November 09, 2016
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Brachytherapy underused in treatment of locally advanced cervical cancer

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Only 44% of women with locally advanced cervical cancer received the standard-of-care treatment with radiation, chemotherapy and brachytherapy, according to results of a National Cancer Data Base analysis.

Women who received all three treatments lived longer than those given any combination of two components, yet less than half of patients studied underwent brachytherapy with external beam radiation therapy (EBRT). Further, black women and those with low socioeconomic status were less likely to receive the standard of care.

Christine Fisher

“A lot of this has to do with the fact that brachytherapy requires equipment and expertise,” Christine Fisher, MD, MPH, radiation oncologist at University of Colorado Cancer Center, said in a press release. “And there’s no substitute for it. We see some patients whose care is managed in less specialized settings coming to University of Colorado just for the brachytherapy component of their treatments. Others simply miss out on this important piece of their care. Unfortunately, not all women have access to a center that offers this technique.”

Standard of care for locally advanced cervical cancer includes pelvic EBRT with chemotherapy and interdigitated brachytherapy, a procedure in which radioactive implants are inserted into the body in or near a tumor. Previous research showed brachytherapy confers superior survival rates over EBRT alone, and that brachytherapy boost improves outcomes compared with intensity-modulated radiation therapy.

Researchers used the National Cancer Data Base to identify 15,194 women with locally advanced cervical cancer treated with definitive radiation or chemoradiation therapy.

In total, only 44.3% of patients received the full standard-of-care therapy.

Median OS was significantly longer among patients who received brachytherapy compared with patients treated with EBRT alone (93.04 months vs. 32.95 months; P < .001). Patients who received an ERBT–only boost had longer median OS than women who received no radiotherapy boost at all (47.05 months vs. 27.63 months; P < .001); however, both these groups had shorter survival than women who received brachytherapy.

When stratified by chemotherapy use, median OS was 20.34 months among women who received EBRT alone, 43.74 months among women who received EBRT with concurrent chemotherapy, 56.18 months among women who received EBRT with brachytherapy, and 105.23 months among women who received all three treatment modalities, or the standard of care.

Results of a multivariate analysis showed that, compared with women who received EBRT alone, survival improved among women who received standard-of-care treatment (HR = 0.43; 95% CI, 0.4-0.46), EBRT with chemotherapy (HR = 0.66; 95% CI, 0.62-0.71) and EBRT with brachytherapy (HR = 0.57; 95% CI, 0.55-0.62).

Further, patients who received an EBRT–only boost (HR = 0.72; 95% CI, 0.67-0.76) or brachytherapy boost (HR = 0.55; 95% CI, 0.52-0.58) had reduced mortality risk compared with patients who did not receive a radiotherapy boost.

Standard-of-care therapy was more common among patients who were younger; had a lower Charlson/Deyo combined comorbidity score; were treated at high-volume centers, academic centers or comprehensive community cancer centers; had private insurance; and had higher income.

Receipt of radiation boost was less common among patients who were older, had a higher Charlson/Deyo combined comorbidity score, had a lower income, had Medicaid, or were treated at noncomprehensive community cancer centers and low-volume centers.

Fisher and colleagues noted it was “alarming” that about 25% of all treated patients in their cohort received no radiotherapy boost at all.

“We have a couple take-home messages,” Fisher said. “First is that virtually all of these cervical cancers are preventable with vaccination against the HPV virus by screening, which can catch the precursors of cervical cancer before the development of the disease itself. By far, the best solution is prevention.

“Then, if a woman does develop cervical cancer, she should look for a center that offers brachytherapy,” Fisher added. “It’s critically important.” – by Chuck Gormley

Disclosure: Fisher and colleagues report no relevant financial disclosures.