Toxicity and quality of life after adjuvant chemoradiotherapy versus radiotherapy alone for women with high-risk endometrial cancer (PORTEC-3): an open-label, multicentre, randomised, phase 3 trial

Multifunctional nanozymes: Promising applications in clinical diagnosis and cancer treatment

Cancer remains one of the greatest challenges in modern medicine. Traditional chemotherapy drugs often cause severe side effects, including nausea, vomiting, diarrhea, neurotoxicity, liver damage, and nephrotoxicity. In addition to these adverse effects, high recurrence and metastasis rates following treatment pose significant challenges for clinicians. There is an urgent need for novel therapeutic strategies to improve cancer treatment outcomes. In this context, nanozymes-artificial enzyme mimetics-have attracted considerable attention due to their unique advantages, including potent tumor-killing effects, enhanced biocompatibility, and reduced toxicity. Notably, nanozymes can dynamically monitor tumors through imaging and tracing. The multifunctional nanozyme (MN) is a promising research focus, integrating multiple catalytic activities, signal enhancement, sensing capabilities, and diverse modifications within a single nanozyme system. MNs can selectively target tumor regions, facilitating synergistic effects with other cancer therapies while enabling real-time imaging and tumor tracking. In this review, we first categorize MNs based on their composition and structural characteristics. We then discuss the primary mechanisms by which MNs exert their anticancer effects. Additionally, we review three types of MN biosensors and four MN-based therapeutic approaches applied in cancer treatment. Finally, we highlight the current challenges in MN research and provide an outlook on future developments in this field.

Retinoblastoma Protein Loss in p53 Abnormal Endometrial Carcinoma: Histologic and Clinicopathological Correlates

Of the 4 molecular subtypes of endometrial cancer (EC), p53-abnormal (p53abn) EC is associated with abundant copy number alterations and the worst clinical outcome. Patients with p53abn EC have the highest risk of disease recurrence and death, independent of tumor grade and histologic subtype. Currently, all invasive p53abn ECs are considered high risk, and no prognostic biomarkers have yet been found that can aid in clinical management. Here, we aimed to test whether loss of retinoblastoma (RB) protein expression using immunohistochemistry has the potential for prognostic refinement of p53abn EC. A large cohort of 227 p53abn ECs collected from the PORTEC-1/2/3 clinical trials and the Medisch Spectrum Twente cohort study was investigated, and RB loss was identified in 7.0% (n = 16/227). RB-lost p53abn ECs were predominantly high-grade endometrioid ECs (n = 6, 37.5%) and carcinosarcomas with endometrioid-type epithelial component (n = 5, 31.3%). Histologically, RB-lost p53abn ECs were typified by high-grade nuclear atypia (n = 16, 100%), predominantly solid growth pattern (n = 15/16, 93.8%), and polypoid growth (n = 9/16, 56.3%). Copy number loss involving the RB1 locus was identified in the majority of RB-lost p53abn EC (n = 13/14, 92.9%), explaining the loss of RB expression. Comparative analysis also showed that RB-lost p53abn ECs were diagnosed at earlier stages than RB-retained p53abn EC (P = .014). Interestingly, RB-lost p53abn EC showed prolonged time to overall recurrence (P = .038), even within stage I alone (P = .040). These findings highlight distinct morphomolecular features in RB-lost p53abn ECs and confirm the utility of RB immunohistochemistry as a surrogate for underlying molecular RB1 alterations. To our knowledge, this is the first study to show the potential use of RB in prognostic refinement of p53abn EC, although validation is warranted.

A comparative analysis of toxicity and treatment outcomes of adaptive radiotherapy and intensity-modulated radiotherapy in cervical cancer

Adaptive radiotherapy (ART) provides greater benefits than intensity-modulated radiotherapy (IMRT) regarding dosimetric outcomes in patients with cervical cancer. To investigate the clinical benefits of ART, we have collected data from 115 cervical cancer patients who underwent radical radiotherapy at our institution. Fifty-nine patients received a single course of IMRT. Fifty-six patients underwent offline ART, defined as the reduction of the gross tumor volume (GTV) by at least 30% after 30 Gy of radiotherapy, followed by a modified treatment plan for the second-stage. After treatment, 53 patients of ART group achieved a partial response (PR) or completement response (CR), resulting in an objective response rate (ORR) of 94.6% for the ART group, compared to 93.2% for the IMRT group. Patients in both groups exhibited no significant differences in acute toxicities. However, the incidence of chronic constipation was significantly higher in the IMRT group compared to the ART group (p = 0.021). With a median follow-up time of 27 months, the ART group experienced a higher mortality (10/56) than the IMRT group (6/59). However, the difference between the two groups was not statistically significant. In summary, ART may be advantageous in reducing the incidence of chronic constipation among patients with locally advanced cervical cancer, and both clinical prognosis and near-term survival are satisfactory.

Predicting High-Grade Acute Urinary Toxicity and Lower Gastrointestinal Toxicity After Postoperative Volumetric Modulated Arc Therapy for Cervical and Endometrial Cancer Using a Normal Tissue Complication Probability Model

(1) Background: Volumetric modulated arc therapy (VMAT) can deliver more accurate dose distribution and reduce radiotherapy-induced toxicities for postoperative cervical and endometrial cancer. This study aims to retrospectively analyze the relationship between dosimetric parameters of organs at risk (OARs) and acute toxicities and provide suggestions for the dose constraints. (2) Methods: A total of 164 postoperative cervical and endometrial cancer patients were retrospectively analyzed, and the endpoints were grade ≥ 2 acute urinary toxicity (AUT) and acute lower gastrointestinal toxicity (ALGIT). The normal tissue complication probability (NTCP) model was established using the logistic regression model. Restricted cubic spline (RCS) curves were used to explore the association between dosimetric parameters and toxicities. The receiver operating characteristic (ROC) curve, calibration curve, Akaike's corrected information criterion (AICc), decision curve analysis (DCA), and clinical impact curve (CIC) were analyzed to evaluate the performance of NTCP models. (3) Results: Bladder V40Gy was identified to develop the NTCP model of AUT, and the mean AUC was 0.69 (CI: 0.58-0.80). Three candidate predictors, namely the small intestine V30Gy, colon D45%, and rectum D55%, were identified to develop the NTCP model of ALGIT, and the mean AUC was 0.71 (CI: 0.61-0.80). Both models were considered to have relatively good discriminative accuracy and could provide a high net benefit in clinical applications. (4) Conclusions: We developed NTCP models to predict the probability for grade ≥ 2 AUT and ALGIT. We recommend that bladder V40Gy, the small intestine V30Gy, colon D45%, and rectum D55% be controlled below 42%, 20.4%, 16.9 Gy, and 32.0 Gy, respectively.

The Cost-Effectiveness of Sentinel Lymph Node Mapping in High-Risk Endometrial Cancer

Objectives. The aim was to evaluate the cost-effectiveness of sentinel lymph node (SLN) mapping in comparison to routine pelvic lymphadenectomy for lymph node assessment in patients with high-risk endometrial cancer (EC). Methods. A decision-analytic model was developed to compare SLN mapping with pelvic lymphadenectomy for guiding adjuvant therapy in patients with high-risk endometrioid and non-endometrioid EC, focusing on costs and health outcomes. The input data were obtained from systematic literature searches and expert consensus. Quality-adjusted life years (QALYs) was utilized as the measure of effectiveness. The model was constructed from a healthcare perspective, and the impact of uncertainty was evaluated through sensitivity analyses. Results. The base case analysis indicated that sentinel lymph node mapping is the dominant strategy for lymph node assessment in patients with high-risk endometrial cancer, as it was found to be both more effective and less costly than lymphadenectomy. The improved outcomes and reduced costs associated with SLN mapping primarily result from a decrease in the side effects related to lymph node assessment. Sensitivity analyses demonstrated that the outcome of the model was robust to variations in input values. Conclusion. SLN mapping is the most cost-effective strategy to determine the need for adjuvant therapy in patients with high-risk endometrioid and non-endometrioid endometrial cancer.

One-Step Nucleic Acid Amplification Analysis of Sentinel Nodes in Endometrial Cancer Versus Ultrastaging: First Long-Term Follow-Up Data of Discordant Cases

AIMS

Endometrial cancer (EC) is the most common gynecological cancer worldwide and its incidence is rising. The cornerstone of its management is surgical treatment with nodal staging. A monocentric study investigating the potential of the molecular biology method of one-step nucleic acid amplification (OSNA) in sentinel lymph node (SLN) analysis was conducted at our institution between April 2016 and January 2018. Histopathological ultrastaging was used as the reference standard for SLN examination and OSNA as the index test. The aim of this study was to assess the long-term outcome of patients with discordant SLN and OSNA results. To our knowledge, this is the first study exploring this issue.

METHODS AND RESULTS

Patients were followed in line with the current ESMO/ESGO/ESTRO recommendations. The institutional electronic database was retrospectively searched for patients' follow-up data from April 2016 till March 2023. Only patients who provided a written valid consent and had a positive OSNA and negative ultrastaging of their SLN analysis were included in the study. The primary endpoint was the retrospective analysis of their clinical outcome. Data from 58 patients enrolled into our previous study were reviewed and 12 discordant patients who met the inclusion criteria for this study were identified. The median follow-up was 83 months. Disease recurrence was detected in 3 (25%) patients, two of these were nodal and both patients died. One patient had a solitary lung metastasis which was surgically treated, and the patient was disease-free during the whole study period.

