Increasing global accessibility to high-level treatments for cervical cancers

Efficacy of induction chemotherapy during the COVID-19 pandemic for treatment of locally advanced cervical cancer in Botswana

OBJECTIVES

Standard chemoradiation (CRT) treatment for cervical cancer was disrupted in Botswana during the COVID-19 pandemic. Patients were prescribed induction chemotherapy (IC) to bridge delays to radiotherapy (RT) or CRT (IC + RT/CRT).

METHODS

This prospective observational study compared outcomes of locally advanced cervical cancer patients who received IC + RT/CRT (n = 67) between 2019 and 2022 to historical controls who received CRT (n = 169) between 2014 and 2019. IC + RT/CRT consisted of four cycles of paclitaxel 175 mg/m2 and carboplatin (area under the curve 5-6) prescribed once every three weeks followed by external beam RT and high-dose-rate brachytherapy with or without weekly concurrent cisplatin. Two-year overall survival (OS) was estimated using the Kaplan-Meier method; univariable and multivariable analyses (MVA) were conducted using Cox proportional hazards regression.

RESULTS

Median follow-up was 28.9 months (95 % CI 27.4-32.7 months). Two-year OS of the IC + RT/CRT cohort (80.2 % [95 % CI: 69.8-92.1 %]) did not differ from the historical CRT cohort (77.5 % [95 % CI 71.3-84.1 %]). Improved OS was associated with receiving ≥3 cycles of IC on MVA. Secondary analysis among those prescribed IC + RT/CRT (n = 91) demonstrated no difference in 2-year OS (66.8 % [95 % CI: 56.9-78.3 %]) compared to CRT historical controls. Receipt of the prescribed IC + RT/CRT was associated with increased OS on MVA.

CONCLUSIONS

Survival of patients who received IC + RT/CRT did not differ from historical CRT controls and was associated with ≥3 cycles of IC, suggesting that IC may be a feasible treatment pathway when RT is delayed.

The socioeconomic burden of cervical cancer and its implications for strategies required to achieve the WHO elimination targets

INTRODUCTION

Cervical cancer is almost entirely preventable by vaccination and screening. Population-based vaccination and screening programs are effective and cost effective, but millions of people do not have access to these programs, causing immense suffering. The WHO Global Strategy for the elimination of cervical cancer as a public health problem calls for countries to meet ambitious vaccination, screening, and treatment targets.

AREAS COVERED

Epidemiological evidence indicates marked socioeconomic gradients in the burden of cervical cancer and vaccination, screening, and treatment coverage. The unacceptable socioeconomic burden of cervical cancer is largely a function of inequitable access to these programs. We discuss these inequities, and highlight strategies enabled by new evidence and technology. Single dose HPV vaccination, HPV-based screening, and the rapidly moving technology landscape have enabled task-shifting, innovation in service delivery and the possibility of scale. Equitable access to optimal care for the treatment of invasive cancers remains a challenge.

EXPERT OPINION

Cervical cancer can be eliminated equitably. It will require global political will, sustained public and private investment, and community leadership to safely and sustainably embed proven tools, technology and infrastructure in local health and knowledge systems.

Therapeutic Efficacy Studies on the Monoterpenoid Hinokitiol in the Treatment of Different Types of Cancer

Hinokitiol (HK), a monoterpenoid that naturally occurs in plants belonging to the Cupressaceae family, possesses important biological activities, including an anticancer effect. This review summarizes its anticancer potential and draws possible molecular interventions. In addition, it evaluates the biopharmaceutical, toxicological properties, and clinical application of HK to establish its viability for future advancement as a dependable anticancer medication. The assessment is based on the most recent information available from various databases. Findings demonstrate that HK possesses substantial therapeutic advantages against diverse types of cancer (colon, cervical, breast, bone, endometrial, liver, prostate, oral, and skin) through various molecular mechanisms. HK induces oxidative stress, cytotoxicity, apoptosis, cell-cycle arrest at the G and S phases, and autophagy through modulation of phosphatidylinositol 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR), p38/ERK/MAPK, nuclear factor kappa B, and c-Jun N-terminal kinase signaling pathways. Furthermore, this compound exhibits good oral bioavailability with excellent plasma clearance. Clinical uses of HK demonstrate therapeutic advantages without any significant negative effects. A thorough study of the pertinent data suggests that HK may serve as a viable candidate for developing novel cancer therapies. Consequently, more extensive studies are necessary to evaluate its cancer treatment efficacy, safety, and possible long-term hazards.

