Phase 1/2 trial evaluating the effectiveness and safety of dose-adapted Hypofractionated pelvic radiotherapy for Advanced Cervical cancers INeligible for ChemoTherapy (HYACINCT)

Postoperative Hypofractionated Intensity-Modulated Radiotherapy With Concurrent Chemotherapy in Cervical Cancer: The POHIM-CCRT Nonrandomized Controlled Trial

Importance

Prospective data assessing the safety of hypofractionated (40 Gy in 16 fractions) radiotherapy (RT) among patients who receive postoperative concurrent chemoradiotherapy for cervical cancer are lacking.

Objective

To evaluate the acute toxic effects of hypofractionated pelvic intensity-modulated radiotherapy (IMRT) with concurrent chemotherapy among women with cervical cancer who underwent radical hysterectomy.

Design, Setting, and Participants

The POHIM-CCRT (Postoperative Hypofractionated Intensity-Modulated Radiation Therapy With Concurrent Chemotherapy in Cervical Cancer) study was designed as a multicenter, phase 2 nonrandomized controlled trial that accrued and followed up patients from June 1, 2017, to February 28, 2023. In total, 84 patients were enrolled from 5 institutions affiliated with the Korean Radiation Oncology Group. Eligible patients experienced lymph node metastasis, parametrial invasion, or positive resection margins after radical hysterectomy for treatment of confirmed cervical cancer.

Intervention

Postoperative pelvic radiation using hypofractionated IMRT with 40 Gy in 16 fractions to the whole pelvis combined with concurrent chemotherapy.

Main Outcomes and Measures

The primary end point was incidence of acute grade 3 or higher gastrointestinal tract, genitourinary, and hematologic toxic effects (based on the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0) in the evaluable population during RT or within 3 months after RT completion.

Results

Of 84 patients enrolled, 5 dropped out prior to RT, and data from 79 patients were analyzed. The patients' median (IQR) age was 48 (42-58) years, and the median (IQR) tumor size was 3.7 (2.7-4.5) cm. Of these patients, 31 (39.7%) had lymph node metastasis, 4 (5.1%) had positive resection margins, and 43 (54.4%) had parametrial invasion. Grade 3 or higher acute toxic effects occurred in 2 patients (2.5% [90% CI, 0%-4.8%]). After a median (IQR) follow-up of 43.0 (21.1-59.0) months, the 3-year disease-free survival rate was 79.3%, and the overall survival rate was 98.0%.

Conclusions

Findings from this nonrandomized control trial indicated that postoperative pelvic irradiation combined with concurrent chemotherapy using hypofractionated IMRT with 40 Gy in 16 fractions was safe and well-tolerated in women with cervical cancer. Studies assessing long-term toxic effects and oncological outcomes with longer follow-up periods are needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03239613.

Hypofractionated Radiotherapy in Gynecologic Malignancies-A Peek into the Upcoming Evidence

Radiotherapy (RT) has a fundamental role in the treatment of gynecologic malignancies, including cervical and uterine cancers. Hypofractionated RT has gained popularity in many cancer sites, boosted by technological advances in treatment delivery and image verification. Hypofractionated RT uptake was intensified during the COVID-19 pandemic and has the potential to improve universal access to radiotherapy worldwide, especially in low-resource settings. This review summarizes the rationale, the current challenges and investigation efforts, together with the recent developments associated with hypofractionated RT in gynecologic malignancies. A comprehensive search was undertaken using multiple databases and ongoing trial registries. In the definitive radiotherapy setting for cervical cancers, there are several ongoing clinical trials from Canada, Mexico, Iran, the Philippines and Thailand investigating the role of a moderate hypofractionated external beam RT regimen in the low-risk locally advanced population. Likewise, there are ongoing ultra and moderate hypofractionated RT trials in the uterine cancer setting. One Canadian prospective trial of stereotactic hypofractionated adjuvant RT for uterine cancer patients suggested a good tolerance to this treatment strategy in the acute setting, with a follow-up trial currently randomizing patients between conventional fractionation and the hypofractionated dose regimen delivered in the former trial. Although not yet ready for prime-time use, hypofractionated RT could be a potential solution to several challenges that limit access to and the utilization of radiotherapy for gynecologic cancer patients worldwide.

