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Adjuvant external beam radiotherapy combined with brachytherapy for intermediate-risk cervical cancer
  1. Nuria Agusti1,
  2. David Viveros-Carreño2,3,
  3. Alexander Melamed4,
  4. Rene Pareja5,
  5. Alexa Kanbergs1,
  6. Chi-Fang Wu6,
  7. Roni Nitecki7,
  8. Lauren Colbert8 and
  9. Jose Alejandro Rauh-Hain1
    1. 1Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    2. 2Unidad Ginecología Oncológica, Grupo de Investigación GIGA, Centro de Tratamiento e Investigación sobre Cáncer Luis Carlos Sarmiento Angulo – CTIC, Bogota, Colombia
    3. 3Department of Gynecologic Oncology, Clínica Universitaria Colombia, Bogotá, Colombia
    4. 4Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
    5. 5Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogotá, Colombia
    6. 6Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    7. 7Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    8. 8Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    1. Correspondence to Dr Nuria Agusti, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; NAgusti{at}mdanderson.org

    Abstract

    Objective Patients with intermediate-risk cervical cancer receive external beam radiotherapy (EBRT) as adjuvant treatment. It is commonly administered with brachytherapy without proven benefits. Therefore, we evaluated the frequency of brachytherapy use, the doses for EBRT administered alone or with brachytherapy, and the overall survival impact of brachytherapy in patients with intermediate-risk, early-stage cervical cancer.

    Methods This retrospective cohort study was performed using data collected from the National Cancer Database. Patients diagnosed with cervical cancer from 2004 to 2019 who underwent a radical hysterectomy and lymph node staging and had disease limited to the cervix but with tumors larger than 4 cm or ranging from 2 to 4 cm with lymphovascular space invasion (LVSI) were included. Patients with distant metastasis or parametrial involvement were excluded. Patients who underwent EBRT alone were compared with those who also received brachytherapy after 2:1 propensity score matching.

    Results In total, 1174 patients met the inclusion criteria, and 26.7% of them received brachytherapy. After 2:1 propensity score matching, we included 620 patients in the EBRT group and 312 in the combination treatment group. Patients who received brachytherapy had higher equivalent doses than those only receiving EBRT. Overall survival did not differ between the two groups (hazard ratio (HR) 0.88 (95% confidence interval (CI), 0.62 to 1.23]; p=0.45). After stratification according to tumor histology, LVSI, and surgical approach, brachytherapy was not associated with improved overall survival. However, in patients who did not receive concomitant chemotherapy, the overall survival rate for those receiving EBRT and brachytherapy was significantly higher than that for those receiving EBRT alone (HR, 0.48 (95% CI, 0.27 to 0.86]; p=0.011).

    Conclusion About one-fourth of the study patients received brachytherapy and EBRT. The variability in the doses and radiotherapy techniques used highlights treatment heterogeneity. Overall survival did not differ for EBRT with and without brachytherapy. However, overall survival was longer for patients who received brachytherapy but did not receive concomitant chemotherapy.

    • Brachytherapy
    • Radiation Oncology
    • Surgical Oncology

    Data availability statement

    Data are available upon reasonable request.

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • X @RParejaGineOnco, @colbertle

    • Contributors The authors affirm that they have each met criteria for authorship as defined by the International Committee of Medical Journal Editors. NA: conceptualization, data curation, methodology, writing of the original draft, manuscript review and editing, guarantor. AK: writing of the original manuscript draft, manuscript review and editing. AM: methodology, writing of the original manuscript draft, manuscript review and editing. RP: writing of the original manuscript draft, manuscript review and editing. C-FW: data curation, formal analysis, methodology, validation, manuscript review and editing. RN: methodology, writing of the original manuscript draft, manuscript review and editing. LC: methodology, writing of the original manuscript draft, manuscript review and editing. JAR-H: conceptualization, methodology, supervision, writing of the original manuscript draft, manuscript review and editing. DV-C: conceptualization, data curation, methodology, writing of the original manuscript draft, manuscript review and editing.

    • Funding This work was supported by grants from the NIH (JAR-H: K08CA234333, R01MD017999; RN, AK, NA, and JAR-H: P30CA016672; AK: 5T32 CA101642).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.