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manageable rates of vulvar cutaneous toxicity.

Adjuvant chemoradiation: only one study256 enrolling at least 50 patients was identified. As part of a LoE 2-
large population-base analysis, Gill et al.256 evaluated adjuvant chemotherapy for node-positive
vulvar cancer patients who received adjuvant radiotherapy. All patients (N = 1,797) received
external beam radiotherapy as their radiotherapy treatment modality. Radiation modality was
available for 35.7% of patients. For those with modality captured, intensity-modulated radiotherapy
was utilized in 6.5%. Median radiotherapy dose was 54 Gy. Median radiation length and time to
chemotherapy initiation were 44 days and 76 days, respectively. Of patients receiving chemotherapy,
78.5% started chemotherapy within 7 days of the start of radiotherapy.

After a median follow-up of 28.3 months, the unadjusted median survival without (N = 1,324) and
with adjuvant chemotherapy (N = 473) was 29.7 months and 44 months (p = 0.001), respectively. On
multivariate analysis, delivery of adjuvant chemotherapy resulted in a trend towards reduction in the
risk of death among patients who received adjuvant radiotherapy (HR = 0.81, 95% CI = 0.65-1.01, p
= 0.059). On regression modeling with an adjustment using propensity score with IPTW, Gill et
al.256 reported a statistically significant reduction in the risk of death for patients who received
adjuvant chemotherapy (HRIPTW = 0.62, 95% CI = 0.48-0.79, p < 0.001).

Results from the 4 other identified studies225,230,231,236 are limited notably by the very small number of LoE 3
patients evaluated. No study has accrued in excess of 10 patients (Table 12).

12.2 Previous initiatives

Seven previous initiatives1,2,4,37-39,87 presenting guidelines on chemoradiation were identified.

12.3 Development group comments

None.

12.4 Guidelines

C Definitive chemoradiation (with radiation dose escalation) is the treatment of choice in patients with
unresectable disease.

C In advanced stage disease neoadjuvant chemoradiation should be considered in order to avoid
exenterative surgery.

C Radiosensitising chemotherapy, preferably with weekly cisplatin, is recommended.

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