediately after combination immunotherapy, 98% (65% complete response) after chemoradiation, and 90% at treatment completion. High HOT score at baseline and immune changes induced by combination immunotherapy were associated with complete response at treatment completion. Induction immunotherapy may prime tumors for improved response to standard therapy.

Introduction
Cisplatin-based chemoradiation is the standard of care for locally advanced cervical cancer (LACC). However, up to 30% of patients with high-risk LACC experience recurrence within 2 years, cure is rare, and improved treatment for LACC remains an area of unmet need. Established prognostic factors include International Federation of Gynecology and Obstetrics (FIGO) stage, pathologic tumor type, nodal status, and lymphovascular space invasion1. Outcomes in patients with pelvic and para-aortic lymph node metastases are particularly poor.

Neoadjuvant chemotherapy modulates the immune microenvironment in LACC, promoting anti-cancer immunity by increasing tumor-infiltrating effector lymphocytes (CD8+ Teffs) at the expense of regulatory T cells (forkhead box P3 [FOXP3]+ Tregs)2. Indeed, a high tumor CD8+/FOXP3+ cell ratio, as assessed by immunohistochemistry, was associated with better clinical outcomes after platinum-based neoadjuvant chemotherapy in a retrospective study of patients with LACC2.

Immune checkpoint blockade (ICB) combined with chemotherapy is the standard first-line treatment for recurrent, persistent, or metastatic cervical cancer. Randomized phase III trials have demonstrated an overall survival (OS) benefit with the addition of either pembrolizumab (KEYNOTE-826) or atezolizumab (BeatCC) to chemotherapy (with or without bevacizumab)3–5. In high-risk LACC, the phase III CALLA trial failed to demonstrate a significant progression-free survival (PFS) benefit from durvalumab given in combination with and following chemoradiotherapy6. However, pembrolizumab significantly improved PFS and OS when combined with chemoradiation for high-risk LACC in the ENGOT-cx11/GOG-3047/KEYNOTE-A18 trial7,8. A better understanding of the impact of ICB on the tumor microenvironment will help in refining immunotherapy approaches and patient selection with the goal of improving clinical outcomes.

When immunotherapy is given before local therapy (surgery or radiotherapy), the presence of the tumor in situ provides a source of antigens that may favor potent reinvigoration of tumor-specific T cells with ICB. In several cancer types, accumulating evidence indicates that neoadjuvant immunotherapy may expand tumor-specific T-cell clones and modify their transcriptional features9. This can lead to a more robust anti-tumor immune response and a greater number of functional effector T cells (Teffs) able to recirculate and ready to fight cancer cells, even after local therapy10. The neoadjuvant setting also provides a unique opportunity to elucidate the impact of immunotherapy on the tumor immune microenvironment in LACC. In the phase I GOG-9929 study, chemoradiation followed by two doses of the cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) inhibitor ipilimumab for node-positive human papillomavirus (HPV)-related LACC was associated with activation of immune cells in blood, and a significant expansion of central and effector memory T-cell populations11. However, in this study, the impact of immunotherapy alone before chemotherapy was not investigated.

High CTLA-4 transcript expression is common in cervical cancer and correlates significantly with high PD-1 RNA levels12. Co-expression of PD-1 and CTLA-4 is associated with more severe dysfunction of tumor-specific CD8+ T cells13. In in vivo models, dual PD-1 and CTLA-4 blockade reversed tumor-infiltrating lymphocyte dysfunction, increased proliferation of CD8+ and CD4+ Teffs, and depleted Tregs in tumors13. In another study, high-dimensional single-cell profiling demonstrated that dual PD-1 and CTLA-4 blockade elicited distinct cellular responses, including expansion of activated CD8+ Teffs14. Finally, promising and durable clinical activity, coupled with favorable tolerability, was seen in the largest trial to date evaluating dual PD-1/CTLA-4 blockade in patients with recurrent and/or metastatic cervical cancer15. In the window-of-opportunity COLIBRI study, we explored the effect of ICB on the tumor immune microenvironment, aiming to understand how dual PD-1/CTLA-4 blockade affects the T-cell immune infiltrate in cervical cancer and how sequencing ICB before and after chemoradiotherapy affects the immune response and anti-tumor efficacy (Fig. 1).

Results
Patient population and treatment exposure
Forty female patients were enrolled from sites in France with gynecologic oncology expertise between June 28, 2020, and August 4, 2021. Baseline characteristics are shown in Table 1. The median duration of follow-up was 95 (95% confidence interval [CI] 73–114) weeks. Tumor samples were collected before immune treatment and before chemoradiation from 39 patients (98%) (Supplementary Fig. 1). Thirteen patients (33%) refused biopsy after chemoradiotherapy because of procedure-associated pain.

All 40 patients received neoadjuvant nivolumab and ipilimumab. Only one patient (3%) required dose modification (temporary nivolumab interruption because of treatment-related pruritic rash). During chemoradiotherapy, 39 patients (98%) received cisplatin and three (8%) received carboplatin (Supplementary Table 1). Chemotherapy was interrupted for toxicity in six patients (15%). External beam radiotherapy was delivered per protocol in all 40 patients (median duration 36 days, range 32–71 days) and brachytherapy was delivered in 36 patients (90%) (Supplementary Table 1). All but one patient (39; 98%) received all radiotherapy within ≤55 days and started maintenance nivolumab. In the maintenance phase, 34 patients (85%) completed all six cycles of nivolumab. Reasons for discontinuing maintenance therapy before cycle 6 were disease progression (PD; two patients) and adverse events (AEs), AE/non-compliant concomitant medication, and patient decision (each in one patient). Four patients (10%) underwent optional surgery before starting maintenance therapy.

Biomarker analysis
At baseline (before ICB), multiplex-immunofluorescence (mIF) and high-throughput genomic (HTG) sequencing were each evaluable in 39 patients. After ICB (before chemoradiation), mIF and HTG were evaluable in 32 and 37 patients, respectively. Among patients evaluable for the primary study endpoint, paired samples (pre- and post-ICB before chemoradiation) were available for mIF and HTG analysis from 31 and 37 patients, respectively (Supplementary Fig. 1). Figure 2A shows representative images of mIF staining at baseline and after ICB, revealing an increase in total and proliferating CD8+ T cells. Quantitative digital image analysis revealed significantly increased CD4+ (P=0.0091) and CD8+ (P=0.0132) Teffs post-ICB (before chemoradiation) and more variable effects on Tregs (CD3+ FOXP3+) (P=0.0903) and B cells (CD20+, P>0.5), resulting in higher ratios of CD8+/FOXP3+ (P=0.0164), but not CD4+/FOXP3+ (P>0.5) cells (Fig. 2B).

