Gynecologic cancers include uterine, cervical, ovarian, vulvar, vaginal, and fallopian tube malignancies, classified based on tumor location. These cancers represent key causes of morbidity and mortality worldwide (1). The incidence and survival rates of gynecologic cancers, whether considered collectively or individually, vary according to geographic region and a country’s level of development (2). Türkiye, an upper-middle-income country in the Europe and Central Asia region, has a very high human development index (HDI) (3). Studies of gynecologic cancers in Türkiye have indicated that survival rates are comparable to those in developed countries (4, 5).

The gynecologic oncology tumor board plays a critical role in the management of gynecologic cancers; radiation oncology is one of its key disciplines (6). There is evidence that timely treatment at fully equipped oncology centers, where multidisciplinary treatment plans are implemented, improves prognosis and reduces mortality associated with gynecologic cancers (4). Our university hospital, a tertiary cancer referral center, provides multidisciplinary care for gynecologic cancer patients from the Black Sea Region of Türkiye.

Considerable advancements have been made in gynecologic radiation oncology, particularly in radiotherapy (RT) planning and delivery techniques for both external beam radiotherapy (EBRT) and brachytherapy (BRA). RT can be administered at all stages of disease, including curative treatment for localized, regional, and oligometastatic cases, as well as palliative treatment for polymetastatic disease. Therefore, RT remains an integral component of multimodal treatment approaches for gynecologic cancers (1).

Although institutional reports on individual gynecologic cancers exist, there is a scarcity of studies that collectively analyze all gynecologic malignancies from a radiation oncology perspective, especially in settings with high brachytherapy utilization. This study aims to fill that gap by providing a holistic view of patient profiles, treatment patterns, and outcomes across all gynecologic cancer types treated in a tertiary radiotherapy center. To address this gap, a retrospective analysis was conducted involving gynecologic cancer patients who presented to our radiation oncology department from the Black Sea Region of Türkiye. This study is expected to serve as a valuable reference for Türkiye, the surrounding region, and other countries with a high or very high HDI.

In total, 11,720 cancer patients were evaluated for RT over a 10-year period. Of these, 41% (n = 4,781) were women. Among female patients, gynecologic cancers comprised 30% of cases (n = 1,450), making them the second most common malignancy after breast cancer, which comprised 35% of cases (n = 1,669) (Figure 1). Among all cancers diagnosed in women (n = 4,781), corpus uteri cancer was the most common gynecologic malignancy, representing 20% (n = 944) of cases, followed by cervical cancer (9%, n = 429), ovarian cancer (<1%, n = 33), vulvar cancer (<1%, n = 26), and vaginal cancer (<1%, n = 18). When considering only gynecologic cancers (n = 1,450), these malignancies constituted 65%, 30%, 2%, 2%, and 1% of cases, respectively (Figure 2).

After breast cancer, gynecologic cancers are the second most common group of malignancies in women: they constitute 11% of all cancers in women in Türkiye and 15% worldwide (2, 5). According to a study conducted by the Turkish Republic Ministry of Health, the three most prevalent gynecologic cancers among all female malignancies were corpus uteri cancer (ranked fourth overall), ovarian cancer (ranked sixth overall), and cervical cancer (ranked tenth overall) (7). The incidence of cervical cancer in Türkiye is particularly low; however, a comprehensive oncology center in Türkiye reported that cervical cancer was the second most common gynecologic malignancy after corpus uteri cancer (5). Their study also indicated that gynecologic cancers are the second most frequently diagnosed group of cancers in women after breast cancer (23%); corpus uteri cancer ranks fifth overall, cervical cancer ranks eighth, and ovarian cancer ranks ninth. According to GLOBOCAN 2022, the global ranking of gynecologic cancers differs, with cervical cancer ranking fourth overall, corpus uteri cancer ranking sixth, and ovarian cancer ranking eighth (8). In high or very high HDI countries, including Türkiye, corpus uteri cancer is the most frequently diagnosed gynecologic malignancy, whereas cervical cancer is predominant in low or medium HDI countries (9). In our radiation oncology practice, gynecologic cancers were the second most frequently treated malignancies after breast cancer, occurring 2.0–2.7 times more frequently compared with reports from other sources. The two most common gynecologic cancers were corpus uteri cancer (ranked second overall, occurring 3.3–4.6 times more frequently) and followed by cervical cancer (ranked third overall, occurring 1.3–1.8 times more frequently) (Figure 3). It should be noted that our cohort represents a selected referral population to a tertiary radiotherapy center and is not population-based. Therefore, direct comparisons with national or international registry data should be interpreted with caution, as differences may reflect referral patterns, clinical selection, and institutional expertise rather than true epidemiological variation.