Atezolizumab plus bevacizumab and chemotherapy versus bevacizumab plus chemotherapy for metastatic cervical cancer: a cost-effectiveness analysis

Aim

The objective of this study is to conduct a cost-effectiveness analysis in order to evaluate the economic advantages of incorporating atezolizumab into a standard bevacizumab plus platinum regimen for the treatment of metastatic cervical cancer from the Chinese medical system perspective.

Method

We developed a partitioned survival model based on data obtained from the recently published BEATcc clinical trial and economic cost data. Our model utilized a tree-based decision analysis approach to simulate two different treatment strategies for metastatic cervical cancer: the standard bevacizumab plus platinum regimen, and the addition of atezolizumab to the standard treatment regimen. The economic assessment data included the costs of the drugs, costs related to treatment-induced adverse events. The cost-effectiveness metrics used in the analysis were quality-adjusted life-year (QALY) and incremental cost-effectiveness ratio (ICER). The robustness of our model was assessed through sensitivity analysis.

Result

The total costs of the atezolizumab group were $128179.56, while the costs of chemotherapy group were $42065.89. The atezolizumab group gained 3.52 QALYs, whereas the chemotherapy group gained 2.35 QALY. The atezolizumab regimen resulted in an increase of 1.17 QALYs at an incremental cost of $86113.67. This led to an ICER of $73601.43, which exceeds the willingness-to-pay (WTP) threshold of $39855.79 in China. Sensitivity analysis demonstrated none of the parameters within a margin of ±25% result in significant alterations to the analysis findings.

Conclusion

Atezolizumab plus bevacizumab and chemotherapy was not to be a cost-effective option for the treatment of metastatic cervical cancer compared to bevacizumab plus chemotherapy.

Psychosocial Burden of Women Who Are to Undergo Additional Diagnostic Procedures Due to Positive Screening for Cervical Cancer

Background/Objectives: This study aimed to evaluate psychosocial burden and its associated factors in women who were referred for additional diagnostic procedures following receipt of a positive cervical-cancer-screening smear result. Methods: A cross-sectional study was performed in a consecutive cohort of only women who received an abnormal Papanicolaou screening result and therefore presented to a gynecologist for additional diagnostic examinations (colposcopy/biopsy/endocervical curettage) at the Clinic for Gynecology and Obstetrics of the Clinical Center. Multivariate linear regression was used for data analysis, with Bonferroni correction applied for multiple comparisons. Results: Significant independent predictors for the occurrence of psychosocial burden-worry in women with a positive Papanicolaou screening test before diagnostic procedures were the use of oral contraceptives (β = -0.174, p < 0.001), alcohol consumption (β = 0.188, p < 0.001), anxiety (β = -0.189, p = 0.001), high burden of depressive symptoms (β = 0.191, p = 0.001) and insufficient knowledge of the meaning of the term dysplasia/precancerous (β = -0.187, p < 0.001), according to the multivariate linear regression. The significant independent predictor for the occurrence of psychosocial burden-satisfaction with information/support in women with a positive Papanicolaou screening test before diagnostic procedures was psychological distress (β = -0.210, p = 0.001). Conclusions: Providing information in order to improve understanding of the term dysplasia/precancerous, as well as identifying which women are at risk of psychosocial burden, may help protect against this potential harm among women who receive a positive cervical-cancer-screening result and may facilitate their intention to undergo further diagnostic procedures.

