Early Clinical Outcomes in Patients of Carcinoma Cervix Treated With Volumetric Modulated Arc Therapy

Objective Carcinoma cervix is one of the major cancers affecting Indian women. Concurrent chemo-radiotherapy is the standard of care in the treatment of carcinoma cervix. We aimed to study the outcomes and toxicity profile of volumetric modulated arc therapy (VMAT), an advanced modality of radiation delivery when used to treat patients with carcinoma cervix. Materials and methods Patients of carcinoma cervix belonging to FIGO (The International Federation of Gynecology and Obstetrics) stages IB2- IVA were recruited into the study. The patients were treated with VMAT to an EBRT (External Beam Radiation Therapy) dose of 50.4Gy in 28 fractions, which was followed by a brachytherapy schedule of 8Gy for each fraction to point A for three fractions. Toxicities were monitored weekly during the course of treatment and thereafter at every follow-up visit. A response assessment CECT (Contrast Enhanced Computed Tomography) scan was done three months after treatment and the response was recorded using RECIST (Response Evaluation Criteria In Solid Tumors) criteria. Results Sixty-four patients were available for analysis and most of the patients belonged to stage IIB (50.3%) followed by stage IIIB (28.5%). The complete response rate was 90.6% at three months and at a median follow-up of 12 months, the overall survival was 100% and disease-free survival was 89.1%. An analysis of clinically significant toxicities (grade 2 or worse) showed that diarrhea was the most common (20.3%) followed by proctitis (14%) and anemia (9.3%). Conclusion The results of the study established that volumetric modulated arc therapy is an acceptable modality of treatment of carcinoma cervix with an attractive toxicity profile. However, longer follow-ups will provide valuable information regarding the long-term disease control and late toxicities of the treatment.

Radiotherapy Versus Chemotherapy in Locally Advanced Cervical Cancer

Eighty percent of women who have cervical cancer present at such an alarmingly advanced stage leading to high morbidity and mortality. Due to a lack of public awareness and inadequate infrastructure for screening and early identification in resource-poor countries like India, this tardy presentation is anticipated to continue in the future. Standard management for locally advanced squamous cell cervical cancer is radiotherapy. To increase responses and survival, neoadjuvant chemotherapy (NACT) was introduced to the arsenal. Recent studies from India have shown encouraging results for women getting concomitant chemo-radiation for locally advanced cervical cancer. However, toxicities are still a major problem. The approximated five-year actuarial survival rate with NACT is roughly 45% (95% confidence interval, 37-53%) with a median survival rate of 56 months. Compared to radiotherapy alone, patients receiving chemo-radiation are said to have a considerably better survival rate. Vomiting and nausea are the adverse effects that occur most frequently. Renal dysfunction and myelosuppression can also happen. However, there is evidence of effective tumor control. We will talk about a 55-year-old, para 5 elderly lady who had white discharge coming from her vagina and a cervical mass that bled when touched. She underwent NACT for six weekly cycles, followed by definitive chemo-radiation, and she responded favorably to this management strategy, indicating that the addition of chemotherapy is yet another cause for optimism in the management of cancer of the cervix.

Ten years survival results of randomized study comparing weekly vs. triweekly cisplatin with concurrent radiation in locally advanced carcinoma cervix

Background

The current standard of treatment for locally advanced cervical cancer is concurrent chemo-radiation with improved overall survival (OS) by 6% with manageable toxicities. The cisplatin 40 mg/m2 given weekly is the widely practiced regimen for 4-6 cycles concurrently with irradiation.

Materials and methods

Two hundred and twelve patients with histologically proven squamous cell carcinoma of cervix with stages IIB to IIIB were enrolled between 2007-2011. External beam radiation dose of 45 Gy in 25 fractions was delivered over 5 weeks. Brachytherapy was delivered by manual afterloading cesium-137 (Cs137) low dose brachytherapy (LDR) using modified Fletcher suit intracavitary applicators to a total dose of 30 Gy to Point A or interstitial template to dose of 21 Gy/3 fractions with remote afterloading iridium-192 (Ir192) high dose brachytherapy (HDR). Patients were randomized to arm A receiving 40 mg/m2 of concurrent cisplatin weekly and arm B receiving 100 mg/m2 of concurrent cisplatin triweekly.

