Postoperative Adjuvant Treatments for Cervical Cancer: A Network Meta-Analysis

Abstract

This study aimed to perform a comprehensive network meta-analysis assessing the efficacy and safety of 5 postoperative adjuvant therapies (PATs) for early-stage cervical cancer, comparing their effects on survival and adverse outcomes to identify the therapy with the most significant survival benefit. We comprehensively searched PubMed, Web of Science, the Cochrane Library, Embase, CNKI, VIP, Wanfang, and CBM for randomized controlled trials on PATs-including concurrent chemoradiation therapy (CCRT), radiation therapy (RT), chemotherapy (CT), sequential chemoradiation therapy (SCRT), and CCRT followed by consolidation chemotherapy (CCRT + CT)-in patients with cervical cancer from inception to October 2024. Study bias was assessed with the Cochrane ROB.2. A Bayesian random-effects network meta-analysis was conducted for indirect comparisons, with τ² used to evaluate heterogeneity. Treatment rankings were generated using the surface under the cumulative ranking (SUCRA) curve, and evidence certainty was assessed with the Confidence in Network Meta-Analysis framework. Nineteen randomized controlled trials with a total of 2937 patients met the inclusion criteria. In our network meta-analysis, CCRT + CT showed the most significant benefit for overall survival (hazard ratios [HR], 0.46; 95% CI, 0.28-0.71; SUCRA 95%, high-certainty evidence), followed by SCRT (1.59; 95% CI, 1.04-2.33; SUCRA 65%, high-certainty evidence) and CCRT alone (HR, 0.71; 95% CI, 0.5-0.95; SUCRA 48%, moderate-certainty evidence). For disease-free survival, CCRT + CT again showed a significant advantage over RT (HR, 0.48; 95% CI, 0.23-0.91; SUCRA 88%, low-certainty evidence). In recurrence analysis, CCRT + CT demonstrated the most substantial reduction in relative risk (RR, 0.45; 95% CI, 0.15-0.83; 85%), followed by CCRT (RR, 0.59; 95% CI, 0.24-0.97; SUCRA 68%) and SCRT (RR, 1.17; 95% CI, 1.01-3.28; SUCRA 40%). No statistically significant differences were observed for distant recurrence or metastasis among the therapies; however, SUCRA rankings indicated that CCRT + CT and CCRT might offer some benefit in reducing these outcomes. For adverse events-specifically myelosuppression, proctitis, cystitis, and nausea/vomiting-no significant differences in risk were observed across therapies. However, SUCRA rankings favored RT as the most favorable option for minimizing these events. This study provides a comprehensive assessment of PATs for early-stage cervical cancer. Among the evaluated options, CCRT + CT showed the most promising trend toward improving overall and disease-free survival and reducing recurrence, particularly in patients with high-risk features. However, further high-quality studies are needed to confirm these findings and guide treatment decisions for specific subgroups.