Feasibility and benefit of concurrent chemoradiotherapy for elderly patients with uterine cervical cancer

Predictors of Clinical Hematological Toxicities under Radiotherapy in Patients with Cervical Cancer-A Risk Analysis

BACKGROUND

Cervical cancer ranks third in frequency among female cancers globally and causes high mortality worldwide. Concurrent chemoradiotherapy improves the overall survival in cervical cancer patients by 6% but it can cause significant acute and late toxicities affecting patient quality of life. Whole pelvis radiotherapy doses of 10-20 Gy can lead to myelosuppression and to subsequent hematological toxicities since pelvic bones contain half of bone marrow tissue.

METHODS

A total of 69 patients with IB-IVB-staged cervical cancer have been included in this retrospective cohort study. We analyzed clinical adverse events and changes in blood cell counts (hemoglobin, neutrophils, leukocytes, and platelets) during radiation or chemoradiotherapy received at the Oncological Institute of Bucharest from 2018 to 2021.

RESULTS

Decreases in hemoglobin levels of over 2.30 g/dL during treatment were associated with BMI > 23.2 kg/m2 (OR = 8.68, 95%CI = [1.01, 75.01]), age over 53 years (OR = 4.60 95%CI = [1.10, 19.22]), with conformational 3D irradiation (OR = 4.78, 95%CI = [1.31, 17.40]) and with total EQD2 of over 66.1 Gy (OR = 3.67, 95%CI = [1.02, 13.14]). The hemoglobin decrease rate of 0.07 g/dL/day was related to 95% isodose volume (OR = 18.00). Neutropenia is associated frequently with gastrointestinal side effects and with the bowel and rectal V45 isodoses (OR = 16.5 and OR = 18.0, respectively). Associations of total external and internal radiation dose with the time durations calculated from the initiation of treatment to the onset of hematological adverse reactions were also obtained. The maximum drop in leukocytes was observed before day 35 from the RT initiation in patients who underwent treatment with 3D conformal radiotherapy (OR = 4.44, 95%CI = [1.25, 15.82]). Neutrophil levels under 2.2 × 103/μL and thrombocyte levels under 131 × 103/μL during the follow-up period were associated with a total planned dose of 54 Gy to the pelvic region volume (OR = 6.82 and OR = 6.67, respectively).

CONCLUSIONS

This study shows the existence of clinical and blood predictors of hematological adverse reactions in cervical cancer patients. Thus, patients who are in a precarious clinical situation, with low hematological values (but not yet abnormal), should be monitored during days 29-35 after the initiation of RT, especially if they are obese or over 53 years of age.

Experiences of human papillomavirus self-sampling by women >60 years old: A qualitative study

BACKGROUND

Human papillomavirus (HPV) self-sampling has shown to be acceptable and feasible across cultures and effective in reaching women who do not participate in regular cervical cancer screening. However, most of these studies have included younger women. There is a lack of knowledge of how older women reason about HPV self-sampling.

OBJECTIVE

The aim of this study was to describe how women (>60 years old) experience the offering of self-sampling of HPV, compared to having a sample collected by a healthcare professional.

DESIGN AND PARTICIPANTS

The study had a qualitative explorative design. Four focus group discussions were conducted with women 60-69 years old (n = 22). Data were analysed using principles of interpretive description.

RESULTS

Five themes were identified: self-sampling-convenient and without pain, lack of knowledge, worries related to HPV self-sampling, need for information and taking a societal perspective.

CONCLUSION

Women aged >60 years found that HPV self-sampling was convenient and easy to perform. Further, they stressed the importance of being able to remain in the screening programme in advanced age and that self-sampling could be a possible solution. This study also revealed a lack of knowledge among women in this age group regarding HPV infection, how the disease is transmitted and its relation to cervical cancer.

PUBLIC CONTRIBUTION

Women who had performed HPV self-sampling participated in the focus group discussion.

Outcomes with definitive radiotherapy among patients with locally advanced cervical cancer with relative or absolute contraindications to cisplatin: A systematic review and meta-analysis

BACKGROUND

The standard treatment for locally advanced cervical cancer (LACC) is chemoradiation (CRT) with cisplatin, followed by brachytherapy, but is less defined for cisplatin-intolerant patients. We synthesized evidence on treatment outcomes with definitive radiotherapy (RT) with or without chemotherapy (ChT) in these patients.

METHODS

We performed a systematic search and included 20 relevant studies. We extracted data on response, survival, compliance, and toxicity, and performed meta-analyses of outcome rates and risk ratios. Sensitivity and subgroup analyses were performed to explore sources of heterogeneity. Meta-regression was performed to examine the effects of other variables.

