Open Journal Systems

Cervical Cancer in the COVID-19 Era – the Potential Role of Adapting Newer Treatment Protocols

Bindhu Joseph (Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bangalore)
Nikhila Radhakrishna (Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bangalore)
Nithin Bhaskar Valuvil (Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bangalore)
Lokesh Vishwanath (Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bangalore)


Background: The COVID-19 pandemic has resulted in unprecedented problems in cancer management and providing a safe organised work flow for oncological health care systems to operate.

The treatment of advanced cervical cancer stage IIB - IVA has received higher priority in most international guidelines for risk adaptation in relation to COVID-19 situation.

There is an urgent need to revise the established standard treatment protocol of concurrent chemo-irradiation followed by brachytherapy, usually delivered over 6-7 weeks, which is associated with technical difficulties and would pose risks to both the patient and treating health care personnel.

Aims & Objectives: To propose alternative treatment protocols that are supported by scientific data and may be better suited to meet the needs of the unique situation.

Methods: A systematic literature search was performed using PubMed and other search engines. The studies evaluated were those published from 1990 to April 2020. The focus was on scientific rationale and non-inferiority with standards of care.

Conclusions: The authors propose Simultaneous Integrated Boost for treatment of large volume disease and Stereotactic Body Radiotherapy boost for smaller tumour volumes, where facilities are available. 3DCRT with an integrated or sequential IMRT boost can be considered in institutes with technical limitations.


Cervical cancer ; SBRT ; SIB ; EBRT Boost

Full Text:



Zhu N, Zhang D, Wang W, et al. A novel coronavirus from

patients with pneumonia in China, 2019. N Engle J Med

; 382:727-733

Wu Z, McGoogan JM. Characteristics of and Important

Lessons from the Coronavirus Disease 2019 (COVID-19)

Outbreak in China: Summary of a Report of 72 314 Cases

from the Chinese Centre for Disease Control and Prevention. JAMA. 2020;323(13):1239–1242.

Bogoch II, Watts A, Thomas-Bachli A, et al. Potential for

global spread of a novel coronavirus from China. J Travel

Med. 2020. [PMID: 31985790]

Clinical guide for the management of non-coronavirus patients requiring acute treatment: Cancer – NHS 2020

Arbyn M, Weiderpass E, Bruni L, de Sanjose S, Saraiya M,

Ferlay J, Bray F. Estimates of incidence and mortality of

cervical cancer in 2018: a worldwide analysis The Lancet

Global Health 2019, 8 (2), pp. e191-e203. PMID 31812369

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA,

Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers

in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.

Chopra SJ, Mathew A, Maheshwari A, Bhatla N, Singh

S, Rai B et al. National Cancer Grid of India Consensus

Guidelines on the Management of Cervical Cancer. Journal

of Global Oncology 2018 :4, 1-15

Van Leeuwen CM, Oei AL, Crezee J, Bel A, Franken NAP,

Stalpers LJA, Kok HP. The alfa and beta of tumours: a review of parameters of the linear-quadratic model, derived

from clinical radiotherapy studies. Radiat Oncol. 2018

May 16;13(1):96. doi: 10.1186/s13014-018-1040-z. PMID:

; PMCID: PMC5956964.

Lanciano RM, Won M, Coia LR, Hanks GE. Pretreatment

and treatment factors associated with improved outcome

in squamous cell carcinoma of the uterine cervix: A final

report of the 1973 and 1978 patterns of care studies. Int J

Radiat Oncol Biol Phys 1991; 20:667-76

Montana GS, Hanlon AL, Brickner TJ, Owen JB, Hanks

GE, Ling CC, et al. Carcinoma of the cervix: Patterns of

care studies: Review of 1978, 1983, and 1988-1989 surveys. Int J Radiat Oncol Biol Phys 1995; 32:1481-6

Robin TP, Amini A,Schefter TE, et al. Disparities in standard of care treatment and associated survival decrement

in patients with locally advanced cervical cancer. Gynecol Oncol. 2016; 143:319–325.

Matsuura K, Okabe T, Fujita K, Tanimoto H, Akagi Y,

Kagemoto M. Clinical results of external beam radiotherapy alone with a concomitant boost program or with conventional fractionation for cervical cancer patients who did

not receive intracavitary brachytherapy. J Radiat Res. 2012

Nov 1;53(6):900-5. doi: 10.1093/jrr/rrs051. Epub 2012

Aug 1. PMID: 22859563; PMCID: PMC3483852.

Lazzari R, Riva G, Augugliaro M, et al. Intensity modulated radiation therapy boost in locally-advanced cervical

cancer in the absence of brachytherapy. Int J Gynecol Cancer. 2020;30(5):607-612.

Mahmoud O, Kilic S, Khan AJ, Beriwal S, Small W Jr.

External beam techniques to boost cervical cancer when

brachytherapy is not an option-theories and applications.

Ann Transl Med. 2017 May;5(10):207. PMID: 28603722;

PMCID: PMC5451624.

Chuang LT, Temin S, Berek JS. Management and Care of

Women with Invasive Cervical Cancer: American Societyof Clinical Oncology Resource-Stratified Clinical Practice

Guideline Summary. J Oncol Pract 2016; 12:693-6

Mazzola R, Ricchetti F, Fiorentino A, et al. Weekly Cisplatin and Volumetric-Modulated Arc Therapy with Simultaneous Integrated Boost for Radical Treatment of Advanced

Cervical Cancer in Elderly Patients: Feasibility and Clinical Preliminary Results. Technol Cancer Res Treat 2017;


Guerrero M, Li XA, Ma L, Linder J, Deyoung C, Erickson

B. Simultaneous integrated intensity-modulated radiotherapy boost for locally advanced gynecological cancer.

radiobiological and dosimetric considerations. Int J Radiat

Oncol Biol Phys. 2005;62(3):933–939.