From barriers to opportunities from COVID-19 pandemic: Stakeholder perspectives on cervical cancer screening programs in LMICs of the Asia-Pacific region

Cervical cancer is preventable, yet it remains the fourth most common cancer in women globally. The highest incidence and mortality occur in low- and middle-income countries (LMICs), where over 70% of women have never been screened, and 58% of the cases are in Asia. While the COVID-19 pandemic caused significant disruptions to cervical screening programs, particularly for LMICs, there were opportunities that emerged from the pandemic that were enablers of program recovery. Stakeholders played key roles in materialising strategy into implementation. Therefore, in this study, we examined the barriers and facilitators to implementing recovery strategies from the stakeholders' perspectives. We interviewed fifteen stakeholders from nine LMICs in the Asia-Pacific region directly involved in the implementation of the cervical screening program. A total of 23 barriers and 21 facilitators were identified, of which seven barriers and nine facilitators related directly to the pandemic. Pandemic-related barriers included movement restrictions, resource diversion, cancelled campaigns and training, deprioritisation of HPV prevention efforts, and a reduced health workforce. Stakeholders concurred that most barriers had predated the pandemic and remained as the pandemic eased. Conversely, the pandemic introduced facilitators such as means for targeted campaigns, improved understanding of viruses, accessible training with online platforms, better PCR testing capabilities, a shift in the government's position towards preventive health services, and openness to HPV testing and self-swabs. The emerging facilitators offered opportunities to address some of the persistent barriers, such as limited cervical cancer awareness and insufficient healthcare providers in screening programs. However, effective implementation of these emerging facilitators requires improved communication and collaboration between policymakers and implementers to accelerate the recovery of screening programs in LMICs. Further work is necessary to align emerging facilitators with the health system goals and resource settings of each country in turning these opportunities into actions.

Exploring the therapeutic potential of quercetin in cancer treatment: Targeting long non-coding RNAs

The escalating global incidence of cancer, which results in millions of fatalities annually, underscores the pressing need for effective pharmacological interventions across diverse cancer types. Long noncoding RNAs (lncRNAs), a class of RNA molecules that lack protein-coding capacity but profoundly impact gene expression regulation, have emerged as pivotal players in key cellular processes, including proliferation, apoptosis, metastasis, cellular metabolism, and drug resistance. Among natural compounds, quercetin, a phenolic compound abundantly present in fruits and vegetables has garnered attention due to its significant anticancer properties. Quercetin demonstrates the ability to inhibit cancer cell growth and induce apoptosis-a process often impaired in malignant cells. In this comprehensive review, we delve into the therapeutic potential of quercetin in cancer treatment, with a specific focus on its intricate interactions with lncRNAs. We explore how quercetin modulates lncRNA expression and function to exert its anticancer effects. Notably, quercetin suppresses oncogenic lncRNAs that drive cancer development and progression while enhancing tumor-suppressive lncRNAs that impede cancer growth and dissemination. Additionally, we discuss quercetin's role as a chemopreventive agent, which plays a crucial role in mitigating cancer risk. We address research challenges and future directions, emphasizing the necessity for in-depth mechanistic studies and strategies to enhance quercetin's bioavailability and target specificity. By synthesizing existing knowledge, this review underscores quercetin's promising potential as a novel therapeutic strategy in the ongoing battle against cancer, offering fresh insights and avenues for further investigation in this critical field.

Matrine induces ferroptosis in cervical cancer through activation of piezo1 channel

BACKGROUND

Cervical cancer, which is a significant public health concern in women, currently lacks effective therapeutic drugs. Matrine, a constituent of the traditional Chinese herb Sophora flavescentis Radix, is known for its anti-cervical cancer properties and ability to induce programmed cell death. The induction of cancer cell ferroptosis, which is a novel cell death pattern, can become an effective clinical therapy for tumor in the future. However, the effect of matrine on ferroptosis in cervical cancer remains to be elucidated.