RESULTS

Due to lack of comparative data, most comparisons were indirect and derived from the proportional meta-analyses. Complete response (85%) and survival (62% 5yOS) rates are comparable to those published for LACC without contraindications to cisplatin. Survival rate is better with CRT than RT alone (5yOS, 73% vs 58%), and with nodal boost (NB) than without (5yOS, 71% vs 56%). Carboplatin CRT is associated with lower 5yOS (44%) but better ChT compliance (86%) when compared to other interventions. ChT compliance is better in renal failure than elderly cohorts (89% vs 67%). RT compliance is lower with CRT than RT alone (90% vs 96%), and higher with NB than none (96% vs 93%). NB is associated with lower RT compliance than no NB, when ChT is given. Meta-regression results affirm ChT and NB to be significant positive factors for survival, and NB, which is associated with greater use of advanced RT techniques, for RT compliance.

CONCLUSION

For those with relative contraindications, cisplatin CRT is effective and well-tolerated. For those with absolute contraindications, carboplatin is well-tolerated but with unclear effectiveness. Nodal boost is effective and well-tolerated, but is less tolerated when concurrent ChT is given.

Non-stereotactic radiotherapy in older cancer patients

Old or very old oncological patients represent a heterogeneous and frail population due to concomitant comorbidities. Whether radiotherapy alone or in combination with novel cancer drugs may provide a clear benefit in this setting of patients is still a matter of debate.

The aim of our review is to analyze the evaluation process and the different therapeutic possibilities in older cancer patients, focusing on the different and most disparate applications of radiotherapy. We reviewed the most recent literature on radiotherapy in older patients providing clinical evidence of treatment related toxicity, tolerance and outcomes using standard fractionated and/or hypofractionated irradiation alone or in combination with chemotherapy, targeted and immunotherapy.

In older cancer patients unfit for systemic therapy or surgery, radiotherapy represents a valid therapeutic approach, both with curative and palliative intents, ensuring excellent patient compliance in terms of local toxicity and adherence to therapy.

Characteristics and Treatments of Patients Aged 65 Years or Over with Cervical Cancer

Purpose

Although the mortality of elderly women with cervical cancer is high, their characteristics and prognosis have not attracted sufficient attention. This study aims to clarify the prognostic factors of cervical cancer patients aged ≥65.

Patient and Methods

The incidences and characteristics of patients diagnosed with cervical cancer (aged ≥65 and <65) during 2004–2015 were obtained through the Surveillance, Epidemiology, and End Results Program (SEER) database. The differences of distributions of characteristics between two age groups were compared by chi-squared (χ²) test. Kaplan–Meier survival method, Log-rank test, Cox-regression and visual nomogram were utilized for survival analysis.

Results

The annual incidences of two age groups with cervical cancer were (5.5–7.5)/100,000 and (3.4–3.9)/100,000, respectively, during 2004–2015. The 1-year and 5-year cancer-specific survival rates of old patients were both lower than those of young patients (P <0.001). The proportions of unmarried state and advanced International Federation of Gynecology and Obstetrics (FIGO) stage in old patients were higher than those in relatively young patients, and fewer elderly patients received surgery. Univariate and multivariate survival analysis showed non-squamous cell carcinoma, poor differentiation and late FIGO stage were independent poor prognostic factors for patients aged ≥65. Treatments improved the outcomes of elderly patients, and the effect of surgery was better than non-surgical treatment on elderly patients with FIGO I. Besides, geriatric score and survival probability could be accomplished by our nomogram with a c-index of 0.7945.

Conclusion

Delayed diagnosis and insufficient treatment were two distinct features of elderly patients and correlated with their poor clinical outcomes. More attention and active treatments should be adopted in elderly women based on their general condition.

Benefit of Cisplatin With Definitive Radiotherapy in Older Women With Cervical Cancer

Background: Cisplatin with definitive radiotherapy (RT) is considered the standard of care for cervical cancer; however, older women are frequently undertreated and have worse outcomes compared with younger patients. Because women aged ≥65 years have been disproportionately underrepresented in clinical trials, uncertainties exist regarding how much they benefit from the addition of cisplatin to RT. Patients and Methods: Women aged ≥65 years with nonmetastatic cervical cancer treated with definitive external-beam RT and brachytherapy were identified in the SEER-Medicare database. Death attributable to cervical cancer (cancer-specific mortality [CSM]) was evaluated against competing risks of death using Gray’s test. Propensity score analysis and the Fine-Gray multivariable regression model were used to adjust for baseline differences, including comorbidity. Results: The total cohort comprised 826 patients, of whom 531 (64%) received cisplatin, 233 (28%) were FIGO stage I, 374 (45%) were stage II, and 219 (27%) were stage III–IVA. Older age and chronic kidney disease significantly predicted omission of cisplatin. Virtually all cisplatin dosing was weekly, with a median of 5 cycles. Death from cervical cancer was significantly lower with cisplatin than without (5-year CSM, 31% vs 39%; P=.02; adjusted hazard ratio, 0.72; P=.02), which persisted in propensity score analysis. Receiving ≥5 cycles was required for benefit, as no difference in CSM was seen in patients receiving 1 to 4 cycles versus no cisplatin. Subgroup analyses revealed that the benefit of cisplatin persisted in women aged ≥75 years and those with early-stage disease. Incidence of cytopenia, nausea/vomiting, and hypovolemia increased in patients treated with cisplatin. Conclusions: Administration of cisplatin with definitive RT in women aged ≥65 years was associated with a significant benefit in the incidence of death attributable to cervical cancer, despite competing risks for mortality in an older population. Receiving at least 5 cycles of weekly cisplatin was required for benefit.