The incidence of corpus uteri cancer has been increasing, particularly in high or very high HDI countries, including Türkiye. In these regions, as observed in our study, the most frequently diagnosed age group, FIGO stage, and SEER stage at presentation were 50–59 years, stage I, and localized stage, respectively (1, 4, 7). The standard first-line treatment for corpus uteri cancer is surgery; adjuvant therapy, including RT and/or chemotherapy, is administered based on disease stage and risk factors for recurrence (1, 10, 11). In our radiation oncology practice, 82% of operable patients with corpus uteri cancer underwent adjuvant RT, and 87% of those with endometrial carcinoma required BRA. Relapse rates for endometrial carcinoma range from 15% to 20% (12), whereas for uterine sarcoma are reportedly between 53% and 71% (13). In our study, relapse occurred in 15% of endometrial carcinoma cases and 50% of uterine sarcoma cases; distant metastases were the most common pattern of relapse for both, consistent with the literature. Studies from high or very high HDI countries (9) have revealed 5-year OS rates of up to 88.1% for endometrial carcinoma (14) and 74.0% for uterine sarcoma (15). In our study, the corresponding 5-year OS rates were 88.1% and 70.0%, respectively.

The incidence of cervical cancer has declined in developed countries (16). In regions with high or very high HDI, including Türkiye, the most commonly diagnosed age group, FIGO stage, and SEER stage at presentation were 40–49 years, stage I, and localized stage, respectively (4, 7, 17). However, in our radiation oncology practice, patients presented approximately one decade later and at more advanced stages compared with cohort analyses. For early-stage disease (FIGO IA–IB2), surgery is the standard first-line treatment; adjuvant therapy is administered based on stage and risk factors for recurrence. For advanced stages (FIGO IB3–IVA), radical RT remains the standard treatment (16). In our practice, most cervical cancer patients treated with curative intent were inoperable (62%) and received EBRT combined with BRA (91%). Relapse rates in cervical cancer ranges from 20% to 40% (18–20); in our study, relapse occurred in 28% of cases (most commonly as distant metastases), consistent with the literature. Studies have demonstrated 5-year OS rates for cervical cancer ranging from 56.8% to 76.5% in countries with high or very high HDI (9, 21). In our study, the 5-year OS rate was 76.3%.

Ovarian cancer is the most lethal gynecologic malignancy (4). In high- and very high-HDI countries, including Türkiye, the most commonly diagnosed age group, FIGO stage, and SEER stage at presentation were 50–59 years, stage III (26%), and distant stage (39–59%), respectively (4, 7, 22). Although our findings regarding age and SEER stage were consistent with these cohort analyses, we observed a higher frequency of FIGO stage IV disease, and that FIGO IV and SEER distant-stage cases occurred at substantially higher rates (26% vs. 93% and 59% vs. 93%, respectively). Surgery is the primary treatment for ovarian cancer, and chemotherapy serves as a key neoadjuvant and/or adjuvant therapy in the presence of adverse prognostic factors (23). RT is primarily used for palliative purposes in polymetastatic, symptomatic patients (85% in our study) and less frequently as a curative option with stereotactic irradiation techniques for oligorecurrent or oligometastatic disease (24). The relapse rate after first-line treatment is high, such that locoregional relapse occurs in up to 80% of cases (25, 26), consistent with findings in our curatively treated patients. Studies have shown 5-year OS rates for ovarian cancer ranging from 29.7% to 64.0% in high- and very high-HDI countries (9). In our study, the 5-year OS rate was 29.6%, which declined sixfold to 4.9% after RT. Unfortunately, studies indicate that survival outcomes are worse in ovarian cancer patients requiring RT (27).

Vulvar cancer comprises 5–8% of all gynecologic cancers, although it constituted only 2% of cases in our study. Its incidence has been increasing (28). In high- and very high-HDI countries, the most commonly diagnosed age group, FIGO stage, and SEER stage at presentation were ≥70 years, stage I, and localized stage, respectively (29, 30), consistent with our findings. Surgery is the standard first-line treatment; RT is administered as neoadjuvant or definitive therapy for inoperable patients, adjuvant therapy for high-risk cases, or palliative treatment for metastatic disease (31). In our radiation oncology practice, curative RT was delivered to 92% of vulvar cancer patients using EBRT alone, with half receiving definitive and the other half receiving adjuvant treatment. Relapse rates for vulvar cancer range from 22% to 61% (32, 33); in our study relapse occurred in 65% of cases (most commonly as locoregional disease), consistent with literature. The 2-year OS rate for vulvar cancer in high- and very high-HDI countries is reportedly between 47.2% and 72.0% (34, 35); the 2-year OS rate was 65.0% in our study.

