Overview of brachytherapy resources in Latin America: a patterns-of-care survey

Patterns of care for brachytherapy in Japan

This study aimed to assess the current state of brachytherapy (BT) resources, practices and resident education in Japan. A nationwide survey was undertaken encompassing 177 establishments facilitating BT in 2022. Questionnaires were disseminated to each BT center, and feedback through online channels or postal correspondence was obtained. The questionnaire response rate was 90% (159/177), and every prefecture had a response in at least one center. The number of centers in each prefecture ranged from 0.6 to 3.6 (median: 1.3) per million population. The annual number of patients in each center ranged from 0 to 272 (median: 31). While most prefectures provided intracavitary (IC) BT for gynecological cancers and interstitial (IS) BT for prostate cancer, only one-third of the prefectures provided IS BT for cancer sites other than the prostate. The institutional image-guided BT implementation rate was 71%. IC and IS BT was performed for 15.4% of IC BT cases of gynecological cancer. Only 47% of the BT training centers answered that they could provide adequate training in BT for residents. The most common reason for this finding was the insufficient number of patients in each center. The results show that, although BT has achieved uniformity in terms of facility penetration, new technologies are not yet widespread enough. Furthermore, IS BT, which requires advanced skills, is limited to a few BT centers, and considerable number of BT training centers do not have sufficient caseloads to provide the necessary experience for their residents.

Treatment of cervical cancer: overcoming challenges in access to brachytherapy

INTRODUCTION

Brachytherapy is an essential component of the cervical cancer treatment paradigm as it contributes to improved clinical outcomes and overall survival. Yet brachytherapy remains globally underutilized, with disparities in access at both national and international levels.

AREAS COVERED

The review explores current brachytherapy utilization practices and efforts being undertaken to address barriers to implementation in low-, middle-, and high-income countries, and how these efforts are projected to impact future brachytherapy access. The content presented is based on a review of published literature and the authors' collective clinical experiences.

EXPERT OPINION

There exists a tremendous opportunity to expand access to essential brachytherapy services for women with cervical cancer. Many national and international brachytherapy efforts exist; yet it remains imperative that such focused efforts continue to grow and provide further access to this critical treatment modality for women in need worldwide.

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

A disproportionate burden of gynecologic malignancies occurs in low- and middle-income countries. Radiation therapy is an integral component of treatment for gynecologic malignancies both from a curative (locally advanced cervical cancer) and palliative (bleeding cervical or pelvic mass) standpoint. Critical to understanding how better to serve patients in this regard is understanding both the extent of disease epidemiology and the radiotherapy infrastructure to treat these diseases. In this review, we explore various geographic regions and how they address a unique set of challenges specific to the peoples and culture of the region. We identify common threads across regions, including sparse distribution of radiation equipment, geographic access, and specialized training. We also highlight examples of success in the use of telemedicine and cross-cultural partnerships to help bolster access to training to ensure increased access to adequate and appropriate treatment of gynecologic malignancies.

Radiotherapy for cervical cancer: Chilean consensus of the Society of Radiation Oncology

Background

Cervical cancer is a public health problem in Latin America. Radiotherapy plays a fundamental role both as definitive or adjuvant treatment. There are important intra and inter-country differences regarding access and availability of radiotherapy facilities in this region. The aim of a study was to standardize the basic clinical and technical criteria for the radiation treatment of patients with CC in Chile and provide a guide for Latin American Radiation Oncologists.

Materials and methods

Forty-one expert radiation oncologists from the Chilean Radiation Oncology Society made a consensus using the Delphi methodology.

Results

There was a high degree of agreement for each of the recommendations. Those with the lowest percentage were related to the definition of the conformal 3D technique as the standard for definitive external radiotherapy (81%) and the criteria for extended nodal irradiation (85%).

Conclusions

These recommendations present an updated guide for radiotherapy treatment of patients with cervical cancer for Latin America. Those should be implemented according to local resources of each institution.

The Unique Issues With Brachytherapy in Low- and Middle-Income Countries

Gynecologic carcinomas, including cervical cancer, present a significant burden on low- and middle-income countries (LMICs). Brachytherapy plays an integral role in the treatment of gynecologic carcinomas, as it is essential for both curative and palliative treatment. However, there are numerous geographic and economic barriers to providing brachytherapy to cancer patients in LMICs. This article examines the role and delivery of brachytherapy in gynecological cancer treatment; brachytherapy capacity in LMICs, including infrastructure, equipment, and human resources considerations; commissioning, training, and clinical implementation of brachytherapy in LMICs; other challenges, and strategies for improvement in brachytherapy delivery in LMICs, including innovation and current and upcoming international initiatives.

