Radiation Therapy for Cervical Cancer

Publication Date: June 1, 2020
Last Updated: March 14, 2022

Recommendations

Postoperative RT with or without systemic therapy

For women undergoing surgery for cervical cancer who have high surgicopathologic risk factors, adjuvant EBRT and concurrent platinum-based chemotherapy are recommended. (StrongHigh)
Implementation remark:
High-risk factors include positive margin(s) or positive lymph node(s) or extension into the parametrial tissue.
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For women with cervical cancer and intermediate-risk factors, adjuvant EBRT is recommended to decrease locoregional recurrence. (StrongHigh)
Implementation remark: Intermediate-risk factors include:
• LVSI plus deep one-third cervical stromal invasion with any tumor size
• LVSI plus middle one-third stromal invasion and tumor size ≥2 cm
• LVSI plus superficial one-third stromal invasion and tumor size ≥5 cm
• No LVSI but deep or middle one-third stromal invasion plus tumor size ≥4 cm
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Definitive RT with and without systemic therapy and hysterectomy after RT

For women with FIGO stage IB3-IVA* squamous cell or adenocarcinoma of the cervix, RT with concurrent platinum-based chemotherapy is recommended for definitive treatment. (StrongHigh)
Implementation remark:
Recommended dose for cisplatin is 40 mg/m2 weekly for 5-6 cycles.
* Stage IIA1 cancers may be managed with radical hysterectomy in well-selected (eg, nonbulky, with limited vaginal involvement) cases.
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For women with FIGO stage IB3-IVA cervical cancer, a planned adjuvant hysterectomy after RT or chemoradiation is not recommended.† (Strong, High)
† In the setting of biopsy-proven gross residual disease after point-A–based dose specification for brachytherapy, surgery may be an option.
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In women with FIGO stage IA1-IB2 that are deemed medically inoperable, RT with or without chemotherapy is conditionally recommended. (ConditionalExpert Opinion)
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Intensity modulated radiation therapy (IMRT)

In women with cervical cancer treated with postoperative RT with or without chemotherapy, IMRT is recommended to decrease acute and chronic toxicity.
  • Acute
(StrongModerate)
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  • Chronic
(StrongLow)
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In women with cervical cancer treated with definitive RT with or without chemotherapy, IMRT is conditionally recommended to decrease acute and chronic toxicity.
  • Acute
(ConditionalModerate)
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  • Chronic
(ConditionalModerate)
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Brachytherapy

For women receiving definitive RT for intact cervical cancer, brachytherapy is recommended. (StrongModerate)
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For women with cervical cancer receiving postoperative whole pelvis radiation, a brachytherapy boost is conditionally recommended in the presence of positive margin(s). (Conditional, Low)
Implementation remark:
The brachytherapy technique selected is based on the location and volume of the positive margin(s).
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Brachytherapy technique

For women receiving brachytherapy for cervical cancer, intra-procedure imaging is recommended if available. (StrongLow)
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For women receiving brachytherapy for cervical cancer, MRI or CT-based planning to a volume-based prescription is recommended. (StrongModerate)
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For women receiving brachytherapy for cervical cancer, if volume-based planning cannot be performed, then 2-D/point-based planning is recommended. (StrongModerate)
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For women treated with definitive RT for cervical cancer, the total EQD210 of EBRT and brachytherapy should be ≥8000 cGy. (StrongModerate)
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For women with cervical cancer receiving volume-based brachytherapy, HR-CTV D90 greater than or equal to prescription dose (≥8000 cGy) is conditionally recommended, with careful consideration of normal tissue constraints. (ConditionalModerate)
Implementation remark:
• For patients with poor response or large-volume (>4 cm) disease, D90 ≥8500 cGy is reasonable.
• Utilization of a hybrid intracavitary/interstitial technique can help improve the dose distribution when not achieving appropriate target and/or OAR dose constraints with an intracavitary alone approach.
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In women treated with brachytherapy for intact cervical cancer, volumetric contouring of the OARs and use of appropriate dose constraints are recommended. (StrongModerate)
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If volumetric planning is not available for women treated with brachytherapy for intact cervical cancer, 2-D/point-based dose constraints should be applied. (StrongModerate)
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Recommendation Grading

Overview

Title

Radiation Therapy for Cervical Cancer

Authoring Organization

Publication Month/Year

June 1, 2020

Last Updated Month/Year

September 11, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

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.

