Underutilization of brachytherapy and disparities in survival for patients with cervical cancer in California

Racial and ethnic disparities in reproductive medicine in the United States: a narrative review of contemporary high-quality evidence

There has been increasing debate around how or if race and ethnicity should be used in medical research-including the conceptualization of race as a biological entity, a social construct, or a proxy for racism. The objectives of this narrative review are to identify and synthesize reported racial and ethnic inequalities in obstetrics and gynecology (ob/gyn) and develop informed recommendations for racial and ethnic inequity research in ob/gyn. A reproducible search of the 8 highest impact ob/gyn journals was conducted. Articles published between January 1, 2010 and June 30, 2023 containing keywords related to racial and ethnic disparities, bias, prejudice, inequalities, and inequities were included (n=318). Data were abstracted and summarized into 4 themes: 1) access to care, 2) adherence to national guidelines, 3) clinical outcomes, and 4) clinical trial diversity. Research related to each theme was organized topically under the headings i) obstetrics, ii) reproductive medicine, iii) gynecologic cancer, and iv) other. Additionally, interactive tables were developed. These include data on study timeline, population, location, and results for every article. The tables enable readers to filter by journal, publication year, race and ethnicity, and topic. Numerous studies identified adverse reproductive outcomes among racial and ethnic minorities as compared to white patients, which persist despite adjusting for differential access to care, socioeconomic or lifestyle factors, and clinical characteristics. These include higher maternal morbidity and mortality among Black and Hispanic/Latinx patients; reduced success during fertility treatments for Black, Hispanic/Latinx, and Asian patients; and lower survival rates and lower likelihood of receiving guideline concordant care for gynecological cancers for non-White patients. We conclude that many racial and ethnic inequities in ob/gyn cannot be fully attributed to patient characteristics or access to care. Research focused on explaining these disparities based on biological differences incorrectly reinforces the notion of race as a biological trait. More research that deconstructs race and assesses efficacy of interventions to reduce these disparities is needed.

Explainable artificial intelligence analysis of brachytherapy boost receipt in cervical cancer during the COVID-19 era

PURPOSE

Brachytherapy is a critical component of the standard-of-care curative radiotherapy regimen for women with locally advanced cervical cancer (LACC). However, existing literature suggests that many patients will not receive the brachytherapy boost. We used machine learning (ML) and explainable artificial intelligence to characterize this disparity.

MATERIALS AND METHODS

Patients with LACC diagnosed from 2004 to 2020 who received definitive radiation were identified in the National Cancer Database. Five ML models were trained to predict if a patient received a brachytherapy boost. The best-performing model was explained using SHapley Additive exPlanation (SHAP) values. To identify trends that may be attributable to the coronavirus disease 2019 (COVID-19) pandemic, the previous analysis was repeated and limited to 2019 to 2020.

RESULTS

A total of 37,564 patients with LACC were identified; 5799 were diagnosed from 2019 to 2020 (COVID cohort). Of these patients, 59.3% received a brachytherapy boost, with 76.4% of patients diagnosed in 2019 to 2020 receiving a boost. The random forest model achieved the best performance for both the overall and COVID cohorts. In the overall cohort, the most important predictive features were the year of diagnosis, stage, age, and insurance status. In the COVID cohort, the most important predictive features were FIGO stage, age, insurance status, and hospital type. Of the 26 patients who tested positive for COVID-19 during their course of radiotherapy, 19 (73.1%) received a brachytherapy boost.

CONCLUSIONS

A gradual increase in brachytherapy boost utilization has been noted, which did not seem to be significantly impacted by the onset of the COVID-19 pandemic. ML could be considered to identify patient populations where brachytherapy is underutilized, which can provide actionable feedback for improving access.

Updated Trends in Cervical Cancer Brachytherapy Utilization and Disparities in the United States From 2004 to 2020

PURPOSE

Lower brachytherapy utilization for cervical cancer patients is associated with decreased survival. This study examines more recent trends in brachytherapy utilization from 2004 to 2020 to assess any trend reversal after awareness increased regarding the importance of brachytherapy.

METHODS AND MATERIALS

This study analyzed data from the National Cancer Database of patients with Federation of Gynecology and Obstetrics (FIGO) IB to IVA cervical cancer treated with radiation therapy between 2004 and 2020. To compare brachytherapy utilization over time, 2- to 3-year categories were created to account for potential variation seen in individual years. A multivariate log binomial regression with robust variance was used to estimate the incidence rate ratio (IRR) of brachytherapy utilization in each year category in reference to the 2004-2006 category. Additionally, risk factors for brachytherapy utilization were identified.

RESULTS

Overall brachytherapy utilization for cervical cancer increased from 54.9% in 2004 to 75.7% in 2020. Compared with 2004 to 2006 when rates of utilization totaled 55.2%, brachytherapy utilization significantly increased to 63.4% in 2011 to 2014 (IRR, 1.15; 95% CI, 1.11-1.19), 66.0% in 2015 to 2017 (1.20 [1.16-1.23]), and 76.0% in 2018 to 2020 (1.38 [1.34-1.42]). Sociodemographic factors associated with lower brachytherapy utilization included Black race (0.94 [0.92-0.97]), Hispanic ethnicity (0.92 [0.90-0.95]), and age >59 years (age ≥60-69: 0.96 [0.94-0.98]; age ≥70-79: 0.89 [0.87-0.92]; age ≥80: 0.73 [0.69-0.77]). Positive predictors of brachytherapy utilization included having insurance (IRR, 1.11; 95% CI, 1.07-1.14).

CONCLUSIONS

In patients with FIGO IB-IVA cervical cancer treated with radiation therapy from 2004 to 2020, brachytherapy utilization has increased during the past decade. These results are encouraging given the known benefit to cause-specific survival and overall survival provided by brachytherapy treatment and indicate a reversal in the trend of declining brachytherapy noted previously. Concerns related to disparities by race, ethnicity, and insurance status require further interventions.

Characteristics, treatment patterns, and outcomes in patients with high-risk locally advanced cervical cancer

OBJECTIVE

To characterize the real-world treatment patterns and outcomes of patients with high-risk locally advanced cervical cancer (HR-LACC).

