The addition of interstitial needles to intracavitary applicators in the treatment of locally advanced cervical cancer: Why is this important and how to implement in low- and middle-income countries?

5528 Background: Cervical cancer is the leading cause of cancer mortality of women in Low and Middle Income Countries (LMIC). Interstitial needles (IN) have improved outcomes but the resources required in comparison to intracavitary brachytherapy (IC) alone has impeded uptake in endemic regions. We conducted a retrospective review of the utilisation of IN in the management of locally advanced cervical cancer and simulated 2D planning by loading the applicators using standard Manchester loading (ML) to explore the magnitude of benefit that interstitial needles provide. Methods: 72 brachytherapy plans of 18 patients who had undergone treatment using tandem and ring and had interstitial brachytherapy between 04/2016 and 10/2018 were reviewed. ML plans prescribed to point A were generated to represent a 2D scenario but the known HR-CTV was taken into consideration and its dosimetric outcomes were compared to those of the 3D based plans. Results: The median tumour volume was 23 cm3. IN was used in 82 % of the insertions. The median number of IN was 2 (range 0 – 6) with median percentage of IN dwell time 6.6 % (range 0.68 – 38.5). V100 was excellent 98.2% for ML 97.3% for 3D IN and 98.7% for 3D non-IN plans. The median HRCTV D90 was 8.5 Gy/fraction (cumulative EQD210101.4 Gy) for ML plans and 8.0 Gy/fraction (cumulative EQD210 91.4 Gy) for 3D plans. The ML plans failed to meet the OAR goals except for the rectum, which was optimally distanced by the rectal paddle. The median bladder, sigmoid and small bowel doses were 24% above the recommended constraint in the individual plans and 15% cumulative EQD2. A statistically significant relationship was found between the number of needles utilised, tumour volume (p < 0.001) and coverage (p = 0.006) but not delivered dose (p < 0.068). Conclusions: 2D brachytherapy can provide adequate dose coverage for most tumours but IN provide a benefit in reducing the doses to OARs in a significant number of patients. This justifies investment in resources for uptake of interstitial needles to increase access to optimal treatment of cervical cancer for women in LMIC. This research was made possible an ASCO Conquer Cancer Foundation grant.

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Bevacizumab in Advanced Cervical Cancer: Issues and Challenges for Low- and Middle-Income Countries

Journal of Global Oncology ◽

10.1200/jgo.2016.004895 ◽

2017 ◽

Vol 3 (2) ◽

pp. 93-97 ◽

Cited By ~ 9

Author(s):

Bishal Gyawali ◽

Mahesh Iddawela

Keyword(s):

Cervical Cancer ◽

Cost Effective ◽

Optimal Number ◽

Advanced Cervical Cancer ◽

Cancer Trial ◽

Middle Income ◽

Middle Income Countries ◽

The Status ◽

Number Of Cycles ◽

Low And Middle Income

Bevacizumab became the first molecular antibody to show survival benefit in advanced cervical cancer. In the GOG-0240 (Paclitaxel and Cisplatin or Topotecan With or Without Bevacizumab in Treating Patients With Stage IVB, Recurrent, or Persistent Cervical Cancer) trial, it improved overall survival by a significant 3.7 months over platinum doublet chemotherapy alone. However, this discovery is not likely to improve the status of global cervical cancer because more than 85% of patients with cervical cancer live in low- and middle-income countries and cannot afford bevacizumab. This commentary looks at the options by which this drug can be made more affordable and cost-effective for patients in low- and middle-income countries. We also discuss other important questions related to its affordability and cost issues such as the optimal number of cycles and personalizing the treatment. Finally, we emphasize that although the unaffordability of bevacizumab in cervical cancer seems to be a very important issue, the best cost-effective strategy against cervical cancer is prevention with screening and vaccination.

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