In most patients, ICB drastically increased proliferative (Ki67+) CD4+ and CD8+ T cells (both P<0.0001) and the ratio of proliferative CD8+ Teffs to Tregs (P<0.0001). Dynamic changes in all evaluable immune parameters between paired pre- and post-ICB samples are shown in Fig. 3.

In exploratory analyses, the HTG HOT score (a 27-gene-based signature identifying immunologically active tumors) increased significantly (P<0.0001) after dual ICB (Fig. 2C). At baseline, only 10 (26%) of 39 evaluable samples were classified as HOT compared with 22 (56%) after ICB (Fig. 2D).

Subgroup analyses are limited by small patient numbers, but the baseline CD8+ Teff/Treg ratio appeared to be higher in patients with FIGO stage III/IV than stage I/II disease and this appears to be largely driven by lower Treg levels (Fig. 4). There were no differences in other immune parameters at baseline, including HOT score, according to FIGO stage.

Clinical response and correlation with biomarkers
By the data extraction date (February 11, 2023), six patients (15%) had experienced PD (of whom four [10%] had died).

The global objective response rate was 13% (95% CI 4–27%, with a further 83% of patients experiencing stable disease) after ICB within 1 week before chemoradiation. The objective response rate was 98% (95% CI 87–100%; complete response [CR] in 65%, partial response [PR] in 33%) 4 weeks after chemoradiation, and 90% (95% CI 76–97%; CR in 78%, PR in 13%) at the end-of-treatment visit (Table 2). Both patients with PD before chemoradiation had a PR after chemoradiation, with no evidence of PD during follow-up until the data cutoff.

Heatmaps showed that several immune parameters measured at baseline or before chemoradiation significantly differed between patients classified according to their response to treatment, assessed either before chemoradiation or at the end of treatment (Fig. 5A, B and Supplementary Fig. 2a, b). Although few patients showed a PR before chemoradiation, most of them displayed high lymphocyte infiltration at baseline (Fig. 5A). Indeed, compared with non-PR patients, this group showed a tendency for higher baseline infiltration by CD8+ T cells and displayed significantly higher ratios of total CD8+ Teff/FOXP3+ Treg (P=0.0011), proliferating CD8+ Teff/FOXP3+ Treg (P=0.0001), and proliferating CD4+ Teff/FOXP3+ Treg (P=0.0087) (Fig. 5C and Supplementary Fig. 2c). When considering the response at the end of maintenance therapy, only two baseline parameters were associated with CR: CD4+ density and, to a lesser (non-significant) extent, CD8+ Teffs (Fig. 5C and Supplementary Fig. 2b). In contrast, total and proliferating CD8+ T cells, proliferating CD4+ T cells and CD20+ B cells, and the ratio of proliferative CD8+ Teff/FOXP3+ Tregs before chemoradiation (i.e., after dual ICB) correlated significantly with CR at the end of maintenance therapy (Fig. 5C and Supplementary Fig. 2c). A similar (non-significant) tendency was seen for the CD8+ Teff/FOXP3+ Treg ratio (Fig. 5C). In contrast, none of the four patients with PD during treatment showed any significant change in CD8+ Teffs infiltrate or CD8+ Teff/FOXP3+ Treg ratio, nor did we observe changes in their HOT/COLD status after dual ICB (Supplementary Fig. 2b). Similar comparisons according to the HOT score showed a significant relationship between elevated HOT score at baseline and CR at the end of maintenance treatment (Fig. 5D). Graphs depicting the P-values for all measured immune parameters obtained by univariate analysis are shown in Fig. 6. Tertiary lymphoid structures with segregated T- and B-cell zones were detected in very few patients (5/39 at baseline and 3/32 after ICB, Supplementary Fig. 3), preventing evaluation of their relationship with clinical response. To explore further the relationship between treatment-induced immune changes and clinical response, we constructed a multivariate longitudinal linear model adjusted on the immune values measured at baseline to control for baseline differences between patients. This analysis revealed that CR at the end of maintenance treatment correlated with high densities of total and proliferating CD8+ Teff and, to a lesser extent, proliferating CD4+ Teff (Table 3). CR at the end of maintenance treatment also correlated with high proliferative CD8+ Teff/Treg ratios measured before chemoradiation (i.e., immediately after neoadjuvant ICB). The relationship between PR before chemoradiation and high proliferating CD8+ Teff density and CD8+ Teff/Treg ratio bordered on statistical significance.

Safety
Grade ≥2 AEs were reported in 14 (35%) patients during ICB, 33 (83%) during chemoradiation, and 17 (44%) during maintenance nivolumab (Table 4 and Supplementary Table 2). Grade ≥3 AEs were considered possibly related to ICB in one patient (3%) during induction ICB (grade 3 asthenia) and three patients (8%) during chemoradiation (grade 3 lymphopenia in two patients, grade 3 asthenia in one patient), and possibly related to nivolumab in five (13%) patients during maintenance therapy. There were no treatment-related deaths. The most common any-grade AEs were asthenia (28%; grade 1/2 in 25%) and pruritus (20%; all grade 1/2) during induction therapy; diarrhea (58%), nausea (53%), anemia (48%), asthenia (38%), and hypothyroidism (23%) during chemoradiation; and asthenia (26%; 23% grade 1/2) during maintenance nivolumab.

In exploratory analyses, we observed that, compared with patients who experienced grade ≤1 immune-related AEs, patients with grade 2/3 immune-related AEs showed significantly lower CD8+ Teff/Treg ratio in their tumor at baseline but quite similar individual densities of CD8+ Teff or total Treg cells (Supplementary Fig. 4). Furthermore, a statistically significant increase in Tregs (total and proliferating) and proliferating B cells, and a decrease in proliferating CD4+ Teff/Treg ratio, was observed in samples collected after ICB before chemoradiation from patients with grade 2/3 immune-related AEs compared with patients who had only grade 1 or no immune-related AEs (Supplementary Fig. 4).

