ASTRO Provides New Guidelines for Use of Radiation and Systemic Therapies in Endometrial Cancer

Beth A. Erickson, MD, FASTRO

The American Society for Radiation Oncology (ASTRO) has updated guidance for the use of radiation therapy and systemic therapy for patients who’ve undergone surgery for endometrial cancer. The guideline also considers the role of surgical staging and molecular profiling techniques in determining whether a patient should receive post-operative therapy.¹

The guideline is scheduled to be published in the January/February 2023 issue of Practical Radiation Oncology.² Beth A. Erickson, MD, FASTRO, chair of the guideline task force and a professor of radiation oncology at the Medical College of Wisconsin in Milwaukee, said these guidelines reflect advancements published over the past decade.

“Since ASTRO published its original endometrial cancer guideline in 2014, multiple research teams have published high-quality clinical trials on the usefulness of post-operative therapy for patients with different disease stages and risk profiles,” she said in a news release.

“For patients with an elevated risk of recurrence following endometrial cancer surgery, clinical trials consistently show that adjuvant therapy can improve outcomes,” Erickson added. “Our task force synthesized findings from these trials into recommendations for external beam radiation, brachytherapy and chemotherapy in the post-surgical setting, with a focus on multidisciplinary, patient-centered care.”

The multidisciplinary guideline committee conducted a systematic literature review of articles published through August 2021. The guideline was developed in collaboration with the American Brachytherapy Society, the American Society of Clinical Oncology and the Society of Gynecologic Oncology.

The guideline also acknowledges the negative impact of systemic racial disparities on endometrial cancer outcomes. While the guideline is focused on the medical considerations for treatment, the task force also wanted to recognize the complex nature of access to care for underserved patient populations. The task force considered ethnicity, race, gender, experience, practice setting, and geographic location in drafting the recommendations.

The task force accounted for new data assessing the accuracy of surgical staging techniques and the growing use of molecular profiling for endometrial tumors to guide adjuvant therapy decisions. The task force noted that investigators have identified several potential biomarkers for endometrial cancer. They are now exploring whether these molecular markers can identify which patients will benefit from adjuvant therapy.

The guideline includes treatment algorithms for stage I-II endometrial cancers, stage I-II cancers with high-risk histologies, and stage III-IVA cancers. The guideline further provides guidance on the use of external beam radiation therapy (EBRT), vaginal brachytherapy (VBT), and chemotherapy for patients with different risk profiles, and identifies which patients should not receive adjuvant therapy. The committee made 5 key recommendations:

• Radiation therapy is recommended to reduce the risk of locoregional recurrence, depending on a patient’s clinical-pathologic risk factors.
  • Patients with stage I disease with high-risk features, stage II disease or stage III-IVA disease should receive EBRT.
  • Lymph node assessment and uterine risk factors should determine whether to use EBRT or VBT in FIGO stage I disease.
• Sequence systemic chemotherapy with radiation therapy for patients with high-risk histologies and/or stage III-IVA disease to decrease the risk of distant and locoregional recurrence, respectively.
• Intensity-modulated radiation therapy with daily image-guidance is associated with improved patient-reported outcomes and reduced side effects.
• Sentinel lymph node mapping is recommended over pelvic lymphadenectomy for surgical nodal staging. Use of adjuvant therapy should be based on a patient's pathologic ultrastaging status.
• Molecular tumor profiling is recommended and may be used to guide recommendations for adjuvant therapy.

References

1. Hackenrider MM, Abu-Rustum N, Albuquerque K, et al. Radiation therapy for endometrial cancer: an American Society for Radiation Oncology clinical practice guideline. Pract Radiat Oncol. Published online October 21, 2022. doi:10.1016/j.prro.2022.09.002
2. ASTRO issues updated guideline on radiation therapy for endometrial cancer. News release. ASTRO. December 7, 2022. Accessed December 8, 2022. https://bit.ly/3he9FEY