CONCLUSION

The recurrence rate of patients included in the study was in the intermediate-high and high-risk group range, and hence, higher than expected based on ultrastaging results. Furthermore, benign epithelial inclusions do not seem to adversely affect OSNA SLN analysis in EC patients.

Endometrial cancer in the elderly: Characteristics, prognostic and risk factors, and treatment options

Endometrial cancer incidence and related mortality are on the rise due to aging demographics. This population often presents with unfavorable features, such as myometrial invasion, non-endometrioid histology, high-grade tumors, worse prognosis, etc. The role of age as an independent prognostic factor is still debated, and screening tools addressing frailty emerge as pivotal in guiding treatment decisions; however, they are still underutilized. Treatment disparities are evident in the case of older patients with endometrial cancer, who frequently receive suboptimal care, hindering their survival. Radiotherapy and minimally invasive surgical approaches could be performed in older patients. Data on chemotherapy and immunotherapy are scarce, but their potential remains promising and data are being gathered by recent trials, contingent on optimal patient selection through geriatric assessments. Overall, we recommend personalized, screening tool-guided approaches, adherence to guideline-recommended treatments, and inclusion of older people in clinical trials to help identify the best course of treatment.

Guiding adjuvant radiotherapy in stage III endometrial cancer: a prognostic model based on SEER

Background

The effect of overall survival (OS) with adjuvant radiotherapy in stage III endometrial cancer (EC) remains controversial, and the adverse invents were unignorable.

Methods

A total of 4,064 stage III EC patients who underwent adjuvant chemotherapy post-operatively were selected from Surveillance, Epidemiology, and End Results (SEER) Program. Independent risk factors were identified through Cox regression models. A nomogram was developed accordingly to predict OS. The concordance index (C-index), calibration, and Receiver Operating Characteristic (ROC) curves were applied to assess the model. Patients were divided into the low- and high-risk groups based on the optimal risk cutoff. Stratified analysis was conducted by radiation in both groups, and interactions between radiation and the risk groups were conducted to explore if any benefit less from adjuvant radiotherapy.

Results

A total of five candidate factors were identified from the model showing good calibration and consistency discriminative power in the training (C-index: 0.73; 95% CI: 0.70-0.75), testing (C-index: 0.73; 95% CI: 0.69-0.77), and external validation cohorts (C-index: 0.88, 95% CI, 0.78-0.97). Patients were categorized into the low- and high-risk groups based on the optimal risk cutoff of 2.1048630. The women in the high-risk group experience significantly less (42% vs. 63% reduction) or none (0 vs. 63%) benefit (p-interaction = 0.049 vs. 0.016 in training and testing cohorts, respectively).

Conclusion

A nomogram incorporating five variables was established to predict OS in stage III EC patients with adjuvant chemotherapy. The high-risk groups benefit less or none from adjuvant radiotherapy, which may serve as a useful reference for better guidance of radiotherapy in stage III EC patients.

Adjuvant Therapy for Endometrial Cancer in the Era of Molecular Classification

Endometrial cancer primarily undergoes surgical intervention, with adjuvant treatments such as external beam pelvic radiotherapy, vaginal brachytherapy, chemotherapy, and combined therapy investigated in randomized trials. Treatment decisions hinge on clinicopathological risk factors. Low-risk cases usually require surgery alone, whereas high-intermediate risk often benefit from adjuvant vaginal brachytherapy for enhanced local control with minimal side effects. Recent trials advocate pelvic radiotherapy for high-risk cases, particularly in Stage I-II tumors with risk factors. Chemoradiation proves advantageous for serous cancers and Stage III disease, improving recurrence-free, and overall survival. Molecular studies, notably the Cancer Genome Atlas project, identified four distinct molecular classes, transcending stages, and histological types. These molecular subtypes exhibit a stronger prognostic impact than histopathological characteristics, heralding a shift toward molecular-integrated diagnostics and treatments. Incorporating molecular factors into adjuvant strategies, including targeted therapies, marks a new paradigm in endometrial cancer management, underpinning ongoing research, and clinical trials. This review outlines current adjuvant approaches, underscores the emergence of molecular-integrated risk profiling, and touches on developments in targeted therapy.

Molecular Classification of Endometrial Cancer and Its Impact on Therapy Selection

Endometrial cancer (EC) accounts for 90% of uterine cancer cases. It is considered not only one of the most common gynecological malignancies but also one of the most frequent cancers among women overall. Nowadays, the differentiation of EC subtypes is based on immunohistochemistry and molecular techniques. It is considered that patients' prognosis and the implementation of the appropriate treatment depend on the cancer subtype. Patients with pathogenic variants in POLE have the most favorable outcome, while those with abnormal p53 protein have the poorest. Therefore, in patients with POLE mutation, the de-escalation of postoperative treatment may be considered, and patients with abnormal p53 protein should be subjected to intensive adjuvant therapy. Patients with a DNA mismatch repair (dMMR) deficiency are classified in the intermediate prognosis group as EC patients without a specific molecular profile. Immunotherapy has been recognized as an effective treatment method in patients with advanced or recurrent EC with a mismatch deficiency. Thus, different adjuvant therapy approaches, including targeted therapy and immunotherapy, are being proposed depending on the EC subtype, and international guidelines, such as those published by ESMO and ESGO/ESTRO/ESP, include recommendations for performing the molecular classification of all EC cases. The decision about adjuvant therapy selection has to be based not only on clinical data and histological type and stage of cancer, but, following international recommendations, has to include EC molecular subtyping. This review describes how molecular classification could support more optimal therapeutic management in endometrial cancer patients.

Antitumour mechanisms of traditional Chinese medicine elicited by regulating tumour-associated macrophages in solid tumour microenvironments

Tumour-associated macrophages (TAMs), particularly M2-TAMs, constitute the largest proportion of immune cells in the solid tumour microenvironment, playing a crucial role in tumour progression and correlating with poor prognosis. TAMs promote the proliferation, invasion, and metastasis of tumour cells by remodelling the extracellular matrix, inhibiting immunity, promoting immune escape and tumour angiogenesis, and affecting cell metabolism. Traditional Chinese medicine (TCM) has been used clinically in China for millennia. Chinese herbs exhibit potent antitumour effects with minimal to no toxicity, substantially contributing to prolonging the lives of patients with cancer and improving their quality of life. TCM has unique advantages in improving the solid tumour microenvironment, particularly in regulating TAMs to further inhibit tumour angiogenesis, reduce drug resistance, reverse immunosuppression, and enhance antitumour immunity. This review highlights the TAM-associated mechanisms within the solid tumour microenvironment, outlines the recent advancements in TCM targeting TAMs for antitumour effects, emphasises the superiority of combining TCM with standard treatments or new nano-drug delivery systems, and evaluates the safety and efficacy of TCM combined with conventional treatments via clinical trials to provide insights and strategies for future research and clinical treatment.

Adjuvant carboplatin and paclitaxel with "sandwich" method radiotherapy for stage III or IV endometrial cancer: long-term follow-up at a single-institution

OBJECTIVE

To evaluate disease-free survival (DFS) and overall survival (OS) associated with adjuvant carboplatin and paclitaxel chemotherapy interposed with radiation for advanced endometrial cancer.

METHODS

This is a cohort study of adult women with stage III or IV endometrial cancer treated at a single institution, between April 2002 and October 2017. Tumor and treatment characteristics were recorded. Treatment consisted of 4 cycles of intravenous paclitaxel and carboplatin every 3 weeks, followed by external beam radiotherapy to the pelvis (45-50 Gy), and another 2 cycles of chemotherapy. One cohort of patients were prospectively enrolled from 2002 through 2006 and an additional cohort from 2007 to 2017, which was retrospectively analyzed. Primary endpoints for this study were DFS and OS rates which were calculated using Cox regression models.

RESULTS

Eighty-two patients with a median age of 66.5 years (range, 35-83 years) were included. Median follow-up was 46 months (range, 9-196 months). Most patients had stage IIIC disease (62.2%) and serous carcinoma histology (46.3%). Median OS was 146 months and median DFS was 71 months. A 5-year OS and DFS were 64.9% and 55.7%, respectively. Age >60 years subgroup was at a significantly higher risk of DFS event or death. Histological subtype, location of positive nodes, and cancer stage (IIIa vs. higher stage) did not correlate to a higher risk of recurrence or death.

CONCLUSION

Long term follow-up and a larger population confirm that the chemoradiotherapy sandwich method yields favorable outcomes in patients with high-risk endometrial cancer.

Systematic Review of the Literature on Multiple Co-occurring Symptoms in Patients Receiving Treatment for Gynecologic Cancers

OBJECTIVE

Patients with gynecologic cancers experience a very high symptom burden that has a negative impact on their quality of life. This systematic review aims to identify the common co-occurring symptoms, the prevalence of common symptoms, common instruments used to measure symptoms, associated risk factors, and the symptom burden in patients with gynecologic cancers.

DATA SOURCES

A search of four databases (ie, PubMed, Embase, Web of Science, and CINAHL) was done from January 1, 2012, through September 5, 2022. A qualitative synthesis of the extant literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA 2020).

CONCLUSION

A total of 118 studies met the prespecified inclusion criteria. Ninety-six symptoms were assessed across these studies. The top six symptoms and their grand mean prevalence rates were lack of energy (64.4%), fatigue (62.1%), abdominal pain (53.3%), depression (52.6%), concentration dysfunction (52.0%), and drowsiness (51.9%). Numerous methodologic challenges were evident across studies. Future research needs to develop a disease-specific symptom assessment measure, evaluate for risk factors associated with a higher symptom burden, and determine the impact of multiple symptoms on patient outcomes.