Methods
Study design
The multicenter single-arm phase II COLIBRI pilot study (GINECO-CE108b; NCT04256213) evaluated the immune impact and safety of a single cycle of nivolumab and ipilimumab combination therapy before primary chemoradiation for cervical cancer. The study was performed in accordance with ethical principles of the Declaration of Helsinki and International Conference on Harmonization Good Clinical Practice and applicable regulatory requirements. The final study protocol (available as a supplementary file) and informed consent form, including biomarker sample consents and any other patient materials, were approved by the national ethics committee (Comité de Protection des Personnes Est I; CPP EST I).

Objectives
The primary objective was to evaluate changes in the CD8+/FOXP3+ T-cell ratio in biopsies collected before versus after nivolumab and ipilimumab combination treatment before chemoradiation. The CD8+/FOXP3+ ratio was assessed by evaluating the composition of the immune infiltrate using seven-color spatial mIF.

Key secondary objectives included assessment of dynamic changes in the immune microenvironment (including CD8+, FOXP3+ Tregs, CD4+ T cells, and CD20+ B cells) before and after chemoradiation using mIF tissue imaging and HTG sequencing, clinical activity (including objective response rate according to RECIST version 1.1; by MRI and PET-CT if required) before and after chemoradiation (and at treatment completion as an exploratory objective), potential correlations between biologic changes in the tumor microenvironment and clinical activity, and tolerability.

Patients
Eligible patients had histologically confirmed squamous cell cervical carcinoma (FIGO 2018 stage IB3–IVA) for which standard-of-care chemoradiation was required as initial therapy. Patients had to be aged ≥18 years, with performance status 0 or 1, and adequate hematologic, hepatic, and renal function. All patients provided written informed consent before undergoing any study-specific procedure, and consented to collection of blood samples, formalin-fixed paraffin-embedded tumor tissue, and fresh tumor biopsies for correlative studies. Patients were ineligible if they required neoadjuvant chemotherapy before chemoradiation, had previously received an immune checkpoint inhibitor, had any contraindication to nivolumab or ipilimumab, or had known or suspected uncontrolled CNS metastases, active, known or suspected autoimmune disease, or a history of chronic hepatitis.

Procedures
Patients were enrolled by investigators at participating centers and received a single cycle of intravenous ipilimumab 1 mg/kg on day 1 with nivolumab 3 mg/kg on days 1 and 15 before undergoing chemoradiation for 5–8 weeks per standard practice, with brachytherapy or external boost if brachytherapy was not feasible (Fig. 1). After chemoradiation, patients received maintenance nivolumab 480 mg every 28 days for 6 months. If required, residual disease was surgically resected 4–6 weeks after completing chemoradiation per local standards.

All patients underwent pelvic and abdominal MRI and PET-CT within 28 days before starting study treatment (with bone and CT scans if clinically indicated), and MRI within 1 week before and 4 weeks after chemoradiation. Tumor imaging was performed at the end of treatment visit for exploratory analysis of response rate. Cervical biopsies were mandatory before and after chemoradiation and optional during follow-up. AEs, graded according to Common Terminology Criteria for Adverse Events version 4.03, were followed for 100 days after the last nivolumab dose or until starting another anti-cancer therapy. A data safety monitoring board reviewed each event that could modify the benefit:risk ratio. Patients were followed actively for approximately 12 months or until PD.

Clinical data were collected using the Clinsight v8.2.110 (Euraxi Pharma) clinical data management system, CSOnline v8.2.110 web interface (https://ecrf.euraxipharma.fr/CSOnline/), Oracle 11g back-end database, and MedDRA v21.1 and WHO Drug Format C March 2017 for medical coding.

Translational methods
Seven-color mIF methods were similar to previous studies30,31 (Supplementary Methods). Targeted gene expression profiling of 2549 genes was performed using HTG sequencing to evaluate the 27-gene-based “HOT” score as a biomarker of immunologically active tumors. The HOT score evaluated the following genes: CCL19, CCR2, CCR4, CCR5, CD27, CD40LG, CD8A, CXCL10, CXCL11, CXCL13, CXCL9, CXCR3, CXCR6, FASLG, FGL2, GZMA, GZMH, IDO1, IFNG, IRF8, LAG3, LYZ, MS4A1, PDCD1, TBX21, TLR7, and TLR8. This signature has been validated as a prognostic marker in patients receiving first- or second-line anti-PD-(L)1 with or without chemotherapy for other tumor types17 and is computed using the Gene Set Variation Analysis to classify scores as positive (HOT) or negative (COLD).

Statistical analysis
It was planned to enroll 40 patients. Assuming a standard deviation of 14 units, this would provide a 95% CI with a precision of 5 units around the mean estimation of the CD8+/FOXP3+ relative change of lymphocytes between pre- and post-treatment biopsies. Paired pre- and post-treatment biopsies were compared using Wilcoxon matched-pairs signed-rank tests. The association between mIF and HTG data with tumoral response was assessed using Wilcoxon Mann–Whitney and Fisher exact tests. For each immune parameter and for each objective response time point (1 week before chemoradiation and end of treatment), a multivariate longitudinal linear model was performed to compare the immune responses between the overall tumoral responses (CR vs non-CR or PR vs non-PR). The models were adjusted on the baseline immune response level to control for initial differences between subjects. To consider repeated measurement by subject over time (biopsies performed at baseline and at 1 week before chemoradiation), the variance-covariance matrix used was compound-symmetry. The variances heterogeneity between groups was considered in the models. Adjusted means were calculated for the interaction between time effect and immune response, adjusting for baseline. Multiple comparisons were performed using Tukey–Kramer’s adjustment to control for type I error. P-values <0.05 were considered to indicate statistical significance in all tests. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA), R version 4.1.1, and GraphPad Prism 9.

