Locally advanced cervical cancer treatment guidelines for low-resource settings
| Guideline | Optimal treatment | Limited resources |
| International Atomic Energy Agency 2013 54 |
Stages IB2 and IIA2
Concurrent chemoradiation, followed by brachytherapy |
Stages IB2 and IIA2
Where brachytherapy is not available, surgery followed by adjuvant radiotherapy or chemoradiation |
|
Stages IIB–IVA
External beam radiation therapy with or without concurrent chemotherapy, followed by brachytherapy |
Stages IIB–IVA
Where treatment compliance, patient health factors (eg, nutrition, performance status), or the inability to treat complications of chemoradiation are a concern, treatment with definitive radiotherapy +brachytherapy without chemotherapy is an option | |
| 3-dimensional conformal external beam radiation therapy using CT imaging is ideal to limit radiation to the surrounding organs | Where 3-dimensional techniques are not available, 2-dimensional treatment planning and delivery for external beam radiation therapy should be based on bony landmarks | |
| American Society of Clinical Oncology 2016 55 |
Stages IB2–IVA
Concurrent pelvic chemoradiation |
Stages IB2 and IIA2
No radiotherapy or surgical experts: neoadjuvant chemotherapy, then extrafascial hysterectomy Chemotherapy and surgical experts available, no radiotherapy: neoadjuvant chemotherapy, then radical hysterectomy External beam radiation therapy available, no brachytherapy: concurrent chemoradiation, then extrafascial hysterectomy Brachytherapy available, no external beam radiation therapy: brachytherapy concurrent with chemotherapy, then radical hysterectomy IIB and IIIA No external beam radiation therapy or brachytherapy: neoadjuvant chemotherapy, then extrafascial or modified hysterectomy No chemotherapy or brachytherapy: external beam radiation therapy, then extrafascial or modified hysterectomy Chemotherapy and external beam radiation therapy available, no brachytherapy: concurrent chemoradiation, then hysterectomy IIIB to IVA No external beam radiation therapy, chemotherapy, brachytherapy: palliative care No external beam radiation therapy or brachytherapy: neoadjuvant chemotherapy, then hysterectomy No chemotherapy or brachytherapy: external beam radiation therapy, then hysterectomy Chemotherapy and external beam radiation therapy available, no brachytherapy: concurrent chemoradiation, then hysterectomy |
| International Federation of Gynecology and Obstetrics 2015 56 |
Stages IB2–IVA
Radical chemoradiation, followed by brachytherapy The total radiotherapy dose should be 80–85 EQD2 to point A |
Stages IB2–IVA
Where treatment compliance, patient health factors (eg, nutrition, performance status), or the inability to treat complications of chemoradiation are a concern, treatment with definitive radiotherapy +brachytherapy without chemotherapy is an option |
| MRI-guided brachytherapy is optimal | Where MRI is unavailable, CT or ultrasound imaging should be used to guide brachytherapy | |
| American Brachytherapy Society 2017 57 |
Locally advanced disease confined to pelvis
External beam radiation therapy using 4-field technique with blocking, dose 45 Gy in 1.8 Gy fractions, CT-based planning is ideal Chemotherapy concurrent with external beam radiation therapy is recommended Brachytherapy should be planned with 3-dimensional imaging, preferably CT, and given to a minimum EQD2 of 80 Gy |
Locally advanced disease confined to pelvis
In the absence of custom blocking for external beam radiation therapy, corner shields may be used Where CT-based testing is not possible, use bony landmarks in field design Radiotherapy alone may be appropriate if access to chemotherapy is limited or due to patient status/comorbidities is prohibitive Brachytherapy planning with 2-dimensional imaging, or, if 2-dimensional imaging is not available, planning to point A with modifications based on tumor volume and organ-at-risk doses |
| National Cancer Grid India 2018 58 |
Stages IB2–IVA
Concurrent pelvic chemoradiation, using intensity-modulated radiotherapy, followed by chemotherapy or MRI-based brachytherapy |
Stages IB2–IVA
Concurrent pelvic chemoradiation, followed by brachytherapy, but with 3-dimensional external beam radiation therapy and 2-dimensional brachytherapy techniques |
CT, computed tomography; EQD2, equi-effective dose to 2 Gy per fraction; MRI, magnetic resonance imaging.