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Adjuvant radiotherapy and chemoradiation after surgery for cervical cancer

Linda Rogers, Shing Shun N Siu, David Luesley, Andrew Bryant, Heather O Dickinson
Cochrane Database of Systematic Reviews 2009, (4): CD007583

BACKGROUND: There is an ongoing debate about the indications for, and value of, adjuvant pelvic radiotherapy after radical surgery in women with early cervical cancer. Certain combinations of pathologic risk factors are thought to represent sufficient risk for recurrence, that they justify the use of post-operative pelvic radiotherapy, though this has never been shown to improve overall survival, and use of more than one type of treatment (surgery and radiotherapy) increases the risks of side-effects and complications.

OBJECTIVES: To evaluate the effectiveness and safety of adjuvant therapies (radiotherapy, chemotherapy followed by radiotherapy, chemoradiation) after radical hysterectomy for early stage cervical cancer (FIGO stages IB1, IB2 or IIA).

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2008. The Cochrane Gynaecological Cancer Group Trials Register, MEDLINE (January 1950 to November 2008), EMBASE (1950 to November 2008). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared adjuvant therapies (radiotherapy, chemotherapy followed by radiotherapy, or chemoradiation) with no radiotherapy or chemoradiation, in women with a confirmed histological diagnosis of early cervical cancer who had undergone radical hysterectomy and dissection of the pelvic lymph nodes.

DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted data and assessed risk of bias. Information on grade three and four adverse events was collected from the trials. Results were pooled using random effects meta-analyses.

MAIN RESULTS: Two RCTs, which compared adjuvant radiotherapy with no adjuvant radiotherapy, met the inclusion criteria; they randomised and assessed 397 women. Meta-analysis of these two RCTs indicated no significant difference in survival at five years between women who received radiation and those who received no further treatment (Relative risk (RR) = 0.8, 95% Confidence interval (CI): 0.3 to 2.4). However, women who received radiation had a significantly lower risk of disease progression at five years (RR = 0.6, 95% CI 0.4 to 0.9).Although the risk of serious adverse events was consistently higher if women received radiotherapy rather than no further treatment, these increased risks were not statistically significant, probably because the rate of adverse events was low.

AUTHORS' CONCLUSIONS: We found evidence, of moderate quality, that radiation decreases the risk of disease progression compared with no further treatment, but little evidence that it might improve overall survival. The evidence on serious adverse events was equivocal.

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