IMPLICATION FOR NURSING PRACTICE

The results are relevant for oncology clinicians to assess patients with gynecologic cancers for the presence of common symptoms and risk factors for higher symptom burden in the patients and to offer effective management interventions.

Assessing health-related quality of life among cancer survivors during systemic and radiation therapy in Bangladesh: a cancer-specific exploration

BACKGROUND

Evaluating the effects of cancer diagnosis and treatment on a patient's overall well-being is crucial and health-related quality of life (HRQoL) is a reliable metric for assessing this impact. Little is known about HRQoL among cancer survivors across various stages and treatments. The study examined individual and clinical factors influencing HRQoL among cancer survivors.

METHODS

A cross-sectional study was conducted in two specialised cancer care hospitals in Dhaka, Bangladesh. Cancer-diagnosed adults receiving treatment at selected hospitals from January to May 2022 were enrolled. The 5-level EuroQol-5 Dimensions version (EQ-5D-5L) instrument was used to collect HRQoL data. HRQoL scores were derived using UK value sets. The investigation used a multivariable Tobit regression model to determine the association between independent variables and HRQoL scores.

RESULTS

A total of 607 adult patients were enrolled, with 55% being females and 66% aged 36 to 64 years. Reported health problems in five EQ-5D domains include mobility (11%), self-care (11%), usual daily activities (19%), pain/discomfort (21%), and anxiety/depression (46%). Patients with throat, brain, lung, blood, and liver cancer had lower utility scores. Advanced-stage cancer survivors had lower utility scores (β = -49 units, 95% codfidence interval [CI]: -0.75 to -0.22) compared to early-stage survivors. Physically inactive survivors had lower utility scores by 0.41 units (95% CI: -0.51 to -0.30) compared to their counterparts. Private hospital patients had higher utility scores, whereas patients belonged to poor socioeconomic groups scored worse than wealthier ones.

CONCLUSIONS

This study highlights the impact of clinical and individual characteristics on HRQoL among cancer survivors. These findings advocate for an enhanced Bangladeshi cancer patient care model through timely interventions or programs, early detection or diagnosis, tailored treatments, and the promotion of physical activity to bolster HRQoL outcomes.

Endometrial Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry Number 032/034-OL, September 2022) - Part 2 with Recommendations on the Therapy of Precancerous Lesions and Early-stage Endometrial Cancer, Surgical Therapy, Radiotherapy and Drug-based Therapy, Follow-up Care, Recurrence and Metastases, Psycho-oncological Care, Palliative Care, Patient Education, and Rehabilitative and Physiotherapeutic Care

Summary The S3-guideline on endometrial cancer, first published in April 2018, was reviewed in its entirety between April 2020 and January 2022 and updated. The review was carried out at the request of German Cancer Aid as part of the Oncology Guidelines Program and the lead coordinators were the German Society for Gynecology and Obstetrics (DGGG), the Gynecology Oncology Working Group (AGO) of the German Cancer Society (DKG) and the German Cancer Aid (DKH). The guideline update was based on a systematic search and assessment of the literature published between 2016 and 2020. All statements, recommendations and background texts were reviewed and either confirmed or amended. New statements and recommendations were included where necessary. Aim The use of evidence-based risk-adapted therapies to treat low-risk women with endometrial cancer prevents unnecessarily radical surgery and avoids non-beneficial adjuvant radiation therapy and/or chemotherapy. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimum level of radical surgery and indicates whether chemotherapy and/or adjuvant radiation therapy is necessary. This should improve the survival rates and quality of life of these patients. The S3-guideline on endometrial cancer and the quality indicators based on the guideline aim to provide the basis for the work of certified gynecological cancer centers. Methods The guideline was first compiled in 2018 in accordance with the requirements for S3-level guidelines and was updated in 2022. The update included an adaptation of the source guidelines identified using the German Instrument for Methodological Guideline Appraisal (DELBI). The update also used evidence reviews which were created based on selected literature obtained from systematic searches in selected literature databases using the PICO process. The Clinical Guidelines Service Group was tasked with carrying out a systematic search and assessment of the literature. Their results were used by interdisciplinary working groups as a basis for developing suggestions for recommendations and statements which were then modified during structured online consensus conferences and/or additionally amended online using the DELPHI process to achieve a consensus. Recommendations Part 2 of this short version of the guideline provides recommendations on the treatment of precancerous lesions and early-stage endometrial cancer, surgical treatment, radiotherapy and drug-based therapy, follow-up, recurrence, and metastasis of endometrial cancer as well as the state of psycho-oncological care, palliative care, patient education, rehabilitative and physiotherapeutic care.

LncRNA-LA16c-313D11.11,A Signature to Predict Endometrial Carcinoma Patients with a Better Survival

The aim of this study was to develop and internally validate a nomogram of the probability EC patients surviving longer than 5 years. Quantitative real-time PCR (qRT-PCR) was implemented to analyze the expression of lncRNA-LA16c-313D11.11 in 60 EC tissues. The clinicopathological characteristics and follow-up data were retrospectively gathered and analyzed. To establish the prediction model, multivariate logistic regression analysis was applied, and the discrimination, calibration, and clinical practicability of the prediction model were assessed with a concordance index (C-index), calibration chart, and decision curve analysis. Bootstrap validation was performed for internal validation. The prediction factors included the age of patients, myometrial invasion, lymphovascular space invasion, histological subtype, and the expression of lncRNA-LA16C-313D11.11. The model demonstrated good calibration and modest discrimination (C-index = 0.860, 95% confidence interval: 0.724-0.946). Moreover, the interval validation achieved a high C-index value of 0.778. This study revealed the predictive value of lncRNA-LA16C-313D11.11 and successfully developed a nomogram for predicting EC patients survival longer than 5 years, which may facilitate the institution of personalized treatment algorithms, surveillance strategies, and lifestyle interventions.

Impact of Treatment Modality on Quality of Life Among Uterine Cancer Survivors

AIMS

Our understanding of the impact of adjuvant therapy on longitudinal quality of life (QoL) following surgery for patients with uterine cancer is limited. The purpose of this study was to compare QoL in patients who have undergone surgery with or without radiation therapy for uterine cancer.

MATERIALS AND METHODS

This was a cross-sectional cohort study that examined women treated for uterine cancer at MD Anderson Cancer Center from 2006 to 2017. Participants included those who underwent hysterectomy/bilateral salphingo-oophorectomy alone, with brachytherapy or external beam radiation therapy (EBRT). A non-cancer cohort of women who underwent a hysterectomy/bilateral salphingo-oophorectomy for benign indications was also identified (non-CA). To compare QoL we used the Functional Assessment of Cancer Therapy - Endometrial survey (FACT-En), a validated survey used to assess QoL. The survey has five subscales: physical, social, emotional, functional and an endometrial cancer-specific subscale. Cohorts were compared using ANOVA tests.

RESULTS

In total, 309 women responded to the questionnaire (hysterectomy/bilateral salphingo-oophorectomy 64, brachytherapy 77, EBRT 96, non-CA 72). The median time from surgery to survey completion was 6.7 years. The mean total FACT-En score for the entire cohort was 144 [standard deviation 22]. Overall QoL was different between cohorts, with the EBRT cohort reporting the lowest QoL (mean 139.4 [21.6]) and the brachytherapy cohort the highest (150.6 [18.2], P = 0.006). Among patients who had undergone cancer treatment, the EBRT cohort reported the worst endometrial-specific QoL (53.5 [8.6]), while again the brachytherapy group reported the highest score (57.5 [6.1], P = 0.007).

CONCLUSIONS

QoL differences in women who have undergone different treatments for uterine cancer may persist years after treatment. In women with endometrial cancer who require adjuvant therapy, brachytherapy does not appear to have any long-term detriments on QoL.

Defining the Optimal Treatment Strategy in Patients With Uterine Serous Carcinoma

AIMS

Uterine serous carcinoma (USC) is an aggressive subtype of endometrial cancer with high rates of relapse and death. As adjuvant therapy might be beneficial in early-stage disease, the impact of standard complete surgical staging is questioned. Therefore, we wanted to explore the optimal treatment strategy for women diagnosed with USC.

MATERIALS AND METHODS

A retrospective multicentre study of women diagnosed with primary USC in the UK and the Netherlands. Treatment strategy in relation to overall survival and progression-free survival was recorded and evaluated with Kaplan-Meier and Cox regression analysis. Furthermore, primary surgical staging and/or adjuvant treatment in relation to patterns of recurrence were evaluated.

RESULTS

In total, 272 women with a median age of 70 years were included. Most patients presented with International Federation of Gynecology and Obstetrics (FIGO) stage I disease (44%). Overall, 48% of patients developed recurrent disease, most (58%) with a distant component. Women treated with chemotherapy showed significantly better overall survival (hazard ratio 0.50, 95% confidence interval 0.31-0.81; P = 0.005) and progression-free survival (hazard ratio 0.48, 95% confidence interval 0.28-0.80; P = 0.04) in multivariable analysis. Furthermore, even in surgically staged women with FIGO stage IA disease, a high recurrence rate of 42% was seen.