Peer review rounds
[{"round": 1, "reviewer_comments": {"reviewer_1": "Strengths\nComprehensive Data Presentation: The article provides detailed information on the study design, patient demographics,\ntreatment protocols, and outcomes. This thoroughness allows readers to understand the scope and impact of the research.\nInnovative Approach: The use of neoadjuvant immune checkpoint blockade (ICB) before chemoradiation for cervical cancer\nis a novel approach. The article highlights the potential benefits of this strategy in enhancing the immune response and\nimproving clinical outcomes.\nDetailed Biomarker Analysis: The article includes extensive biomarker analysis, such as multiplex-immunofluorescence\n(mIF) and high-throughput genomic (HTG) sequencing. This adds depth to the understanding of how ICB affects the tumor\nmicroenvironment.\nClear Presentation of Results: The results are presented clearly, with figures and tables that help visualize the data. This\nmakes it easier for readers to grasp the key findings and their implications.\nWeaknesses\nComplex Language: The article uses highly technical language, which may be difficult for non-specialist readers to\nunderstand. Simplifying some sections could make the content more accessible.\nLimited Sample Size: The study's sample size is relatively small, which may limit the generalizability of the findings. Larger,\ncontrolled trials are needed to confirm the results.\nAbsence of Concurrent ICB with Chemoradiation: The article mentions that ICB was not administered concurrently with\nchemoradiation, which could be seen as a limitation. Concurrent administration might have provided additional insights into\nthe combined effects of these treatments.\nMissing Data: Some data points were missing due to technical issues or patient refusal for biopsies. This could potentially\nimpact the robustness of the conclusions drawn.\nOpportunities for Improvement\nExpand Sample Size: Future studies should aim for larger sample sizes to improve the reliability and generalizability of the\nfindings.\nExplore Concurrent ICB: Investigating the effects of concurrent ICB with chemoradiation could provide valuable insights and\npotentially improve treatment outcomes.\nAddress Missing Data: Implementing strategies to minimize missing data, such as better patient support during biopsy\nprocedures, could strengthen the study's conclusions.\nConclusion\nOverall, the article presents a promising approach to treating locally advanced cervical cancer with neoadjuvant ICB. While\nthere are some limitations, the detailed data and innovative strategies offer valuable insights and pave the way for future\nresearch in this area.\nSpecific items to address\nPlease explain why on 88% got brachytherapy?\nWhy did you allow carboplatin on the study and who got this?\nHow did you chose 6 cycles of adjuvant nivo?\nIs the HOT score used in other tumors? Do you see an ability to translate this in to the clinic?\nHow did you determine ORR prior to CRT at 13%? Was it using clinical exam or imaging?\nConsider rephrasing:\nTwo patients receiving concurrent\n263 atezolizumab and chemoradiation experienced colitis and one experienced\n264 thrombocytopenia resulting in a >2-week delay in cisplatin therapy. This contrasts with the\n265 tolerability observed in COLIBRI.\nto :\nOn NRG GY017 the authors report tolerability of induction immunotherapy followed by chemoradiation and concurrent\nimmunotherapy with two patients with acute colitis and one with thrombocytopenia of the 36 evaluable patients.", "reviewer_2": "This manuscript reports findings from the COLIBRI study, a window-of-opportunity trial evaluating neoadjuvant dual immune\ncheckpoint blockade with nivolumab and ipilimumab prior to standard chemoradiation and brachytherapy, followed by\nmaintenance nivolumab, in patients with FIGO stage IB3–IVA cervical squamous cell carcinoma. The authors present a\ncompelling translational dataset linking dynamic immune changes with clinical response and suggest a potential therapeutic\nstrategy to improve outcomes in locally advanced cervical cancer.\nThe manuscript is well written and provides valuable translational data, in a timely context for the use of immunotherapy in\nLACC.\nBelow are some comments/suggestions that would strengthen the manuscript:\n1. Timing of Checkpoint Blockade Relative to Chemoradiation\nPlease mention in your introduction the rationale and implications of administering checkpoint blockade before versus\nconcurrently with or after chemoradiation.\n2. Mechanistic Considerations add-on of CTLA-4 blockade to PD-1 Blockade\nPlease discuss the specific interest in cervical cancer of the potential distinct and complementary roles of CTLA-4 blockade\nversus PD-1 inhibition monotherapy.\n3. Impact of HPV and PD-L1 Status\nPlease provide data or commentary on how HPV status and PD-L1 expression correlate with baseline immune infiltration,\nCD8+/FOXP3+ ratio, or HOT score.\n4. Impact of Clinical Stage-Specific Analyses\nWere any differences observed between patients with stage I–II vs III–IVA disease in terms of immune parameters, response\nto ICB, or outcomes?\n5. TLS Detection\nDid the tissue imaging approach allow for identification of tertiary lymphoid structures (TLS), either directly or via surrogate\nmarkers (B cell aggregates, or CXCL13 expression)?\n6. Immune-Related Adverse Events (irAEs)\nWere irAEs ≥ grade 2 or ≥ grade 3 associated with any immune biomarkers (e.g., CD8+ infiltrate, CD8+/FOXP3+ ratio,\nHOT score)?\n7. Detailed AE Reporting\nPlease provide a supplementary table detailing the most common AEs (≥10%) stratified by treatment phase (ICB,\nchemoradiation, maintenance nivolumab), along with their grade.\n8. AEs Comparison to Standard Chemoradiation Toxicity\nDo you observe a higher frequency, severity, or duration of chemoradiation-associated side effects compared to historical\ncontrols treated with chemoradiation alone?\n9. Recurrence and Long-Term Outcomes\nBased on updated follow up, can you provide information about your recurrence free survival ?\n10. Role of Maintenance Nivolumab\nDo you believe the maintenance nivolumab contributed meaningfully to disease control, or were most responses\nconsolidated by the chemoradiation phase?", "reviewer_3": "NCOMMS-25-28924\nThe manuscript entitled “GINECO window-of-opportunity COLIBRI study of neoadjuvant immune checkpoint blockade\nbefore chemoradiation for cervical squamous carcinoma” reports a single-arm, phase II clinical trial investigating immune\ncheckpoint blockade in patients with LACC. The manuscript is well-structured and thorough, with high-quality figures. Upon\ncareful evaluation, I find that the majority of the concerns raised by previous reviewers have been adequately addressed.\nHowever, I still have a few minor comments regarding the discussion section before the manuscript can be accepted for\npublication in Nature Communications.