Portfolio of prospective clinical trials including brachytherapy: an analysis of the ClinicalTrials.gov database

Background

To evaluate the current status of prospective interventional clinical trials that includes brachytherapy (BT) procedures.

Methods

The records of 175,538 (100 %) clinical trials registered at ClinicalTrials.gov were downloaded on September 2014 and a database was established. Trials using BT as an intervention were identified for further analyses. The selected trials were manually categorized according to indication(s), BT source, applied dose rate, primary sponsor type, location, protocol initiator and funding source. We analyzed trials across 8 available trial protocol elements registered within the database.

Results

In total 245 clinical trials were identified, 147 with BT as primary investigated treatment modality and 98 that included BT as an optional treatment component or as part of the standard treatment. Academic centers were the most frequent protocol initiators in trials where BT was the primary investigational treatment modality (p < 0.01). High dose rate (HDR) BT was the most frequently investigated type of BT dose rate (46.3 %) followed by low dose rate (LDR) (42.0 %). Prostate was the most frequently investigated tumor entity in trials with BT as the primary treatment modality (40.1 %) followed by breast cancer (17.0 %). BT was rarely the primary investigated treatment modality for cervical cancer (6.8 %).

Conclusion

Most clinical trials using BT are predominantly in early phases, investigator-initiated and with low accrual numbers. Current investigational activities that include BT mainly focus on prostate and breast cancers. Important questions concerning the optimal usage of BT will not be answered in the near future.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-016-0624-8) contains supplementary material, which is available to authorized users.

Current status of brachytherapy in Korea: a national survey of radiation oncologists

OBJECTIVE

The aim of the present study was to acquire information on brachytherapy resources in Korea through a national survey of radiation oncologists.

METHODS

Between October 2014 and January 2015, a questionnaire on the current status of brachytherapy was distributed to all 86 radiation oncology departments in Korea. The questionnaire was divided into sections querying general information on human resources, brachytherapy equipment, and suggestions for future directions of brachytherapy policy in Korea.

RESULTS

The response rate of the survey was 88.3%. The average number of radiation oncologists per center was 2.3. At the time of survey, 28 centers (36.8%) provided brachytherapy to patients. Among the 28 brachytherapy centers, 15 (53.5%) were located in in the capital Seoul and its surrounding metropolitan areas. All brachytherapy centers had a high-dose rate system using (192)Ir (26 centers) or (60)Co (two centers). Among the 26 centers using (192)Ir sources, 11 treated fewer than 40 patients per year. In the two centers using (60)Co sources, the number of patients per year was 16 and 120, respectively. The most frequently cited difficulties in performing brachytherapy were cost related. A total of 21 centers had a plan to sustain the current brachytherapy system, and four centers noted plans to upgrade their brachytherapy system. Two centers stated that they were considering discontinuation of brachytherapy due to cost burdens of radioisotope source replacement.

CONCLUSION

The present study illustrated the current status of brachytherapy in Korea. Financial difficulties were the major barriers to the practice of brachytherapy.

Reproducibility and interoperator reliability of obtaining images and measurements of the cervix and uterus with brachytherapy treatment applicators in situ using transabdominal ultrasound

PURPOSE

To validate interoperator reliability of brachytherapy radiation therapists (RTs) in obtaining an ultrasound image and measuring the cervix and uterine dimensions using transabdominal ultrasound.

METHODS AND MATERIALS

Patients who underwent MRI with applicators in situ after the first insertion were included in the study. Imaging was performed by three RTs (RT1, RT2, and RT3) with varying degrees of ultrasound experience. All RTs were required to obtain a longitudinal planning image depicting the applicator in the uterine canal and measure the cervix and uterus. The MRI scan, taken 1 hour after the ultrasound, was used as the reference standard against which all measurements were compared. Measurements were analyzed with intraclass correlation coefficient and Bland-Altman plots.

RESULTS

All RTs were able to obtain a suitable longitudinal image for each patient in the study. Mean differences (SD) between MRI and ultrasound measurements obtained by RTs ranged from 3.5 (3.6) to 4.4 (4.23) mm and 0 (3.0) to 0.9 (2.5) mm on the anterior and posterior surface of the cervix, respectively. Intraclass correlation coefficient for absolute agreement between MRI and RTs was >0.9 for all posterior measurement points in the cervix and ranged from 0.41 to 0.92 on the anterior surface. Measurements were not statistically different between RTs at any measurement point.

CONCLUSIONS

RTs with variable training attained high levels of interoperator reliability when using transabdominal ultrasound to obtain images and measurements of the uterus and cervix with brachytherapy applicators in situ. Access to training and use of a well-defined protocol assist in achieving these high levels of reliability.