METHODS

This retrospective study identified and randomly selected adults diagnosed between 2010 and 2018 from the ConcertAI Oncology Dataset. For patients initially treated with concurrent chemoradiotherapy (CCRT), we estimated real-world progression-free survival (rwPFS) among those with persistent disease, real-world time on CCRT, and recurrence-free survival (rwRFS) using Kaplan-Meier methods.

RESULTS

The cohort included 300 patients. Median age at diagnosis was 51 years. 53.7 % were White and 30.0 % were Black; 52.0 % were premenopausal; 89.3 % had squamous cell histology; 75.3 % had stage III disease, and 92.7 % had no evidence of performance status impairment. Initial treatment included CCRT (N = 229), surgery (N = 28), antineoplastics only (N = 11), and radiation only (N = 5). Twenty-seven patients were untreated. Baseline characteristics for the CCRT-first patients were similar to the overall cohort; their median real-world time on treatment was 1.6 months; 78.2 % received cisplatin for a median of 1.2 months; 28.4 % received antineoplastics after CCRT, and 11.8 % initiated a second antineoplastic therapy. Of the CCRT-first patients, 27/143 with a complete response had subsequent recurrent disease (median rwRFS not reached). 179 patients had persistent disease, among whom median (95 % confidence interval [CI]) rwPFS was 29.7 (16.9-59.3) months.

CONCLUSION

In this study of United States-based clinical practices, most HR-LACC patients received CCRT as initial treatment. Many patients developed persistent disease after CCRT indicating a need for improved first treatment and maintenance options.

The interaction between social determinants of health and cervical cancer survival: A systematic review

OBJECTIVE

This systematic review aimed to investigate what are the most relevant social determinants of health (SDH), how they are measured, how they interact among themselves and what is their impact on the outcomes of cervical cancer patients.

METHODS

Search was performed in PubMed, Scopus, Web of Science, Embase, Cochrane, and Google Scholar databases from January 2001 to September 2022. The protocol was registered at PROSPERO (CRD42022346854). We followed the PICOS strategy: Population- Patients treated for cervical cancer in the United States; Intervention - Any SDH; Comparison- None; Outcome measures- Cancer treatment outcomes related to the survival of the patients; Types of studies- Observational studies. Two reviewers extracted the data following the PRISMA guidelines. Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies was used for risk of bias (ROB) assessment.

RESULTS

Twenty-four studies were included (22 had low and 2 had moderate ROB). Most manuscripts analyzed data from public registries (83.3%) and only one SDH (54.17%). The SDH category of Neighborhood was not included in any study. Although the SDH were measured differently across the studies, not being married, receiving treatment at a low-volume hospital, and having public insurance (Medicaid or Medicare) or not being insured was associated with shorter survival of cervical cancer patients in most studies.

CONCLUSIONS

There is a deficit in the number of studies comprehensively assessing the impact of SDH on cervical cancer treatment-related outcomes. Marital status, hospital volume and health insurance status are potential predictors of worse outcome.

Disparities in brachytherapy utilization in cervical cancer in the United States: A comprehensive literature review

Brachytherapy (BT) is an integral component of treatment for patients with locally advanced cervical cancer, significantly improving local control and overall survival. There is an overall trend of decreased utilization of BT in United States (US) in the last few decades with around 50% of patients being treated without BT. The cause of decreased utilization is multifactorial including physician comfort, facility volume, low reimbursements rates and costs of starting and maintaining a brachytherapy program. This decrease coincides with an increase in the use of newer advanced techniques like intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) boost resulting in inferior oncological outcomes and increased toxicity. Moreover, racial and socioeconomic disparities in BT utilization have been widely reported in the US. Various factors including age, race, socio-economic status, location, facility type, facility volume and insurance status result in limited access to brachytherapy, which jeopardizes oncologic outcomes. This comprehensive review discusses the BT utilization in the US, examines the impact of race and socioeconomic factors on BT utilization, and highlights its impact on outcomes.

Identifying disparities in brachytherapy delivery for locally advanced cervical cancer

INTRODUCTION

The standard of care for locally advanced cervical cancer is concurrent chemotherapy and external beam radiation therapy (EBRT) followed by a brachytherapy boost. Some studies show a decreased usage of brachytherapy in cervical cancer patients despite the standard of care and known survival advantage. This study aims to characterize the utilization of brachytherapy in Oregon and identify where disparities in treatment may exist.

METHODS

The Oregon State Cancer Registry database was used to identify patients diagnosed with FIGO Stage IB2-IVB cervical cancer between 2007 and 2016. Patients who received initial EBRT were categorized by whether they received brachytherapy boost or not. Age at diagnosis, county of patient residence, rural-urban status of the county, race/ethnicity, and insurance payer were studied using multivariable logistic regression to identify possible underserved populations. Survival data was compared using a Cox proportional hazard survival model.

RESULTS

401 patients who received primary EBRT for FIGO stage IB2-IVB cervical cancer were identified in the 10-year span. Breakdown by stage is: 16% stage IB2, 23.9% stage II, 37.4% stage III, and 22.7% stage IV. Of those, 154 (38.4%) received brachytherapy boost treatment, 75 (18.7%) received a different boost modality, and 42.9% received no boost. Stage IV (p = 0.001) and uninsured patients (p = 0.04) were significantly less likely to receive brachytherapy. Older age was also associated with decreased brachytherapy usage, as each additional year of life decreased brachytherapy receipt by 1.8% (p = 0.04). Native American and Pacific Islander patients were the only group significantly more likely to receive brachytherapy (p=0.003). There was no significant difference in the rate of brachytherapy boost identified based on urban/rural status of the county (p = 0.63 to 0.69), other racial/ethnic categories (p = 0.66 to 0.80), or among the other stages (p=0.45 to 0.63). In Cox proportional hazard survival analysis, patients that received brachytherapy showed a 42% reduction in risk of cancer specific mortality, though this did not reach the predetermined level of statistical significance (p = 0.057).

