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Original Investigation
January 14, 2021

Effectiveness of Sequential Chemoradiation vs Concurrent Chemoradiation or Radiation Alone in Adjuvant Treatment After Hysterectomy for Cervical Cancer: The STARS Phase 3 Randomized Clinical Trial

Author Affiliations
  • 1Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
  • 2Guangdong Provincial People’s Hospital, Guangzhou, China
  • 3Guangzhou Panyu Central Hospital, Guangzhou, China
  • 4Hunan Cancer Hospital, Changsha, China
  • 5Shenzhen People’s Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
  • 6Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
  • 7Guangxi Medical University Affiliated Tumor Hospital, Nanning, China
  • 8The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
JAMA Oncol. 2021;7(3):361-369. doi:10.1001/jamaoncol.2020.7168
Visual Abstract. Effectiveness of Sequential Chemoradiation vs Concurrent Chemoradiation or Radiation Alone in Adjuvant Treatment After Hysterectomy for Cervical Cancer
Effectiveness of Sequential Chemoradiation vs Concurrent Chemoradiation or Radiation Alone in Adjuvant Treatment After Hysterectomy for Cervical Cancer
Key Points

Question  When compared with radiation alone, does sequential chemoradiation or concurrent chemoradiation improve disease-free survival (DFS) in patients with early-stage cervical cancer after radical hysterectomy?

Findings  In this phase 3 randomized clinical trial of 1048 eligible women, sequential chemoradiation improved 3-year DFS and distant DFS compared with concurrent chemoradiation or radiation alone, with tolerable toxic effects, especially in patients with high-risk factors. However, no substantial improvements in survival were seen among patients receiving concurrent chemoradiation compared with radiation alone.

Meaning  Sequential chemoradiation may be an optimal adjuvant treatment after radical hysterectomy for early-stage cervical cancer.


Importance  There is no current consensus on the role of chemotherapy in addition to radiation for postoperative adjuvant treatment of patients with early-stage cervical cancer with adverse pathological factors.

Objective  To evaluate the clinical benefits of sequential chemoradiation (SCRT) and concurrent chemoradiation (CCRT) compared with radiation alone (RT) as a postoperative adjuvant treatment in early-stage cervical cancer.

Design, Setting, and Participants  After radical hysterectomy at 1 of 8 participating hospitals in China, patients with FIGO (International Federation of Gynecology and Obstetrics) stage IB to IIA cervical cancer with adverse pathological factors were randomized 1:1:1 to receive adjuvant RT, CCRT, or SCRT. Data were collected from February 2008 to December 2018.

Interventions  Patients received adjuvant RT (total dose, 45-50 Gy), CCRT (weekly cisplatin, 30-40 mg/m2), or SCRT (cisplatin, 60-75 mg/m2, plus paclitaxel, 135-175 mg/m2) in a 21-day cycle, given 2 cycles before and 2 cycles after radiotherapy, respectively.

Main Outcomes and Measures  The primary end point was the rate of disease-free survival (DFS) at 3 years.

Results  A total of 1048 women (median [range] age, 48 [23-65] years) were included in the analysis (350 in the RT group, 345 in the CCRT group, and 353 in the SCRT group). Baseline demographic and disease characteristics were balanced among the treatment groups except that the rate of lymph node involvement was lowest in the RT group (18.3%). In the intention-to-treat population, SCRT was associated with a higher rate of DFS than RT (3-year rate, 90.0% vs 82.0%; hazard ratio [HR], 0.52; 95% CI, 0.35-0.76) and CCRT (90.0% vs 85.0%; HR, 0.65; 95% CI, 0.44-0.96). Treatment with SCRT also decreased cancer death risk compared with RT (5-year rate, 92.0% vs 88.0%; HR, 0.58; 95% CI, 0.35-0.95) after adjustment for lymph node involvement. However, neither DFS nor cancer death risk was different among patients treated with CCRT or RT.

Conclusions and Relevance  In this randomized clinical trial, conducted in a postoperative adjuvant treatment setting, SCRT, rather than CCRT, resulted in a higher DFS and lower risk of cancer death than RT among women with early-stage cervical cancer.

Trial Registration  ClinicalTrials.gov Identifier: NCT00806117

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