PURPOSE

In this study, we investigated whether matrine induces ferroptosis in cervical cancer and elucidated the underlying mechanisms.

METHODS

We established an SiHa-derived tumor-bearing mouse model using CB17 severe combined immunodeficient (SCID) mice and administered a group of matrine (25, 50, and 75 mg/kg) and cisplatin (2 mg/kg). We meticulously tracked alterations in body weight and tumor size and evaluated liver and kidney health using haematoxylin and eosin (H&E) staining. Using Gene Expression Omnibus (GEO) Dataset (GSE201309), we evaluated the relationship between the effects of matrine on malignant tumor cells and ferroptosis. In vitro, tetrazolium-based colorimetric (MTT), lactate dehydrogenase (LDH) and colony formation assays were used to study the effects of matrine on SiHa cell activity and cytotoxicity. We assessed ferroptosis-related protein abundance using western blotting and ferroptosis-related indices in cells using confocal immunofluorescence microscopy. The interaction of matrine with a protein linked to ferroptosis was studied using cellular thermal shift assay (CETSA). The effects of matrine on Piezo1 expression were investigated using calcium imaging. We also used Piezo1-specific siRNA to explore the role of Piezo1 in ferroptosis.

RESULTS

Matrine administration effectively inhibited tumor growth in a SiHa-derived tumor-bearing mouse model without inducing noticeable harm. The analysis results of GEO data set show matrine-induced effects in tumor cells were indeed involved in the process of ferroptosis. Treatment with matrine resulted in a significant reduction in GPX4 protein levels and a concurrent increase in lipid peroxide and Fe2+ content, suggesting matrine-induced modulation of ferroptosis. Matrine promoted SiHa cell death in vitro, as evidenced by the results of MTT and LDH assays. Cell death coincides with increases in intracellular Fe2+, reactive oxygen species (ROS), and lipid peroxides. Our study also revealed significant upregulation of Piezo1 expression through the action of matrine, whereas transferrin receptor (Tfr) and System Xc- (xCT) expression and interaction remained unaffected. We provided further evidence that matrine induces calcium influx through the Piezo1 channel, thereby potentially influencing ferroptosis. Transfection with Piezo1 siRNA reversed the effects of matrine in SiHa cell.

CONCLUSIONS

Our findings indicate that matrine exerts a protective effect against cervical cancer by inducing ferroptosis through the activation of Piezo1, but not xCT or Tfr.

The recovery strategies to support cervical cancer elimination in lower-and middle-income countries (LMICs) following COVID-19 disruptions

The COVID-19 pandemic has exacerbated the existing challenges to achieving the WHO target of eliminating cervical cancer as a public health problem by working towards the target of fewer than four cases per 100 000 women. We reviewed the literature to identify potential recovery strategies to support cervical cancer prevention programs in lower-and middle-income countries (LMICs) following COVID-19 disruptions and the extent to which strategies have been implemented. Utilising the WHO health systems framework, we mapped these recovery strategies against the six building blocks to examine their reach across the health system. Most recovery strategies were focused on service delivery, while leadership and governance played a pivotal role in the continuity of cervical cancer prevention programs during the pandemic. Leadership and governance were the drivers for outcomes in the building blocks of health information systems, financing and critical support in operationalising service delivery strategies. In the aftermath of the COVID-19 pandemic with strained health resources and economies, stakeholders would significantly influence the coverage and sustainability of cervical cancer prevention programs. The support from multisectoral stakeholders would accelerate the recovery of cervical cancer prevention programs. To achieve the WHO target by 2030, we call for future studies to understand the barriers and facilitators from the perspectives of stakeholders in order to support the decision-making processes and information required to implement recovery strategies in LMICs.