Radiation therapy for elderly patients with uterine cervical cancer: feasibility of curative treatment

As the average lifespan lengthens worldwide, and the older adult population increases, the number of elderly patients with uterine cervical cancer is increasing. Because intensive and invasive treatments, including surgery, are frequently unacceptable in elderly patients, cancer treatments for these patients must be carefully considered. Elderly patients have undergone radiation therapy as less-invasive curative treatment, and it has been shown to be safe and effective for local control of cervical cancer in this population, even among patients aged ≥80 years treated with curative radiation doses. Although concurrent chemoradiotherapy is the standard treatment for locally advanced cervical cancer, it is unclear whether the addition of chemotherapy to radiation therapy prolongs survival in elderly patients. Elderly patients treated with curative radiation therapy for cervical cancer might develop more therapy-related gastrointestinal and hematological toxicities and insufficiency fractures compared with younger patients. However, advanced techniques of radiation therapy (eg, intensity-modulated radiation therapy and volumetric modulated arc therapy with photons, charged-particle radiation therapy with protons and carbon ions in external-beam radiation therapy, and image-guided adaptive brachytherapy) can minimize radiation-induced toxicities and thus make curative treatment safer and more effective for elderly patients with uterine cervical cancer.

Assessment of treatment factors and clinical outcomes in cervical cancer in older women compared to women under 65 years old

OBJECTIVE

This study aims to understand the treatment patterns and clinical outcomes of older women with cervical cancer compared to younger women.

METHODS

Women undergoing care for cervical cancer between 2000 and 2013 at two academic institutions were identified. The cohort of older patients was defined as >65 years old at diagnosis. Patient charts were retrospectively reviewed, and clinical variables were extracted. Fisher's exact tests, logistic regression, and Kaplan-Meier analyses were performed.

RESULTS

From 2000 to 2013 1119 women with cervical cancer were identified. Of these, 191 (17.0%) were >65 years old at the time of diagnosis. Older women were more likely to present with higher stage disease (p < 0.001). Controlling for stage, older women were less likely to undergo surgery during their treatment course (38% versus 70%, p < 0.001) and more likely to undergo radiation (77% versus 52%, p < 0.001), but no more likely to receive chemotherapy (p = 0.34). If they did undergo surgery, older women were less likely to have a pelvic lymph node dissection performed (41% versus 61%, p = 0.04), though the rate of positive pelvic lymph nodes was not different (p = 0.80). Overall survival was decreased in the older cohort (p < 0.001). A multivariate model identified age > 65 (HR 1.76, 95%CI 1.30-2.40), stage (HR 2.77, 95%CI 2.40-3.21), and ever undergoing surgery (HR 0.60, 95%CI 0.44-0.82) as independently associated with overall survival.

CONCLUSIONS

Women over age 65 with cervical cancer are less likely to undergo surgical management and were observed to have a decreased overall survival, even when controlling for use of surgery and stage of disease.

Definitive Chemoradiotherapy in Elderly Cervical Cancer Patients: A Multiinstitutional Analysis

Objective

The aim of the study was to investigate the prognostic factors for survival and treatment-related toxicities in older (≥65 years) cervical cancer patients treated with definitive chemoradiotherapy. In addition, we sought to compare the outcomes between the older elderly (≥75 years) and their younger old counterparts (age, 65–74 years).

Materials and Methods

We retrospectively reviewed medical records from 269 biopsy-proven nonmetastatic cervical cancer patients treated with external radiotherapy and intracavitary brachytherapy at the departments of radiation oncology in 2 different universities. The prognostic factors for survival, local control, and distant metastasis (DM) were analyzed.

