significantly improved survival among women with locally advanced cervical cancer. Additional randomized trials comparing radiation alone to various chemotherapy regimens have demonstrated an approximate 10% improvement in survival with the addition of cisplatin weekly at 40 mg/m2 . The standard approach in the USA is 45 Gy to the whole pelvis, HDRBT at 5 to 5.5 Gy per fraction in five fractions, and weekly chemotherapy consisting of cisplatin. Unless there is obvious lymphadenopathy in the common iliac or para-aortic lymph nodes, external radiation fields target the whole pelvic region (see recent IAEA guidelines on the treatment of cervical cancer [2.24]). Lack of benefit for concomitant chemotherapy has been found in two studies conducted in India and Uganda [2.25, 2.26]. 38 2.8.1. Endometrium — PORTEC 2 The investigators carried out a multicentre prospective randomized trial to determine whether post-operative pelvic radiotherapy improves locoregional control and survival for patients with stage I endometrial carcinoma [2.27]. Patients with stage I endometrial carcinoma (grade 1 with deep (≥50%) myometrial invasion, grade 2 with any invasion, or grade 3 with superficial (< 0.001). Actuarial five year overall survival rates were similar in the two groups: 81% (radiotherapy) and 85% (controls) (p = 0.31). Endometrial cancer related death rates were 9% in the radiotherapy group and 6% in the control group (p = 0.37). Treatment related complications occurred in 25% of radiotherapy patients, and in 6% of the controls (p < 0.000 1). Two thirds of the complications were grade 1. Grade 3–4 complications were seen in eight patients, of whom seven were in the radiotherapy group (2%). Two year survival after vaginal recurrence was 79%, in contrast to 21% after pelvic recurrence or distant metastases. Survival after relapse was significantly better (p = 0.02) for patients in the control group. Multivariate analysis showed that for locoregional recurrence, radiotherapy and age below 60 years were significant favourable prognostic factors. Post-operative radiotherapy in stage I endometrial carcinoma reduces locoregional recurrence, but has no impact on overall survival. Radiotherapy increases treatment related morbidity. Post-operative radiotherapy is not indicated in patients with stage I endometrial carcinoma below 60 years of age and in patients with grade 2 tumours with superficial invasion. The role of vaginal cuff brachytherapy was also investigated in the PORTEC-2 study [2.28, 2.29]. This trial randomized patients with ‘high intermediate risk’ endometrial cancer to receive either pelvic external beam or vaginal cuff brachytherapy irradiation following hysterectomy. Patients eligible for this study were: (1) patients whose age was greater than 60 years with grade 1 or 2 disease invading the outer half of the myometrium, or grade 3 invading the inner half of the myometrium; or (2) patients of any age with endocervical gland involvement (apart from grade 3 with greater than 50% myometrial invasion). 39 There was no significant difference in the vaginal recurrence rate between the two arms (1.8% versus 1.6%, p = 0.74). The five year pelvic relapse rate was 3.8% in the vaginal cuff brachytherapy arm and 0.5% in the pelvic radiotherapy arm (p = 0.02). Patients with deeply invasive grade 3 disease were not eligible for this study. Central pathology review, performed after enrolment, demonstrated that the vast majority of patients (79%) had grade 1 disease. These results support the use of vaginal cuff brachytherapy in patients with intermediate risk presentations such as deeply invasive grade 1 disease. However, PORTEC-2 included very few patients with deeply invasive grade 2 disease and none with deeply invasive grade 3 disease, so this study does not provide support for vaginal cuff brachytherapy in the place of pelvic irradiation in these specific subgroups of patients. Vaginal cuff brachytherapy is as effective as pelvic radiotherapy for patients with intermediate risk factors, such as deeply invasive grade 1 tumours. Patients with multiple risk factors, including age, deep invasion, high grade, and lymphovascular space invasion, may be better treated with external beam