Limited applicability and implementation of the international oncology treatments guidelines in low- and middle-income countries, an example from the Mediterranean area borders

The quality of cancer care in the modern era is based on a precise diagnosis and personalized therapy according to patients and their disease based on validated guidelines with a high level of evidence. During cancer patients' management, the objective is first to make an accurate diagnosis and then offer the best treatment, validated beforehand in a multidisciplinary board meeting, with the best benefit/risk ratio. In the context of many low- and middle-income countries, the limited available means do not allow an adequate offer, resulting in non-optimal patients' care. In addition, in many low- and middle-income countries, priority can be given to other types of disease than cancer, which may considerably reduce allocation of specific resources to cancer care. Thus, the limited availability of systemic therapy, radiotherapy machines, brachytherapy and technological development may come up against another difficulty, that of geographical distribution of the means in the countries or a lack of expertise due to insufficient training programs. For all these reasons, the implementation of the guidelines established in Western countries could be impossible for many low- and middle-income countries which, moreover, have to face a completely different epidemiology of cancers compared to developed countries. In this work, we will discuss through a few examples of common cancers on both borders of the Mediterranean area, the applicability of the guidelines and the limits of their implementation for optimal cancer care.

Global cancer surgery in low-resource settings: A strengths, weaknesses, opportunities, and threats analysis

Global cancer surgery is an essential and complex component of oncologic care. This study aims to describe global cancer surgery literature since the 2015 Lancet Commission on Global Surgery and Cancer Surgery and perform a strengths, weaknesses, opportunities, and threats (SWOT) analysis. A systematic search was performed in PubMed of global cancer surgery articles. Themes were extracted from the included studies based on the following criteria: (1) performed in low- or low-middle-income countries, (2) published during or after 2015, (3) published in peer-reviewed journals, (4) written in the English language, and (5) accessible to the authors. Themes were further grouped into strengths, weaknesses, opportunities, and threats (SWOT analysis). The search strategy identified 154 articles published from 1992 to 2022. Forty-six articles were included in the qualitative synthesis and SWOT analysis. Recurring themes included local epidemiologic studies, local innovations and feasibility studies, prioritizing quality of life outcomes, multidisciplinary team approaches, limited resources, health system gaps, lack of economic analyses, diverse cancer management strategies and priorities, inter-setting collaboration, research expansion, the coronavirus disease 2019 pandemic, and unchecked technological advancements. These strengths, weaknesses, opportunities, and threats were described and related to the themes of research, surgical systems strengthening, economics and financing, and political framing of the 2015 Lancet Commission on Global Cancer Surgery. SWOT analyses of global cancer surgery may be helpful in suggesting future strategies for this expanding field. PLAIN LANGUAGE SUMMARY: Cancer surgery is a resource-intensive yet essential component of cancer care. In the face of projected growth of cancer burden, the present gap in cancer surgery care in low-resource settings with stressed health care and surgical infrastructure risks further exacerbation. We present a strengths, weaknesses, opportunities, and threats analysis of recent global cancer surgery literature pertaining to low-resource settings.

Two lateral parametria in radical hysterectomy: History and outcome

AIM

Some anatomic concepts for 20th century radical hysterectomy (RH) did not conform to progress in surgical technique. The purpose of this article was to put forward a new practical anatomy and application to surgical procedures.

METHODS

Following a historical review the author reexamined his surgical procedures from 1980 to 2005 on 131 patients with cervical cancer. One hundred and eight of these patients had undergone RH and 23 super RH plus neoadjuvant chemotherapy, 7 had RH combined with a total mesorectal excision because of infiltration into the lateral rectal ligament due to rectal cancer. Also reviewed were data on surgical procedures and anatomy following a series of mock RH on 26 donated female cadavers.

RESULTS

It was found that the cardinal ligament and transverse cervical ligament must be distinguished. The vesicohypogastric fascia, transverse cervical ligament, and lateral rectal ligament formed a continuum with their relationship to the organs being perpendicular. The surgical technique for an RH is total excision of the transverse cervical ligament, whereas the one for a semi-RH is partial or total excision of the deep uterine vein. The paracolpium is the caudal extension of the cardinal ligament, not the medial extension of the superior fascia of pelvic diaphragm.