\nIt is recommended that the authors include a discussion of the methodological limitations of this study—particularly in light of\nReviewer 2’s concern regarding the potential toxicity associated with this combination therapy, which may have important\nimplications for clinical translation. Additionally, the discussion would benefit from the inclusion of a section outlining future\nresearch directions, as well as the broader clinical implications of implementing this combination therapy in practice.", "reviewer_4": "Neoadjuvant Immune Checkpoint Blockade Before Chemoradiation for Patients with FIGO Stage IB3–IVA Cervical Squamous\nCarcinoma: GINECO Window-of-Opportunity COLIBRI Study\nRay-Coquard and colleagues have submitted the results from a window of\nopportunity study that evaluated the potential impact on the ratio of\nCD8+/FOXP3+, based on paired tumor biopsies, for individuals receiving\nneoadjuvant or induction dual immune blockade with ipilimumab and\nnivolumab for locally advanced cervical cancer. In addition to induction,\nparticipants also received maintenance nivolumab for up to 6 months,\nalthough evaluation of this maintenance was not the primary objective of the\nstudy. As designed the study aimed to recruit 40 individuals with squamous\ncell carcinoma of the cervix that were deemed to have LACC and\nnecessitated treatment with chemoradiation. In general, the manuscript is\nwell written and does endorse an ongoing area of investigation in LACC. I\nhave the following additional comments and/or questions for the authors.\nProtocol - Please comment on the exclusion of the patient being a candidate\nfor neoadjuvant chemotherapy (NACT) prior to RT-CT? It seems that all\nenrolled patients would have been considered a \"candidate\" for NACT?\nAlso, the protocol states that the goal was to enroll 40 patients while in the\nmanuscript it was noted the goal was to enroll \"approximately\" 40 patients.\nTitle - No comments. No change required.\nAbstract -\nMethods - would add \"…planned brachytherapy.\" As 5 participants per the\nappendix did not receive brachytherapy.\nResults - Although not a typical reported outcome, can you provide the HOT\nscore and the 95% CI rather than just a p value? The comparison group is the subset without treatment-\ninduced immune changes.\nConclusion - while the treatment-induced immune changes were associated\nwith clinical response, even without dual ICB the expectation is for most to\nhave a clinical response. Without a comparison group it is hard to know how\nrobust this response in fact is.\nIntroduction\n1st paragraph - Consider noting the improving treatment/treatment of LACC is\nthe area of unmet need.\nAlso, the recurrence rate is not 40% for Stage IB LACC tumors treated with\nchemoradiation, consider revising and noting this is up to 40% but really\napplies more to the stage III/IV cancers.\n2ND paragraph - Consider noting that the current indication for\npembrolizumab in LACC in the US is for T3/4 cancers only which could\nprovide further support for the need to determine other active agents,\nespecially in \"smaller\" cervical cancers based on the Tumor (T1/2).\nMethods\n1. Consider stating that this was a single cycle of therapy prior to\nchemoradiation in the study design.\n2. Please state the objective response per RECIST was per pre-\nchemoradiation MRI as described in the protocol.\n3. Patients - I apologize if I overlooked this in the protocol but why did you\ninclude adenosquamous histology if the protocol states it was squamous\nhistology only? Other studies tend to differentiate between squamous and\nadenosquamous and although I see no reason the exclude\nadenosquamous,\n4. Procedures - For what proportion of patients is brachytherapy in unusual\nclinical practice in your institutions considered not feasible?\n5. Did any participants undergo surgical excision 4-6 weeks after completing\nCRT?\n6. Why did you state the follow-up as approximately 12 months? The\nprotocol notes follow-up to be every 6 months for two years and then\nannually. Please reconcile.\n7. Analysis - Similar to previous comment, why did you use the word\napproximately. The study protocol states the goal was to enroll 40\npatients.\nResults\n1. Consider moving the sentence about 13 patients refusing biopsy after\nchemoradiation to the end of the first paragraph and perhaps after a\nsentence noting the proportion that had pre-treatment and pre-CRT\nbiopsies.\n2. See later comment re: need for more details on the use of carboplatin\nas compared to cisplatin as was done with brachytherapy in the appendix.\n3. Can you comment on what the 4 patients that had optional surgery was?\nIs this similar to your usual practice?\n4. Biomarker - Similar to clinical trials with their consort diagram you should\nconsider including Appendix Figure A2 in the manuscript as an identified\nfigure rather than the appendix as it demonstrates the \"eligible\" patients.\n5. HTG HT - Consider including the scores with 95% CIs here rather than\njust a p value.\n6. Clinical responses - Were 95% CIs calculated for the objective response\nrates?\n7. Consider adding the word \"global\" to read, \"The global objective….\"\nWhich is what is noted in\nTable 2. Also 78%+13% is 91% and not 90%.\nTable 2. This is a question of rounding. 31+5 = 36, and\n36/40 = 90%\nDiscussion\nConsider noting up to 6 months of maintenance therapy for more granular\ninformation.\nThird paragraph need to add \"+\" to CD8.\nPage 18 - I am not exactly sure what the authors are referring to with the\nsentence re: not being cured after PD-(l)1 inhibitor treatment. Are you\nreferring to A18 like treatment? Keynote-826 treatment? What exactly?\nPage 19 - Need to add the new reference for NRG-GY017 since it is in\npress.\nTables & Figures\nTable 1 - Please add the primary tumor size at baseline since this was\ncollected and followed for objective response.\nAlso would it be informative to add the T stage for the IIIC1 and IIIC2 patients\nas they made up 50% of the study population. Were these \"smaller\" tumors\nfor nodal metastasis or were they bigger? If there is a mix of small and large\ntumors can information be gleaned between the groups meaning is the\nimmunologic response of a small tumor with nodal metastasis similar to or\ndifferent than a larger tumor with nodal involvement?\nPlease comment on why you think the rate of LVSI status as missing is nearly\n50%?\nFor HPV status was specific high-risk typing performed?\nTable 2 - See previous comment about use of \"Global Response\" or perhaps\noverall response. Also consider moving the rows on local to the bottom?\nTable 3 - No comments.\nFigure 1 - No comments other than perhaps add Appendix Figure 2A to this?\nFigure 2 - Kind of busy but I guess it is okay.\nFigure 3 - Similar to figure 2 but even more data.\nData Supplement\nNo brachytherapy in 5 patients\n3 received Carboplatin - provide more details here similar to the details for\nlack of brachytherapy. We used RCT consistently in all figures for brevity, but have\nAppendix Figure A2 - A very minor question but why was RCT selected here\nas RT-CT I used in the protocol and in general it is spelled out in the\nmanuscript?