Vaginal cancer is the rarest gynecologic malignancy (31). Primary vaginal cancer comprises approximately 10% of all vaginal cancers, corresponding to 1–2% of all gynecologic cancers (36). In high- and very high-HDI countries, it is most commonly diagnosed in individuals over 60 years of age (70%) and in FIGO stage I–II disease (67–74%) (31, 37). In our radiation oncology practice, although the frequency of primary vaginal cancer (1%) and age distribution (≥ 60 years, 71%) were consistent with these cohort analyses, a higher percentage of advanced FIGO stage disease (50%) was observed. Due to its rarity, management strategies for vaginal cancer are primarily based on a limited number of retrospective studies and extrapolated from cervical cancer treatment protocols. The standard first-line treatment for primary vaginal cancer is RT, typically involving EBRT with or without concurrent chemotherapy, followed by BRA. However, select early-stage cases may be treated with surgery or BRA alone (31, 37). In our practice, the majority of patients (93%) received curative treatment; 62% underwent definitive RT, most commonly EBRT followed by BRA (71%). Relapse rate for vaginal cancer is approximately 30% (38); in our study, relapse occurred in 31% of cases (most commonly as locoregional disease), consistent with literature. Studies have shown 2-year OS rates for vaginal cancer ranging from 62.0% to 91.0% in high- and very high-HDI countries (39), whereas the 2-year OS rate in our study was 57.0%. This lower survival rate can be attributed to the higher percentage of advanced-stage patients treated in our practice.

Palliative RT plays a crucial role in gynecologic cancer management, providing effective and well-tolerated symptom relief, particularly with modern RT techniques. Existing literature regarding palliative RT primarily focuses on specific tumor sites (40, 41), symptom control (42), and RT dose-fractionation schemas (43). However, studies evaluating palliative RT across all gynecologic cancers are extremely limited (44). Therefore, data concerning the most frequently treated primary tumor sites remain scarce. Reports have suggested that uterine corpus cancer is the most common indication for bleeding control, ovarian cancer for central nervous system symptom management, and vaginal cancer for general symptom relief (40, 42, 44). Patients requiring palliative RT frequently present at first diagnosis with advanced FIGO or SEER stage disease, as observed in our study, and RT achieves symptom control rates exceeding 70% (40–42, 44). Among patients undergoing palliative RT for gynecologic cancers, studies have demonstrated 1-year OS rates ranging from 21.0% to 28.0% in high- and very high-HDI countries (43, 44); in our study, the 1-year OS rate was 17.5%. This lower survival rate can be attributed to the high percentage (30%) of patients with brain metastases in our radiation oncology practice.

The main limitations of this study include its retrospective design, its single-center structure, the lack of analysis of potential technological changes during the study period, and the relatively small number of patients with ovarian, vulvar, and vaginal cancer. Survival estimates for ovarian, vulvar, and vaginal cancers due to the small number of cases, should be interpreted with caution, as they may be unstable and influenced by individual patient characteristics. Additionally, data regarding quality of life and treatment-related toxicities, which are critical factors when evaluating treatment outcomes, were unavailable.

To our knowledge, this is the first study to comprehensively analyze the characteristics and survival outcomes of all gynecologic cancers in a radiation oncology practice. Our findings indicated that gynecologic cancers are the second most common malignancies among women in radiation oncology practice, after breast cancer. Corpus uteri and cervical cancers ranked higher in our radiation oncology center compared with reports from the International Agency for Research on Cancer, the National Cancer Registry Center, and comprehensive oncology center. Additionally, we observed that, except for ovarian cancer, most gynecologic cancers were referred for treatment at FIGO stages I–II. The most frequently performed RT technique was a combination of EBRT and BRA, with an overall BRA application rate of 82% in gynecologic radiation oncology. Furthermore, adjuvant RT was administered in 75% of cases. Given that our relapse and survival outcomes closely align with data from high- and very high-HDI countries, we believe that our findings broadly will reflect similar healthcare settings.