CONCLUSION

Women with USC who received adjuvant chemotherapy showed better survival rates compared with those who received other or no adjuvant treatment. The benefit of adjuvant chemotherapy was observed across all tumour stages, including surgically staged FIGO stage IA. These data question the role of surgical staging in the absence of macroscopic disease in USC.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Stage I Clear Cell and Serous Uterine Carcinoma: What Is the Right Adjuvant Therapy?

This single-center study aimed to retrospectively evaluate the survival outcomes of patients with FIGO stage I clear cell and serous uterine carcinoma according to the type of adjuvant treatment received. The data were collected between 2003 and 2020 and only patients with stage I clear cell or serous uterine carcinoma treated with primary surgery were included. These were classified into three groups: No treatment or brachytherapy only (G1), radiotherapy +/- brachytherapy (G2), chemotherapy +/- radiotherapy +/- brachytherapy (G3). In total, we included 52 patients: 18 patients in G1, 16 in G2, and 18 in G3. Patients in the G3 group presented with poorer prognostic factors: 83.3% had serous histology, 27.8% LVSI, and 27.8% were FIGO stage IB. Patients treated with adjuvant radiotherapy showed an improved 5-year overall survival (OS) (p = 0.02) and a trend towards an enhanced 5-year progression-free survival (PFS) (p = 0.056). In contrast, OS (p = 0.97) and PFS (p = 0.84) in the chemotherapy group with poorer prognostic factors, were similar with increased toxicity (83.3%). Radiotherapy is associated with improved 5-year OS and tends to improve 5-year PFS in women with stage I clear cell and serous uterine carcinoma. Additional chemotherapy should be cautiously considered in serous carcinoma cases presenting poor histological prognostic factors.

Health-related quality of life and patient-reported symptoms after postoperative proton beam radiotherapy of cervical and endometrial cancer: 2-year results of the prospective phase II APROVE-trial

INTRODUCTION

The APROVE-trial investigated the tolerability of postoperative proton beam therapy in women with cervical or endometrial cancer. The present analysis evaluated the secondary endpoints of health-related quality of life (HRQOL) and patient-reported symptoms.

METHODS

25 patients were included in this prospective phase-II-trial and treated with postoperative radiotherapy using protons alone or in combination with chemotherapy. To attain general and gynecologic-specific HRQOL measures, the EORTC-QLQ-C30 questionnaires combined with -QLQ-CX24 for cervical and -QLQ-EN24 for endometrial cancer were assessed at baseline, at the end of RT and up to 2 years after radiotherapy. The results were compared to an age-matched norm reference population. Symptoms were assessed using Common Terminology Criteria for Adverse Events (CTCAE) and institutional patient-reported symptoms grading.

RESULTS

Scores regarding global health status were markedly impaired at baseline (mean: 58.0 ± 20.1) compared to reference population data, but significantly (p = 0.036) improved and evened out to comparable norm values 2 years after proton therapy (mean: 69.9 ± 19.3). Treatment caused acute and long-term worsening of pain (p = 0.048) and gastrointestinal symptoms (p = 0.016) for women with endometrial cancer, but no higher-grade CTCAE ≥ 3° toxicity was observed. Dosimetric evaluation of rectum, sigmoid, large and small bowel showed no correlation with the reported gastrointestinal symptoms. After 2 years, fatigue had significantly improved (p = 0.030), whereas patients with cervical cancer experienced more often lymphedema (p = 0.017). Scores for endometrial cancer pertaining to sexual activity (p = 0.048) and body image (p = 0.022) had improved post treatment; in the latter this effect persisted after 2 years.

CONCLUSION

Proton beam therapy in the adjuvant setting was well tolerated with only low-grade side effects concerning gastrointestinal symptoms, lymphedema and pain. Overall quality of life was impaired at baseline, but patients were able to recover to values comparable to norm population 2 years after proton therapy. Larger studies are needed to confirm whether the benefit of proton therapy translates into a clinical effect. Sexual dysfunction remains an important issue.

TRIAL REGISTRATION

The trial was registered at https://clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT03184350, 09th June 2017).

Refining adjuvant treatment in endometrial cancer based on molecular features: the RAINBO clinical trial program

BACKGROUND

The endometrial cancer molecular classification has been integrated into the 2020 World Health Organization (WHO) diagnostic classification and European treatment guidelines, and provides direction towards more effective and less toxic adjuvant treatment strategies for women with endometrial cancer.

PRIMARY OBJECTIVES

The RAINBO program of clinical trials will investigate four molecular class-directed adjuvant treatment strategies following surgical resection to either increase cure rates through the addition of novel targeted therapies or safely reduce toxicity and improve quality of life through treatment de-escalation.

STUDY HYPOTHESIS

Molecular-directed adjuvant treatment strategies will improve clinical outcomes and reduce toxicity of unwarranted therapies in women with endometrial cancer. The overarching and translational research RAINBO program will advance knowledge of predictive and prognostic (bio)markers that will improve prognostication and treatment allocation.

TRIAL DESIGN

The RAINBO program is a platform of four international clinical trials and an overarching research program. The randomized phase III p53abn-RED trial for women with invasive stage I-III p53abn endometrial cancer compares adjuvant chemoradiation followed by olaparib for 2 years with adjuvant chemoradiation alone. The randomized phase III MMRd-GREEN trial for women with stage II (with lymphovascular space invasion (LVSI)) or stage III mismatch repair-deficient (MMRd) endometrial cancer compares adjuvant radiotherapy with concurrent and adjuvant durvalumab for 1 year to radiotherapy alone. The randomized phase III NSMP-ORANGE trial is a treatment de-escalation trial for women with estrogen receptor positive stage II (with LVSI) or stage III no specific molecular profile (NSMP) endometrial cancer comparing radiotherapy followed by progestin for 2 years to adjuvant chemoradiation. The POLEmut-BLUE trial is a phase II trial in which the safety of de-escalation of adjuvant therapy is investigated for women with stage I-III POLEmut endometrial cancer: no adjuvant therapy for lower-risk disease and no adjuvant therapy or radiotherapy alone for higher-risk disease. The overarching RAINBO program will combine data and tumor material of all participants to perform translational research and evaluate molecular class-based adjuvant therapy in terms of efficacy, toxicity, quality of life, and cost-utility.

MAJOR INCLUSION/EXCLUSION CRITERIA

Inclusion criteria include a histologically confirmed diagnosis of endometrial cancer treated by hysterectomy and bilateral salpingo-oophorectomy with or without lymphadenectomy or sentinel lymph node biopsy, with no macroscopic residual disease after surgery and no distant metastases, and molecular classification according to the WHO 2020 algorithm.

PRIMARY ENDPOINTS

Recurrence-free survival at 3 years in the p53abn-RED, MMRd-GREEN, and NSMP-ORANGE trials and pelvic recurrence at 3 years in the POLEmut-BLUE trial.

SAMPLE SIZE

The p53abn-RED trial will include 554 patients, the MMRd-GREEN trial 316, the NSMP-ORANGE trial 600, and the POLEmut-BLUE trial 145 (120 for lower-risk disease and approximately 25 for higher-risk disease). The overarching research program will pool the four sub-trials resulting in a total sample size of around 1600.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

The four clinical trials will have different completion dates; main results are expected from 2028.

TRIAL REGISTRATION NUMBER

The RAINBO program is registered at clinicaltrials.gov (NCT05255653).

The "Sandwich" Schedule: A Well-Tolerated Adjuvant Treatment Both in Intermediate-High- and High-Risk Endometrial Cancer

(1) Background: In intermediate-high- and high-risk endometrial cancer (EC), radiotherapy (RT) and chemotherapy (CT) play a basic role. However, there is controversy regarding the optimal timing of their combination. The "sandwich" schedule involves adjuvant CT followed by RT and subsequent CT. The aim of this study is to assess the tolerability and efficacy of the "sandwich" schedule. (2) Methods: A retrospective study was conducted in two gynecological oncology units in Torino, Italy, from 1 January 2003 until 31 December 2021. Intermediate-high- and high-risk patients with available clinical data were included. Compliance with treatment, CT and RT toxicities, disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) were analyzed. (3) Results: A total of 118 patients were selected: 27.1% FIGO I-II stages and 72.9% III-IV. Most of the patients (75.4%) received a carboplatin-paclitaxel combination, and as much as 94.9% of CT cycles were completed. Chemotherapy-related G3-4 toxicities were detected in 5.3% of the patients, almost half of which were hematological. Grade 2 gastrointestinal and genitourinary toxicities were reported in 8.4% and 4.2% of cases, respectively. With a median follow-up of 46 months, DFS was 77.6%, CSS was 70% and 5-year OS was 54%. (4) Conclusions: The "sandwich" schedule for CT and RT combination is an effective adjuvant treatment with low toxicity both in intermediate-high- and high-risk EC.

Health-related quality of life with pembrolizumab monotherapy in patients with previously treated advanced microsatellite instability high/mismatch repair deficient endometrial cancer in the KEYNOTE-158 study

OBJECTIVE

Pembrolizumab demonstrated a clinically meaningful objective response rate in patients with previously treated, advanced MSI-H/dMMR endometrial cancer in the multicohort phase 2 KEYNOTE-158 study (ClinicalTrials.gov, NCT02628067). We present health-related quality of life (HRQoL) results for these patients.

