Outcomes of patients with cervical cancer treated with low- or high-dose rate brachytherapy after concurrent chemoradiation

Abstract

ObjectiveThe majority of patients with cervical cancer in Ghana present with locally advanced disease. In October 2014, high-dose rate (HDR) brachytherapy was introduced at the National Center for Radiotherapy, Accra after years of using low-dose rate (LDR) brachytherapy. The aim of this study was to compare the treatment outcomes of patients treated with LDR versus HDR brachytherapy.MethodsPatients with cervical cancer treated from January 2008 to December 2017 were reviewed. Those with stage IB–IIIB who received chemoradiation plus brachytherapy were included in the study. Post-operative patients and those with stage IV were excluded. The study end points were local control, disease-free survival, and overall survival at 2 years. Endpoints were estimated using the Kaplan–Meier method. Comparisons between treatment groups were performed using the log-rank test and Cox proportional hazards model.ResultsWe included 284 LDR and 136 HDR brachytherapy patients. For stages IB, IIA, IIB, IIIA and IIIB disease, the 2-year local control for LDR versus HDR brachytherapy was 63% and 61% (p=0.35), 86% and 90% (p=0.68), 86% and 88% (p=0.83), 66% and 60% (p=0.56), and 77% and 40% (p=0.005), respectively. The 2-year disease-free survival for LDR versus HDR brachytherapy was 64% and 61% (p=0.50), 81% and 69% (p=0.18), 81% and 80% (p=0.54), 62% and 33% (p=0.82), and 71% and 30% (p=0.001) for stages IB, IIA, IIB, IIIA, and IIIB, respectively. The 2-year overall survival for LDR versus HDR brachytherapy was 94% and 93% (p=0.92), 98% and 68% (p=0.21), 89% and 88% (p=0.60), and 88% and 82% (p=0.34) for stages IB, IIA, IIB, and IIIB disease, respectively.ConclusionThere was no difference between LDR and HDR brachytherapy in local control and disease-free survival for all stages of disease, except in stage IIIB. These findings highlight the need to refine this brachytherapy technique for this group of patients.

Brachytherapy infrastructure in sub-Saharan Africa and quest for cervical cancer elimination

“…Throughout the continent, in recent years, there has been a continuous movement from LDR to HDR brachytherapy delivery. Currently, in numerous nations, including Nigeria, Ghana, Zimbabwe, and Botswana [15][16][17], HDR afterloaders are used (Table 2). Although there is no evidence to suggest that LDL and HDL techniques have any impact on clinical outcomes [18], HDR has the advantage of reducing staff's and patient's radiation exposure and can treat more patients each week than LDR [19].…”

“…On the other hand, the HDR sources (iridium-192 has a half-life of 74 days, and cobalt-60 has a half-life of 5.3 years) have a shorter half-life, and hence require regular replacement. This presents significant logistical and regulatory issues for countries, which use these radioisotopes [15][16][17][18][19][20][21][22][23][24][25].…”

Building a sustainable future: Closing the gap in radiotherapy and brachytherapy resources to achieve the sustainable development agenda 2030 goals for cervical cancer control in Africa

“…In recent times, there has been a steady transition from delivering LDR brachytherapy to HDR across the continent. HDR afterloaders are actively operational in many countries, such as Botswana, Zimbabwe, Ghana and Nigeria (Clayman, 2015; Hegazy et al, 2021; Scott et al, 2021). Despite the lack of evidence indicating any difference between HDL and LDL procedures in terms of clinical outcomes (Chibonda et al, 2021), HDR offers the benefit of decreasing the rate at which patients, as well as staff, are being exposed to radiation and can serve more patients per weekly than LDR (Hegazy et al, 2021).…”

Gynecological radiation oncology in sub-Saharan Africa: status, problems and considerations for the future

“…In fact, it must look to increasing its high dose rate brachytherapy capacity to meet the ambitious 90-70-90 target of the WHO cervical cancer elimination agenda, which looks at ensuring 90% of eligible girls are vaccinated against human papilloma virus, 70% of eligible women are screened for cervical cancer with a high performance test and 90% of women with invasive cervical cancer have access to quality treatment and palliative care services 19. Although the equivalence of low dose rate and high dose rate for cervical cancer treatment has been validated, the volume of patients in sub-Saharan Africa makes a high dose rate a more prudent choice 20…”

“…19 Although the equivalence of low dose rate and high dose rate for cervical cancer treatment has been validated, the volume of patients in sub-Saharan Africa makes a high dose rate a more prudent choice. 20 Indeed, in a well implemented system, high dose rate brachytherapy can result in an even bigger benefit due to reduced occupancy time of external beam machines providing capacity for other sites such as prostate and penile cancers. A recent policy brief reports only one additional country in sub-Saharan Africa has gained brachytherapy access and 33 countries remain without this service.…”