International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationFive Years' Experience Treating Locally Advanced Cervical Cancer With Concurrent Chemoradiotherapy and High-Dose-Rate Brachytherapy: Results From a Single Institution
Introduction
Cervical cancer is the second most common cause of female cancer death worldwide. The incidence is greatest in developing countries, and the peak incidence is in the 40–45-year age group. Although in the United Kingdom, the incidence has decreased in recent years because of the success of the national screening program to 9/100,000 women, the European Age Standardised Rate 1, 2, 3, 4, cervical cancer is still a significant cause of morbidity and mortality. Until 1999, the main curative treatment option for patients with bulky tumors was radical radiotherapy (RT) using external beam RT and brachytherapy. However, after the publication of five randomized trials 5, 6, 7, 8, 9, a consensus of expert opinion (10), and two meta-analyses 11, 12, the standard treatment has become concurrent cisplatin-based chemotherapy and radical RT.
Worldwide, most experience in brachytherapy for carcinoma of the cervix has been with low-dose-rate (LDR) treatment. Radiation protection issues and machine availability have led to the more widespread use of high-dose-rate (HDR) brachytherapy, but few randomized trials have examined its use. Those that have been published 13, 14, 15, 16, 17, 18, 19 have been examined by the National Institute for Clinical Excellence (NICE) (20), which concluded that the use of HDR brachytherapy for cervical cancer gave overall survival (OS) rates similar to those with medium-dose-rate or LDR brachytherapy when used in combination with external beam RT.
With regard to the use of concurrent chemoradiotherapy and HDR brachytherapy, very few published series have examined its benefits and toxicities, and no standard treatment regimen exists. The present report considered 5 years' experience at the Velindre Cancer Centre, Cardiff, United Kingdom using radical RT and concurrent chemotherapy with cisplatin followed by HDR brachytherapy for primary treatment of Stage IB–IVA cervical cancer, including those with radiologically enlarged pelvic or para-aortic lymph nodes.
Section snippets
Data collection
The Velindre Cancer Centre is a tertiary referral center specializing in nonsurgical oncology treatment. Most referrals are from within the South East Wales Cancer Network. All women treated for cervical cancer at the Velindre Cancer Centre between June 1999 and May 2004 were identified. They were grouped according to treatment, and all those who were treated with primary chemoradiotherapy with cisplatin were included in this data set. For each patient, the case notes were evaluated to collect
Radiotherapy compliance
Of the 92 women, 91 (98.9%) completed the planned external beam RT; 84 (91.3%) completed all the planned RT (external beam RT and brachytherapy). Of the 8 women who did not, 1 patient had missed an external beam fraction receiving only 43.2 Gy but still had all four brachytherapy insertions (EQD2, 74.5 Gy), and 7 had completed the external beam RT but had fewer than four brachytherapy insertions. Of these 7 patients, 4 had three of four brachytherapy insertions (EQD2, 68.25 Gy; 1 patient was
Discussion
The series we have presented has demonstrated that concurrent chemoradiotherapy with cisplatin and HDR brachytherapy is safe and effective. One of the strengths of this study was that it included all patients treated with this regimen; therefore, it represents the results of treatment in the general population. A limitation of the study, because it was retrospective, was that late Grade 1 or 2 toxicity might have been underestimated.
Conclusion
The schedule we have presented is a safe primary treatment for cancer of the uterine cervix in our population. To our knowledge, this regimen has not been previously reported. The pretreatment hemoglobin level, tumor size, and the presence of lymphadenopathy were all independent prognostic factors for OS in our multivariate analysis. The number of brachytherapy insertions was prognostic for LC. The number of chemotherapy treatments was prognostic for metastatic control, supporting the possible
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Conflict of interest: none.