Results

One hundred and nine patients were randomized to weekly cisplatin and one hundred and three patients to triweekly cisplatin at the end of recruitment. At ten years, the OS was higher in the weekly arm (79.8%) compared to triweekly arm (70.9%). Disease free survival (DFS) was almost equal (76.1% and 73.8%) in the weekly and three-weekly arms. There is definite significance in overall DFS with patients receiving the cumulative cisplatin doses of more than 250 mg (p = 0.028). The patients with more than 45 years of age had better overall survival (OS) (79%) with statistical significance 31 (p = 0.020).

Conclusion

Both cisplatin based triweekly and weekly concurrent chemotherapy are equally effective in terms of OS and DFS.

Reporting of Inter Fraction Dose Variations of Organs at Risk in Computed Tomography-Guided High Dose Rate Intracavitary Brachytherapy in Carcinoma Cervix

Assess the interfraction dose variations of the organs at risk (OARs) in carcinoma cervix high dose rate (HDR) computed tomography (CT)-guided intra cavitary brachytherapy (ICBT). 120 CT scans of 40 patients who had undergone three fractions of ICBT (7 Gy/fr) were analyzed. Dose to Point A and the minimum doses to the volumes of 2, 1, and 0.1cc of bladder, rectum and sigmoid colon were recorded. Revised plans were generated in 20 patients. Paired t-test was used to compare the difference in the means. Point "A" mean dose difference was statistically significant between the treated and revised plans. For bladder, the difference in means of dosage to all volumes, whilst for the rectum and sigmoid colon, the low volume dosage (0.1cc) was statistically significant. Absence of individualized planning would have resulted in underdosage of tumor and increased dosage of up to 30% to OARs. CT-guided ICBT should be implemented for each HDR fraction treatment.

Weekly vs. tri-weekly cisplatin based chemoradiation in carcinoma cervix: a prospective randomized study of toxicity and compliance

BACKGROUND

Addition of chemotherapy to radiation has improved 5-year survival by 6%. However, the optimal dose and schedule of concurrent cisplatin is not well defined, though widely accepted practice is the weekly schedule of 40 mg/m2 for 5 weeks. Repeated admissions for weekly cisplatin drain the limited resources in high volume centres. We intended to study the compliance and toxicity of two cisplatin schedules in our patients diagnosed with carcinoma cervix.

MATERIALS AND METHODS

Between 2007-2011, 212 patients, histologically proven squamous cell carcinoma with stages IIB to IIIB were randomized into two arms. All patients were planned for external beam radiotherapy 45 Gy/25 frs over 5 weeks followed by Intracavitary or Interstitial brachytherapy to a total BED dose of 75-85 Gy. Single agent cisplatin given concomitantly, was scheduled weekly (40 mg/m2/cycle, 5 cycles) in an arm A and three weekly (100 mg/m2/cycle, 2 cycles) in an arm B. Toxicity and compliance were evaluated weekly according to the RTOG guidelines. Analysis of the compiled data was done using SSPS version 20.

RESULTS

Of the evaluable 212, 109 patients received weekly cisplatin chemotherapy and 103 patients received three weekly cisplatin. The most common acute toxicity observed was grade I-II leucopoenia. The upper and lower gastrointestinal reactions were high in three weekly arms, which was statistically significant (57% and 42.7%, p < 0.05). Proctitis was observed in 10% of patients in both of the arms and only two patients had Gr1 Cystitis after 6 months of treatment.

CONCLUSIONS

Tri-weekly cisplatin based concurrent chemoradiation can be adopted in high volume centres with manageable haematological and gastrointestinal acute toxicities.

Awareness of cancer cervix and its prevention among students in Melaka, Malaysia

BACKGROUND

Cancer cervix is caused by human papillomavirus (HPV), oncogenic virus and has vaccines and screening as its preventive measures. This study analyzes the change in awareness and attitudes of nonmedical students toward the condition following the use of an educational module.

METHODOLOGY

The study design was quasi-experimental. The interprofessional (IP) team implemented an educational module and analyzed the difference in awareness of young individuals toward the cancer cervix. A pretest and posttest written questionnaire, customized for both genders, was administered with the intervention of the educational module in between. The module consisted of a short educational presentation along with a group activity. A follow-up survey was also done after 2 months to check the attrition of awareness. The statistical analysis was done using MacNemar test using SPSS 12 IBM software and significance of differences were determined.

RESULTS

There was a significant improvement of knowledge and awareness on linkage between HPV and cervical cancer (P < 0.001). There was also significant change with regard to attitudes toward cervical cancer vaccination (P = 0.004). The knowledge of HPV linkage to the malignancy was maintained after 2 months of gap. The subjects also wished for more future awareness program.

