Disparities in the Use of Adjuvant External Beam Radiation Therapy in Node-positive Cervical Cancer Patients Following Hysterectomy.

OBJECTIVE: The objective of this study was to investigate the use of adjuvant external beam radiation therapy (EBRT) among patients with early-stage cervical carcinoma metastatic to regional lymph nodes (LNs). MATERIALS AND METHODS: The National Cancer Database was accessed and patients with early-stage cervical carcinoma diagnosed between 2004 and 2015 were identified. Those with regional LN metastases who had a hysterectomy were selected and administration of adjuvant EBRT was evaluated. Travel distance from the reporting facility was categorized into short (<12.5 miles), intermediate (12.5 to 49.9 miles) and long (>49.9 miles). RESULTS: A total of 3436 patients met the inclusion criteria; the rate of EBRT use was 69.7%. Black women were less likely to receive EBRT compared with white (64.2% vs. 70.6%, P=0.037), while patients who had radical hysterectomy were more likely to receive EBRT compared with those who had simple hysterectomy (72.6% vs. 66%, P<0.001). Rates of EBRT administration for patients who traveled short distance was 74.3% compared with 68.9% and 56.9% for those who traveled intermediate and long distance, respectively (P<0.001). On multivariate analysis, patients who traveled long (odds ratio: 0.44, 95% confidence interval [CI]: 0.36, 0.54) or intermediate (OR: 0.73, 95% CI: 0.61, 0.86) distances were less likely to receive EBRT. After controlling for age, race, insurance, presence of comorbidities, stage, histology, and type of hysterectomy, omission of EBRT was associated with worse survival (hazard ratio: 1.53, 95% CI: 1.32, 1.78). CONCLUSIONS: A large percentage of patients with early-stage cervical cancer and positive LNs did not receive EBRT following hysterectomy. Black women were less likely to receive EBRT than white women. Travel burden may negatively influence appropriate treatment.

Declining brachytherapy utilization for high-risk prostate cancer-Can clinical pathways reverse the trend?

PURPOSE: Although external beam radiation therapy (EBRT) plus a brachytherapy boost (BB) offers a 20% improvement in biochemical progression-free survival compared with dose-escalated EBRT alone for men with intermediate and high-risk prostate cancer, population studies show a concerning decline in BB utilization. METHODS: We modified our clinical pathway (CP) in January 2016 to indicate EBRT with BB as first-choice modality for high-risk prostate cancer, based on preliminary findings of Androgen Suppression Combined with Elective Nodal and Dose-Escalated Radiation Therapy. A retrospective review was performed on 659 patients with high-risk prostate cancer treated with definitive intent EBRT ± BB within a network of 19 sites between December 2011 and July 2017. χ2 test was used to determine changes in practice pattern before vs. after CP modification. RESULTS: Before CP modification, 25.2% of patients were planned for BB, compared with 45.4% afterward (p < 0.001). Among 23 nonbrachytherapist physicians, utilization of BB increased from 3.4% to 14.8% (p < 0.001) after CP modification. Among nine brachytherapists, utilization increased from 46.4% to 55.6% (p = 0.120). Among patients treated by a nonbrachytherapist who did not receive BB, the reason was physician preference in 59.7%, patient preference in 19.9%, and other in 20.4%. CONCLUSION: Based on recent evidence suggesting improved biochemical progression-free survival with use of BB for high-risk prostate cancer, we modified our CP, after which we observed increased use of a BB across a network, especially among physicians who do not perform brachytherapy. However, physician preference remains the most significant factor in the nonutilization of BB. New mechanisms are needed to overcome this barrier.

Brachytherapy boost for prostate cancer: Trends in care and survival outcomes.

PURPOSE: Androgen suppression combined with elective nodal and dose-escalated radiation therapy recently demonstrated an improved biochemical failure-free survival in men who received external beam radiation therapy (EBRT) plus a brachytherapy boost (BB) compared with dose-escalated external beam radiotherapy (DE-EBRT). We sought to analyze the factors predictive for use of EBRT + BB as compared with DE-EBRT and report resulting survival outcomes on a national level using a hospital-based registry. METHODS AND MATERIALS: We identified 113,719 men from the National Cancer Database from 2004 to 2013 with intermediate- or high-risk prostate cancer who were treated with EBRT + BB or DE-EBRT. We performed univariate and multivariate analyses of all available factors potentially predictive of receipt of treatment selection. Survival was evaluated in a multivariable model with propensity adjustment. RESULTS: For intermediate-risk patients, utilization of BB decreased from 33.1% (n = 1742) in 2004 to 12.5% (n = 766) in 2013 and for high-risk patients, utilization dropped from 27.6% (n = 879) to 10.8% (n = 479). Numerous factors predictive for use of BB were identified. Cox proportional hazards analysis was performed-adjusting for age, Charlson-Deyo comorbidity score, T stage, prostate-specific antigen, Gleason score, and sociodemographic factors-and demonstrated BB use was associated with a hazard ratio of 0.71 (95% confidence interval, 0.67-0.75; p < 0.0005) and 0.73 (95% confidence interval, 0.68-0.78; p < 0.0005) for intermediate- and high-risk patients, respectively. CONCLUSIONS: There has been a concerning decline in the utilization of BB for intermediate- and high-risk prostate cancer patients despite an association with improved on overall survival. Numerous factors predictive for use of BB have been identified.