CONCLUSIONS

The brachytherapy boost rate among locally advanced cervical cancer patients was 38.4%. The data also indicated a likely reduction in cancer specific mortality in patients receiving brachytherapy. Older patients, stage IV patients, and uninsured patients were less likely to receive brachytherapy. Given the low overall brachytherapy usage, these data indicate access and delivery of brachytherapy care needs to be improved across the state. The increased brachytherapy use in the American Indian and Pacific Islander patient population should be further studied to identify facilitators to treatment completion and potentially extrapolate to other groups.

Racial Disparities in Brachytherapy Treatment among Women with Cervical and Endometrial Cancer in the United States

Brachytherapy improves clinical outcomes among women diagnosed with cervical and endometrial cancers. Recent evidence demonstrates that declining brachytherapy boosts for women with cervical cancer were associated with higher mortality. In this retrospective cohort study, women diagnosed with endometrial or cervical cancer in the United States between 2004 and 2017 were selected from the National Cancer Database for evaluation. Women ≥18 years of age were included for high intermediate risk (PORTEC-2 and GOG-99 definition) or FIGO Stage II-IVA endometrial cancers and FIGO Stage IA-IVA-non-surgically treated cervical cancers. The aims were to (1) evaluate brachytherapy treatment practice patterns for cervical and endometrial cancers in the United States; (2) calculate rates of brachytherapy treatment by race; and (3) determine factors associated with not receiving brachytherapy. Treatment practice patterns were evaluated over time and by race. Multivariable logistic regression assessed predictors of brachytherapy. The data show increasing rates of brachytherapy for endometrial cancers. Compared to non-Hispanic White women; Native Hawaiian and other Pacific Islander (NHPI) women with endometrial cancer and Black women with cervical cancer were significantly less likely to receive brachytherapy. For both NHPI and Black women, treatment at community cancer centers was associated with a decreased likelihood of brachytherapy. The data suggest racial disparities among Black women with cervical cancer and NHPI women with endometrial cancer and emphasize an unmet need for brachytherapy access within community hospitals.

Outcomes from a 3-fraction high-dose-rate brachytherapy regimen for patients with cervical cancer

PURPOSE

To estimate local control, survival, and toxicity associated with a 3-fraction (3F) image-guided brachytherapy (IGBT) regimen compared to longer fraction (LF) for cervical cancer.

METHODS

150 patients treated between 2015-2020 with 3F (24Gy in 3 fractions) or LF (28...30 Gy in 4-5 fractions) were reviewed. The primary outcome was 2-year local failure. We compared overall survival (OS), disease-free survival (DFS), hospitalizations, and toxicity.

RESULTS

There were 32 patients in the 3F group and 118 in the LF group, with a median follow up of 22 months. The 3F had worse performance status (p = 0.01) but otherwise similar characteristics. The 2-year local failure rate was 3.6% (95% CI 0%, 10.6%) for 3F, and 7.5% (95% CI 2.4%, 12.6%) for LF. The univariable hazard ratio (HR) for local failure for 3F was 0.43 (0.05, 3.43; p = 0.43). Moreover, 2 of 32 (6.3%) 3F patients experienced Grade ...3 toxicity compared to 7 of 118 (5.9%) LF patients (p = 1.0), with no difference in hospitalization within 2 years (p = 0.66) and no treatment-related deaths.

CONCLUSIONS

Local control was excellent, with long term survival and toxicity similar between the groups. These findings support consideration of 3F.

Underutilization of brachytherapy for cervical cancer in the United States

Brachytherapy is a critical component of the definitive management of cervical cancer and allows for the safe delivery of about half of the total effective radiation dose needed for optimal outcomes. Moreover, the dose distribution of brachytherapy is highly conformal, allowing for a therapeutic index currently unmatched by alternative techniques. However, a modern brachytherapy program requires special equipment, infrastructure, and procedural expertise. Unfortunately, multiple lines of evidence suggest that brachytherapy is currently underutilized in the United States. In this review, we examine the importance of brachytherapy, contemporary recommendations, and avenues for growth.

Intracavitary brachytherapy with additional Heyman capsules in the treatment of cervical cancer

PURPOSE

Brachytherapy is a mandatory component of primary radiochemotherapy in cervical cancer. The dose can be applied with a traditional intracavitary approach (IC alone) or with multiple catheter brachytherapy to optimize dose distribution in an individual concept. We therefore evaluated whether the utilization of a tandem-ring applicator plus additional intracavitary applicators (add IC) provides an advantage over the traditional IC alone approach, as this method is less time consuming and less invasive compared to a combined intracavitary/interstitial brachytherapy.

METHODS

Twenty three procedures of intracavitary brachytherapy for cervical cancer with additional intracavitary applicators performed in seven patients treated between 2016 and 2018 in our institution were included in this study. Plans were optimized for D90 HR-CTV with and without the utilization of the additional applicators and compared by statistical analysis.

RESULTS

D90 for HR-CTV was 5.71 Gy (±1.17 Gy) for fractions optimized with add IC approach and 5.29 Gy (±1.24 Gy) for fractions without additional applicators (p < 0.01). This translates to a calculated mean EQD2 HR-CTV D90 of 80.72 Gy (±8.34 Gy) compared to 77.84 Gy (±8.49 Gy) after external beam therapy and four fractions of brachytherapy for add IC and IC alone, respectively (p < 0.01). The predictive value of improved coverage of HR-CTV in the first fraction was high.

CONCLUSION

In a subgroup of cases, the addition of intracavitary Heyman capsules can be an alternative to interstitial brachytherapy to improve the plan quality compared to standard IC alone brachytherapy. The benefit from the addition of applicators in the first fraction is predictive for the following fractions.

Improved survival in cervical cancer patients receiving care at National Cancer Institute-designated cancer centers

Background

Locally advanced cervical cancer (CC) remains lethal in the United States. We investigate the effect of receiving care at an National Cancer Institute–designated cancer center (NCICC) on survival.

Methods

Data for women diagnosed with CC from 2004 to 2016 who received radiation treatment were extracted from the California Cancer Registry (n = 4250). Cox proportional hazards regression models assessed whether (1) receiving care at NCICCs was associated with risk of CC‐specific death, (2) this association remained after multivariable adjustment for age, race/ethnicity, and insurance status, and (3) this association was explained by receipt of guideline‐concordant treatment.