CONCLUSIONS

There is improved awareness in the dental and foundation in science students, and this improved awareness will ensure favorable attitudes toward cervical cancer vaccines or will attend regular screening programs. Awareness program must be held at regular intervals at different locations to enhance the knowledge dissemination of this common yet preventable genital malignancy of females. The IP collaboration and practices will help in reducing the disease burden of the society in future.

Comparison of iso-effective and cost-effective high-dose-rate brachytherapy treatment schedules in cervical cancer - regional cancer center experience

Purpose

The study is to evaluate the difference between outcomes of two high-dose-rate fractionation schedules in the treatment of intracavitary brachytherapy (ICBT) of cervical cancer.

Material and methods

A retrospective analysis of 163 cervical cancer patients was completed. All patients received external beam radiotherapy (EBRT) to whole pelvis with concurrent weekly chemotherapy, followed by ICBT with either 7 Gy per fraction in three fractions (arm A) or 9 Gy per fraction in two fractions (arm B). Median follow-up was 19 months. The outcomes were compared in terms of 2-year actuarial local control, disease-free survival, overall survival, and late toxicity in the two treatment arms.

Results

The 2-year actuarial local control rates in arm A and arm B were 88.5% and 91.5%, respectively. The actuarial 2-year disease-free survival rates in arm A and arm B were 85.9% and 82.6%, respectively. The actuarial 2-year overall survival in arm A and arm B were 95.7% and 100%, respectively (p = 0.06). There were 12.7% and 15.2% local failures in arm A and arm B, respectively. Distant metastases were seen in 8.5% and 7.6% in arm A and arm B, respectively. The 2-year actuarial risk of developing late rectal toxicity in arm A and arm B were 5.6% and 5.4%, respectively. The 2-year actuarial risk of developing late bladder toxicity in arm A and arm B were 2.8% and 2.2%, respectively.

Conclusions

ICBT treatment with 9 Gy in two fractions offers equivocal local control rates and survival rates in cancer cervix cases with many advantages of short overall treatment time, improved patient compliance, cost effectiveness, and reduced exposure to aesthetic agents. The toxicities observed were few, low grade, and easily manageable.

Dose verification in carcinoma of uterine cervix patients undergoing 3D conformal radiotherapy with Farmer type ion chamber

External beam radiotherapy (EBRT) for carcinoma of uterine cervix is a basic line of treatment with three dimensional conformal radiotherapy (3DCRT) in large number of patients. There is need for an established method for verification dosimetry. We tried to document absorbed doses in a group of carcinoma cervix patients by inserting a 0.6 cc Farmer type ion chamber in the vaginal cavity. A special long perspex sleeve cap is designed to cover the chamber for using in the patient's body. Response of ionization chamber is checked earlier in water phantom with and without cap. Treatment planning was carried out with X-ray computed tomography (CT) scan and with the chamber along with cap in inserted position, and with the images Xio treatment planning system. Three measurements on 3 days at 5-6 fraction intervals were recorded in 12 patients. Electrometer measured charges are converted to absorbed dose at the chamber center, in vivo. Our results show good agreement with planned dose within 3% against prescribed dose. This study, is a refinement over our previous studies with transmission dosimetry and chemicals in ampules. This preliminary work shows promise that this can be followed as a routine dose check with special relevance to new protocols in the treatment of carcinoma cervix with EBRT.

A Community-based Cervical Cancer Screening Program among Women of Delhi using Camp Approach

BACKGROUND

Cervical cancer is the commonest malignancy among women in developing countries. Cytological screening (Pap smear) have been claimed to reduce incidence and mortality of carcinoma cervix significantly for which sensitization of women is required through community-based approach.

OBJECTIVES

To find out number of cervical cancer cases among patients reporting to a general health care camp through screening program and study the prevalence of perceived morbidity and its confirmation.

SETTINGS

Cross-sectional study among women attending cancer awareness camps.

MATERIALS AND METHODS

A total of 435 women attending cancer awareness camps were screened for carcinoma cervix. The findings of history and clinical examination were recorded. Pap smears of all the symptomatic patients were collected and cytological diagnosis was confirmed by a pathologist.

RESULTS AND CONCLUSIONS

The perceived gynecological morbidity was observed to be 59.8%. The smear of the women who were suspected of carcinoma on clinical examination was confirmed to be the cases of carcinoma-in-situ (7.8%) and high-grade neoplasia (2.9%) on laboratory investigations. The findings of the study highlight the utility and need of cancer cervix screening among the women at regular intervals through camp approach in the community.