Counterpoint: The role of adjuvant radiation in endometrial cancer. Inside, outside, or not at all?

Abstract

Following surgery for endometrial cancer, patients may be advised to receive adjuvant radiation with or without chemotherapy. Historically, many patients were routinely given adjuvant radiation without any real evidence base or rational policies. More recently, we have seen evidence-based practice that has taken into account important contemporary clinical trials, including the PostOperative Radiation Therapy for Endometrial Carcinoma-1 (PORTEC-1), A Study in the Treatment of Endometrial Cancer, (ASTEC), and Gynecologic Oncology Group 99 (GOG 99), which compared adjuvant postoperative radiation with no radiation ( 1 Creutzberg C.L. van Putten W.L. Koper P.C. et al. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: Multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet. 2000; 355: 1404-1411 Abstract Full Text Full Text PDF PubMed Scopus (1467) Google Scholar , 2 Creutzberg C.L. van Putten W.L.J. Koper P.C. et al. For the PORTEC Study GroupSurvival after relapse in patients with endometrial cancer. Results from a Randomized Trial. Gynecol Oncol. 2003; 89: 201-209 Abstract Full Text Full Text PDF PubMed Scopus (305) Google Scholar , 3 Keys H.M. Roberts J.A. Brunetto V.L. et al. A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: A Gynecologic Oncology Group study. Gynecol Oncol. 2004; 92: 744-751 Abstract Full Text Full Text PDF PubMed Scopus (1306) Google Scholar , 4 Blake P. Swart A.M. Orton J. et al. ASTEC/EN.5 Study GroupAdjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): Pooled trial results, systematic review, and meta-analysis. Lancet. 2009; 373: 137-146 Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar ), studies from Japan and Italy where chemotherapy was compared with radiation ( 5 Susumu N. Sagae S. Udagawa Y. et al. Japanese Gynecologic Oncology GroupRandomized phase III trial of pelvic radiotherapy versus cisplatin-based combined chemotherapy in patients with intermediate- and high-risk endometrial cancer: A Japanese Gynecologic Oncology Group study. Gynecol Oncol. 2008; 108: 226-233 Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar , 6 Maggi R. Lissoni A. Spina F. et al. Adjuvant chemotherapy vs radiotherapy in high-risk endometrial carcinoma: Results of a randomised trial. Br J Cancer. 2006; 95: 2662-2671 Crossref Scopus (369) Google Scholar ), and the Nordic Society for Gynecologic Oncology/European Organisation for Research and Treatment of Cancer study of radiation vs. sequential chemoradiotherapy ( [7] Hogberg T. Signorelli M. de Oliveira C.F. et al. Sequential adjuvant chemotherapy and radiotherapy in endometrial cancer—Results from two randomised studies. Eur J Cancer. 2010; 46: 2422-2431 Abstract Full Text Full Text PDF PubMed Scopus (370) Google Scholar ). In many of these studies, except GOG 99, the surgery did not routinely include pelvic lymph node dissection; the staging information from this is valuable even if we argue about the therapeutic benefit.