ASTRO Clinical Practice Guidelines in Cervical Cancer in Gynecologic Oncology

The December 2020 edition of Gynecologic Oncology includes the Clinical Commentary, “The ASTRO clinical practice guidelines in cervical cancer: Optimizing radiation therapy for improved outcomes,” which provides a summary update of the 2020 ASTRO clinical practice guideline on radiation therapy for cervical cancer, “Radiation Therapy for Cervical Cancer: An ASTRO Clinical Practice Guideline,” (Practical Radiation Oncology May 18, 2020). It includes authors representing several medical societies, including the American Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), American Brachytherapy Society (ABS) and the Society of Gynecologic Oncology. Christine H. Holschneider, MD, served as the representative for SGO with members of the SGO Clinical Practice Committee providing review and input for the guidelines.

The authors note that much has changed in radiation therapy in the past two decades, both in the realm of external beam treatments (EBRT) to the pelvis, and in the practice of brachytherapy (BT). The guideline is centered around five key questions (KQ), which were addressed by a multidisciplinary task force, utilizing a robust literature search and review process to provide answers, as well as a measure of the quality of evidence. The key questions are as follows:

• Following primary surgery for cervical cancer, when is it appropriate to deliver postoperative RT with or without systemic therapy?
• When is it appropriate to deliver definitive RT with and without systemic therapy?
• For patients receiving definitive or postoperative RT for cervical cancer, when is it appropriate to deliver IMRT?
• For patients receiving definitive or postoperative RT for cervical cancer, when is brachytherapy indicated?
• For patients receiving definitive RT for cervical cancer, what is the optimal dose/fractionation schedule, imaging, and technique for the delivery of brachytherapy?

“While many of the recent advances in radiation oncology such as IMRT or SBRT are offering wonderful improvements in the treatment for our patients, it is important to remember that they are not a substitute for brachytherapy,” said Dr. Holschneider “For patients who receive curative intent radiation for cervical cancer brachytherapy as the most conformal form of radiation remains essential towards achieving cure.”

In conclusion, the authors added, “There have been many advances in the methods by which radiation therapy can be delivered, however the core principals remain intact–whole pelvic radiation therapy with concurrent cisplatin-based chemotherapy followed by high quality brachytherapy results in the best outcomes for locally advanced disease. Earlier stages are best treated with optimal surgery, with postoperative risk adapted radiation therapy offered when indicated. In the end, however, no guideline is a replacement for discussion and co-management of all cases by a dedicated multidisciplinary team.”