CONCLUSION

New practical anatomy and surgical technique were established through recognition of morphology of the living body being transformed by surgical maneuvers.

Image-guided adaptive brachytherapy for advanced cervical cancer spreading to the bladder and/or rectum: Clinical outcome and prognostic factors

INTRODUCTION

Refinements of brachytherapy techniques have led to better local control of locally advanced cervical cancer (LACC), especially with the development of image-guided adaptive brachytherapy (IGABT). Data on the efficacy of brachytherapy in cervical cancer spreading to adjacent organs are scarce. We report the experience of our institution in the treatment of these advanced tumors with IGABT.

MATERIALS AND METHODS

Medical records of patients treated for a LACC spreading to the bladder and/or rectum between 2006 and 2020 at Gustave Roussy Institute were analyzed. Dosimetric parameters were collected and converted into 2 Gy per fraction equivalent doses, including the minimal dose received by 90% of the high-risk target volume (D₉₀ CTV_HR) and intermediate-risk target volume (D₉₀ CTV_IR), as well as the dose received by the most exposed 2 cm³ of the organs at risk. A Cox regression model was used to study the potential associations between clinical and dosimetric factors with survival endpoints and fistula formation.

RESULTS AND STATISTICAL ANALYSIS

A total of 81 patients were identified. All patients received pelvic+/- para-aortic radiotherapy, 45 Gy in 25 fractions +/- boost to gross lymph nodes. Concomitant platinum-based chemotherapy was administered in 93.8% of cases. The median D₉₀ CTV_HR dose was 75.5 Gy_EQD2 (SD: 10.39 Gy_EQD2) and median CTV_HR volume was 47.6 cm³ (SD: 27.9 cm³). Median bladder and rectal D2_cm3 dose were 75.04 Gy_EQD2 (SD: 8.72 Gy_EQD2) and 64.07 Gy_EQD2 (SD: 6.68 Gy_EQD2). After a median follow-up of 27.62 ± 25.10 months, recurrence was found in 34/81 patients (42%). Metastatic failure was the most common pattern of relapse (n = 25). Use of a combined interstitial/intracavitary technique and D₉₀ CTV_HR ≥ 75.1 Gy_EQD2 were prognostic factors for OS in univariate analysis (HR = 0.24, 95%IC: 0.057-1, p = 0.023; HR = 0.2, 95%IC: 0.059-0.68, p = 0.0025, respectively). In multivariate analysis, a D₉₀ CTV_HR ≥ 75.1 Gy_EQD2 was significant for OS (HR = 0.23; 95%IC: 0.07, 0.78, p = 0.018). The occurrence of vesicovaginal fistula (VVF) was the most frequent pattern of local recurrence (HR = 4.6, 95%CI: 1.5-14, p = 0.01).

CONCLUSION

Advances in brachytherapy modalities improved local control and survival while reducing toxicities. Enhancing local control through dose escalation and combined intracavitary/interstitial brachytherapy techniques is a major factor in patients cure probability, together with systemic intensification to better control distant events.

RGS1 and related genes as potential targets for immunotherapy in cervical cancer: computational biology and experimental validation

Background

Effective treatment is needed for advanced, inoperable, or chemotherapy-resistant cervical cancer patients. Immunotherapy has become a new treatment modality for cervical cancer patients, and there is an urgent need to identify additional targets for cervical cancer immunotherapy.