Fowler JF. The linear-quadratic formula and progress in

fractionated radiotherapy. Br J Radiol 1989; 62:679-94.

Buffa FM, Davidson SE, Hunter RD, et al. Incorporating

biologic measurements (SF (2), CFE) into a tumor control

probability model increases their prognostic significance: a

study in cervical carcinoma treated with radiation therapy.

Int J Radiat Oncol Biol Phys 2001; 50:1113-22.

Gasinska A, Fowler JF, Lind BK, et al. Influence of overall

treatment time and radiobiological parameters on biologically effective doses in cervical cancer patients treated with

radiation therapy alone. Acta oncologica 2004; 43:657-66.

Vandecasteele K, Makar A, Van den Broecke R, et al.

Intensity-modulated arc therapy with cisplatin as neo-adjuvant treatment for primary irresectable cervical cancer.

Toxicity, tumour response and outcome. Strahlenther

Onkol. 2012;188(7):576-581.

Wang X, Zhao Y, Shen Y, et al. Long-term follow-up results of simultaneous integrated or late course accelerated

boost with external beam radiotherapy to vaginal cuff for

high risk cervical cancer patients after radical hysterectomy. BMC Cancer. 2015; 15:257.


Advances in Modern Oncology Research | Volume 06 | Issue 01 | February 2020

Cheng JY, Huang EY, Hsu SN, Wang CJ. Simultaneous

integrated boost (SIB) of the parametrium and cervix in

radiotherapy for uterine cervical carcinoma: a dosimetric

study using a new alternative approach. Br J Radiol. 2016


L.A. Daley, O.I. Craciunescu, G. Suneja, K. Light, A. Rodrigues, J.P. Chino. Simultaneous Integrated Parametrial/

Sidewall Boosts for Cervical Cancer: Late Toxicity and

Outcomes. Daley, L.A. et al. Int J Radiat Oncol Biol Phys.

; 99 (2): E288

Marnitz S, Kohler C, Budach V, et al. Brachytherapy-emulating robotic radiosurgery in patients with cervical carcinoma. Radiation oncology 2013; 8:109.

Haas JA, Witten MR, Clancey O, et al. CyberKnife Boost

for Patients with Cervical Cancer unable to Undergo

Brachytherapy. Front Oncol 2012; 2:25.

Kubicek GJ, Xue J, Xu Q, et al. Stereotactic body radiotherapy as an alternative to brachytherapy in gynecologic

cancer. Biomed Res Int 2013; 2013:898953

Mantz C. Stereotactic Body Radiation Therapy as a Boost

Alternative for Nonmetastatic Cancer of the Cervix and Endometrium: Disease Control and Quality of Life Outcomes

from a Phase 2 Trial at 3 Years’ Minimum Follow-up. Int J

Radiat Oncol Biol Phys 2016;96: E286.

Cengiz M, Dogan A, Ozyigit G, et al. Comparison of intracavitary brachytherapy and stereotactic body radiotherapy

dose distribution for cervical cancer. Brachytherapy 2012;


Khosla D, Patel FD, Rai B, et al. Dose escalation by intensity-modulated radiotherapy boost after whole pelvic radiotherapy in postoperative patients of carcinoma cervix with

residual disease. Clin Oncol (R Coll Radiol). 2013;25(1):


Hsieh CH, Tien HJ, Hsiao SM, et al. Stereotactic body

radiation therapy via helical tomotherapy to replace

brachytherapy for brachytherapy-unsuitable cervical cancer

patients - a preliminary result. Onco Targets Ther 2013;


Clivio A, Kluge A, Cozzi L, et al. Intensity modulated proton beam radiation for brachytherapy in patients

with cervical carcinoma. Int J Radiat Oncol Biol Phys.


Chan P, Yeo I, Perkins G, et al. Dosimetric comparison of

intensity-modulated, conformal, and four-field pelvic radiotherapy boost plans for gynecologic cancer: a retrospective planning study. Radiat Oncol 2006; 1:13.

Barraclough LH, Swindell R, Livsey JE, et al. External

beam boost for cancer of the cervix uteri when intracavitary therapy cannot be performed. Int J Radiat Oncol Biol

Phys 2008; 71:772-8.

Molla M, Escude L, Nouet P, et al. Fractionated stereotactic radiotherapy boost for gynecologic tumors: an alternative to brachytherapy? Int J Radiat Oncol Biol Phys. 2005;


Jorcano S, Molla M, Escude L, et al. Hypofractionated

extracranial stereotactic radiotherapy boost for gynecologic tumors: a promising alternative to high-dose rate

brachytherapy. Technol Cancer Res Treat. 2010;9(5):509-

Park HC, Shimizu S, Yonesaka A, et al. High dose three-dimensional conformal boost using the real-time tumor

tracking radiotherapy system in cervical cancer patients

unable to receive intracavitary brachytherapy. Yonsei Med




  • There are currently no refbacks.

Copyright (c) 2020 Bindhu Joseph, Nikhila Radhakrishna, Nithin Bhaskar Valuvil, Lokesh Vishwanath

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.