METHODS

This analysis included patients from cohorts D (endometrial cancer with any MSI status) and K (any MSI-H/dMMR solid tumor except colorectal) who had previously treated, advanced MSI-H/dMMR endometrial cancer. Patients received pembrolizumab 200 mg Q3W for 35 cycles. EORTC QLQ-C30 and EQ-5D-3L questionnaires were administered at baseline, at regular intervals during treatment, and 30 days after treatment discontinuation. Pre-specified exploratory analyses included changes from baseline to week 9 in QLQ-C30 global health status (GHS)/QoL and EQ-5D-3L visual analog scale (VAS) score for all patients and by best overall response.

RESULTS

84 of 90 enrolled patients completed ≥1 HRQoL questionnaire and were included in the analysis. QLQ-C30 and EQ-5D-3L compliance rates were 90% and 94%, respectively, at baseline, and 92% and 93% at week 9. Mean (95% CI) QLQ-C30 GHS/QoL scores improved from baseline to week 9 by 6.08 (0.71-11.46) points in the overall population, with greater improvement in patients who achieved complete or partial response (11.67 [5.33-18.00]-point increase). Mean (95% CI) EQ-5D-3L VAS scores improved by 6.00 (2.25-9.75) points in the overall population and 9.11 (5.24-12.98) points in patients with CR/PR.

CONCLUSIONS

Pembrolizumab maintained or improved HRQoL in patients with previously treated, advanced MSI-H/dMMR endometrial cancer, further supporting efficacy and safety results from KEYNOTE-158 and pembrolizumab use in this setting.

Impact of the new molecular classification of endometrial cancer: A French cohort study

OBJECTIVE

To evaluate the potential impact of the latest ESGO guidelines for endometrial cancer with molecular classification on the management strategy in a French cohort.

METHODS

All patients treated between January 1st, 2014 and December 31, 2020 for an endometrial cancer at the Centre Hospitalier Intercommunal de Créteil (CHIC, FRANCE) were selected from our prospectively maintained database. All postoperative samples were reviewed to confirm histological subtype, myometrial infiltration, cytonuclear grade and presence of lymphovascular emboli. Analysis of p53, MLH1, MSH2, MSH6, PMS2 genes was performed by immunohistochemistry first then a systematic POLE sequencing was performed to identify gene mutation. The impact of the latest ESGO 2020 guidelines was assessed regarding adjuvant therapy, surgical strategy, and survival.

RESULTS

Eighty patients were analyzed, including 70% NSMP (n = 56), 13.75% MSI (n = 11), 10% p53 mutated (n = 8) and 6.25% POLEmut (n = 5). A total of 21 patients (26.3%) were reclassified using the latest ESGO classification. Patients classified at low risk or with advanced / metastatic disease were not reclassified using molecular analysis. Molecular analysis and the latest ESGO classification had the most important impact on patients initially classified at intermediate - high risk that were reclassified in intermediate (10/23) and in low (4/23) risk. Nine patients (11.3%) were overtreated according to the 2020 ESGO classification: six patients in the low - risk group (4 received vaginal brachytherapy and 2 external radiotherapy) and three in the intermediate risk group (3 received external irradiation and 1 received chemotherapy). None of the patients in our cohort would have been undertreated using the 2020 ESGO classification. Patients within the p53 mutated group were the most likely to experience recurrence (37.5%, 3/8) and none of the patients POLE mutated recurred.

CONCLUSION

Around one in 4 patients were reclassified in a more accurate prognostic group using molecular diagnosis and the latest ESGO guidelines which could decrease the use of adjuvant therapies to spare morbidity.

Current Standards in the Management of Early and Locally Advanced Cervical Cancer: Update on the Benefit of Neoadjuvant/Adjuvant Strategies

Globally, cervical cancers continue to be one of the leading causes of cancer-related deaths. The primary treatment of patients with early-stage disease includes surgery or radiation therapy with or without chemotherapy. The main challenge in treating these patients is to maintain a curative approach and limit treatment-related morbidity. Traditionally, inoperable patients are treated with radiation therapy solely and operable patients undergo upfront surgery followed by adjuvant (chemo) radiotherapy in cases with poor histopathological prognostic features. Patients with locally advanced cervical cancers are treated with concurrent chemoradiotherapy followed by an image-guided brachytherapy boost. In these patients, the main pattern of failure is distant relapse, encouraging intensification of systemic treatments to improve disease control. Ongoing trials are evaluating immunotherapy in locally advanced tumours following its encouraging efficacy reported in the recurrent and metastatic settings. In this article, clinical evidence of neoadjuvant and adjuvant treatments in cervical cancer patients is reviewed, with a focus on potential strategies to improve patients' outcome and minimize treatment-related morbidity.

Adjuvant and First Line Chemotherapy Use for Endometrial Cancer

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Among subjects who underwent hysterectomy for endometrial cancer, 19% received adjuvant chemotherapy.

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Platinum and taxane based chemotherapy is the most commonly used adjuvant chemotherapy.

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Platinum and taxane combination therapy was used in 48% of patients at first recurrence.

Objective

The objective of this study was to describe patterns of utilization of cytotoxic, hormonal, and immunotherapy in patients with endometrial cancer in the adjuvant setting and at the time of first recurrence.

Methods

We identified patients in the IBM MarketScan database with endometrial cancer who underwent hysterectomy from 2011 to 2019. The use of clinically relevant therapeutic agents and combination regimens was determined in the adjuvant setting and at the time of first recurrence.

Results

A total of 22,632 patients were identified. Of these, 7,147 patients (31.6%) received adjuvant radiation and 4,381 (19.4%) received adjuvant chemotherapy following surgery. Of those who received adjuvant chemotherapy, the most commonly utilized agents were carboplatin (90.3%), paclitaxel (85.8%), cisplatin (9.4%), docetaxel (9.3%), gemcitabine (3.8%), and doxorubicin (2.0%), while bevacizumab was utilized in 1.5% of patients. A combination of platinum and a taxane were utilized as adjuvant therapy in 88.8% of women. Of the cohort, 1,825 patients (8.1%) recurred, of whom 1,017 patients had already received adjuvant chemotherapy. The median time from hysterectomy to initiation of chemotherapy for recurrence was 13.3 months (IQR: 7.6–23.1 months). Overall, platinum and taxane combination therapy was used in 788 (46.8%) of patients with recurrent disease, platinum alone or with other drugs in 194 (11.5%), taxanes alone or with other drugs in 145 (8.6%), and non-platinum and non-taxane based therapy in 31.3%.

Conclusions

Among patients with endometrial cancer who underwent hysterectomy, platinum-taxane combination chemotherapy was used in almost 90% of patients who received adjuvant chemotherapy while nearly 70% of patients who recurred were treated with platinum or taxane based therapy at first recurrence.

Impact of external beam pelvic radiotherapy of endometrial carcinoma: A focus on chronic digestive toxicity

PURPOSE

The standard treatment for endometrial cancer is surgery, although depending on the risk factors, adjuvant radiation therapy may also be given. It is proposed for high-risk carcinomas for which an improvement in progression-free survival though not overall survival has been shown. However, despite the development of radiotherapy treatments with intensity modulation and image guidance, adjuvant radiation therapy remains toxic to the digestive system. We aimed to investigate the incidence of digestive toxicity and the presence of any predictive factors.

MATERIALS AND METHODS

Data were retrospectively collected from patients treated with adjuvant radiotherapy for endometrial carcinoma at the Institut de cancérologie de Lorraine and centre hospitalier Émile-Durkheim between January 2010 and October 2016 and analyzed to identify factors associated with chronic digestive toxicity.

RESULTS

One hundred and thirty-nine patients received a total dose of 50Gy fractionated into 25 sessions, five per week for five weeks. The median follow-up after irradiation completion was 38 months. The incidence of gastrointestinal and rectal toxicity in all patients treated with pelvic irradiation for endometrial carcinoma was 11.1% (95% confidence interval [95%CI]: 5.4-19%) for grade 3-4 and 25.6% (95%CI: 17.0-34.9%) for grade 2-4. No factor was found to be significantly predictive of chronic digestive toxicity. At five years, the overall survival was 74.3%, (95%CI: 65.3-81.4%), progression-free survival was 69.6% (95%CI: 60.1-77.3%) and incidence of pelvic recurrence was 7.9% (95%CI: 3.8-13.9%).

CONCLUSION

Our results confirmed that pelvic radiotherapy can induce a relatively high rate of digestive toxicity but failed to identify relevant factors able to predict it.

Patient reported outcomes for cisplatin and radiation followed by carboplatin/paclitaxel versus carboplatin/paclitaxel for locally advanced endometrial carcinoma: An NRG oncology study

INTRODUCTION

Chemotherapy plus radiation (Cis-RT + CP) did not demonstrate superiority in prolonging relapse-free survival compared to chemotherapy alone in patients with stage III or IVA endometrial carcinoma. The impact of treatment on quality of life (QOL), neurotoxicity (NTX) and psychometric properties of the gastrointestinal (GI) symptoms subscale during treatment and up to 1 year are described herein.

METHODS

QOL assessments were scheduled at baseline, 6 weeks (post completion of RT (Cis-RT + CP) or prior to cycle 3 (CP)), then 18 weeks (end of treatment) and 70 weeks (1 year after the end of treatment) after starting treatment. QOL instruments included the FACT-En TOI, FACT/GOG-neurotoxicity (Ntx) subscale (short), and the gastrointestinal (GI) symptoms subscale.

