KEY POINTS
- JROSG22-1/JGOG1088S was a nationwide Japanese multicenter retrospective study of 343 patients with newly diagnosed FIGO 2018 stage IVB cervical cancer treated from 2016–2020. Patients received chemotherapy alone (n=137) or chemotherapy plus definitive-dose pelvic radiotherapy (n=206).
- Definitive pelvic RT was defined as pelvic EBRT ≥40 Gy, brachytherapy, or both. Among patients with available dosimetry, median total EQD2 was 65.4 Gy at point A and 70.3 Gy to CTVHR D90; 67% of the pelvic-RT group received brachytherapy and 78% received concurrent chemoradiotherapy.
- After 1:1 propensity-score matching, 103 patients per group were compared. Median overall survival was 25.0 months with pelvic RT versus 18.0 months with chemotherapy alone, corresponding to HR 0.58 (95% CI 0.42–0.79; P<.001); two-year survival was 50.3% versus 31.0%.
- Progression-free survival also favored pelvic treatment, although the absolute median difference was modest: 9 versus 8 months, HR 0.65 (95% CI 0.48–0.87; P=.002). Sensitivity analyses using inverse-probability weighting and a six-month landmark analysis continued to show a significant survival association.
- Pelvic disease control improved substantially. In the overall cohort, the first progression was local in 19% with pelvic RT versus 34% with chemotherapy alone (P=.003), while any pelvic first progression occurred in 22% versus 41% (P<.001).
- The survival association was seen across most metastatic patterns but was absent in patients with T1–2 disease, HR 1.11 (95% CI 0.64–1.92), with a significant interaction by T stage (Pinteraction=.008). Even among patients with organ metastases, the matched analysis favored pelvic RT, HR 0.66 (95% CI 0.46–0.95).
- Brachytherapy emerged as an important treatment-associated factor within the pelvic-RT cohort: on multivariable analysis it was associated with better overall survival, HR 0.48 (95% CI 0.33–0.71; P<.001), and progression-free survival, HR 0.66 (95% CI 0.47–0.93; P=.016). Median survival was 38 months with pelvic RT plus brachytherapy, 23 months with EBRT alone and 18 months with chemotherapy alone in the overall cohort.
- Treatment intensification came with greater gastrointestinal morbidity. In the matched cohort, late grade ≥3 gastrointestinal toxicity occurred in 13.6% with pelvic RT versus 4.9% with chemotherapy alone (P=.030); grade ≥3 genitourinary toxicity was similar at 5.8% versus 4.9%. Importantly, the cohort predates contemporary first-line checkpoint-inhibitor therapy.
CLINICAL TAKEAWAY
Definitive treatment of the pelvis may matter even when cervical cancer is already metastatic: pelvic RT was associated with a seven-month median survival advantage and substantially less pelvic progression, with the strongest signal when brachytherapy was incorporated. This is compelling real-world evidence, but selection bias, non-standardized systemic therapy and the absence of modern immunotherapy mean pelvic RT cannot yet be considered a proven survival-improving standard for unselected stage IVB disease.