Results

Median age was 50 years (interquartile range [IQR] 41–61 years), with median follow‐up of 2.7 years (IQR 1.3–6.0 years). One‐third of patients were seen at an NCICC, and 29% died of CC. The hazard of CC‐specific death was reduced by 20% for those receiving care at NCICCs compared with patients receiving care elsewhere (HR = .80; 95% CI, 0.70–0.90). Adjustment for guideline‐concordant treatment and other covariates minimally attenuated the association to 0.83 (95% CI, 0.74–0.95), suggesting that the survival advantage associated with care at NCICCs may not be due to receipt of guideline‐concordant treatment.

Conclusions

This study demonstrates survival benefit for patients receiving care at NCICCs compared with those receiving care elsewhere that is not explained by differences in guideline‐concordant care. Structural, organizational, or provider characteristics and differences in patients receiving care at centers with and without NCI designation could explain observed associations. Further understanding of these factors will promote equality across oncology care facilities and survival equity for patients with CC.

This study demonstrates survival benefit for patients receiving care for cervical cancer at National Cancer Institute–designated cancer centers that is not explained by receipt of guideline‐concordant treatment. Further understanding of these factors will promote equality across oncology care facilities resulting in survival equity for patients with cervical cancer.

Integration of immunotherapy into treatment of cervical cancer: Recent data and ongoing trials

Cervical cancer constitutes a significant health burden for women globally. While most patients with early-stage disease can be cured with radical surgery or chemoradiotherapy, patients with high-risk locally advanced disease or with recurrent/metastatic disease have a poor prognosis with standard treatments. Immunotherapies are a rational treatment for this HPV-driven cancer that commonly expresses programmed cell death ligand-1. Before 2021, pembrolizumab was the only United States Food and Drug Administration-approved immunotherapy in cervical cancer, specifically for the second-line recurrent or metastatic (r/m) setting. In late 2021, the antibody-drug conjugate tisotumab vedotin was approved for second-line r/m cervical cancer and pembrolizumab combined with chemotherapy ± bevacizumab was approved for first-line r/m disease based on results from KEYNOTE-826. Moreover, with at least 2 dozen additional immunotherapy clinical trials in the second-line and first-line r/m setting, as well as in locally advanced disease, the treatment landscape for cervical cancer may eventually encounter a potential paradigm shift. Pivotal trials of immunotherapies for cervical cancer that were recently approved or with the potential for regulatory consideration through 2024 are reviewed. As immunotherapy has the opportunity to establish new standards of care in the treatment of cervical cancers, new biomarkers to identify the ideal patient populations for these therapies may also become important. However, issues with access, affordability, and compliance in low- and middle-income countries are anticipated.

Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study

Objective

To determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA.

Methods

A retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31, 2015 in the National Cancer Database (NCDB) was identified. Tumor characteristics as well as race, income, insurance type, and treating facility types were compared among nine geographic regions. χ2 tests and Cox regression were used to compare differences between regions; p values <0.05 were considered significant.

Results

A total of 48 787 patients were included. Survival was inferior in seven of nine regions for underinsured patients. In six regions survival was inferior for Medicaid and Medicare patients, respectively: Middle Atlantic: hazard ratio (HR) 1.25 and 1.22; South Atlantic: HR 1.41 and HR 1.22; East North Central: HR 1.36 and HR 1.25; East South Central: HR 1.37 and HR 1.25; West North Central: HR 1.67 and HR 1.42; West South Central: HR 1.44 and HR 1.46. In the Pacific region survival was inferior for Medicare patients (HR 1.35) but not inferior for Medicaid patients. Being uninsured was associated with worse survival in the South Atlantic (HR 1.23), East North Central (HR 1.23), East South Central (HR 1.56), and West South Central (HR 1.31) regions. Annual income level under $38 000 was associated with worse survival in the Middle Atlantic (HR 1.24), South Atlantic (HR 1.35), and East North Central (HR 1.49) regions. Lastly, when compared with academic research institutions, comprehensive community cancer centers had significantly worse survival in four of the nine regions.

Conclusions

Cervical cancer mortality is higher for women with a low income, underinsured (Medicaid or Medicare) or uninsured status, and decreased access to academic institutions in most US regions. An increase in cervical cancer mortality was associated with underinsured or uninsured populations in regions mainly located in the South and Midwest.

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.

Updates in the treatment of vaginal cancer

Vaginal cancer is a rare cancer. A lot of the data used in the treatment of this cancer are extrapolated from cervical cancer data. Radiation therapy plays a significant role in the treatment of vaginal cancer. The advances in radiation therapy in both external beam and brachytherapy have improved local control, survival, and toxicity. Brachytherapy plays an important role in treating vaginal cancer, but treatment should be individualized to each tumor. Imaging, particularly magnetic resonance imaging, plays an essential role in the management of patients with vaginal cancer, from diagnosis to staging to treatment management to surveillance.

Global challenges of radiotherapy for the treatment of locally advanced cervical cancer

Cervical cancer represents a significant portion of the global cancer burden for women, with low- and middle-income countries carrying the bulk of this burden. Additionally, underserved populations in countries with sufficient resources may have a higher incidence of cervical cancer and poorer outcomes. Concurrent chemoradiotherapy is the standard-of-care treatment for locally advanced cervical cancer, which includes patients with stage IB3 to IVA disease, and it is effective for many patients; however, cervical cancer-related mortality remains high. The critical nature of cervical cancer treatment is underscored by the recent launch of the World Health Organization global initiative to accelerate the elimination of cervical cancer using a triple-intervention strategy of increased vaccination, screening, and treatment. The initiative calls for 90% of all patients diagnosed with cervical cancer to receive the appropriate treatment, but to reach this global goal there are significant barriers related to radiotherapy that must be addressed. We discuss and review evidence of the lack of adherence to guideline-recommended treatment, brachytherapy underutilization, limited access to radiotherapy in low- and middle-income countries, as well as regional limitations within high-income countries, as the major barriers to radiotherapy treatment for locally advanced cervical cancer. We further review ways these barriers are currently being addressed and, in some cases, make additional recommendations to address these issues. Finally, despite receiving recommended treatments, many patients with locally advanced cervical cancer have a poor prognosis. With effective administration of current standards of care, the global community will be able to shift focus to advancing treatment efficacy for these patients. We review several types of therapies under clinical investigation that are additions to concurrent chemoradiotherapy, including immune checkpoint inhibitors, antiangiogenic agents, DNA repair inhibitors, human papillomavirus vaccines, and radiosensitizing nanoparticles.