\nReferences - See previous comments. Updated with published paper.", "reviewer_5": "While I find the concept of neoadjuvant I-O prior to definitive chemoRT and\nmaintenance I-O an important consideration worthy of study, I do not think\nthis study and this manuscript will be of interest to the journal's readership.\nThe primary objective of this study is a translational endpoint and with most\npatients with locally advanced disease expected to respond very well to\ndefinitive chemoRT, a randomized trial is important to be able better\nassesses the impact of response of neoadjuvant I-O as well as the surrogate\nbiomarker that is being studied in this study; other more relevant biomarkers\nwarrant evaluation as well. Although there was only 1 patient that\nexperienced a grade 3 AE attributable to induction I-O, my concern is that the\ncombination of Nivo-Ipi may end up being too toxic for this patient population.\nIn any event, this paper may be better suited to an AACR journal or even Gyn\nOncology.", "reviewer_6": "This manuscript reports the results of a Window-of-Opportunity (WOO), single\narm, phase II trial evaluating neoadjuvant immune checkpoint blockade (ICB)\nbefore chemoRT for pts with FIGO stage IB3-IVA cervical squamous\ncarcinoma (LACC). The regimen to be evaluated was combination of Nivo\nand Ipi delivered prior to standard chemoRT and brachytherapy. After\nstandard chemoRT, pts also received 6m of maintenance nivo.\nThe primary endpoint was CD8+/FOXP3+T-cell ratio changes from pretreatment to end of\nICB (before chemoRT). Total of 39 pts were evaluable. Among them 31\n(79%) had paired samples for primary endpoint analyses. I included my\ncomments for authors' considerations, below:\n1. In abstract,\na. Method: it would be great to clarify if HOT score and objective\nresponse rate were 2nd endpoints (vs. exploratory endpoints). It also would\nbe beneficial to readers if the power/sample size consideration can be\ndescribed with one sentence.\nb. Results, it would be great to indicate the estimate of increases in\nCD8+/FOXP3+T-cell ratio and provide p value. Same for HOT score, add\nestimate of the changes.\nc. Conclusion: Results section only indicated that baseline biomarker\nvalues (as opposed to changes from baseline to end of ICB) were associated\nwith different types of response at different timepoints during the whole\ntreatment duration. The statement of \"these treatment-induced immune\nchanges were associated with clinical response\" seems misleading. More\nimportantly, without proper comparisons to standard of care treatment, the\nlast statement in conclusion section seems exaggerating what the data\nreported can conclude.\n2. 27-gene-based HOT score was highlighted in abstract. However, it\nseems that it was not a predefined 2nd endpoint in main text, objectives\nsection. This raised the question, if the significant results seen in this\nvariable might be highly data driven. Regardless, it should be clearly stated if this\nvariable was due to an exploratory analysis, and limitations of data driven\nresults should be discussed.\n3. Surgical resection was allowed for residual disease. It will be\ninteresting to see how many pts without CR or PR per RECIST observed but\nhad R0 resection or pCR status after resection.\n4. In the method section, it would be critical to include details on the\ntimepoints of objective responses analyses with indications of which ones\nwere pre-defined, which ones were ad hoc.\n5. The baseline (pre-neoadjuvant IO) biomarker levels can affect how\nbig the changes in these biomarkers can potentially have from baseline to\ndifferent time points of the treatment, especially, many of these biomarkers at\nbaseline do differ between responders vs. non-responders. MV models,\nadjusting for baseline values, should be performed to confirm the\nassociations between biomarker changes and response outcomes. Other\npotential confounding factors should also be evaluated to confirm the\nreported relationships.\n6. Given multiple biomarkers and objective responses at timepoints,\nmultiple comparisons are concerns for interpretation of the results. It will be\ncritical for study team to apply appropriate multiple comparison adjustment\nmethods and re-evaluate the conclusions of the study. Univariate comparisons were performed for each biomarker\nat each biopsy timepoint and for each objective response\ntimepoint (ie, four comparisons for each biomarker). Here,\nmultiple comparisons were considered exploratory rather\nthan confirmatory as the main objective of these\ncomparisons was to identify trends or hypotheses to be\ntested in future studies. Nevertheless, on the models\npresented above, p-value adjustments were performed."}, "author_response": "Responses to reviewers\n1. If the research findings apply to only one sex or gender, that must be indicated in the title and/or\nabstract.\nResponse: The abstract now specifies female patients.\n2a. For studies involving vertebrates animal and cell lines- The Reporting Summary should include\nwhether sex was considered in the study design.\nResponse: Not applicable\n2b. For studies involving human research participants- The Reporting Summary should include\nwhether sex and/or gender was considered in the study design and whether sex and/or gender of\nparticipants was determined based on self-report or assigned (and methodology used).\nResponse: All patients enrolled in this study in cervical cancer were female.\n3. Data should be reported disaggregated for sex and gender where this information has been\ncollected and consent has been obtained for reporting and sharing individual-level data;\ndisaggregated numbers for individual experiments must be provided in the source data as\nappropriate whereas overall numbers may be provided in the Nature Portfolio Reporting Summary.\nResponse: Not applicable\nREVIEWER COMMENTS\nReviewer #1 (Remarks to the Author):\nStrengths\nComprehensive Data Presentation: The article provides detailed information on the study design,\npatient demographics, treatment protocols, and outcomes. This thoroughness allows readers to\nunderstand the scope and impact of the research.\nInnovative Approach: The use of neoadjuvant immune checkpoint blockade (ICB) before\nchemoradiation for cervical cancer is a novel approach. The article highlights the potential benefits\nof this strategy in enhancing the immune response and improving clinical outcomes.\nDetailed Biomarker Analysis: The article includes extensive biomarker analysis, such as multiplex-\nimmunofluorescence (mIF) and high-throughput genomic (HTG) sequencing. This adds depth to the\nunderstanding of how ICB affects the tumor microenvironment.\nClear Presentation of Results: The results are presented clearly, with figures and tables that help\nvisualize the data. This makes it easier for readers to grasp the key findings and their implications.\nResponse: We appreciate this very positive feedback from the reviewer.