mortality rate in the patients assigned to the high dose radiation arm, it did not seem to be related to the higher radiation dose. The standard radiation dose for patients treated with concurrent 5-FU and cisplatin chemotherapy is 50.4 Gy in 28 fractions of 1.8 Gy. Unfortunately, the local failure rates are still quite high at 50%, justifying the rationale for trimodality therapy (see below). For the palliation of dysphagia caused by oesophageal cancer, 219 patients were randomized to adding EBRT or not, after receiving two fractions of high dose rate brachytherapy (HDRBT) within one week [2.21]. Each HDRBT consisted of 8 Gy prescribed at 1 cm from the source centre. Patients randomized to EBRT received 30 Gy in ten fractions. The primary outcome was dysphagia relief experience (DRE). Additional outcomes included various scores, performance status, weight and adverse events. A majority of charts, imaging and radiotherapy plans were externally audited. Median follow-up was 197 days, with a median overall survival of 188 days and an 18% survival rate at one year. DRE was significantly improved with combined therapy for an absolute benefit of +18% at 200 days from randomization (p = 0.019). In longitudinal regression analyses, scores for dysphagia (p = 0.000 05), odynophagia (p = 0.006), regurgitation (p = 0.000 05), chest pain (p = 0.003 8) and performance status (p = 0.001 5) were all significantly improved. In contrast, weight, toxicities and overall survival were not different between study arms. In conclusion, symptom improvement occurred with the addition of EBRT to standard HDRBT. The combination was well tolerated and relatively safe. In the CROSS (Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study) [2.22] by van Hagen et al., pre-operative neoadjuvant chemotherapy consisting of carboplatin and paclitaxel for five weeks concurrent with radiation of 41.4 Gy in 23 fractions was compared with surgery alone. Three hundred and sixty-six patients (75% adenocarcinomas, 23% squamous cell carcinomas and 2% large cell undifferentiated carcinomas) were enrolled. The trimodality group had a complete resection rate of 92% (R0) compared with 69% in the surgery alone group, with a median survival of 49 months and 24 months, respectively. For medically fit patients who have stage II or III disease, there appears to be a role for pre-operative chemoradiotherapy to maximize regional control and overall survival, as found in the CROSS study. 37 2.8. CERVIX UTERI A randomized trial [2.23] compared the effect of radiotherapy to a pelvic and para-aortic field with that of pelvic radiation and concurrent chemotherapy with 5-FU and cisplatin in women with advanced cervical cancer. Between 1990 and 1997, 403 women with advanced cervical cancer confined to the pelvis (stages IIB through IVA or stage IB or IIA with a tumour diameter of at least 5 cm or involvement of pelvic lymph nodes) were randomly assigned to receive either 45 Gy of radiation to the pelvis and para-aortic lymph nodes or 45 Gy of radiation to the pelvis alone plus two cycles of 5-FU and cisplatin on days 1–5 and days 22–26 of radiation. Patients were then to receive one or two applications of low dose rate intracavitary radiation, with a third cycle of chemotherapy planned for the second intracavitary procedure in the combined therapy group. Of the 403 eligible patients, 193 in each group could be evaluated. The median duration of follow-up was 43 months. Estimated cumulative rates of survival at five years were 73% for patients treated with radiotherapy and chemotherapy and 58% for patients treated with radiotherapy alone (p = 0.004). Cumulative rates of disease free survival at five years were 67% among patients in the combined therapy group and 40% among patients in the radiotherapy group (p < 0.001). The rates of both distant metastases (p < 0.001) and locoregional recurrences (p < 0.001) were significantly higher among patients treated with radiotherapy alone. The seriousness of side effects was similar in the two groups, with a higher rate of reversible haematological effects in the combined therapy group. The addition of chemotherapy with 5-FU and cisplatin to treatment with external beam and intracavitary radiation