Brachytherapy Remains Important in Cervical Cancer Management

Coordinating Treatment Components

The SGO/ABS statement spotlighted computed tomography (CT) and magnetic resonance imaging (MRI)-guided adaptive brachytherapy and the feasibility of delivering coordinated EBRT and brachytherapy at different treatment centers “without compromising treatment time and outcome in areas where access to brachytherapy might be limited.”¹ However, patient navigation and careful coordination of care are crucially important for multifacility delivery of EBRT and brachytherapy.¹ Coordination requires multidisciplinary cooperation between gynecologic, radiation, and medical oncology teams and support staff such as patient navigators and scheduling staff.¹

Integrated EBRT/brachytherapy treatment plans should always include these seven components¹:

• Date of radiation initiation, with cisplatin chemotherapy initiation within 5 days, preferably on a Monday or Tuesday.¹
• Dates for subsequent cycles of chemotherapy, with labs checked weekly.¹
• Brachytherapy planning.¹
• Decision making about gynecologic oncologist’s role in the first brachytherapy fraction (to place a disposable Smit sleeve tube).¹
• Initial imaging date for brachytherapy planning and subsequent repeat imaging schedules for adaptive brachytherapy.¹
• Hematologic toxicity management planning, including filgrastim as indicated for adequate neutrophil counts prior to brachytherapy and availability of transfusion and growth factor support for neutropenia.¹
• Insurance authorizations for EBRT and brachytherapy to avoid interruptions in treatment plan completion.¹

When EBRT and brachytherapy are performed at separate treatment centers, plans should specify which clinicians will plan and deliver radiation boosts.¹

IMRT and SBRT have proven to be poor substitutes for cervical cancer brachytherapy, the authors concluded, although the available evidence base is based largely on relatively small studies.¹ There is evidence that brachytherapy delivers a superior biologic effective dose compared with IMRT.¹

Another Option

The ABS recently published a consensus statement on intraoperative radiotherapy (IORT) recommending consideration of using IORT in managing recurrent cervical cancer when microscopic disease-positive surgical margins are a concern, although IORT is not a standard of care for treating recurrent cervical cancer.⁶ Managing locoregional cervical cancer recurrence can be difficult because prior radiotherapy increases the risk of radiotoxicities associated with re-irradiation.⁶ But IORT after salvage surgery might reduce this risk while eliminating residual disease. Although limited, the evidence base suggests adding EBRT to IORT might improve outcomes.⁶

“[T]he addition of IORT to salvage resection for isolated recurrence of gynecologic cancers has not been evaluated prospectively,” and although retrospective data suggest improved local control, they do not conclusively demonstrate that IORT improves survival, the statement authors cautioned.⁶

References

1. Holschneider CH, Petereit DG, Chu C, et al. Brachytherapy: a critical component of primary radiation therapy for cervical cancer: from the Society of Gynecologic Oncology (SGO) and the American Brachytherapy Society (ABS). Gynecol Oncol. 2019;152(3):540-547.
2. Ma TM, Harkenrider MM, Yashar CM, Viswanathan AN, Mayadev JS. Understanding the underutilization of cervical brachytherapy for locally advanced cervical cancer. Brachytherapy. 2019;18(3):361-369.
3. Schad M, Kowalchuk R, Beriwal S, Showalter TN. How might financial pressures have impacted brachytherapy? A proposed narrative to explain declines in cervical and prostate brachytherapy utilization. Brachytherapy. doi: 10.1016/j.brachy.2019.07.001
4. Furlow B. US urology clinics overprescribe prostate radiotherapy. Lancet Oncol. 2011;12(2):122.
5. Alimena S, Yang DD, Melamed A, et al. Racial disparities in brachytherapy administration and survival in women with locally advanced cervical cancer. Gynecol Oncol. 2019;154(3):595-601.
6. Tom MC, Joshi N, Vicini F, et al. The American Brachytherapy Society consensus statement on intraoperative radiation therapy. Brachytherapy. 2019;18(3):242-257.