Christine Fisher, MD
Fewer than half of women with advanced cervical cancer are receiving all 3 of the treatments that are standard of care (SOC) for the disease: external beam radiation therapy (EBRT), brachytherapy, and chemotherapy, and the presence or absence of brachytherapy was the major difference between patients who did and did not receive SOC, a new study has found.
The research showed that patients who did not receive brachytherapy had a lower chance of survival than those who received all 3 SOC treatments, explained Christine Fisher, MD, a radiation oncologist at the University of Colorado Cancer Center and an investigator on the study.
“Brachytherapy, or internal radiation, is a very, very critical component of the treatment,” said Fisher. “It allows a very high dose of radiation to the tumor, and it is really what allows us to cure these patients, even those who have very large cervical cancers.”
Investigators utilized the National Cancer Database to identify women with locally advanced cervical cancer treated with definitive radiation or chemoradiation therapy, and stratified these patients by treatment received. Of the 15,194 patients included in the study, only 44.3% received SOC treatment, and this group had significantly improved overall survival (OS).
Some patients did receive alternatives to brachytherapy, including 23.8% who received an EBRT boost by itself. Nearly 50% of patients received EBRT with brachytherapy and 26.8% of patients received no radiation boost.
Although an EBRT boost was advantageous over no boost at all (HR, 0.72; P
<.001), OS was superior in patients who received brachytherapy (HR, 0.55; P
“Not having that additional radiation, the brachytherapy, leads to a survival detriment that can not be made up in other ways,” said Fisher. “We really find that some people either get no additional treatment or external beam treatment, and none of those are equivalent to using the internal beam radiation.”
“With image-guided brachytherapy we now have good data, primarily from Europe, telling us that we can improve survival and also reduce complications for these women with brachytherapy,” she added.
The study found that patients were more likely to receive no radiotherapy boost if they had lower incomes or Medicaid. African-American patients were also less likely to receive SOC.
Unfortunately, this is the same group of women who have very poor access to care and are less likely to receive preventive services for cervical cancer in the first place, said Fisher.
A lack of expertise in brachytherapy at non–comprehensive community cancer centers or centers that don’t regularly see many patients with cervical cancer may also be contributing to the problem, said Fisher.
“In terms of thinking about what might be causing this issue, part of it is the comfort level and expertise with brachytherapy as a technique,” said Fisher. “It’s been around for a very long time, but it does require procedural skills and comfort with dosing high levels of radiation. It is very time consuming for physicians, it requires a large team of experts, the correct type of machine, and many smaller radiation centers do not have that available.”
Fisher recommends that physicians who did not feel comfortable or are unable to offer patients brachytherapy should refer their patients to a higher-volume center, preferably a comprehensive cancer center, instead of doing alternative treatment or skipping the treatment entirely. For some patients, it may be easier to receive chemotherapy and external beam radiation closer to home, and then travel to a larger center for brachytherapy.
While improving access to SOC treatment for all patients with cervical cancer is essential, the bigger message is to improve and promote cervical cancer screening and prevention, said Fisher.
“Cervical cancer is nearly 100% preventable,” said Fisher. “The ideal goal would be that we wouldn’t have to put patients through this treatment at all anymore, and that we could really prevent this cancer perfectly through vaccination or—next-best option—through routine screening with pap testing, as well as testing for high-risk HPV DNA. Those are always preferred options to having an invasive cancer, which either requires major surgery or radiation.
Robin TP, Amini A, Schefter TE, et al. Disparities in standard of care treatment and associated survival decrement in patients with locally advanced cervical cancer. Gynecol Oncol