Socioeconomic and Racial Determinants of Brachytherapy Utilization for Cervical Cancer: Concerns for Widening Disparities

PURPOSE

Cervical cancer (CC) disproportionately affects minorities who have higher incidence and mortality rates. Standard of care for locally advanced CC involves a multimodality approach including brachytherapy (BT), which independently improves oncologic outcomes. Here, we examine the impact of insurance status and race on BT utilization with the SEER database.

MATERIALS AND METHODS

In total, 7,266 patients with stage I-IV CC diagnosed from 2007 to 2015 were included. BT utilization, overall survival (OS), and disease-specific survival (DSS) were compared.

RESULTS

Overall, 3,832 (52.7%) received combined external beam radiation therapy (EBRT) + BT, whereas 3,434 (47.3%) received EBRT alone. On multivariate logistic regression analysis, increasing age (OR, 0.98; 95% CI, 0.98 to 0.99; P < .001); Medicaid (OR, 0.80; 95% CI, 0.72 to 0.88; P < .001), uninsured (OR, 0.67; 95% CI, 0.56 to 0.80; P < .001), and unknown versus private insurance (OR, 0.61; 95% CI, 0.43 to 0.86; P < .001); Black (OR, 0.68; 95% CI, 0.60 to 0.77; P < .001) and unknown versus White race (OR, 0.30; 95% CI, 0.13 to 0.77; P = .047); and American Joint Committee on Cancer stage II (OR, 1.07; 95% CI, 0.93 to 1.24; P = .36), stage III (OR, 0.82; 95% CI, 0.71 to 0.94; P = .006), stage IV (OR, 0.30; 95% CI, 0.23 to 0.40; P < .001), and unknown stage versus stage I (OR, 0.36; 95% CI, 0.28 to 0.45; P < .001) were associated with decreased BT utilization. When comparing racial survival differences, the 5-year OS was 44.2% versus 50.9% (P < .0001) and the 5-year DSS was 55.6% versus 60.5% (P < .0001) for Black and White patients, respectively. Importantly, the racial survival disparities resolved when examining patients who received combined EBRT + BT, with the 5-year OS of 57.3% versus58.5% (P = .24) and the 5-year DSS of 66.3% versus 66.6% (P = .53) for Black and White patients, respectively.

CONCLUSION

This work demonstrates notable inequities in BT utilization for CC that particularly affects patients of lower insurance status and Black race, which translates into inferior oncologic outcomes. Importantly, the use of BT was able to overcome racial survival differences, thus highlighting its essential value.

Knowledge-Based Planning for Intact Cervical Cancer

Cervical cancer radiotherapy is often complicated by significant variability in the quality and consistency of treatment plans. Knowledge-based planning (KBP), which utilizes prior patient data to correlated achievable optimal dosimetry with patient-specific anatomy, has demonstrated promise as a quality control tool for controlling this variability, with consequences for patient outcomes, as well as for the reliability of data from multi-institutional clinical trials. In this article we highlight the application of KBP-based quality control to cervical cancer radiotherapy. We discuss the potential impact of KBP on multi-institutional clinical trials to standardize cervical cancer treatment planning across diverse clinics, and discuss challenges and progress in the implementation of KBP for brachytherapy treatment planning. Additionally, we briefly discuss secondary applications of KBP for cervical cancer. The emerging picture from these studies indicates several exciting opportunities for increasing the utilization of KBP in day-to-day cervical cancer radiotherapy.

Age, racial, and ethnic disparities in reported clinical studies involving brachytherapy

PURPOSE

The purpose of this study was to evaluate for age, racial, and ethnic disparities among clinical studies where patients can potentially receive brachytherapy treatment.

METHODS AND MATERIALS

Trials involving brachytherapy for breast, cervical, prostate, and uterine cancers were identified using ClinicalTrials.gov. The age, racial, and ethnic breakdown of the identified trials were compared to US population-estimates derived from the Surveillance, Epidemiology, and End Results (SEER) Program. Primary outcomes were gaps between gaps between mean age and race and ethnic proportions in trials and the US population. Secondary outcomes included proportions of racial and ethnic data reporting. Descriptive statistics, t-tests, χ2 tests, and univariate analysis were used to analyze the data.

RESULTS

A total of 77 trials with reported data were identified, representing 13,580 patients. The overall difference in mean age in the identified trials compared to US population estimates was -2.29 years (p < 0.001), with the largest difference occurring in prostate cancer at -2.72 years (p < 0.001). With the exception of ethnicity in cervical cancer (p = 0.18), all racial and ethnic distributions were statistically significantly different. Overall, the largest disparity was among Asian (-2.65%) and Hispanic patients (-1.05%). Of the 77 trials, 76 (98.7%) reported age, 36 (46.8%) reported race, and 24 (31.2%) reported ethnicity.

CONCLUSIONS

Diversity data is underreported among clinical studies where brachytherapy is a potential treatment component. However, among reported trials, disparities are present albeit relatively small compared to previous studies reporting on disparities in clinical trials. Future efforts should emphasize increased reporting of racial and ethnicity data as well as ensuring inclusion of older patients and minorities.

An Analysis of the Racial Disparities Among Cervical Cancer Patients Treated at an Academic Medical Center in the Southeastern United States

Objective

The purpose of this study was to identify racial disparities in treatment outcomes, if any, among patients with carcinoma of the cervix treated at a tertiary care institution in the state of Mississippi.