RESULTS

At the end of treatment, patients receiving Cis-RT + CP reported a statistically significant decreased QOL when compared to CP. The decline in QOL was reflected in physical well-being, functional well-being, and endometrial cancer specific concerns, but the minimally important differences (MID) were not considered clinically meaningful. Patients in both groups reported increased chemotherapy-induced Ntx symptoms with the CP group having worse scores and reaching peak symptoms at the time of chemotherapy completion. Patients on Cis-RT + CP reported statistically significantly worse GI symptoms after radiation therapy compared to patients on CP, this occurred across assessment intervals, though the MID was not meaningful. Psychometric evaluations indicated that the GI symptom scale is reliable, valid, and responsive to change.

CONCLUSIONS

PROs indicate that the chemoradiotherapy group experienced worse HRQoL and GI toxicity compared to patients randomized to chemotherapy alone for locally advanced endometrial cancer though based on the MID, these were not clinically meaningful differences. The GI symptom subscale was a reliable and valid scale that has value for future trials.

TRIAL REGISTRATION

NCT00942357.

Longitudinal effects of adjuvant chemotherapy and lymph node staging on patient-reported outcomes in endometrial cancer survivors: a prospective cohort study

BACKGROUND

Most patients with endometrial cancer with localized disease are effectively treated and survive for a long time. The primary treatment is hysterectomy, to which surgical staging procedures may be added to assess the need for adjuvant therapy. Longitudinal data on patient-reported outcomes comparing different levels of primary treatment are lacking, especially when adjuvant radiotherapy is omitted.

OBJECTIVE

We assessed the impact of lymphadenectomy and adjuvant chemotherapy on patient-reported symptoms, function, and quality of life. We hypothesized that these treatment modalities would substantially affect patient-reported outcomes at follow-up.

STUDY DESIGN

We prospectively included patients with endometrial cancer enrolled in the ongoing MoMaTEC2 study (ClinicalTrials.gov Identifier: NCT02543710). Patients were asked to complete the patient-reported outcome questionnaires European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire EN24 preoperatively and at 1 and 2 years of follow-up. Functional domains and symptoms were analyzed for the whole cohort and by treatment received. To assess the effect of the individual treatment modifications, we used mixed regression models.

RESULTS

Baseline data were available for 448 patients. Of these patients, 339 and 219 had reached 1-year follow-up and 2-year follow-up, respectively. Treatment included hysterectomy (plus bilateral salpingo-oophorectomy) alone (n=177), hysterectomy and lymph node staging without adjuvant therapy (n=133), or adjuvant chemotherapy irrespective of staging procedure (n=138). Overall, patients reported improved global health status and quality of life (+9 units; P<.001), increased emotional and social functioning, and increased sexual interest and activity (P<.001 for all) from baseline to year 1, and these outcomes remained stable at year 2. Means of functional scales and quality of life were similar to age- and sex-weighted reference cohorts. Mean tingling and numbness and lymphedema increased after treatment. The group who received adjuvant chemotherapy had a larger mean reduction in physical functioning (-6 vs +2; P=.002) at year 1, more neuropathy (+30 vs +5; P<.001; year 1) at years 1 and 2, and more lymphedema at year 1 (+11 vs +2; P=.007) than the group treated with hysterectomy and salpingo-oophorectomy only. In patients not receiving adjuvant chemotherapy, patient-reported outcomes were similar regardless of lymph node staging procedures. Adjuvant chemotherapy independently increased fatigue, lymphedema, and neuropathy in mixed regression models.

CONCLUSION

Patients with endometrial cancer receiving adjuvant chemotherapy reported significantly reduced functioning and more symptoms up to 2 years after treatment. For patients treated by surgery alone, surgical staging did not seem to affect the quality of life or symptoms to a measurable degree at follow-up. Therefore, subjecting patients to lymph node removal to tailor adjuvant therapy seems justified from the patient's viewpoint; however, efforts should increase to find alternatives to traditional chemotherapy.

Endometrial cancer

Although endometrial cancer management remains challenging, a deeper understanding of the genetic diversity as well as the drivers of the various pathogenic states of this disease has led to development of divergent management approaches in an effort to improve therapeutic precision in this complex malignancy. This comprehensive review provides an update on the epidemiology, pathophysiology, diagnosis and molecular classification, recent advancements in disease management, as well as important patient quality-of-life considerations and emerging developments in the rapidly evolving therapeutic landscape of endometrial cancers.

Functional Changes of the Genitourinary and Gastrointestinal Systems before and after the Treatment of Endometrial Cancer-A Systematic Review

The incidence of endometrial cancer (EC), which coexists with such civilization diseases as diabetes, obesity or hypertension, is constantly increasing. Treatment includes surgery as well as brachytherapy, teletherapy, rarely chemotherapy or hormone therapy. Due to the good results of the treatment, the occurrence of side effects of therapy becomes a problem for the patients. One of the large groups of side effects includes the pelvic organ prolapse, urinary and fecal incontinence. The aim of this study was to present current knowledge on the occurrence of pelvic floor dysfunction in women treated for EC. A literature review was conducted in the PubMED and WoS databases, including articles on pelvic floor dysfunction in women with EC. PRISMA principles were followed in the research methodology. A total of 1361 publications were retrieved. Based on the inclusion and exclusion criteria, 24 papers were eligible for the review. Mostly retrospective studies based on different questionnaires were evaluated. No prospective studies were found in which, in addition to subjective assessment, clinical examination and objective assessment of urinary incontinence were used. Studies show a significant increase in the incidence of pelvic floor disorders, including urinary incontinence, after various forms of EC treatment. We believe that assessment of complications after endometrial cancer treatment is clinically relevant. The review emphasizes the importance of programming prospective studies to prevent and address these disorders at each stage of oncologic treatment.

Risk Stratification of Endometrial Cancer Patients: FIGO Stage, Biomarkers and Molecular Classification

Endometrial cancer (EC) is the most common gynaecologic malignancy in developed countries. The main challenge in EC management is to correctly estimate the risk of metastases at diagnosis and the risk to develop recurrences in the future. Risk stratification determines the need for surgical staging and adjuvant treatment. Detection of occult, microscopic metastases upstages patients, provides important prognostic information and guides adjuvant treatment. The molecular classification subdivides EC into four prognostic subgroups: POLE ultramutated; mismatch repair deficient (MMRd); nonspecific molecular profile (NSMP); and TP53 mutated (p53abn). How surgical staging should be adjusted based on preoperative molecular profiling is currently unknown. Moreover, little is known whether and how other known prognostic biomarkers affect prognosis prediction independent of or in addition to these molecular subgroups. This review summarizes the factors incorporated in surgical staging (i.e., peritoneal washing, lymph node dissection, omentectomy and peritoneal biopsies), and its impact on prognosis and adjuvant treatment decisions in an era of molecular classification of EC. Moreover, the relation between FIGO stage and molecular classification is evaluated including the current gaps in knowledge and future perspectives.

Adjuvant Chemotherapy versus Radiotherapy in High-risk, Early-stage Endometrioid Endometrial Carcinoma

OBJECTIVE

The present study was designed to evaluate the effects of adjuvant chemotherapy (CT) vs. radiotherapy (RT, alone or combined with CT) on the prognosis of patients with high-risk, early-stage (stage I and stage II) endometrioid endometrial carcinoma.

METHODS

This single-center retrospective clinical study was conducted in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology between 2010 and 2019. In the present study, endometrioid endometrial carcinoma patients, who underwent total hysterectomy and bilateral salpingo-oophorectomy followed by postoperative adjuvant CT or RT (alone or combined with CT), and were diagnosed with stage IA grade 2/3 with lymph-vascular space invasion (LVSI), and stage IB with two or more uterine risks, including old age, histological grade 2 or 3, LVSI and stage II, were included. According to the postoperative adjuvant therapy, all eligible patients were divided into two groups: CT group and RT (RT±CT) group. The primary objective was to investigate overall survival (OS) and disease-free survival (DFS) between the CT and RT groups. Grade 3 or worse adverse events were also presented in the present study.

RESULTS

A total of 145 eligible patients were included. Among these patients, 97 patients underwent adjuvant CT and 48 patients underwent adjuvant RT (RT±CT). The median follow-up was 47.2 months, and the five-year OS rate was 92.7% in the CT group and 88.6 % in the RT group [hazard ratio (HR): 0.81, 95% confidence interval (CI): 0.22-2.99). The 5-year DFS rate for the two groups was 85.7% and 80.2%, respectively (HR: 0.82, 95% CI: 0.33-2.05). The cumulative incidence of local-regional disease recurrence at 60 months of follow-up was 6.2% in the CT group and 6.3% in the RT group (HR=1.11; 95%CI: 0.28-4.35). The cumulative incidence of distant recurrence at 60 months of follow-up was 5.2% in the CT group and 10.4% in the RT group (HR=0.65; 95%CI: 0.19-2.24). Both groups of patients were well-tolerant, and the only grade 3 or worse adverse events were neutropenia and thrombocytopenia.

CONCLUSION

There was no difference in efficacy for adjuvant CT or adjuvant RT (RT±CT) in high-risk, early-stage endometrioid endometrial carcinoma. CT exhibited a trend of reducing the distant relapse, although there was no significant difference, when compared with adjuvant RT (RT±CT).

Radiation Therapy Techniques and Treatment-Related Toxicity in the PORTEC-3 Trial: Comparison of 3-Dimensional Conformal Radiation Therapy Versus Intensity-Modulated Radiation Therapy

PURPOSE

Radiation therapy techniques have developed from 3-dimensional conformal radiation therapy (3DCRT) to intensity modulated radiation therapy (IMRT), with better sparing of the surrounding normal tissues. The current analysis aimed to investigate whether IMRT, compared to 3DCRT, resulted in fewer adverse events (AEs) and patient-reported symptoms in the randomized PORTEC-3 trial for high-risk endometrial cancer.

