Optimizing Local and Neoadjuvant Therapies in Cervical Cancer: Recent Advances in Hypofractionated Radiotherapy

Moderately hypofractionated radiotherapy shortens overall treatment time while maintaining comparable short‑term tumor control. That change matters for patients facing long daily travel, financial barriers, or treatment pathways that depend on timely neoadjuvant or adjuvant sequencing.

It is actionable now because modern image‑guided techniques and brachytherapy integration provide the precision needed for shorter schedules; the current evidence—multiple early‑phase series and randomized studies—supports broader adoption in selected centers, though longer follow‑up and larger trials are still required to define long‑term safety and high‑risk indications.

Pooled early‑phase reports and randomized cohorts summarized in the canonical review of moderately hypofractionated radiotherapy describe regimens that raise dose per fraction (commonly 2.1–4.9 Gy) and reduce total sessions (typical schedules ≈15–20 fractions with an HDR brachytherapy boost). The synthesis includes prospective single‑institution series, multicenter phase II trials, and small randomized comparisons (sample sizes from several dozen to low hundreds), using endpoints such as local control, complete clinical or radiographic response, and progression‑free or recurrence‑free survival. Across early follow‑up, these data show similar short‑ to medium‑term local control and early progression metrics versus conventional fractionation.

Acute and late toxicities are dominated by gastrointestinal, genitourinary, and hematologic events. Most pooled summaries report overall grade ≥3 toxicity rates that are numerically similar to conventional schedules when modern planning (IMRT/VMAT) and image‑guided brachytherapy are used; studies relying on older 3D conformal techniques recorded higher acute grade ≥3 GI events, underscoring technique‑dependent risk.

Shorter external beam courses also compress the interval to surgery or systemic therapy, enabling earlier response assessment and, in limited cohorts, timely radical hysterectomy or neoadjuvant chemotherapy sequencing without clear increases in perioperative complications. Overall, the toxicity profile to date supports feasibility of integrating MHRT into multimodality care in centers with coordinated planning and surgical pathways.

Reducing fractions from ~25–28 to ~15–20 cuts patient visits and machine occupancy by an estimated 30–40%, improving adherence, shortening waitlists, and lowering per‑patient resource use—benefits that are especially meaningful where machine time and travel distance limit completion rates. Safe scale‑up in resource‑constrained settings requires prerequisites: robust treatment‑planning systems, IMRT/VMAT capability, image‑guided adaptive workflows, HDR brachytherapy access, and QA programs with trained staff. Expansion can enhance equity by increasing throughput, but must be paired with QA investments, training, and validated brachytherapy delivery; pragmatic rollout should follow protocolized implementation in capable centers and, when possible, within trial frameworks.

The consolidated clinical message is straightforward: moderately hypofractionated radiotherapy shortens overall treatment duration with comparable early tumor control and a manageable toxicity profile when delivered with modern planning and brachytherapy support. Centers with established QA, IMRT/VMAT, and HDR brachytherapy capacity should consider pathway adoption for selected patients, with prospective outcome monitoring.

Priority research needs are large randomized trials powered for long‑term local control and survival, extended toxicity surveillance, stratified studies in high‑risk or bulky disease, and implementation research in LMIC contexts to ensure safe scale‑up. Aligning operational planning with prospective trial enrollment and robust QA will accelerate validation and responsible adoption.

Key Takeaways:

• Moderately hypofractionated radiotherapy shortens treatment time while showing comparable short‑term control in early studies.
• Typical MHRT schedules increase dose per fraction (≈2.1–4.9 Gy) and reduce fractions to ~15–20 with HDR brachytherapy boosts.
• Toxicity is generally manageable with modern IMRT/IGBT workflows, but technique quality is critical to avoid excess GI toxicity.
• LMICs can gain throughput and adherence benefits, provided investments in planning, QA, and brachytherapy are made.
• Immediate needs: larger randomized trials, longer‑term toxicity and survival data, and implementation studies in diverse settings.