Methods

A retrospective review of patients with carcinoma of the cervix treated in the Department of Radiation Oncology at our institution between 2010 and 2018 was performed. Data regarding demographics, disease stage, treatments administered, and follow-up were collected. Patient outcomes, including median survival and overall survival, were analyzed using the Kaplan-Meier method. All analyses were performed using SPSS Statistics version 24 (IBM, Armonk, NY).

Results

Between January 2010 and December 2018, a total of 165 patients with carcinoma of the cervix were treated at our institution. We had a significantly higher proportion of African American (AA) compared to Caucasian American (CA) patients (59.4 vs. 36.4%; p=0.03). There was a significant difference in the disease stage at the time of presentation between AA and CA in that compared to AA women, a higher number of CA patients presented with locally advanced disease [Federation of Gynecology and Obstetrics (FIGO) stages IB2 to IVA] (78.6 vs. 86.7%; p<0.001). However, a higher number of AA patients presented with metastatic disease at diagnosis compared to CA women (13.3 vs. 8.3%; p<0.001).

Regarding their treatment, 157 (95.2%) underwent definitive chemoradiotherapy, while three (1.8%) had definitive surgery followed by adjuvant radiation or chemoradiation, depending on the risk factors identified operatively. The treatment details of five patients were not available. The median follow-up and the median survival of the entire cohort were 16 months and 79 months, respectively. In our cohort, there was no significant difference in overall survival between AA and CA patients at either three years (80 vs. 68%; p=0.883) or five years (77 vs. 68%; p=0.883). As expected, patients with locally advanced disease showed a significantly better median survival of 79 months compared to only 11 months for those with metastatic disease at their presentation (p<0.001).

Conclusions

Our study revealed that more AA women presented with metastatic disease compared to CA women. However, our analysis did not identify any racial disparities in the prognosis of the entire cohort.

Practical brachytherapy solutions to an age-old quandary

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Age should not be a limiting factor for brachytherapy in patients with localised cancer or for palliation in metastatic disease.

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In tumour streams where brachytherapy forms part of the curative management, it should not be omitted in elderly patients who are medically fit for treatment.

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Treatment decisions should factor in patient preferences, the relative merits of different therapeutic approaches and maintaining minimal impact on quality of life.

Cancer is predominantly a disease of the elderly and as population life expectancy increases, so will the incidence of malignant disease. Elderly patients often have other comorbidities and social complexities, increasing the support required to safely deliver all treatment modalities. Brachytherapy is a relatively simple technique by which radiation therapy can be delivered. It offers dosimetric advantages through a highly conformal dose distribution thereby limiting radiation exposure to normal tissues reducing toxicity. Requiring fewer hospital visits, it also offers practical and logistical advantages to the elderly population and in many cases can be performed without the need for general anaesthesia. In tumour streams where brachytherapy forms part of the curative management, it should not be omitted in elderly patients who are medically fit for treatment. In the palliative setting, brachytherapy often offers an excellent means for achieving either local tumour and/or symptom control and should be actively considered in the therapeutic armamentarium of the oncologist in this context.

A guide to curriculum inquiry for brachytherapy simulation-based medical education

PURPOSE

Brachytherapy is a required clinical competency within radiation oncology training but decreased utilization and volume have limited trainee exposure. Simulation-based medical education is an established educational tool that allows learners to engage in higher-order learning in a safe space and has unique application in brachytherapy instruction.

METHODS AND MATERIALS

We reviewed best practices in curriculum development for simulation-based medical education in brachytherapy, current works in brachytherapy simulation, and identify areas for future development.

RESULTS

The systematic curriculum inquiry method as it relates to brachytherapy was described using the "six-step approach" of problem identification and general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation and feedback. Best practices in simulation identified several features of effective learning, including feedback, repetitive practice, and curriculum integration. A review of current simulation-based medical education brachytherapy publications revealed five manuscripts to date with a focus on feasibility across a variety of disease sites, including the prostate, cervical, breast, and head and neck. Potential areas of future development include curricular quality improvement, long-term outcomes, objectives that scale to the learner's competencies, and expansion beyond psychomotor skills.

CONCLUSIONS

Brachytherapy is an essential modality in radiation oncology. Simulation-based medical education provides a powerful opportunity to improve brachytherapy training effectively.

[Can stereotactic body radiotherapy replace brachytherapy for locally advanced cervical cancer? French society for radiation oncology statement]

Brachytherapy is part of the treatment of locally advanced cervical cancers, accounting for about half of the total delivered dose. The benefit of dose escalation is the most important in advanced cases or if the tumor has responded poorly. The use of interstitial implantations makes it possible to reach doses of the order of 85 to 90Gy (including external beam radiotherapy contribution) in most patients, through image-guided approaches. Brachytherapy delivery is one of the quality criteria for patient care. To date, no data allow us to consider as an alternative the use of external boost through intensity-modulated or stereotactic body radiotherapy. Indeed, the doses delivered to the tumor and the capacity to spare normal tissues remains lower, as compared to what is permitted by brachytherapy. It is therefore appropriate for centers that do not have access to the technique to establish networks with centers where brachytherapy is performed, to allow each patient to have access to the technique. It is also necessary to promote brachytherapy teaching. The issue of reimbursement will be crucial in the coming years to maintain expertise that is today insufficiently valued in its financial aspects, but has a very high added value for patients.