Methods

In this study the core gene, RGS1, which affects immune status and the FIGO stage of cervical cancer patients was identified by WGCNA analysis and differential analysis using TCGA database. 10 related genes interacting with RGS1 were identified using PPI network, and the functional and immune correlations were analyzed. Based on the expression of RGS1 and related genes, the consensus clustering method was used to divide CESC patients into two groups (group 1, high expression of RGS1; group 2, low expression of RGS1). Then, the functional enrichment analysis was used to search for the functional differences in differentially expressed genes (DEGs) between group 1 and group 2. Immune infiltration analysis was performed using ESTIMATE, CIBERSORT, and ssGSEA, and the differences in expression of immune checkpoint inhibitors (ICIs) targets were assessed between the two groups. We investigated the effect of RGS1 on the clinical relevance of CESC patients, and experimentally verified the differences in RGS1 expression between cervical cancer patient tissues and normal cervical tissues, the role of RGS1 in cell function, and the effect on tumor growth in tumor-bearing mice.

Results

We found that RGS1 was associated with CD4, GNAI3, RGS2, GNAO1, GNAI2, RGS20, GNAZ, GNAI1, HLA-DRA and HLA-DRB1, especially CD4 and RGS2. Functional enrichment of DEGs was associated with T cell activation. Compared with group 2, group 1 had stronger immune infiltration and higher ICI target expression. RGS1 had higher expression in cervical cancer tissues than normal tissues, especially in HPV-E6 positive cancer tissues. In cervical cancer cell lines, knockdown of RGS1 can inhibited cell proliferation, migration, invasion, and tumor growth in nude mice and promoted apoptosis.

Conclusions

RGS1, as an oncogenic gene of cervical cancer, affects the immune microenvironment of patients with cervical cancer and may be a target of immunotherapy.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

Simple Summary

For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care.

Abstract

Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.

Providing Patients with Locally Advanced Cervical Cancer Access to Brachytherapy: Experience from a Referral Network for Women Treated in Overseas France

Image-guided adaptive brachytherapy (IGABT) is part of the standard of care for locally advanced cervical cancer (LACC). Access to IGABT is limited in many regions, thus leading to treatment care disparities. We report the experience of a referral network for women with LACC between radiotherapy facilities in Overseas France and Gustave Roussy. This is a retrospective review of patients with LACC referred to Gustave Roussy, for pulsed-dose-rate (PDR) image-guided adaptive BT after initial radiation therapy in the French overseas between 2014 and 2021. Sixty-four patients were eligible to receive IGABT. Overall treatment time (OTT) was 60.5 days (IQR: 51−68.5). The median follow-up time was 17 months. At two years, estimated probabilities of LC, progression-free survival, and overall survival (OS) were 94.6% (95% CI: 88.9−100.0%), 72.7% (95% CI: 61.1−86.5%), and 82.5% (95% CI: 72.0−94.5%). In multivariable analysis, a D90CTVHR < 85GyEQD2 and a CTVHR volume > 40 cm3 were significant for poorer PFS (p = 0.001 and p = 0.009, respectively) and poorer OS (p = 0.004 and p = 0.004). The centralization of this advanced technique to expert centers requires a well-defined workflow and appropriate dimensioning of resources to minimize OTT.

Current Standards in the Management of Early and Locally Advanced Cervical Cancer: Update on the Benefit of Neoadjuvant/Adjuvant Strategies

Globally, cervical cancers continue to be one of the leading causes of cancer-related deaths. The primary treatment of patients with early-stage disease includes surgery or radiation therapy with or without chemotherapy. The main challenge in treating these patients is to maintain a curative approach and limit treatment-related morbidity. Traditionally, inoperable patients are treated with radiation therapy solely and operable patients undergo upfront surgery followed by adjuvant (chemo) radiotherapy in cases with poor histopathological prognostic features. Patients with locally advanced cervical cancers are treated with concurrent chemoradiotherapy followed by an image-guided brachytherapy boost. In these patients, the main pattern of failure is distant relapse, encouraging intensification of systemic treatments to improve disease control. Ongoing trials are evaluating immunotherapy in locally advanced tumours following its encouraging efficacy reported in the recurrent and metastatic settings. In this article, clinical evidence of neoadjuvant and adjuvant treatments in cervical cancer patients is reviewed, with a focus on potential strategies to improve patients' outcome and minimize treatment-related morbidity.