METHODS AND MATERIALS

Data on AEs and patient-reported quality of life (QoL) of the PORTEC-3 trial were available for analysis. Physician-reported AEs were graded using Common Terminology Criteria for Adverse Events v3.0. QoL was assessed by the European Organisation for Research and Treatment of Cancer QLQC30, CX24, and OV28 questionnaires. Data were compared between 3DCRT and IMRT. A P value of ≤ .01 was considered statistically significant due to the risk of multiple testing. For QoL, combined scores 1 to 2 ("not at all" and "a little") versus 3 to 4 ("quite a bit" and "very much") were compared between the techniques.

RESULTS

Of 658 evaluable patients, 559 received 3DCRT and 99 IMRT. Median follow-up was 74.6 months. During treatment no significant differences were observed, with a trend for more grade ≥3 AEs, mostly hematologic and gastrointestinal, after 3DCRT (37.7% vs 26.3%, P = .03). During follow-up, 15.4% (vs 4%) had grade ≥2 diarrhea, and 26.1% (vs 13.1%) had grade ≥2 hematologic AEs after 3DCRT (vs IMRT) (both P < .01). Among 574 (87%) patients evaluable for QoL, 494 received 3DCRT and 80 IMRT. During treatment, 37.5% (vs 28.6%) reported diarrhea after 3DCRT (vs IMRT) (P = .125); 22.1% (versus 10.0%) bowel urgency (P = 0039), and 18.2% and 8.6% abdominal cramps (P = .058). Other QoL scores showed no differences.

CONCLUSIONS

IMRT resulted in fewer grade ≥3 AEs during treatment and significantly lower rates of grade ≥2 diarrhea and hematologic AEs during follow-up. Trends toward fewer patient-reported bowel urgency and abdominal cramps were observed after IMRT compared to 3DCRT.

Late Toxicity After Adjuvant Conventional Radiation Versus Image-Guided Intensity-Modulated Radiotherapy for Cervical Cancer (PARCER): A Randomized Controlled Trial

PURPOSE

Postoperative Adjuvant Radiation in Cervical Cancer (PARCER), a phase III randomized trial, compared late toxicity after image-guided intensity-modulated radiotherapy (IG-IMRT) with three-dimensional conformal radiation therapy (3D-CRT) in women with cervical cancer undergoing postoperative radiation.

METHODS

Patients were randomly assigned to receive either IG-IMRT or 3D-CRT after stratification for the type of hysterectomy and use of concurrent chemotherapy. The primary end point was 3-year grade ≥ 2 late GI toxicity assessed using Common Toxicity Criteria for Adverse Events v 3.0 and estimated using time-to-event, intention-to-treat analysis, with a study level type I error of 0.05 and a nominal α of .047 after accounting for one interim analysis. Secondary end points included acute toxicity, health-related quality of life, and pelvic relapse-free, disease-free, and overall survival.

RESULTS

Between 2011 and 2019, 300 patients were randomly assigned (IG-IMRT 151 and 3D-CRT 149). At a median follow-up of 46 (interquartile range 20-72) months, the 3-year cumulative incidence of grade ≥ 2 late GI toxicity in the IG-IMRT and 3D-CRT arms were 21.1% versus 42.4% (hazard ratio [HR] 0.46; 95% CI, 0.29 to 0.73; P < .001). The cumulative incidence of grade ≥ 2 any late toxicity was 28.1% versus 48.9% (HR 0.50; 95% CI, 0.33 to 0.76; P < .001), respectively. Patients reported reduced diarrhea (P = .04), improved appetite (P = .008), and lesser bowel symptoms (P = .002) with IG-IMRT. However, no difference was observed in the time by treatment interaction. The 3-year pelvic relapse-free survival and disease-free survival in the IG-IMRT versus the 3D-CRT arm were 81.8% versus 84% (HR 1.17; 95% CI, 0.68 to 1.99; P = .55) and 76.9% versus 81.2% (HR 1.03; 95% CI, 0.62 to 1.71; P = .89), respectively.

CONCLUSION

IG-IMRT results in reduced toxicity with no difference in disease outcomes.

Outcome and safety analysis of endometrial cancer patients treated with postoperative 3D-conformal radiotherapy or intensity modulated radiotherapy

BACKGROUND

We sought to analyze the toxicity rates and the treatment outcomes in endometrial cancer (EC) patients treated with postoperative three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT).

MATERIAL AND METHODS

The clinical data of 646 EC patients treated with postoperative adjuvant 3DCRT (265 patients, 41%) or with IMRT (381 patients, 59%) between April 2007 and August 2019 were retrospectively analyzed. The primary endpoints were treatment-related acute and late gastrointestinal (GI) and genitourinary (GU) toxicities. The secondary endpoints were LC and overall survival (OS) and disease-free survival (DFS).

RESULTS

Median follow-up time was 37 months. The rates for acute GI and GU toxicities of any grade for the entire group were 55.6% and 46.8%, respectively. Acute grade ≥2 GI toxicity was significantly less in patients treated with IMRT compared to those treated with 3DCRT (11.0% vs. 19.2%, p=.004). However, no significant difference grade ≥2 GU toxicities was observed between the 3DCRT and IMRT groups (15.1% vs. 11.0%; p=.15). Acute grade ≥2 GI and GU toxicities were higher in patients receiving systemic chemotherapy, while paraaortic field irradiation increases only the risk of acute grade ≥2 GI toxicity. Estimated 3-year late grade ≥3 GI toxicity rates in the 3DCRT- and IMRT-treated patients were 4.6% and 1.9% (p= .03), respectively. The patients treated with adjuvant ChT had higher rates of late serious GI complications than those without adjuvant ChT. No significant difference in terms of survival and disease control was observed between the 3DCRT and IMRT treatment groups. No significant factor for LC was found in the multivariate analysis.

CONCLUSION

In this multicentric study involving one of largest patient population, we found that IMRT-treated EC patients showed comparable clinical outcomes but with a lower incidence of GI toxicities compared with those treated with 3DCRT.

Treatment outcomes and complications in FIGO stage IIIC and IVB endometrioid endometrial cancer patients presenting as nodal spreads following systematic lymphadenectomy and adjuvant therapy

OBJECTIVE

To evaluate the treatment outcomes and complications of patients with FIGO stage IIIC and IVB endometrioid endometrial cancer (EC) presenting primarily as nodal spreads following systematic lymphadenectomy and adjuvant therapy.

MATERIAL AND METHODS

Forty-four FIGO stage IIIC and IVB endometrioid EC patients between July 2003 and March 2020 received staging procedures including systematic lymphadenectomy. The survival outcomes and late treatment-related complications were compared between adjuvant chemoradiation-based group and chemotherapy-based group.

RESULTS

Of the 44 patients, 16 (36.4%) had stage IIIC1, 26 (59.1%) had stage IIIC2, and 2 (4.5%) had stage IVB disease. The median follow-up time was 54 months (range, 10-185 months). There was no statistical difference in mortality between the microscopic and macroscopic nodal groups (6.2% vs 4.3%, p > 0.999). Eleven patients (25.0%) and 33 patients (75.0%) received adjuvant chemoradiation and chemotherapy, respectively. The 5-year disease-free and overall survival rates were not different between the two groups (disease-free survival, 81.8% vs 82.1%, p = 0.743; overall survival, 90.9% vs 95.8%, p = 0.537). The incidence rates of grade 2 lymphedema (36.4% vs 9.1%, p = 0.032) and grade 2/3 gastrointestinal complications (36.4% vs 0.0%, p < 0.001) were higher in the chemoradiation-based group than those in the chemotherapy-based group.

CONCLUSIONS

Systematic lymphadenectomy and adjuvant chemotherapy might be the preferred treatment for FIGO stage IIIC and IVB endometrioid EC patients presenting as nodal spreads given that no difference in patient survival was found, but a higher incidence of treatment-related complications was observed in the chemoradiation-based group.

Experiences of cancer immunotherapy with immune checkpoint inhibitors (ExCIm)-insights of people affected by cancer and healthcare professionals: a qualitative study protocol

INTRODUCTION

There is a global interest in cancer immunotherapy. Clinical trials have found that one group, immune checkpoint inhibitors (ICIs), has demonstrated clinical benefits across various cancers. However, research focused on the experiences of people affected by cancer who have undergone this treatment using qualitative methodology is currently limited. Moreover, little is known about the experiences and education needs of the healthcare staff supporting the people receiving these immunotherapies. This study therefore seeks to explore the experiences of using ICIs by both the people affected by cancer and the healthcare professionals who support those people, and use the findings to make recommendations for ICI supportive care guidance development, cancer immunotherapy education materials for healthcare professionals, cancer policy and further research.

METHODS AND ANALYSIS

Patient participants (n=up to 30) will be recruited within the UK. The sample will incorporate a range of perspectives, sociodemographic factors, diagnoses and ICI treatments, yet share some common experiences. Healthcare professionals (n=up to 15) involved in supporting people receiving immunotherapy will also be recruited from across the UK. Data will be generated through in-depth, semistructured interviews. Reflexive thematic analysis will be used to obtain thorough understanding of individual's perspectives on, and experiences of, immunotherapy. Study dates are as follows: December 2019-March 2022.