Cervical cancer: what's new? / Câncer de colo do útero: o que há de novo?

SUMMARY Cervical cancer is the most common gynecological cancer in Brazil. Among women, it is the second most frequent, second only to breast cancer. It is the fourth leading cause of cancer death in the country, with estimated 15,590 new cases (2014) and 5,430 deaths (2013). In order to update information to improve outcomes, reduce morbidity and optimize the treatment of this cancer, this article will address the advancement of knowledge on cervical cancer. The topics covered include the role of surgery in different stages, treatment of locally advanced carcinomas, fertility preservation, the role of the sentinel lymph node technique, indications and techniques of radiotherapy and chemotherapy, and some special situations.

RESUMO O câncer de colo uterino é o câncer ginecológico mais frequente em nosso meio. Entre as mulheres, é o segundo mais frequente, atrás apenas do câncer de mama. É a quarta causa de morte por câncer no Brasil, com estimativa de 15.590 casos novos (2014) e com 5.430 mortes (2013). No intuito de atualizar informações para a melhora do prognóstico, redução da morbidade e otimização do tratamento dessa neoplasia, serão abordados neste artigo os avanços nos conhecimentos sobre o câncer cervical. Entre os temas apresentados, estão o papel da cirurgia nos diferentes estádios, o tratamento dos carcinomas localmente avançados, a preservação da fertilidade, o papel da técnica do linfonodo sentinela, indicações e técnicas da radio e quimioterapia, além de situações especiais.

Cervical cancer: what's new?

Cervical cancer is the most common gynecological cancer in Brazil. Among women, it is the second most frequent, second only to breast cancer. It is the fourth leading cause of cancer death in the country, with estimated 15,590 new cases (2014) and 5,430 deaths (2013). In order to update information to improve outcomes, reduce morbidity and optimize the treatment of this cancer, this article will address the advancement of knowledge on cervical cancer. The topics covered include the role of surgery in different stages, treatment of locally advanced carcinomas, fertility preservation, the role of the sentinel lymph node technique, indications and techniques of radiotherapy and chemotherapy, and some special situations.

Braquiterapia de alta taxa de dose no Brasil / High-dose rate brachytherapy in Brazil

A braquiterapia de alta taxa de dose foi introduzida em nosso meio em janeiro de 1991. Desde então, houve uma mudança significativa na abordagem das neoplasias malignas em relação às vantagens do novo método, e também resolução da demanda reprimida de braquiterapia para as neoplasias ginecológicas. Nos primeiros dez anos de atividade, o Brasil tratou, em 31 serviços, 26.436 pacientes com braquiterapia, sendo mais de 50 por cento das pacientes portadoras de neoplasias do colo uterino. Este estudo mostra o número e o perfil de pacientes tratados com esse método e a sua distribuição no território nacional, deixando explícito o benefício da braquiterapia de alta taxa de dose para o Brasil.

Braquiterapia de Alta Tasa de Dosis. Un Nuevo Principio para una Nueva Terapia contra el Cáncer / High Dose Rate Brachyterapy. A New Principle for a New Therapy against Cancer

La braquiterapia de alta tasa de dosis es una nueva modalidad de tratamiento de radioterapia contra el cáncer. Utiliza fuentes radioactivas de mayor actividad (principalmente Iridio 192), emitiendo dosis de radiación más altas en tiempos más cortos. Las fuentes son de tamaño reducido, muy versátiles y con equipos recientemente desarrollados apoyados por computadores, permitiendo ser llevadas con mayor facilidad a diferentes sitios anatómicos e incluso hasta estructuras donde nunca antes se había podido ubicar una fuente radioactiva. Se ubica dentro de la terapia estándar de gran número de tumores; usualmente se asocia a la radioterapia externa para alcanzar dosis que tengan mayor efecto terapéutico y menor lesión de las estructuras vecinas al volumen tumoral tratado. Con marcadas ventajas supera a la antigua braquiterapia de baja tasa de dosis, tanto en resultados terapéuticos como en mayor comodidad para el paciente

Terapia intracavitaria en el tratamiento del cáncer de cuello uterino / Intracavitery therapy in the treatment of cervix's cancer

Los autores realizan una revisión retrospectiva de 43 planificaciones computarizadas correspondientes a igual número de casos de cáncer de cuello uterino tratados entre enero y febrero de 1992 en el Departamento de Radioterapia del INEN. Se considera la dosis absorbida en diferentes puntos de referencia según el reporte ICRU 38 y gLAC. Se llega a la conclusión que dichos puntos de referencia guardan relación entre sí y que los de mayor importancia son los que se encuentran a nivel de vejiga y recto puesto que la dosis de tolerancia a dicho nivel será la que decida la dosis total. Se recomienda un seguimiento a futuro en los casos para poder establecer una correlación más estrecha entre dosis absorbida en los diferentes puntos de referencia con control local y complicaciones tardías