Patterns of cervical cancer brachytherapy in India: results of an online survey supported by the Indian Brachytherapy Society

Abstract

Purpose: Cervical cancer is the most common gynecological cancer in India. Uniform protocol-based treatment is important for achieving optimal outcomes. We undertook a survey to investigate patterns of care with special regard to patterns of care in cervical cancer brachytherapy in India. Material and methods: A 17-question online survey was sent to radiation oncologists across India. Respondents were required to have a minimum of 1-year experience. One response per center was accepted and deemed as representative. Results: Out of 116 centers, 59 responses were generated. Two-thirds (66.1%) were from academic centers and the majority (96.6%) used high-dose-rate (HDR) brachytherapy. The centers treated an average of 255 patients per year (median 161 patients, IQR 76-355). The majority were locally advanced cancers (FIGO 2009 stage II-IV 87.5%). External beam radiotherapy (EBRT) schedules were fairly consistent, administering doses of 45-50 Gy over 5 weeks. Brachytherapy was performed towards EBRT completion by 37/59 (62%) and 43/59 (74.3%) centers used a schedule of 7 Gy × 4 fractions (HDR). Brachytherapy was commonly performed under anesthesia (spinal/general: 44% each) with ultrasound (USG) guidance (29%). Computed tomography (CT) imaging (65%) and orthogonal X-rays (35%) represented the most common imaging for planning, while point A prescription (66%) or GEC-ESTRO based parameters (35%) with manual/geometric methods represented the most common methodology for dose volume prescription and optimization. Overall treatment time (OTT) reported was within 49-56 days in 50%. Complex implants (IC + IS) were performed for more than 30% of cases by 3 centers. Conclusions: Our survey suggested a fairly uniform treatment paradigm for cervical cancer brachytherapy, with a progressive shift from 2D to 3D image-based parameters for planning, with persistence of point A based prescription. Further efforts are needed to augment and ease this transition.

Clinical audit of dose-escalated radical radiotherapy for advanced cervical carcinoma using a pragmatic protocol (3 fractions of 8 Gy HDR brachytherapy)

“…For CT based planning, dose was prescribed at point A and conventional pear shaped 100% isodose surface was graphically optimized for OAR sparing. This practice of ours is also reflected in an online survey by Indian brachytherapy society done on patterns of cervical cancer brachytherapy in India, published in 2019 ( Chatterjee et al, 2019 ). In this survey, CT imaging was used by two third respondents and despite of availability of CT, point A based dose prescription remained the most common form of prescription (66%).…”

The state of gynecologic radiation therapy in low- and middle-income countries

“…Though the use of image-adapted brachytherapy is common in high-income countries, the same has not been the case in Asia. In a survey of practice in South East Asia, it was observed that this approach has not yet been initiated in many countries with CT scanners, and the use of MRI for treatment remains implausible 48 49. In addition, the recent increase in replacement of brachytherapy by external beam radiation therapy techniques due to lack of brachytherapy equipment and training limitations has resulted in inferior outcomes 50 51.…”

A comparison of dosimetric parameters in high-dose-rate intracavitary brachytherapy using tandem and ring applicators: is the combination of a rectal retractor and radio-opaque vaginal packing better than rectal retractor alone for rectum sparing in cervical cancer?

“…Even with the advent of 3-D image-based BT, these points are still relevant, as many centres in low-and middle-income countries are still prescribing doses to point A, and studies comparing absorbed doses at ICRU reference points with CT-based treatment planning show that the ICRU rectal point dose correlates well with D2cc [12][13][14].…”