\nWeaknesses\nComplex Language: The article uses highly technical language, which may be difficult for non-\nspecialist readers to understand. Simplifying some sections could make the content more accessible.\nResponse: We appreciate the suggestions to strengthen the manuscript. We have tried to simplify\nthe language wherever possible.\nLimited Sample Size: The study's sample size is relatively small, which may limit the generalizability\nof the findings. Larger, controlled trials are needed to confirm the results.\nResponse: We agree that this is a limitation and have highlighted this in the discussion (page 11).\nadministered concurrently with chemoradiation, which could be seen as a limitation. Concurrent\nadministration might have provided additional insights into the combined effects of these\ntreatments.\nResponse: We agree that this may be seen as a limitation. However, as noted in the discussion, the\ndesign of the KEYNOTE-A18 does not allow us to disentangle the contribution of immune checkpoint\nblockade during the chemoradiation phase versus the maintenance phase, so there is no conclusive\nevidence suggesting that they should be given concurrently. Nevertheless, we do agree that this is\nan area potentially meriting future investigation and now mention it in the future directions section\nrequested by reviewer 3 (pages 13–14).\nMissing Data: Some data points were missing due to technical issues or patient refusal for biopsies.\nThis could potentially impact the robustness of the conclusions drawn.\nResponse: We acknowledge in the discussion that data missing because of technical issues led to a\nsmaller sample size than planned. However, given the randomness of the missing data, we do not\nbelieve this had a major impact on estimation of the parameters of interest or the conclusions\ndrawn.\nOpportunities for Improvement\nExpand Sample Size: Future studies should aim for larger sample sizes to improve the reliability and\ngeneralizability of the findings.\nExplore Concurrent ICB: Investigating the effects of concurrent ICB with chemoradiation could\nprovide valuable insights and potentially improve treatment outcomes.\nAddress Missing Data: Implementing strategies to minimize missing data, such as better patient\nsupport during biopsy procedures, could strengthen the study's conclusions.\nResponse: Thank you for these suggestions, which we have incorporated into the new paragraph on\nsuggested directions for future research (pages 13–14).\nConclusion\nOverall, the article presents a promising approach to treating locally advanced cervical cancer with\nneoadjuvant ICB. While there are some limitations, the detailed data and innovative strategies offer\nvaluable insights and pave the way for future research in this area.\nResponse: Thank you for this positive feedback.\nSpecific items to address\nPlease explain why on 88% got brachytherapy?\nResponse: After contacting the centers again for any further information, the final figure is four\npatients who did not receive brachytherapy: three received external tumor boost with external\nbeam radiotherapy, and one decided to stop treatment. These details are provided in the footnote\nto Supplementary Table 1 and we now refer to this table in the main text.\nWhy did you allow carboplatin on the study and who got this?\nResponse: Chemoradiation was to be administered according to each site’s standard of care. The\nmost common pattern comprised five sessions of external radiotherapy and one chemotherapy\n(platinum monotherapy) administration per week, for five weeks. Details of the allowed\nchemoradiation regimens are provided in Figure 1 and available information about the three\npatients who received carboplatin (instead of/as well as cisplatin) are provided in the footnote to\nSupplementary Table 1.\nHow did you chose 6 cycles of adjuvant nivo?\nResponse: There were no data to support this duration when the study was designed; it was simply a\nquestion of practicality and feasibility for the study design balanced with potential benefit.\nResponse: The signature has been validated in several tumor models including head and neck cancer\nand lung cancer (reference 17). It will be extremely interesting to integrate our findings into decision\nmaking for the use of immunotherapy in clinical practice. For this, large randomized prospective\nclinical trials are essential. In the meantime, we are also testing this signature in the prospective\nCOLIBRI 2 trial (NCT06715241) to validate it for cervical cancer; this trial is mentioned in the\ndiscussion (page 14).\nHow did you determine ORR prior to CRT at 13%? Was it using clinical exam or imaging?\nResponse: Imaging for tumor response evaluation (by RECIST) was done using MRI/PET after\nneoadjuvant therapy within 1 week before chemoradiation (please see Figure 1).\nConsider rephrasing:\nTwo patients receiving concurrent atezolizumab and chemoradiation experienced colitis and one\nexperienced thrombocytopenia resulting in a >2-week delay in cisplatin therapy. This contrasts with\nthe tolerability observed in COLIBRI.\nto:\nOn NRG GY017 the authors report tolerability of induction immunotherapy followed by\nchemoradiation and concurrent immunotherapy with two patients with acute colitis and one with\nthrombocytopenia of the 36 evaluable patients.\nResults: Reworded as suggested.\nReviewer #2 (Remarks to the Author):\nThis manuscript reports findings from the COLIBRI study, a window-of-opportunity trial evaluating\nneoadjuvant dual immune checkpoint blockade with nivolumab and ipilimumab prior to standard\nchemoradiation and brachytherapy, followed by maintenance nivolumab, in patients with FIGO\nstage IB3–IVA cervical squamous cell carcinoma. The authors present a compelling translational\ndataset linking dynamic immune changes with clinical response and suggest a potential therapeutic\nstrategy to improve outcomes in locally advanced cervical cancer.\nThe manuscript is well written and provides valuable translational data, in a timely context for the\nuse of immunotherapy in LACC.\nBelow are some comments/suggestions that would strengthen the manuscript:\n1. Timing of Checkpoint Blockade Relative to Chemoradiation\nPlease mention in your introduction the rationale and implications of administering checkpoint\nblockade before versus concurrently with or after chemoradiation.\nResponse: We now introduce the fourth paragraph of the introduction explaining the rationale for\nneoadjuvant administration, citing Liu et al.\n2. Mechanistic Considerations add-on of CTLA-4 blockade to PD-1 Blockade\nPlease discuss the specific interest in cervical cancer of the potential distinct and complementary\nroles of CTLA-4 blockade versus PD-1 inhibition monotherapy.\nResponse: We have expanded the text in the final paragraph of the introduction, where we discuss\ndual blockade in a published trial in cervical cancer.\n3. Impact of HPV and PD-L1 Status\nPlease provide data or commentary on how HPV status and PD-L1 expression correlate with baseline\nimmune infiltration, CD8+/FOXP3+ ratio, or HOT score.