Intensity-Modulated Radiation Therapy for Uterine Cervical Cancer to Reduce Toxicity and Enhance Efficacy - an Option or a Must?: A Narrative Review

Radiotherapy (RT) is a fundamental modality in treatment of cervical cancer. With advancement of technology, conventional RT used for external beam radiotherapy (EBRT) for over half a century has been rapidly replaced with intensity-modulated radiation therapy (IMRT) especially during the last decade. This newer technique is able to differentiate the intensity of radiation within the same field, thus reduces the inevitable exposure of radiation to normal organs and enables better dose delivery to tumors. Recently, the American Society for Radiation Oncology has released a guideline for RT in cervical cancer. Although a section of the guideline recommends IMRT for the purpose of toxicity reduction, a thorough review of the literature is necessary to understand the current status of IMRT in cervical cancer. This narrative review updates the recent high-level evidences regarding the efficacy and toxicity of IMRT and provides a better understanding of the most innovative techniques currently available for EBRT enabled by IMRT.

Development and pilot-testing of the expanded prostate index composite - Filipino version (EPIC-F)

INTRODUCTION

Quality-of-life (QOL) is paramount in clinical decision-making in the management of prostate cancer patients. The expanded prostate index composite (EPIC) is a widely used and well-validated QOL tool that allows for the evaluation of bowel, urinary, sexual, and hormonal domains. A Filipino translation was previously lacking. We describe the development and pilot testing of the Filipino translation of the EPIC (EPIC-F).

METHODOLOGY

The EPIC-32 was translated into Filipino using iterative forward and backward procedures with checks for semantic congruency. The translation was then evaluated by an expert panel consisting of a prostate cancer survivor and pertinent health professionals. A focused group discussion (FGD) was conducted to explore sources of difficulty of use to guide improvement.

RESULTS

The linguistically validated translation was evaluated to have cultural relevancy, adequacy, and representativeness by the expert panel, and to have good understandability and answerability by a representative pilot cohort of prostate cancer patients. Seven unsatisfactory items were identified, all pertaining to the sexual domain, and required minimal revision on review during the FGD.

CONCLUSION

The EPIC-F is a linguistically and culturally validated version of the EPIC 32, with good understandability and answerability, permitting clinical use. Its psychometric properties need to be determined to define its utility in clinical research.

Cost analysis of three-dimensional radiation therapy versus intensity-modulated chemoradiotherapy for locally advanced cervical cancer in Peruvian citizens

Background and objectives

The standard treatment for locally advanced cervical cancer (CC) is chemoradiotherapy (CTRT) followed by high-dose-rate brachytherapy (HDRBT). The ideal scenario would be under novel intensity-modulated radiation therapy (IMRT) volumetric-modulated arc therapy (VMAT) radiation techniques over three-dimensional (3D) radiation therapy. However, radiotherapy (RT) centres in low- and middle-income countries have limited equipment for teletherapy services like HDRBT. This is why the 3D modality is still in use. The objective of this study was to analyse costs in a comparison of 3D versus IMRT versus VMAT based on clinical staging.

Materials and methods

From 02/01/2022 to 05/01/2023 a prospective registry of the costs for oncological management was carried out for patients with locally advanced CC who received CTRT ± HDRBT. This included the administration of radiation with chemotherapy. The cost associated with patient and family transfers and hours in the hospital was also identified. These expenses were used to project the direct and indirect costs of 3D versus IMRT versus VMAT.

Results

The treatment regimens for stage IIIC2, including 3D and novel techniques, are those with the highest costs. The administration of 3D RT for IIIC2 and novel IMRT or VMAT techniques, is $3,881.69, $3,374.76, and $2,862.80, respectively. The indirect cost from stage IIB to IIIC1 in descending order is IMRT, 3D and VMAT, but in IIIC2 the novel technique regimens reduce by up to 33.99% compared to 3D.

Conclusion

In RT centres with an available supply of RT equipment, VMAT should be preferred over IMRT/3D since it reduces costs and toxicity. However, in RT centres where demand exceeds supply in the VMAT technique planning systems, the use of 3D teletherapy over IMRT/VMAT could continue to be used in patients with stage IIB to IIIC1.