Radiotherapy for Cervical Cancer: Technical Advances, Clinical Applications, and Future Perspectives

Radiotherapy is an essential treatment modality for cervical cancer and has evolved substantially with advances in image guidance and treatment delivery. This review summarizes recent technological developments in external beam radiotherapy and brachytherapy, their clinical applications, and future directions, with particular consideration of Japanese practice in an international context. In external beam radiotherapy, conventional techniques incorporating central shielding are increasingly being replaced by intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT). Daily three-dimensional image-guided radiotherapy (3D-IGRT) is essential for the safe implementation of these techniques because of substantial uterine motion and deformation. In brachytherapy, the transition from two-dimensional point-based prescription to three-dimensional image-guided treatment has enabled individualized assessment of target coverage and doses to organs at risk. Although magnetic resonance imaging-based brachytherapy is internationally recommended, computed tomography-based planning predominates in Japan and has achieved favorable outcomes, despite some studies reporting lower cumulative target doses than those recommended internationally. Intracavitary/interstitial brachytherapy (IC/IS BT) further improves dose distribution by combining intracavitary applicators with interstitial needles, particularly when adequate target coverage cannot be achieved with standard intracavitary brachytherapy alone. Future advances may include artificial intelligence (AI)-assisted treatment planning and adaptive workflows, tissue spacers to overcome anatomical constraints, and the incorporation of genomic, multi-omics, and radiomics information. Integrating these approaches may enable cervical cancer radiotherapy to progress beyond increasingly safe and precise treatment toward personalized care tailored to individual patient and tumor characteristics.