Outcomes by Race Among Women Referred to an Academic Colposcopy Clinic with a Patient Navigation Program

Background: Although minority women are at higher risk of cervical cancer in the United States, little is known about differences in rates of colposcopy and loop electrosurgical excision procedure (LEEP) by race once patients present for care. Materials and Methods: A prospective registry of patients presenting to an academic colposcopy clinic was queried from 2008 to 2018. Women with missing race or cytology results, prior hysterectomy, or prior history of cervical, vulvar, or vaginal cancer were excluded. Poisson and logistic regression models were performed to evaluate the associations between race and colposcopy, LEEP, and cancer rates, adjusting for referral Papanicolaou (Pap), human papillomavirus (HPV) result, year of visit, age, insurance, pregnancy, number of sexual partners, and smoking status. Results: A total of 4506 women were included (56.1% white and 43.9% non-white). Referral for high-grade cytology was more likely among white compared to non-white women (22.5% vs. 17.5%, p < 0.001), as well as positive HPV testing (white 7.8% vs. non-white 6.0%, p < 0.001). The colposcopy rate was slightly higher among black (incidence rate ratio [IRR]_adjusted 1.11, 95% confidence interval [CI] 1.03-1.19, p = 0.006) and Hispanic women (IRR_adjusted 1.13, 95% CI 1.06-1.21, p = 0.0003) compared to white women. Hispanic women were significantly more likely to undergo LEEP (odds ratio_adjusted 1.26, 95% CI 1.01-1.58, p = 0.04). However, no significant difference in cancer, adenocarcinoma in situ, or high-grade histology was noted by race. Conclusions: Black and Hispanic women referred for abnormal Pap or HPV results underwent a greater number of colposcopies compared to white women, and Hispanic women underwent a greater number of LEEPs. Although cancer is rare in our cohort, there was no statistical difference in rate of cancer by race.

Definitive radiotherapy with image-guided adaptive brachytherapy for primary vaginal cancer

Primary vaginal cancer is a rare cancer and clinical evidence to support recommendations on its optimal management is insufficient. Because primary vaginal cancer resembles cervical cancer in many aspects, treatment strategies are mainly adopted from evidence in locally advanced cervical cancer. To date, the organ-sparing treatment of choice is definitive radiotherapy, consisting of external beam radiotherapy and brachytherapy, combined with concurrent chemotherapy. Brachytherapy is an important component of the treatment and its steep dose gradient enables the delivery of high doses of radiation to the primary tumour, while simultaneously sparing the surrounding organs at risk. The introduction of volumetric CT or MRI image-guided adaptive brachytherapy in cervical cancer has led to better pelvic control and survival, with decreased morbidity, than brachytherapy based on x-ray radiographs. MRI-based image-guided adaptive brachytherapy with superior soft-tissue contrast has also been adopted sporadically for primary vaginal cancer. This therapy has had promising results and is considered to be the state-of-the-art treatment for primary vaginal cancer in standard practice.

A knowledge-based organ dose prediction tool for brachytherapy treatment planning of patients with cervical cancer

PURPOSE

The purpose of this study is to explore knowledge-based organ-at-risk dose estimation for intracavitary brachytherapy planning for cervical cancer. Using established external-beam knowledge-based dose-volume histogram (DVH) estimation methods, we sought to predict bladder, rectum, and sigmoid D_2cc for tandem and ovoid treatments.

METHODS AND MATERIALS

A total of 136 patients with loco-regionally advanced cervical cancer treated with 456 (356:100 training:validation ratio) CT-based tandem and ovoid brachytherapy fractions were analyzed. Single fraction prescription doses were 5.5-8 Gy with dose criteria for the high-risk clinical target volume, bladder, rectum, and sigmoid. DVH estimations were obtained by subdividing training set organs-at-risk into high-risk clinical target volume boundary distance subvolumes and computing cohort-averaged differential DVHs. Full DVH estimation was then performed on the training and validation sets. Model performance was quantified by ΔD_2cc = D_2cc(actual)-D_2cc(predicted) (mean and standard deviation). ΔD_2cc between training and validation sets were compared with a Student's t test (p < 0.01 significant). Categorical variables (physician, fraction-number, total fractions, and case complexity) that might explain model variance were examined using an analysis of variance test (Bonferroni-corrected p < 0.01 threshold).

RESULTS

Training set deviations were bladder ΔD_2cc = -0.04 ± 0.61 Gy, rectum ΔD_2cc = 0.02 ± 0.57 Gy, and sigmoid ΔD_2cc = -0.05 ± 0.52 Gy. Model predictions on validation set did not statistically differ: bladder ΔD_2cc = -0.02 ± 0.46 Gy (p = 0.80), rectum ΔD_2cc = -0.007 ± 0.47 Gy (p = 0.53), and sigmoid ΔD_2cc = -0.07 ± 0.47 Gy (p = 0.70). The only significant categorical variable was the attending physician for bladder and rectum ΔD_2cc. CONCLUSION: A simple boundary distance-driven knowledge-based DVH estimation exhibited promising results in predicting critical brachytherapy dose metrics. Future work will examine the utility of these predictions for quality control and automated brachytherapy planning.

Racial disparities in brachytherapy administration and survival in women with locally advanced cervical cancer

OBJECTIVE

Black women have the highest incidence and mortality from cervical cancer in the United States. This study evaluated whether racial disparities in the receipt of brachytherapy (BT) for locally advanced cervical cancer mediate survival differences by race using the National Cancer Database.

METHODS

A retrospective cohort study was performed using 16,116 women with stage IB2-IVA cervical cancer treated from 2004 to 2014. Women who did not receive external beam radiation therapy, those with unknown survival data or stage, and those status post hysterectomy or pelvic exenteration were excluded. Multivariate logistic regression was performed to evaluate factors associated with BT use. Using a propensity score adjusted model with inverse probability treatment weighting, adjusted hazard ratios for overall survival were calculated, including an interaction term between BT and race.

RESULTS

Of 16,116 patients, 19.2% were black and 55.8% received BT. Black women were significantly less likely to receive BT (AOR 0.87, 95% confidence interval [CI] 0.79-0.96, p = 0.007) and had worse all-cause mortality (median survival 3.9 years [95% CI 3.6-4.6] versus 5.2 years [95% CI 4.9-5.5] for non-black women, p < 0.001). In the adjusted model, black patients had an increased risk of death compared to non-black patients (AHR 1.14, 95% CI 1.05-1.24; p = 0.002) among women who did not receive BT. However, there was no difference in survival by race when both groups received BT (AHR 1.04, 95% CI 0.95-1.13, p = 0.42; p-interaction = 0.005).

CONCLUSIONS

Black women with locally advanced cervical cancer are less likely to receive brachytherapy, which mediates survival differences by race. Improving access to brachytherapy may improve overall survival.