A questionnaire-based survey on 3D image-guided brachytherapy for cervical cancer in Japan: advances and obstacles

The purpose of this study is to survey the current patterns of practice, and barriers to implementation, of 3D image-guided brachytherapy (3D-IGBT) for cervical cancer in Japan. A 30-item questionnaire was sent to 171 Japanese facilities where high-dose-rate brachytherapy devices were available in 2012. In total, 135 responses were returned for analysis. Fifty-one facilities had acquired some sort of 3D imaging modality with applicator insertion, and computed tomography (CT) and magnetic resonance imaging (MRI) were used in 51 and 3 of the facilities, respectively. For actual treatment planning, X-ray films, CT and MRI were used in 113, 20 and 2 facilities, respectively. Among 43 facilities where X-ray films and CT or MRI were acquired with an applicator, 29 still used X-ray films for actual treatment planning, mainly because of limited time and/or staffing. In a follow-up survey 2.5 years later, respondents included 38 facilities that originally used X-ray films alone but had indicated plans to adopt 3D-IGBT. Of these, 21 had indeed adopted CT imaging with applicator insertion. In conclusion, 3D-IGBT (mainly CT) was implemented in 22 facilities (16%) and will be installed in 72 (53%) facilities in the future. Limited time and staffing were major impediments.

Quality audits of radiotherapy centres in Latin America: a pilot experience of the International Atomic Energy Agency

BACKGROUND

In Latin America radiotherapy quality varies significantly among hospitals, where highly equipped academic centers coexist with others not meeting minimal requirements. In 2007, the International Atomic Energy Agency published guidelines for auditing radiotherapy centers, known as the "Quality Assurance Team for Radiation Oncology" (QUATRO) audits. The present report summarizes a pilot experience with QUATRO audits to 12 radiotherapy centres.

METHODS

The findings from QUATRO audits conducted in 12 radiotherapy centres in Latin America between 2008 and 2013 were analysed. Events representing weaknesses or gaps in the process of radiotherapy were recorded. Relevant data for estimating human and technological needs of visited centres were processed. The main difficulties and strengths faced by institutions were also documented.

RESULTS

All 12 radiotherapy centres were successfully audited following the QUATRO method. IAEA provided a dosimetry kit for quality control. Forty percent of audited institutions were immersed in a health system that did not recognize cancer as a public health priority problem. With few exceptions, local training programs for physicists and technologists were scarce and research was not an activity of interest among physicians. Centres were provided with sufficient staff to meet the local demand, both in the case of radiation oncologists, physicists and radiation therapists. Three centres lacking the minimum infrastructure were identified. Three institutions did not perform gynaecological brachytherapy, and one installation delivered around 900 teletherapy treatments annually without simulation, planning or dosimetry equipment for that purpose. Recommendations to centres were classified as related to personnel, infrastructure, processes and institutional organizational aspects. Many recommendations warned governments about the evident need for allocating more budgetary resources to radiotherapy. Most recommendations pointed out different aspects related to strengthen human resources training and technological support to the audited centres. Scheduled follow-up visits were also stressed.

CONCLUSION

The QUATRO audits proved to be a valuable tool for identifying weaknesses in infrastructure, human resources and procedures in radiotherapy centres. Follow-up visits conducted by the IAEA or by regional or local organizations are necessary in order to evaluate outcomes and sustainability of implemented recommendations.

Evaluation of time, attendance of medical staff, and resources during interstitial brachytherapy for prostate cancer : DEGRO-QUIRO trial

INTRODUCTION

The German Society of Radiation Oncology initiated a multicenter trial to evaluate core processes and subprocesses of radiotherapy by prospective evaluation of all important procedures in the most frequent malignancies treated by radiation therapy. The aim of this analysis was to assess the required resources for interstitial high-dose-rate (HDR) and low-dose-rate (LDR) prostate brachytherapy (BRT) based on actual time measurements regarding allocation of personnel and room occupation needed for specific procedures.

PATIENTS AND METHODS

Two radiotherapy centers (community hospital of Offenbach am Main and community hospital of Eschweiler) participated in this prospective study. Working time of the different occupational groups and room occupancies for the workflow of prostate BRT were recorded and methodically assessed during a 3-month period.

RESULTS

For HDR and LDR BRT, a total of 560 and 92 measurements, respectively, were documented. The time needed for treatment preplanning was median 24 min for HDR (n = 112 measurements) and 6 min for LDR BRT (n = 21). Catheter implantation with intraoperative HDR real-time planning (n = 112), postimplantation HDR treatment planning (n = 112), and remotely controlled HDR afterloading irradiation (n = 112) required median 25, 39, and 50 min, respectively. For LDR real-time planning (n = 39) and LDR treatment postplanning (n = 32), the assessed median duration was 91 and 11 min, respectively. Room occupancy and overall mean medical staff times were 194 and 910 min respectively, for HDR, and 113 and 371 min, respectively, for LDR BRT.

