Concurrent chemoradiation is generally the primary treatment of choice for managing women with cervical cancer either as a definitive treatment for those with locally advanced disease or for those who are poor surgical candidates (NCCN 2017).

Definitive radiation therapy should consist of pelvic external beam radiation (EBRT) and intracavitary brachytherapy (ESMO Guidelines Working Group 2012) to be completed within 56 days. Concurrent radiosensitising chemotherapy with radiotherapy has been shown to significantly improve patient survival compared with radiotherapy alone (NCCN 2017).

In women with high-risk disease (lymph node metastases, parametrial invasion, lymphovascular space invasion, thickness of the residual muscular layer, tumour depth and tumour growth pattern) (Shinohara et al. 2004) postoperative radiation therapy plus/minus chemotherapy following surgery should be offered (ESMO Guidelines Working Group 2012). Where possible, patients with high-risk features who are likely to require adjuvant therapy following surgery should be identified upfront and considered for definitive chemoradiation to minimise the toxicities of trimodality treatment.

For women who present with distant metastatic disease, EBRT may be considered to control pelvic disease and other symptoms.

Training and experience of the radiation oncologist:

• Radiation oncologist (FRANZCR or equivalent) with adequate training and experience that enables institutional credentialling and agreed scope of practice within this area (ACSQHC 2004) and who is also a core member of a gynaecological oncology multidisciplinary team.

Hospital or treatment unit characteristics for providing safe and quality care include:

• trained radiotherapy nurses, physicists and therapists
• access to CT/MRI scanning for simulation and planning
• mechanisms for coordinating combined therapy (chemotherapy and radiation therapy), especially where the facility is not collocated
• access to allied health, especially nutrition health and advice.

There is evidence to suggest that higher caseloads have better clinical outcomes for patients treated with brachytherapy (Moon-Sing et al. 2014). Centres that do not have sufficient caseloads should establish processes to routinely refer brachytherapy cases to a high-volume centre.