Postoperative adjuvant radiation for cervix cancer: reflections on the evidence and a peep into the future

Abstract

Early stage cervical cancer, stages IB1–2 and IIA1, can be treated with (chemo)radiation and brachytherapy or radical hysterectomy with or without further adjuvant (chemo)radiation. In a carefully selected cohort for surgery, traditionally a small proportion of patients would need adjuvant (chemo)radiation so that the therapeutic ratio is maximized. However, advances in radiation technology, specifically intensity modulated radiotherapy, have led to a reduction in treatment related adverse events. Also, recent developments in risk stratification suggest using a lower threshold to offer adjuvant treatment to minimize pelvic relapse. These developments together present opportunities of not only re-examining the therapeutic ratio but also of further evolving postoperative risk stratification. This review article summarizes the current evidence on adjuvant treatment strategies and summarizes the key areas where research should be focused.

Adjuvant treatment after radical surgery for cervical cancer with intermediate risk factors: is it time for an update?

“…For future studies, implementation of these techniques should be considered, seeking to improve pelvic control and thereby disease free survival, with a lower threshold (8-10% risk of pelvic relapse). 36 Further Points of Consideration The study of Sedlis et al demonstrated a reduction in risk of recurrence after radiotherapy, but not in overall survival. One potential reason is that the sample size might have been too small as this study was planned to have 80% power to detect risk reductions of 46% or greater in overall survival; however, patients with radiotherapy had only a 30% reduction in the risk of mortality and significance was not reached.…”

“…Further control in the pelvis, specifically in the vagina, may be achieved by using additional vaginal brachytherapy. 36 Bronsart et al 44 examined the role of adjuvant brachytherapy alone as an alternative to external beam radiation therapy in 40 patients. This treatment was indicated when tumor size was ≥2 cm and/or in the presence of lymphovascular space invasion.…”

“…Currently, radiation techniques such as three-dimensional conformal radiation therapy, intensity modulated radiation therapy, and volumetric modulated arc therapy are the standard of care, with potentially lower long term morbidity. For future studies, implementation of these techniques should be considered, seeking to improve pelvic control and thereby disease free survival, with a lower threshold (8–10% risk of pelvic relapse) 36…”

“…Rotman et al11 noted a high locoregional failure rate (14% in the radiation arm), suggesting the need to increase radiotherapy doses, either by external beam or in conjunction with brachytherapy. Further control in the pelvis, specifically in the vagina, may be achieved by using additional vaginal brachytherapy 36. Bronsart et al44 examined the role of adjuvant brachytherapy alone as an alternative to external beam radiation therapy in 40 patients.…”