Standard Chemoradiation and Conventional Brachytherapy for Locally Advanced Cervical Cancer: Is It Still Applicable in the Era of Magnetic Resonance–Based Brachytherapy?

Abstract

PurposeRecent guidelines recommend magnetic resonance imaging–based brachytherapy (MRBT) for locally advanced cervical cancer. However, its implementation is challenging within the developing world. This article reports the outcomes of patients with locally advanced cervical cancer treated with chemoradiation and point A–based brachytherapy (BT) using x-ray– or computed tomography–based planning.MethodsPatients treated between January 2014 and December 2015 were included. Patients underwent x-ray– or computed tomography–based BT planning with an aim to deliver equivalent doses in 2 Gy (EQD2) > 84 Gy10 to point A while minimizing maximum dose received by rectum or bladder to a point or 2 cc volume to < 75 Gy EQD2 and < 90 Gy EQD2, respectively. The impact of known prognostic factors was evaluated.ResultsA total of 339 patients were evaluated. Median age was 52 (32 to 81) years; 52% of patients had stage IB2 to IIB and 48% had stage III to IVA disease. There was 85% compliance with chemoradiation, and 87% of patients received four or more cycles. Median point A dose was 84 (64.8 to 89.7) Gy. The median rectal and bladder doses were 73.5 (69.6 to 78.4) Gy3 and 83 (73.2 to 90.0) Gy3, respectively. At a median follow-up of 28 (4 to 45) months, the 3-year local, disease-free, and overall survival for stage IB to IIB disease was 94.1%, 83.3%, and 82.7%, respectively. The corresponding rates for stage III to IVA were 85.1%, 60.7%, and 69.6%. Grade III to IV proctitis and cystitis were observed in 4.7% and 0% of patients, respectively.ConclusionThis audit demonstrates good 3-year outcomes that are comparable to published MRBT series. Conventional BT with selective use of interstitial needles and MRBT should continue as standard procedures until level-I evidence for MRBT becomes available.

External Radiation and Brachytherapy Resource Deficit for Cervical Cancer in India: Call to Action for Treatment of All

“…A rate of RT use of 85% was estimated based on available data on incidence of cervical cancer according to stage. 7,8 External radiation fractions needed were calculated on the basis of 25 common fraction schedules as follows: total number of fractions needed for each state = cervical cancers in the state × 0.85 × 25. Presuming that patients with LACC will need four fractions of BT, the overall BT fractions needed were estimated as: cervical cancer cases in state × 0.85 × 4.…”

“…Because most women with cervical cancer in India (as well as in other low-income countries) present with locally advanced–stage disease, the overall need (in both adjuvant and definitive settings) is expected to be as high as 85% to 90%. 7,8,11,12 However, it is unclear if all women with cervical cancer have access to external-beam radiotherapy (EBRT; also known as teletherapy) or BT. A recent analysis reported that overall, only 35% to 40% of patients in India might have access to RT; however, no specific details are available for cervical cancer.…”

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

“…Radiation therapy including brachytherapy forms an indispensable part of the curative management of LACC [9]. Even in FIGO stage IIIB-IVA, local control outside the setting of a clinical trial can be as high as 85% [10], which is unprecedented in locally advanced squamous carcinomas originating at other sites. However, there are several challenges in achieving this, especially in LMICs, including India, in terms of resources, logistics and expertise.…”

Global Collaborations for Cervical Cancer: Can the East–West Alliance Facilitate Treatment for all?

“…Poor compliance and enhanced acute toxicity are reported in patients from a rural and underprivileged background in LMICs [34]. Audits from developing countries report 42e85% compliance to planned chemoradiation schedules, with a substantial majority of patients receiving less than five cycles of concurrent chemotherapy [29,35,36]. The coexistence of HIV infection within high incidence regions is also associated with reduced odds of receiving concurrent chemotherapy.…”

“…Institutions within LMICs/LICs that have access to brachytherapy infrastructure report waiting lists, with treatment times extending beyond 8 weeks. High volume centres often carry out four to eight brachytherapy procedures per day, making it challenging to carry out state of the art MRI-guided brachytherapy for all-comers [35]. Cost-effective and time-efficient alternatives to MRI brachytherapy include the use of ultrasound and computed tomography for target delineation [52e58].…”