CONCLUSION

In this prospective analysis, the resource requirements for the application of HDR and LDR BRT of prostate cancer were assessed methodically and are presented for first time.

Uncertainties of target volume delineation in MRI guided adaptive brachytherapy of cervix cancer: a multi-institutional study

BACKGROUND AND AIM

We aimed to quantify target volume delineation uncertainties in cervix cancer image guided adaptive brachytherapy (IGABT).

MATERIALS AND METHODS

Ten radiation oncologists delineated gross tumour volume (GTV), high- and intermediate-risk clinical target volume (HR CTV, IR CTV) in six patients. Their contours were compared with two reference delineations (STAPLE-Simultaneous Truth and Performance Level Estimation and EC- expert consensus) by calculating volumetric and planar conformity index (VCI and PCI) and inter-delineation distances (IDD).

RESULTS

VCISTAPLE and VCIEC were 0.76 and 0.72 for HR CTV, 0.77 and 0.68 for IR CTV and 0.59 and 0.58 for GTV. Variation was most prominent caudally and cranially in all target volumes and posterolaterally in IR CTV. IDDSTAPLE and IDDEC for HR CTV (3.6±3.5 and 3.8±3.4 mm) were significantly lower than for GTV (4.8±4.2 and 4.2±3.5 mm) and IR CTV (4.7±5.2 and 5.2±5.6 mm) (p<0.05).

CONCLUSIONS

Due to lower delineation uncertainties when compared to GTV and IR CTV, HR CTV may be considered most robust volume for dose prescription and optimization in cervix cancer IGABT. Adequate imaging, training and use of contouring recommendations are main strategies to minimize delineation uncertainties.

Patterns of care of radiotherapy in México

AIM

This survey is performed to learn about the structure of radiotherapy in México.

BACKGROUND

Radiation oncology practice is increasing because of the higher incidence of cancer. There is no published data about radiotherapy in México.

MATERIALS AND METHODS

A questionnaire was sent to the 83 registered centers in the database of the Mexican regulatory agency. One out of the 32 states has no radiotherapy. 27 centers from 14 states provided their answers.

RESULTS

829 patients are treated annually with any radiotherapy modality in each center. Two centers have one cobalt machine, 7 have a cobalt and a linac and 10 have more than one linac. Five centers use 2D planning systems, 22 use 3D; 9, conventional simulators; 22, CT based simulation, and 1 center has no simulation. Most of the centers verify beams with films, electronic portal image devices and cone beam CTs are also used. Intensity modulated and image guided radiotherapy are performed in 5 states. Breast, prostate, cervix, lung, rectum and head and neck cancer are the six most common locations. There are 45 public and 38 private centers, 2 dedicated to children. Two gamma knife units, 5 Novalis systems, 1 tomotherapy and 2 cyberknife machines are working. All centers have at least one radiation oncologist, one physicist and one radiotherapist.

CONCLUSIONS

Definitive conclusions cannot be drawn from this limited feedback due to a low participation of centers. This survey about radiotherapy in Mexico shows the heterogeneity of equipment as well as medical and technical staff in the whole country.

Biochemical control of prostate cancer with iodine-125 brachytherapy alone: experience from a single institution

AIM

Brachytherapy is an adequate option as monotherapy for localised prostate cancer. The objective of this study was to evaluate and compare biochemical failure free survival (BFFS) after low-dose-rate brachytherapy (LDRB) alone for patients with prostate cancer using ASTRO and Phoenix criteria, and detect prognostic factors.

METHODS

Data on 220 patients treated between 1998 and 2002 with LDRB were retrospectively analysed. Neoadjuvant hormone therapy was used in 74 (33.6%) patients.

RESULTS

Median follow-up was 53.5 months (24-116). Five year BFFS was 83.0% and 83.7% using, respectively, the ASTRO and Phoenix criteria. Low -and intermediate- risk patients presented, respectively, 86.7% and 77.8% 5-year BFFS using the ASTRO definition (p=0.069), and 88.5% and 78.6% considering the Phoenix criteria (p=0.016). Bounce was observed in 66 (30%) patients. Multivariate analysis detected PSA at diagnosis <10 ng/ml and less than 50% positive biopsy fragments as favourable prognostic factors, regarding BF using both criteria. For the Phoenix criteria, also Gleason score <7 and low-risk group were identified as independent favourable prognostic factors.

CONCLUSIONS

LDRB alone should be considered mostly for low-risk patients. PSA level was a strong independent prognostic factor. We support the use of the Phoenix criteria for detection of BF in patients submitted to LDRB alone.