ASTRO issues guideline on radiation therapy for cervical cancer
A new guideline issued by the American Society for Radiation Oncology addresses the use of radiation therapy for the treatment of nonmetastatic cervical cancer.
“This is the first guideline from ASTRO on the subject of cervical cancer and was commissioned due to significant advances in the ability to deliver radiation therapy during the past 2 decades,” Junzo Chino, MD, associate professor and director of brachytherapy in the department of radiation oncology at Duke Cancer Center, told Healio. “Intensity-modulated radiation therapy has increased our ability to deliver external beam radiation therapy [EBRT] safely and effectively, while image-guided brachytherapy has improved our ability to specifically target the tumor while limiting the doses to normal healthy tissue. These two advances have improved both control of disease in the pelvis and also improved the long-term quality of life for our patients.”
ASTRO assigned a task force to address key questions, including indications for postoperative and definitive radiation therapy, the use of chemotherapy in sequence or concurrent with radiation therapy, and the use of IMRT and indications and techniques of brachytherapy for the definitive and postoperative management of cervical cancer.
“The guideline recommends the use of radiation therapy and chemotherapy for patients with risk factors after hysterectomy in a stratified manner, based on the results of several pivotal phase 3 trials,” Chino said. “The guideline also recommends IMRT and [image-guided brachytherapy], where available, to improve the overall outcomes of women treated with radiation therapy.”
However, not all advances in technology have proved beneficial, Chino added.
“The guideline specifically recommends against stereotactic body radiation therapy or stereotactic ablative radiotherapy as a means of replacing brachytherapy at this time, due to concerns of worse toxicity and survival,” he said.
The task force recommended radiation therapy with concurrent platinum-based chemotherapy in the postoperative setting after radical hysterectomy for women at increased risk, including those with positive margins. For women with intermediate risk factors, such as larger tumors, postoperative radiation therapy is recommended. The guideline specifies risk criteria.
The task force advised chemoradiation therapy in the definitive setting for women with International Federation of Gynecology and Obstetrics (FIGO) stage IB3 to stage IVA cervical cancer. For women with FIGO stage IA1 to stage IB2 cervical cancer deemed medically inoperable, definitive radiation or chemoradiation is recommended.
To decrease short- and long-term toxicity, the task force recommended IMRT for postoperative EBRT and conditionally recommended IMRT for definitive EBRT.
The guideline strongly recommended brachytherapy for women receiving definitive radiation or chemoradiation, and conditionally recommended brachytherapy in the postoperative setting for women with positive margins.
Other recommendations included image guidance, volume-based treatment planning and strategies to limit radiation spread to organs at risk.
Although the guideline was completed before the COVID-19 pandemic, the task force noted that cancer clinics have implemented measures that have allowed them to continue cervical cancer treatments safely during the outbreak.
“We hope that the items outlined above will give radiation oncologists, medical oncologists and gynecologic oncologists guidance for common scenarios encountered when caring for women with cervical cancer,” Chino said. “No guideline, however, replaces the careful, personalized consideration of each patient case in a multidisciplinary tumor board.”
For more information:
Junzo Chino, MD, can be reached at Duke Cancer Center, 20 Duke Medicine Circle, Durham, NC 27710; email: firstname.lastname@example.org.