Inclusion Criteria

Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Radiology technologist, nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D002577 - Uterine Cervical Diseases, D002583 - Uterine Cervical Neoplasms, D002578 - Uterine Cervical Dysplasia

Keywords

cervical cancer, radiation therapy (RT)

Methodology

Number of Source Documents
135
Literature Search Start Date
January 1, 1993
Literature Search End Date
October 31, 2018
Description of External Review Process
While the guideline is undergoing consensus voting, peer reviewers are identified who have an active clinical and/or research interest in the topic of the guideline. They are drawn from multiple sources, including the ASTRO membership and partner or collaborating organizations, and are selected to provide a variety of perspectives and areas of expertise. The task force chair(s), GLSC, and, where applicable, other committees and panels propose official ASTRO reviewers. Partner, collaborating, and potential endorsing societies are also encouraged to nominate reviewers on their behalf since this is their primary opportunity to recommend changes to the guideline. Like task force members, reviewers must disclose all industry relationships and personal interests and their disclosures are evaluated using a stringent COI review process. Once consensus on the draft guideline is achieved by the task force, the document undergoes review simultaneously by the invited peer reviewers, the GLSC (including in-depth review by 2-3 members for content, process and consistency with other ASTRO clinical documents), and ASTRO staff and legal counsel. The resulting comments are adjudicated by the task force and the guideline revised as appropriate.
Description of Public Comment Process
Following peer review, guidelines are posted on ASTRO’s website for 4-6 weeks for public comment. Announcements are made via emails and postings on the ASTRO website inviting comments from ASTRO members and committees; patient support and advocacy groups; and other potential stakeholders.
Specialties Involved
Family Medicine, Internal Medicine General, Obstetrics And Gynecology, Oncology, Radiation Oncology, Oncology
Description of Systematic Review
The task force also assesses and refines the preliminary KQs using the Patients, Interventions, Comparators, Outcomes, Timing, and Setting (PICOTS) framework, which guides a systematic approach to evidence review for guidelines. Focused questions make the project more manageable and lead to specific recommendations and conclusions that support patient care. Once the KQs are finalized, writing assignments are determined, including leads for each KQ.
List of Questions
See full text
Description of Study Criteria
See full text
Description of Search Strategy
Drawing on the PICOTS for the KQs, a search protocol is developed, which details the search strategies and inclusion and exclusion criteria. The literature is derived from research involving human subjects, published in English, and indexed in MEDLINE. Hand searches of other sources, particularly recent review articles and trial data, may confirm or supplement the electronic searches. Studies published after the end date of the literature search are not used to develop the recommendations but may be discussed in a future directions/ emerging data section.
Description of Study Selection
The literature search results go through a series of reviews to synthesize the evidence based on the pre-defined inclusion and exclusion criteria to determine their relevance to the identified KQs and scope of the guideline. An independent literature review team dual-screens first the titles and then the abstracts of the articles included from title screening. The studies included after the second round are reviewed and further refined by the task force. Study characteristics from the final group of selected articles is abstracted into detailed evidence tables, which summarize the primary evidence base for the guideline and are used to inform the recommendations. The evidence tables are published as a supplement to the document.
Description of Evidence Analysis Methods
To ensure high standards in developing ASTRO’s guidelines, a rigorous, transparent, reproducible, and unbiased review of the evidence is paramount. Through a series of conference calls, small work groups synthesize and summarize the evidence for each KQ to determine the quality of the evidence. These discussions inform the development of draft recommendations, which include assigning the recommendation strength and overall quality of evidence ratings, as defined in Table 1. It is important that guideline recommendations be clear and actionable statements that align with the PICOTS framework, denoting in most instances the patient group, intervention, comparator, and outcome. Implementation remarks are included sparingly to enhance the reader’s interpretation and understanding of a recommendation or to append information like timing, setting, or dosing details to the recommendation.
Description of Evidence Grading
High: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate. Very Low: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate. In 2018, ASTRO’s guideline methodology was modified to incorporate an expert opinion strength of recommendation category and to quantify the number and type of studies that determine the quality of evidence. Expert opinion recommendations are used where guidance is considered essential due to factors such as high prevalence, mortality, or morbidity but either relevant data do not exist, the available evidence does not reflect current technology/practice, or there is substantial variation in practice or controversy
Description of Recommendation Grading
General agreement on the recommendations is achieved during task force discussions throughout the writing process. Formal consensus is then evaluated using a modified Delphi approach. Strong: Definition:  Benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits.  All or almost all informed people would make the recommended choice for or against an intervention. Overall Quality of Evidence Grade:  Any (usually high or moderate) Recommendation Wording:  “Recommendation/Should” Conditional: Definition:  Benefits are finely balanced with risks and burden or appreciable uncertainty exists about the magnitude of benefits and risks.  Most informed people would choose the recommended course of action, but a substantial number would not.  There is a strong role for patient preferences and shared-decision making. Overall Quality of Evidence Grade  Any (usually moderate to very low) Recommended Wording  “Conditionally Recommend”
Description of Funding Source
ASTRO provides funding for Guideline Development.
Company/Author Disclosures
ASTRO has detailed policies and procedures related to disclosure and management of industry relationships to avoid actual, potential, or perceived conflicts of interest. Based on the scope of the guideline, ASTRO staff initially identify categories of affected companies – commercial entities whose business and products may be influenced, positively or negatively, by the guideline recommendations. This list is reviewed during the proposal approval process and further refined by the selected task force chairs. All task force members are required to disclose industry relationships and personal interests that were active within the 12 months before initiation of the project. Disclosures go through a rigorous review process with final approval by ASTRO’s Conflict of Interest Review Committee. A majority of task force members (>50%), including the chairs, do not have relationships with affected companies and certain types of relationships are not permitted at all. For the purposes of full transparency, task force members’ comprehensive disclosure information is published in the guideline.
Percentage of Authors Reporting COI
100