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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Study flow diagram.
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Figure 2

Study flow diagram.

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Comparison 1 Neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone, Outcome 1 Overall survival.
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Analysis 1.1

Comparison 1 Neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone, Outcome 1 Overall survival.

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Comparison 1 Neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone, Outcome 2 Disease or progression‐free survival.
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Analysis 1.2

Comparison 1 Neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone, Outcome 2 Disease or progression‐free survival.

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Neoadjuvant chemotherapy and radical hysterectomy compared with radiotherapy alone for women with locally advanced cervical cancer

Patient or population: Women with locally advanced cervical cancer

Settings: Outpatient

Intervention: Neoadjuvant chemotherapy and radical hysterectomy

Comparison: Radiotherapy alone

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Overall survival

Median follow‐up ranged from 39 to 60 months in the 3 trials

HR 0.71 (0.55 to 0.93)

571
(3 RCTs)

⊕⊕⊕⊝
moderate

Downgraded due to concerns regarding the uncertainty of risk of bias in individual trials

Disease or progression‐free survival

Median follow‐up ranged from 39 to 60 months in the 3 trials

HR 0.75 (0.53 to 1.05)

571
(3 RCTs)

⊕⊕⊕⊝
moderate

Downgraded due to concerns regarding the uncertainty of risk of bias in individual trials and varying definitions of disease and progression‐free survival. Although we did not feel the latter merited a further downgrade to low quality evidence

Severe adverse events and toxicity

Acute severe toxicity: RR 1.32, (0.47 to 3.71)

long‐term severe complications:

RR 0.86 (0.49 to 1.50)

Severe late toxicity: RR 0.60 (0.27 to 1.34)

Acute toxicity

118

(1 RCT)

Long‐term severe complications

409

(1 RCT)

Severe late toxicity:

118

(1 RCT)

⊕⊕⊝⊝
low

Downgraded due to incomplete and poor reporting of important adverse events and toxicities and sparseness of data

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

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Comparison 1. Neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Overall survival Show forest plot

3

571

Hazard Ratio (Random, 95% CI)

0.71 [0.55, 0.93]

2 Disease or progression‐free survival Show forest plot

3

571

Hazard Ratio (Random, 95% CI)

0.75 [0.53, 1.05]
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Comparison 1. Neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone
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