To develop and evaluate a fast, automated multi-criterial treatment planning approach for adaptive high-dose-rate (HDR) intracavitary + interstitial brachytherapy (BT) for locally advanced cervical cancer. Methods and materials: Twenty-two previously delivered single fraction MRI-based HDR treatment plans (SF clin ) were used to guide training of our in-house system for multi-criterial autoplanning, aiming for an autoplan quality superior to the training plans, while respecting the clinically desired ''pear-shaped" dose distribution. Next, the configured algorithm was used to automatically generate treatment plans for 63 other fractions (SF auto ). The SF auto plans were compared to the corresponding SF clin plans in blind pairwise comparisons by an expert clinician. Then, the effect of adaptive autoplanning on total treatment (TT) plans (external beam + 3 BT fractions) was evaluated for 16 patients by simulating the clinically applied adaptive strategy to generate TT auto plans and compare them with the corresponding clinical treatments (TT clin ). Results: In the blind comparisons, all SF auto plans were considered clinically acceptable. In 62/63 comparisons, SF auto plans were considered at least as good as, or better than the corresponding SF clin . The average optimization time for autoplanning was 20.5 ± 19.2 s (range 4.4-106.4 s) per plan. In 14 of 16 TT auto plans, the desired total dose of 90 Gy (EQD 2 ) was obtained, compared to only 9 in the corresponding TT clin , while autoplanning also decreased bladder and rectum doses. Conclusions: Fast, fully-automated multi-criterial treatment planning for adaptive HDR-BT for locally advanced cervical cancer is feasible. Autoplans were superior to corresponding clinical plans.

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