\navailable but we mention in the discussion that these analyses are ongoing and a separate\npublication dedicated to the translational research is planned.\n4. Impact of Clinical Stage-Specific Analyses\nWere any differences observed between patients with stage I–II vs III–IVA disease in terms of\nimmune parameters, response to ICB, or outcomes?\nResponse: We show response according to stage I/II vs III/IV in Table 2 but with such small patient\nnumbers it is difficult to draw any conclusions and the trial was not powered to answer these\nquestions. To address the reviewer’s question about immune parameters, we performed post hoc\nanalyses and found that only the CD8+ Teff/Treg ratio was higher at baseline in FIGO stage III/IV\ncompared with FIGO stage I/II, and this seems to be linked to lower levels of Tregs (Figure 1 below).\nNo changes in other parameters (including the HOT score) were observed. We have added this\ninformation in the biomarker section on page 7 and the corresponding graph could be added, if the\nreviewer feels that this adds value to the paper.\n4\n5. TLS Detection\nDid the tissue imaging approach allow for identification of tertiary lymphoid structures (TLS), either\ndirectly or via surrogate markers (B cell aggregates, or CXCL13 expression)?\nResponse: Thank you for this suggestion. We performed the analyses using the CD3, CD20 and Ki67\nmarkers from the mIF panel. TLS with segregated T and B cell zones were detected in a small\nproportion of patients (5/39 at baseline and 3/32 after ICB, Figure 2 below). No association with\nclinical response was observed, as anticipated with so few TLS-positive patients. We have added a\nsentence on page 9 to mention this finding.\n5\n6. Immune-Related Adverse Events (irAEs)\nWere irAEs ≥ grade 2 or ≥ grade 3 associated with any immune biomarkers (e.g., CD8+ infiltrate,\nCD8+/FOXP3+ ratio, HOT score)?\nResponse: We appreciate this question from the reviewer. We conducted post hoc analyses to\nexplore this and report the findings in the paper (page 10). The data are provided below and could\nbe included in the manuscript on request.\n7. Detailed AE Reporting\nPlease provide a supplementary table detailing the most common AEs (≥10%) stratified by treatment\nphase (ICB, chemoradiation, maintenance nivolumab), along with their grade.\nResponse: Table has been added as requested.\n6\n8. AEs Comparison to Standard Chemoradiation Toxicity\nDo you observe a higher frequency, severity, or duration of chemoradiation-associated side effects\ncompared to historical controls treated with chemoradiation alone?\nResponse: Compared with the EMBRACE-1 study, we did not observe increased toxicity, although\nthere are many limitations of cross-trial comparisons. We now mention EMBRACE-1 in the\ndiscussion, as well as the limitations of the single-arm design.\n9. Recurrence and Long-Term Outcomes\nBased on updated follow up, can you provide information about your recurrence-free survival?\nResponse: The long-term data are not yet mature; a new analysis is anticipated in due course but,\nfortunately for the patients, there are not yet sufficient events.\n10. Role of Maintenance Nivolumab\nDo you believe the maintenance nivolumab contributed meaningfully to disease control, or were\nmost responses consolidated by the chemoradiation phase?\nResponse: In the KEYNOTE-A18 trial, patients receiving maintenance therapy for 90 weeks derived a\nlong-term (overall survival) benefit from immune checkpoint blockade, so we believe the important\nquestion concerns the optimal duration of maintenance therapy. Long-term follow-up data from\nCOLIBRI may enable us to explore whether a shorter duration of maintenance therapy is sufficient,\nbut we do not feel comfortable speculating on the role of maintenance nivolumab based on the\nexisting data from COLIBRI.\nReviewer #3 (Remarks to the Author):\nThe manuscript entitled “GINECO window-of-opportunity COLIBRI study of neoadjuvant immune\ncheckpoint blockade before chemoradiation for cervical squamous carcinoma” reports a single-arm,\nphase II clinical trial investigating immune checkpoint blockade in patients with LACC. The\nmanuscript is well-structured and thorough, with high-quality figures. Upon careful evaluation, I find\nthat the majority of the concerns raised by previous reviewers have been adequately addressed.\nHowever, I still have a few minor comments regarding the discussion section before the manuscript\ncan be accepted for publication in Nature Communications.\nIt is recommended that the authors include a discussion of the methodological limitations of this\nstudy—particularly in light of Reviewer 2’s concern regarding the potential toxicity associated with\nthis combination therapy, which may have important implications for clinical translation.\nAdditionally, the discussion would benefit from the inclusion of a section outlining future research\ndirections, as well as the broader clinical implications of implementing this combination therapy in\npractice.\nResponse: We have restructured the discussion so that the limitations are in a dedicated section and\nwe highlight the impact of study design limitations on translation to clinical practice. We have also\nadded a section outlining future research directions. This first study paves the way for exploring\nimmunotherapy before local treatment (chemoradiation for advanced stages or surgery for large\nstage I tumors). Indeed, adding or proposing immunotherapy while the tumor is in situ is probably\npreferable for obtaining an anti-tumor immune response. The other question will be the\ncombination of several immunotherapies (PD-1 and CTLA-4 as in this trial, PD-1 and LAG3 as in\nCOLIBRI 2, or with other immune checkpoint inhibitors) to confirm the best combination, or even\ncombinations with ADCs, such as tisotumab vedotin or TROP2 ADC, which have shown very\nencouraging results in metastatic situations. We now mention future combinations in the discussion.\n7"}, {"round": 2, "reviewer_comments": {"reviewer_1": "all questions answered", "reviewer_2": "Thank you for addressing my comments and suggestions.\nI would highly recommend including \"response to reviewers figures\" 1, 2 and 3 to the manuscript.", "reviewer_3": "NCOMMS-25-28924A\nThe authors have fully addressed the reviewers' concerns with substantive and thoughtful revisions in the manuscript.\nCurrently, there are no major issues remaining. I appreciate their effort in improving the quality of the work. The revised\nmanuscript is suitable for publication."}, "author_response": "1 GINECO window-of-opportunity COLIBRI study of neoadjuvant immune checkpoint blockade\n2 before chemoradiation for cervical squamous carcinoma\n5\n6\n7\n9 all questions answered\n11\n16 supplement.\n17\n20 in the manuscript. Currently, there are no major issues remaining. I appreciate their effort in\n21 improving the quality of the work. The revised manuscript is suitable for publication."}]

Decision letter