Impact of marital status on receipt of brachytherapy and survival outcomes in locally advanced cervical cancer

PURPOSE

Marriage has been associated with enhanced survival among cancer patients, but conflicting correlations have been suggested in cervical cancer. We assessed the impact of marital status on receipt of brachytherapy and survival in women with locally advanced cervical cancer.

METHODS AND MATERIALS

Three thousand, eight hundred and twelve patients with Stage IB2-IVA cervical cancer diagnosed from 2006 to 2015 treated with external beam radiotherapy were identified from the California Cancer Registry. Chi-square tests were used to compare patient characteristics by marital status and boost type. The association of marital status with brachytherapy (BT) receipt was assessed using multiple logistic regression. Fine and Gray competing risks and Cox proportional hazards regressions were used to estimate cervical cancer-specific survival (CCSS) and overall survival (OS), respectively.

RESULTS

Most women were unmarried (58.8%). Half (50.4%) received BT, while 33.1% received no boost; most (86.3%) received chemotherapy. Unmarried women had similar odds of receiving BT as married women (OR = 1.07, 95% CI: 0.90-1.28, p = 0.4370) but were less likely to receive chemotherapy (84.3% vs. 89.1%, p < 0.0001). Singlehood was significantly associated with worse CCSS (subdistribution hazard ratio = 1.21, 95% CI: 1.03-1.42, p < 0.0174) and OS (hazard ratio = 1.18, 95% CI: 1.03-1.36, p < 0.0153). Not receiving a radiation boost was also significantly associated with worse CCSS (subdistribution hazard ratio = 1.21, 95% CI: 1.02-1.43, p = 0.0317) and OS (hazard ratio = 1.21, 95% CI: 1.05-1.40, p = 0.0100).

CONCLUSIONS

There were no differences in BT receipt in married vs. unmarried patients. However, unmarried patients had worse CCSS and OS and were less likely to receive chemotherapy. Interventions targeting social factors are needed to improve outcomes in this vulnerable population.

Current Quality of Gynecologic Cancer Care in North America

Evaluating the quality of care received by gynecologic cancer patients in the real world is essential for excellent outcomes. The recent population-based literature looking at quality of care was reviewed for all gynecologic malignancies. Outcomes are generally highest when care is provided by high-volume providers in high-volume cancer centers. Provision of care according to clinical practice guidelines has also been demonstrated to improve outcomes in many situations. Disparities exist for marginalized groups in terms of the care they receive and subsequent outcomes. Health systems need to improve care for these populations.

Hyaluronic gel injection into the vesicovaginal septum for high-dose-rate brachytherapy of uterine cervical cancer: an effective approach for bladder dose reduction

Purpose

The purpose of this study was to report our initial experience of hyaluronic acid gel injection (HGI) in the vesicovaginal septum (VVS) for bladder dose reduction in brachytherapy (BT) for uterine cervical carcinoma.

Material and methods

Between September 2016 and May 2018, 15 uterine cervical cancer patients received HGI in the VVS as a part of their definitive radiotherapy (RT) treatment consisting of external beam radiation therapy (EBRT) with additional BT. Of those, 9 patients received BT both with and without HGI, and remaining 6 patients were excluded because these 6 patients received HGI in the VVS for all BT fractions. All 9 patients received HGI in the rectovaginal septum. For these patients, the dosimetric parameters bladder D_2cc, HR-CTV D₉₀, and rectum D_2cc were selected, and two groups were generated (BT with vs. without HGI in the VVS) for dosimetric comparison.

Results

The median cumulative EQD₂ for HR-CTV, rectum D_2cc, and bladder D_2cc for the 9 patients were 73.3, 52.8, and 67.1, respectively. While no statistical difference could be detected for rectal dose reduction, bladder dose was significantly less in the group with HGI in the VVS compared to that without (449 cGy [range, 416-566, 1SD = 66.1] vs. 569 cGy [range, 449-647, 1SD = 59.5], p = 0.033), with no compromising of target coverage. Although it did not reach statistically significance, there was a trend toward better HR-CTV D₉₀ in the group with HGI compared to that without HGI in the VVS (713 cGy vs. 706 cGy, p = 0.085). No severe bleeding, hematuria, bladder wall injury, or urethral injury requiring hospitalization was experienced in association with HGI in the VVS.

Conclusions

HGI in the VVS can be performed safely and can effectively reduce the bladder dose in BT for uterine cervical cancer patients.

Evaluating the urban-rural paradox: The complicated relationship between distance and the receipt of guideline-concordant care among cervical cancer patients

OBJECTIVE

Urban-rural health disparities are often attributed to the longer distances rural patients travel to receive care. However, a recent study suggests that distance to care may affect urban and rural cancer patients differentially. We examined whether this urban-rural paradox exists among patients with cervical cancer.

METHODS

We identified individuals diagnosed with cervical cancer from 2004 to 2013 using a statewide cancer registry linked to multi-payer, insurance claims. Our primary outcome was receipt of guideline-concordant care: surgery for stages IA1-IB1; external beam radiation therapy (EBRT), concomitant chemotherapy, and brachytherapy for stages IB2-IVA. We estimated risk ratios (RR) using modified Poisson regressions, stratified by urban/rural location, to examine the association between distance to nearest facility and receipt of treatment.

RESULTS

62% of 999 cervical cancer patients received guideline-concordant care. The association between distance and receipt of care differed by type of treatment. In urban areas, cancer patients who lived ≥15 miles from the nearest surgical facility were less likely to receive primary surgical management compared to those <5 miles from the nearest surgical facility (RR: 0.77, 95% CI: 0.60-0.98). In rural areas, patients living ≥15 miles from the nearest brachytherapy facility were more likely to receive treatment compared to those <5 miles from the nearest brachytherapy facility (RR: 1.71, 95% CI: 1.14-2.58). Distance was not associated with the receipt of chemotherapy or EBRT.

CONCLUSIONS

Among cervical cancer patients, there is evidence supporting the urban-rural paradox, i.e., geographic distance to cancer care facilities is not consistently associated with treatment receipt in expected or consistent ways. Healthcare systems must consider the diverse and differential barriers encountered by urban and rural residents to improve access to high quality cancer care.