Clinical investigation: cervix
The American Brachytherapy Society recommendations for low-dose-rate brachytherapy for carcinoma of the cervix

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Abstract

Purpose: This report presents guidelines for using low-dose-rate (LDR) brachytherapy in the management of patients with cervical cancer.

Methods: Members of the American Brachytherapy Society (ABS) with expertise in LDR brachytherapy for cervical cancer performed a literature review, supplemented by their clinical experience, to formulate guidelines for LDR brachytherapy of cervical cancer.

Results: The ABS strongly recommends that radiation treatment for cervical carcinoma (with or without chemotherapy) should include brachytherapy as a component. Precise applicator placement is essential for improved local control and reduced morbidity. The outcome of brachytherapy depends, in part, on the skill of the brachytherapist. Doses given by external beam radiotherapy and brachytherapy depend upon the initial volume of disease, the ability to displace the bladder and rectum, the degree of tumor regression during pelvic irradiation, and institutional practice. The ABS recognizes that intracavitary brachytherapy is the standard technique for brachytherapy for cervical carcinoma. Interstitial brachytherapy should be considered for patients with disease that cannot be optimally encompassed by intracavitary brachytherapy. The ABS recommends completion of treatment within 8 weeks, when possible. Prolonging total treatment duration can adversely affect local control and survival. Recommendations are made for definitive and postoperative therapy after hysterectomy. Although recognizing that many efficacious LDR dose schedules exist, the ABS presents suggested dose and fractionation schemes for combining external beam radiotherapy with LDR brachytherapy for each stage of disease. The dose prescription point (point A) is defined for intracavitary insertions. Dose rates of 0.50 to 0.65 Gy/h are suggested for intracavitary brachytherapy. Dose rates of 0.50 to 0.70 Gy/h to the periphery of the implant are suggested for interstitial implant. Use of differential source activity or loading minimizes excessive central dose rates. These recommendations are intended only as guidelines. The responsibility for medical decisions ultimately rests with the treating radiation oncologist.

Conclusion: Guidelines are suggested for LDR brachytherapy for cervical cancer. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose-reporting policies.

Introduction

The success of radiation therapy requires the delivery of a high radiation dose directly to the tumor while sparing, to some degree, the surrounding normal tissues. Low-dose-rate (LDR) brachytherapy has traditionally been an important component in the overall management of patients with cervical carcinoma. Some institutions are now using high-dose-rate (HDR) brachytherapy. Several studies (including randomized and nonrandomized prospective clinical trials, surveys of published studies, and meta-analyses) have compared HDR brachytherapy to LDR brachytherapy in the management of cervical cancer. These have demonstrated comparable local control, survival, and morbidity 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13. A discussion of the debate over the use of LDR and HDR brachytherapy to treat cervical cancer is beyond the scope of this report. The increased integration of chemotherapy has also affected the practice pattern in cervical cancer.

The curative potential of radiation therapy in the management of carcinoma of the cervix is greatly enhanced by the use of intracavitary brachytherapy 14, 15, 16, 17. Although LDR intracavitary brachytherapy has been in use for many years, there is wide variation in its clinical practice (18). Although some dose specification and reporting guidelines exist for gynecologic brachytherapy (ICRU Report 38) (19), they are not widely accepted 20, 21. The American Brachytherapy Society (ABS) has recently issued recommendations for HDR brachytherapy for cervical cancer (22) and felt that specific recommendations should also be provided for LDR brachytherapy for cervical carcinoma. The ABS recognizes that because of the wide variation in clinical practice, it may be difficult to obtain a consensus agreeable to all practitioners.

Section snippets

Methods and materials

Members of the ABS with expertise in LDR cervical brachytherapy performed a literature review and, guided by their clinical experience, formulated specific recommendations and directions for future investigation in LDR cervical brachytherapy. These recommendations were made by consensus opinion and supported by published data whenever possible. In addition, an external multispecialty panel of recognized experts in the field reviewed the consensus recommendations. Revisions were made where

Results

The results of the deliberation of the panel and the ABS recommendations are given in the following sections. These recommendations were at Level 1 consensus, unless specifically noted to be of Level 2 consensus. None of the recommendations was at consensus Level 3.

Conclusion

The ABS has established guidelines for LDR brachytherapy for cervical cancer. The responsibility for medical decisions ultimately rests with the treating radiation oncologist. Practitioners and cooperative groups are encouraged to use these recommendations to formulate treatment and dose-reporting policies.

Acknowledgements

The authors express their gratitude to David Carpenter for editorial assistance. The authors acknowledge the support of the American Brachytherapy Society Board of Directors. We thank Drs. Kaled Alektiar, Alison Calkins, Michael Dullea, Patricia Eifel, Kathy Greven, Jean-Claude Horiot, Robin Hunter, Anuja Jhingran, Robert Kim, Wui-Jin Koh, Jeffery Lee, Jeffery Long, Anita Mahajan, Gustavo Montana, Arno Mundt, Colin Orton, Nilam Ramsinghani, Marcus Randall, Kevin Redmond, Christopher Sinesi,

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