ETHICS AND DISSEMINATION

The research will be performed in accordance with the UK Policy for Health and Social Care Research and Cardiff University's Research Integrity and Governance Code of Practice (2018). The study received ethical approval from the West Midlands and Black Country Research Ethics Committee in October 2019. Health Research Authority and Health and Care Research Wales approvals were confirmed in December 2019. All participants will provide informed consent. Findings will be published in peer-reviewed journals, non-academic platforms, the Macmillan Cancer Support website, disseminated at relevant national and international conferences and presented via a webinar. The study is listed on the National Institute for Health Research (NIHR) Clinical Research Network Central Portfolio.

Quality of life in patients with endometrial carcinoma: A Longitudinal Study

AIM

To investigate the quality of life in patients with endometrial carcinoma and provide theoretical basis for nursing care.

DESIGN

In this study, 69 patients diagnosed with endometrial carcinoma from 2016-2018 were included in the cohort.

METHODS

Sixty-nine patients from our hospital who underwent endometrial cancer surgeries were selected. The SF-36 was used to investigate and analyse the patients' quality of life in the first, second and third months after their operations. Questionnaires were administered to analyse the factors affecting postoperative quality of life.

RESULTS

Quality of life for the second and third months was obviously better than that for the first month after the operation (p < .05). Based on multivariate regression analysis, we found that patients with higher family income had better quality of life after surgery(p < .05). These results can provide some guidance for daily nursing work after endometrial cancer operation.

Adjuvant vaginal cuff brachytherapy in surgically treated endometrial carcinoma patients - in view of the recent evidence

Vaginal cuff brachytherapy is an essential component of adjuvant post-operative therapy in endometrial carcinoma. Brachytherapy boost, as a part of adjuvant pelvic radiotherapy, including concomitant chemoradiotherapy combined with four cycles carboplatin/paclitaxel chemotherapy, is used in early-stage high-risk and advanced stage disease. This strategy is widely accepted and recommended by international guidelines, despite the fact that combined therapy has never been verified in randomized trials. Brachytherapy alone is the adjuvant treatment of choice for many patients with early-stage endometrial cancer, with high-intermediate features, replacing external beam pelvic radiotherapy. It provides equivalent vaginal control with a lower risk of toxicity, and minimal impact on health-related quality of life. Available evidence did not demonstrate the superiority of sole vaginal brachytherapy combined with three cycles of carboplatin/paclitaxel chemotherapy, over the standard pelvic irradiation for patients with early-stage, high-intermediate-, and high-risk endometrial cancer. This article summarized the available evidence on the role of post-operative vaginal cuff brachytherapy in endometrial cancer patients. Additionally, the risk groups definition, some aspects of brachytherapy technique, and the importance of pathological and molecular risk factors for endometrial cancer risk stratification were presented. Furthermore, the role of brachytherapy according to the European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology 2021 guidelines for the management of patients with endometrial carcinoma was presented.

Adjuvant therapy for endometrial cancer in the era of molecular classification: radiotherapy, chemoradiation and novel targets for therapy

Endometrial cancer is primarily treated with surgery. Adjuvant treatment strategies for endometrial cancer, such as external beam pelvic radiotherapy, vaginal brachytherapy, chemotherapy, and combined chemotherapy and radiotherapy, have been studied in several randomized trials. Adjuvant treatment is currently based on the presence of clinico-pathological risk factors. Low-risk disease is adequately managed with surgery alone. In high-intermediate risk endometrial cancer, adjuvant vaginal brachytherapy is recommended to maximize local control, with only mild side effects and without impact on quality of life. For high-risk endometrial cancer, recent large randomized trials support the use of pelvic radiotherapy, especially in stage I-II endometrial cancer with risk factors. For women with serous cancers and those with stage III disease, chemoradiation increased both recurrence-free and overall survival, while GOG-258 showed similar recurrence-free survival compared with six cycles of chemotherapy alone, but with better pelvic and para-aortic nodal control with combined chemotherapy and radiotherapy. Recent molecular studies, most notably the work from The Cancer Genome Atlas (TCGA) project, have shown that four endometrial cancer molecular classes can be distinguished; POLE ultra-mutated, microsatellite instable hypermutated, copy-number-low, and copy-number-high. Subsequent studies, using surrogate markers to identify groups analogous to TCGA sub-classes, showed that all four endometrial cancer sub-types are found across all stages, histological types, and grades. Moreover, the molecular sub-groups have proved to have a stronger prognostic impact than histo-pathological tumor characteristics. This introduces an new era of molecular classification based diagnostics and treatment approaches. Integration of the molecular factors and new therapeutic targets will lead to molecular-integrated adjuvant treatment including targeted treatments, which are the rationale of new and ongoing trials. This review presents an overview of current adjuvant treatment strategies in endometrial cancer, highlights the development and evaluation of a molecular-integrated risk profile, and briefly discusses ongoing developments in targeted treatment.

Urologic, lymphedema, pelvic pain and gastrointestinal symptoms increase after radiotherapy in patients with primary uterine tumors: a prospective longitudinal Swedish cohort study

PURPOSE

Radiotherapy (RT) causes an inflammatory reaction of the tissue which leads to fibrosis and reduced functioning of the pelvic organs. Few studies have shown significant relationships between side effects and RT in uterine tumors. Here, the urological, lymphedema, pelvic pain and gastrointestinal (GI) symptoms were studied before and after RT in patients with primary uterine tumors using the EORTC QLQ-EN24, specifically designed for uterine cancer patients.

METHODS

This prospective cohort study comprised patients with primary uterine tumors who received pelvic radiotherapy (RT). A total of 43 patients were included from May 2014 to February 2019. Patients completed the questionnaires for global health status and functioning before the start of RT and at 3 and 12 months after RT.

RESULTS

We found a significant worsening of the urological symptoms 3 months after RT which persisted up to 12 months after RT compared to baseline values prior to start of RT (p = 0.007). An exacerbation of the urinary symptoms was seen in patients with vaginal brachytherapy/boost compared to patients with pelvic RT at 12 months after RT (p = 0.053). The severity of lymphedema symptoms increased from RT start to 12 months after RT (p = 0.019) and the pelvic pain were higher at 3 months after RT compared to before RT (p = 0.004). Also, the level of GI symptoms was significantly higher 12 months after RT compared to the RT start (p < 0.001).

CONCLUSIONS

The urologic, lymphedema, pelvic pain and GI symptoms all increase after RT.

Surgical lymph node assessment influences adjuvant therapy in clinically apparent stage I endometrioid endometrial carcinoma, meeting Mayo criteria for lymphadenectomy

OBJECTIVE

To evaluate the impact of surgical lymph node assessment for clinically apparent, stage I endometrioid endometrial adenocarcinoma meeting Mayo criteria for lymphadenectomy.

METHODS

Patients with endometrioid endometrial adenocarcinoma meeting Mayo criteria for lymphadenectomy who underwent hysterectomy and lymphadenectomy were identified. Algorithms for adjuvant therapy with and without lymphadenectomy were developed utilizing NCCN guidelines, PORTEC 1, and PORTEC 2. Patients served as their own control to determine the frequency of treatment modification.

RESULTS

A total of 357 patients were analyzed. Using our algorithms treatment modification would have occurred because of lymphadenectomy in 62.8% of patients if whole pelvic external beam radiation was used for patients meeting inclusion criteria for PORTEC 1. Treatment modification would have occurred in 16.2% of patients if vaginal brachytherapy was used for patients meeting the inclusion criteria for PORTEC 2. Of the total, 53.8% of patients meeting inclusion criteria for PORTEC 1 would have had a reduction in adjuvant therapy from whole pelvic radiotherapy to vaginal brachytherapy alone. Only 9.0% of patients would have adjuvant therapy increased to include external beam radiotherapy and chemotherapy based on the presence of positive lymph nodes.

CONCLUSIONS

Applying standard adjuvant treatment algorithms to real patient data, surgical lymph node assessment appears to frequently alter treatment allocation.

Gynecologic Malignancies

Gynecologic malignancies are among the most prevalent cancers affecting women worldwide, but they are heterogeneous diseases with varying risk factors, management paradigms, and outcomes. Gynecologic cancers mediated by human papillomavirus (HPV) are preventable and curable with early detection and treatment. Dramatic reductions in cervical cancer incidence and mortality have been achieved through cancer screening and HPV vaccination. Radiotherapy plays a central role in the management of gynecologic malignancies. For some cancers, radiotherapy alone can be curative. More often, radiotherapy is used in conjunction with surgery and systemic therapy to improve locoregional control and extend overall survival. This chapter reviews recent advances in radiotherapeutic management of gynecologic malignancies.

Radiotherapy and Its Intersections with Surgery in the Management of Localized Gynecological Malignancies: A Comprehensive Overview for Clinicians

Surgery, including minimally invasive surgery, and radiotherapy are key modalities in the treatment of gynecological malignancies. The aim of this review is to offer the multidisciplinary care team a comprehensive summary of the intersections of surgery and radiotherapy in the local treatment of gynecological malignancies. Recent advances in radiotherapy are highlighted. Relevant publications were identified through a review of the published literature. Ovarian, endometrial, cervical, vaginal, and vulvar cancer were included in the search. Current guidelines are summarized. The role of radiotherapy in adjuvant as well as definitive treatment of these entities is synthesized and put into context with surgery, focusing on survival and quality of life. Although these outcomes have improved recently, further research must be focused on the number of life years lost, and the potential morbidity encountered by patients.