Table 2

Treatment indicators

QI 7: Patients are treated with intensity modulated radiotherapy techniques
TypeOutcome indicator
DescriptionPatients receiving pelvic and/or para-aortic radiotherapy are treated with IMRT-like techniques to decrease treatment related toxicity
Specifications Numerator: number of cervical cancer patients treated with curative intent with pelvic and/or para-aortic IMRT per center
Denominator: total number of cervical cancer patients treated with curative intent with pelvic and/or para-aortic external irradiation per center
TargetsOptimal target: 100%
Minimum required target: ≥90%
QI 8: Daily on-board IGRT and individualized margins are used to compensate for internal target motion
TypeOutcome indicator
DescriptionPatients are treated following an IGRT protocol with daily imaging based on on-board three-dimensional imaging (CBCT, MRI, or CT), with individual margins to compensate for internal target motion, daily verification modalities, and couch correction strategies. Replanning is performed when target motion has impact on dosimetric coverage
Specifications Numerator: number of cervical cancer patients treated following an individualized IGRT protocol with daily on-board three-dimensional imaging
Denominator: total number of cervical cancer patients receiving curative intent EBRT
Target≥95%
QI 9: Prescribed pelvic dose is 45 Gy in 1.8 Gy per fraction
TypeOutcome indicator
DescriptionPrescribed dose for pelvic and/or para-aortic EBRT is 45 Gy delivered in fractions of 1.8 Gy
Specifications Numerator: number of patients treated with curative intent for cervical cancer and being prescribed a total dose of 45 Gy EBRT
Denominator: total number of patients treated with curative intent EBRT for cervical cancer
Target≥95%
QI 10: Lymph node boosts are delivered in patients with macroscopic lymph node spread
TypeOutcome indicator
DescriptionSuspicious macroscopic lymph nodes are boosted, preferentially through SIB
SpecificationsLymph node boosts
  • Numerator: number of patients with pelvic and/or para-aortic macroscopic lymph nodes treated with lymph node boost, excluding palliative cases

  • Denominator: total number of patients with pelvic and/or para-aortic macroscopic lymph nodes treated with EBRT, excluding palliative cases

SIB use
  • Numerator: number of patients with pelvic and/or para-aortic macroscopic lymph nodes treated with SIB

  • Denominator: total number of patients with pelvic and/or para-aortic macroscopic lymph nodes receiving lymph node boost

TargetsLymph node boosts: ≥ 95%
SIB use: ≥90%
QI 11: Chemotherapy use
TypeOutcome indicator
DescriptionPatients with cervical tumor are treated with radiotherapy and concurrent chemotherapy
Specifications Numerator: number of patients treated with curative intent EBRT for cervical cancer receiving concurrent chemotherapy
Denominator: total number of patients treated with curative intent EBRT for cervical cancer who are fit for concurrent chemotherapy without contraindications, such as renal insufficiency, hematological comorbidities, etc
Target≥95%
QI 12: Imaging for IGABT
TypeOutcome indicator
DescriptionPatients are treated with IGABT and at least the first brachytherapy fraction is planned based on MRI with applicator in situ
SpecificationsIGABT use
  • Numerator: number of patients treated with uterovaginal brachytherapy having three-dimensional imaging (CT or MRI) with applicator in situ performed at each implant

  • Denominator: total number of patients treated with uterovaginal brachytherapy

MRI at least at the first fraction
  • Numerator: number of patients treated with uterovaginal brachytherapy having an MRI with applicator in situ performed at least at the first fraction

  • Denominator: total number of patients treated with uterovaginal brachytherapy without contraindications for MRI

TargetsIGABT use: 100%
MRI at least at the first fraction: ≥60%
QI 13: Combined intracavitary/interstitial brachytherapy use
TypeOutcome indicator
DescriptionCombination of intracavitary and interstitial implant technique is recommended in patients with advanced stages, poor response to chemoradiotherapy, and/or or large volume and/or asymmetric tumors. It also helps decreasing doses to organs at risk
Specifications Numerator: number of patients treated with combination of intracavitary uterovaginal and interstitial brachytherapy
Denominator: total number of patients treated with uterovaginal brachytherapy
TargetsOptimal target: ≥60%
Minimum required target: ≥40%
QI 14: Brachytherapy is delivered after the patient has received a total EBRT dose ≥36 Gy to allow maximal tumor regression
TypeOutcome indicator
DescriptionBrachytherapy is performed after the patient has received a total EBRT dose ≥36 Gy
Specifications Numerator: number of patients having uterovaginal brachytherapy performed after a total EBRT dose ≥36 Gy
Denominator: total number of patients treated with uterovaginal brachytherapy
Target>95%
QI 15: Overall treatment time does not exceed 50 days
TypeOutcome indicator
DescriptionOverall treatment time, calculated from the first EBRT fraction to the last brachytherapy fraction (for high dose rate treatment) or pulse (for pulsed dose rate treatments), is ≤50 days. Overall treatment time calculation includes the delivery of lymph nodes boosts
Specifications Numerator: number of patients treated with radiotherapy (and/or concurrent chemotherapy) plus brachytherapy boost and having overall treatment time ≤50 days
Denominator: total number of patients treated with radiotherapy (and/or concurrent chemotherapy) plus brachytherapy boost, excluding those with occasional severe medical complications (eg, neutropenia requiring treatment disruption or concurrent infection)
Target≥90%
QI 16: Minimum required criteria for brachytherapy treatment planning
TypeProcess indicator
DescriptionThe center follows a protocol including, at minimum, the criteria for brachytherapy provided in Table 3
Specifications Numerator: not applicable
Denominator: not applicable
TargetBrachytherapy treatment planning meets criteria detailed in the table above
QI 17: Number of patients treated with EBRT plus brachytherapy per center per year
TypeStructural indicator
DescriptionA minimum number of patients treated per year per center with EBRT (and/or concurrent chemotherapy) plus brachytherapy
Specifications Numerator: number of patients treated with EBRT (and/or concurrent chemotherapy) plus brachytherapy for cervical cancer per center per year
Denominator: not applicable
TargetsOptimal target: n ≥20
Minimum required target: n≥10
  • CBCT, cone beam computed tomography; CT, computed tomography; EBRT, external beam radiotherapy; IGABT, image guided adaptive brachytherapy; IGRT, image guided radiotherapy; IMRT, intensity modulated radiotherapy; MRI, magnetic resonance imaging; QI, quality indicator; SIB, simultaneous integrated boost.