Radiation Therapy for Cervical Cancer: Executive Summary of an ASTRO Clinical Practice Guideline

Abstract

Purpose: This guideline reviews the evidence and provides recommendations for the indications and appropriate techniques of radiation therapy (RT) in the treatment of nonmetastatic cervical cancer.

Methods: The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the use of RT in definitive and postoperative management of cervical cancer. These questions included the indications for postoperative and definitive RT, the use of chemotherapy in sequence or concurrent with RT, the use of intensity modulated radiation therapy (IMRT), and the indications and techniques of brachytherapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength.

Results: The guideline recommends postoperative RT for those with intermediate risk factors, and chemoradiation for those with high-risk factors. In the definitive setting, chemoradiation is recommended for stages IB3-IVA, and RT or chemoradiation is conditionally recommended for stages IA1-IB2 if medically inoperable. IMRT is recommended for postoperative RT and conditionally recommended for definitive RT, for the purposes of reducing acute and late toxicity. Brachytherapy is strongly recommended for all women receiving definitive RT, and several recommendations are made for target dose and fractionation, the use of intraoperative imaging, volume-based planning, and recommendations for doses limits for organs at risk.

Conclusions: There is strong evidence supporting the use of RT with or without chemotherapy in both definitive and postoperative settings. Brachytherapy is an essential part of definitive management and volumetric planning is recommended. IMRT may be used for the reduction of acute and late toxicity. The use of radiation remains an essential component for women with cervical cancer to achieve cure.

Figure 1

Cervical cancer algorithm. Abbreviations: BT = brachytherapy; EBRT = external beam radiation therapy; IMRT = intensity modulated radiation therapy; LND = lymph node dissection; RT = radiation therapy.

Figure 2

Example of IMRT PTV definition for intact cervical cancer. A and B axial CT images; C sagittal CT images; and D sagtital MRI images, showing uterine motion; refer to the full-text guideline for a detailed description of PTV definitions. Abbreviations: CT = computed tomography; IMRT = intensity modulated radiation therapy; MRI = magnetic resonance imaging; PTV = planning target volume.

Figure 3

Locally advanced cervical cancer algorithm. Abbreviations: 2-D = 2-dimensional; BT = brachytherapy; EBRT = external beam radiation therapy; EQD2 = equivalent dose at 2 Gy per fraction; HR-CTV = high-risk clinical target volume; OAR = organ at risk.