Results

The median follow-up time was 38.8 months (range, 1.5–175.5 months) for the entire cohort and 70.0 months (range, 6.1–175.7 months) for survivors. The 2- and 5-year overall survival (OS), disease-free survival (DFS), and cause-specific survival rates were 66% and 42%, 63% and 39%, and 72% and 55%, respectively. Patients 75 years or older showed significantly worse OS compared with patients aged 65 to 74 years but showed no significant difference in DFS. The 2- and 5-year local control rates were 86% and 71%, respectively. The incidences of DMs at 2 and 5 years were 22% and 30%, respectively. In multivariate analysis, vaginal infiltration and lymph node metastasis were predictive of OS, DFS, local recurrence, and DM. Concomitant chemotherapy was predictive of OS, DFS, and local recurrence, and larger tumor (>4 cm) was a significant prognostic factor for local recurrence. None of the patients had toxicity that necessitated the discontinuation of radiotherapy. All patients were evaluable for acute toxicity, and no grade higher than 3 adverse events occurred during external beam radiation therapy or brachytherapy.

Conclusions

Although age limited the delivery of aggressive treatment, concurrent chemoradiotherapy in elderly patients associated with improved outcomes similar as in younger counterparts without increasing serious acute and late toxicities.

Quality of life among survivors of early-stage cervical cancer in Taiwan: an exploration of treatment modality differences

PURPOSE

Women with early-stage cervical cancer may experience changes in their quality of life (QoL) due to treatment or to the effects of the cancer. In this study, we examined differences in QoL by treatment modality between women who underwent surgery only and those treated with concurrent chemoradiation (CCRT).

METHODS

The sample of 290 women had been diagnosed with stage I-II cervical cancer. Data were collected on these women's demographic and disease characteristics, general QoL, and cancer-specific QoL using an author-designed demographic-disease survey, the European Organization for Research and Treatment of Cancer QoL questionnaire, and the Taiwanese-version Cervical Cancer Module 24 questionnaire, respectively. Data were analyzed by descriptive statistics and analysis of covariance.

RESULTS

Women with cervical cancer who underwent surgery only had significantly worse constipation and body image than those treated with CCRT. Women who underwent CCRT had worse physical and role functioning than those who underwent surgery only. Women who had CCRT also reported worse symptoms, such as fatigue, appetite loss, diarrhea, financial difficulties, sexual enjoyment, and sexual/vaginal functioning, than those who had only surgery.

CONCLUSIONS

Our results add knowledge about QoL in women with early-stage cervical cancer who receive different treatment modalities. When suggesting treatment modalities for women with cervical cancer, health professionals should also consider changes in women's QoL after cancer treatment. To improve women's QoL after treatment, professionals should also offer timely and individualized interventions based on women's cervical cancer treatment.

Influence of Age on Guideline-Concordant Cancer Care for Elderly Patients in the United States

PURPOSE

To examine the frequency of guideline-concordant cancer care in elderly patients, including "older" elderly (age ≥80 years).

METHODS AND MATERIALS

Using the Surveillance, Epidemiology and End Results-Medicare dataset in patients aged ≥66 years diagnosed with nonmetastatic breast cancer (n=55,094), non-small cell lung (NSCLC) (n=36,203), or prostate cancer (n=86,544) from 2006 to 2011, chemotherapy, surgery, and radiation (RT) treatments were identified using claims. Pearson χ² tested associations between age and guideline concordance.

RESULTS

Older patients were less likely to receive guideline-concordant curative treatment: in stage III breast cancer, receipt of postmastectomy RT (70%, 46%, and 21% in patients aged 66-79, 80-89, and ≥90 years, respectively; P<.0001); in stage I NSCLC, RT or surgery (89%, 80%, and 64% in age 66-79, 80-89, and ≥90 years; P<.0001); in stage III NSCLC, RT or surgery plus chemotherapy (79%, 58%, and 27% in age 66-79, 80-89, and ≥90 years; P<.0001); and in intermediate/high-risk prostate cancer, RT or prostatectomy (projected life expectancy >10 years: 85% and 82% in age 66-69 and 70-75 years; and ≤10 years: 70%, 42%, and 9% in age 76-79, 80-89, and ≥90 years; P<.0001). However, older patients were more likely to receive guideline-concordant de-intensified treatment: in stage I to II node-negative breast cancer, hypofractionated postlumpectomy RT (9%, 16%, and 23% in age 66-79, 80-89, and ≥90 years; P<.0001); in stage I estrogen receptor-positive breast cancer, observation after lumpectomy (12%, 42%, and 84% in age 66-79, 80-89, and ≥90 years; P<.0001); in stage I NSCLC, stereotactic body RT instead of surgery (7%, 16%, and 25% in age 66-79, 80-89, and ≥90 years; P<.0001); and in lower-risk prostate cancer, no active treatment (25%, 54%, and 68% in age 66-79, 80-89, and ≥90 years; P<.0001).

CONCLUSION

Actual treatment of older elderly cancer patients frequently diverged from guidelines, especially in curative treatment of advanced disease. Results suggest a need for better metrics than existing guidelines alone to evaluate quality and appropriateness of care in this population.