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Adjuvant radiotherapy for stage I endometrial cancer

  • Review
  • Intervention

Authors


Abstract

Background

The role of adjuvant radiotherapy (both pelvic external beam radiotherapy and vaginal intracavity brachytherapy) in stage I endometrial cancer following total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO) remains unclear.

Objectives

To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer.

Search methods

The Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2006, MEDLINE, EMBASE, CancerLit, Physician Data Query (PDQ) of National Cancer Institute. Handsearching was also carried out where appropriate.

Selection criteria

Randomised controlled trials (RCTs) which compared adjuvant radiotherapy versus no radiotherapy following surgery for patients with stage I endometrial cancer were included.

Data collection and analysis

Quality of the studies was assessed and data collected using a predefined data collection form. The primary endpoint was overall survival. Secondary endpoints were locoregional recurrence, distant recurrence and endometrial cancer death. Data on quality of life (QOL) and morbidity were also collected. A meta-analysis on included trials was performed using the Cochrane Collaboration Review Manager Software 4.2.

Main results

The meta-analysis was performed on four trials (1770 patients). The addition of pelvic external beam radiotherapy to surgery reduced locoregional recurrence, a relative risk (RR) of 0.28 (95% confidence interval (CI) 0.17 to 0.44, p < 0.00001), which is a 72% reduction in the risk of pelvic relapse (95% CI 56% to 83%) and an absolute risk reduction of 6% (95% CI of 4 to 8%). The number needed to treat (NNT) to prevent one locoregional recurrence is 16.7 patients (95% CI 12.5 to 25). The reduction in the risk of locoregional recurrence did not translate into either a reduction in the risk of distant recurrence or death from all causes or endometrial cancer death. A subgroup analysis of women with multiple high risk factors (including stage 1c and grade 3) showed a trend toward the reduction in the risk of death from all causes and endometrial cancer death in patients who underwent adjuvant external beam radiotherapy.

Authors' conclusions

Patients with stage I endometrial carcinoma have different risks of local and distant recurrence depending on the presence of risk factors including stage 1c, grade 3, lymphovascular space invasion and age. Though external beam pelvic radiotherapy reduced locoregional recurrence by 72%, there is no evidence to suggest that it reduced the risk of death. In patients with multiple high risk factors, including stage 1c and grade 3, there was a trend towards a survival benefit and adjuvant external beam radiotherapy may be justified. For patients with only one risk factor, grade 3 or stage 1c, no definite conclusion can be made and data from ongoing studies (ASTEC; Lukka) are awaited. External beam radiotherapy carries a risk of toxicity and should be avoided in stage 1 endometrial cancer patients with no high risk factors.

Plain language summary

Adjuvant radiotherapy for stage I endometrial cancer

Women with stage I endometrial cancer have a low risk of recurrence of their disease. About 10% of women treated with surgery alone have a recurrence. This risk is significantly higher (and maybe double) for some women with high risk factors including grade 3 histology and deep invasion of the muscle (stage Ic). External beam radiotherapy after hysterectomy reduces the risk of cancer recurring locally by 72% compared to patients who have surgery alone, but does not appear to reduce the risk of death, from endometrial cancer or other causes.

External beam radiotherapy carries an inherent risk of damage and toxicity and should be avoided in stage I endometrial cancer patients with no high risk factors. However, in patients with multiple high risk factors (at least grade 3 and stage 1c), there may be a trend towards a benefit in survival, as well as a reduction in locoregional recurrence. The results of ongoing trials are needed to determine whether external beam radiotherapy can improve survival in those women with stage I endometrial cancer with only one high risk factor (e.g. grade 3 or stage Ic).

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