International Western Radiation Therapy Guidelines Applicability in Low- and Middle-Income Countries for Cervical Cancer Management: A Comparative Survey Example from South and North Border of the Mediterranean Area Countries.

Purpose: This comparative study evaluates the applicability of international radiation therapy guidelines in the management of cervical cancer between high-income countries and low- and middle-income countries (LMICs). Understanding differences in clinical practice is essential to identify gaps and areas for improvement in LMICs. Methods and Materials: A cross-sectional survey was conducted using an online questionnaire distributed among specialists involved in cervical cancer care from France (high-income countries) and Morocco (LMIC). Responses from 77 participants (45 from Morocco, 32 from France), predominantly females aged 40 to 49 years, were analyzed to assess diagnostic, therapeutic, and imaging practices. Results: Significant differences were observed between the 2 countries. Human papillomavirus vaccination coverage was low, with 86.8% of respondents reporting that their patients were not vaccinated. Magnetic resonance imaging use before brachytherapy (BCT) was more frequent in France (90%) compared with Morocco (25%). Positron emission tomography-computed tomography for lumbar-aortic staging was widely used in France (97%) versus 59% in Morocco.Therapeutic approaches for the International Federation of Gynecology and Obstetrics stages IB1 and IB2 varied, with Morocco favoring preoperative BCT more often (34% vs 16%). Image-guided brachytherapy was systematically used in both countries, but combined intracavitary and interstitial applications were more frequent in France (64% vs 9%). In Morocco, dosimetric outcomes were generally satisfactory, with a D90 dose to the high-risk clinical target volume >85 Gy achieved in 78% of cases, supported by volumetric modulated arc therapy and computed tomography-based planning. Conclusions: Our findings highlight the ability of Moroccan teams to adapt their practice to most Western guidelines for cervical cancer, despite resource limitations. However, there is a crucial need for infrastructure development and continuous training to support long-term harmonization of clinical practice. Significant efforts are also required to improve human papillomavirus vaccination coverage, enhance access to magnetic resonance imaging and positron emission tomography-computed tomography, and optimize the use of high-dose-rate BCT.