Improving quality of care and timely access to radiation therapy for patients with invasive cervical cancer at the National Cancer Institute Paraguay.

The purpose of this report is to describe the interventions implemented between 2012 and 2017 at the National Cancer Institute Paraguay (NCI Paraguay) to improve treatment quality and efficiency for patients with cervical cancer, with an emphasis on radiation quality and access. The NCI Paraguay requested collaboration with Health Volunteers Overseas (HVO), an international volunteer organization, to improve the care of patients with cervical cancer. This report is based on site visits to NCI Paraguay by HVO volunteers in 2012, 2013, and 2016, with a follow-up report from the site in 2017. During the study period, increased access to external beam radiation and brachytherapy led to a decrease in wait time to start radiation from 2 to 3 months to 4-6 weeks. The center transitioned from 2-dimensional (2D) to 3-D planning and was able to offer concurrent chemotherapy and radiation, including brachytherapy, to patients with locally advanced cervical cancer. Based on the American Society of Clinical Oncology's resource-stratified clinical guidelines, from 2012 to 2017, the practice transitioned from a "basic setting" to an "enhanced setting".

The Impact of Adjuvant Therapy on Survival and Recurrence Patterns in Women With Early-Stage Uterine Carcinosarcoma: A Multi-institutional Study.

OBJECTIVE: The aim of the study was to characterize the impact of adjuvant therapy on survival in women with stage I/II uterine carcinosarcoma after primary surgery. METHODS: We reviewed records of 118 consecutively treated women with 2009 International Federation of Gynecology and Obstetrics stage I/II uterine carcinosarcoma who underwent hysterectomy between 1990 and 2014 at 4 academic institutions. Patients were categorized by adjuvant treatment group into observation, chemotherapy only, radiation only, and combined chemotherapy and radiation. Survival analyses were conducted using Kaplan-Meier and Cox proportional hazards models. RESULTS: Median follow-up was 28 months (range, 1-244 months). Lymphadenectomy was performed in 94 patients (80%). Postoperative management included observation (n = 37 [31%]), chemotherapy alone (n = 19 [16%]), radiation therapy (RT) alone (n = 24 [20%]), and combined RT and chemotherapy (n = 38 [32%]). Radiation therapy modality included vaginal brachytherapy in 22 patients, pelvic external beam RT in 21 patients, and combination in 19 patients. In 58% of women, chemotherapy consisted of carboplatin/paclitaxel. Median overall survival for all women was 97 months. On univariate analysis, adjuvant treatment group was associated with improved overall survival (hazard ratio [HR], 0.74; confidence interval [CI], 0.58-0.96; p = 0.02), freedom from vaginal recurrence (HR, 0.55; CI, 0.37-0.82]; p = 0.004), and freedom from any recurrence (HR, 0.70; CI, 0.54-0.92; p = 0.01). Pairwise comparisons demonstrated a significant benefit to chemoradiation over other adjuvant treatments. Adjuvant treatment group remained a significant covariate for all 3 end points on multivariate analysis as well. In addition, lymphadenectomy improved overall survival on multivariate analysis (HR, 0.24; CI, 0.09-0.61; p = 0.003). Of patients under observation only who had a recurrence, 8 (44%) of 18 had a recurrence in the vagina as the sole site of recurrence. By contrast, of women who received vaginal brachytherapy, significantly fewer had a recurrence in the vagina (1/42 [2.3%]; p < 0.003, log-rank test). CONCLUSIONS: In women with early-stage uterine carcinosarcoma, our data suggest superior survival end points with combined RT and chemotherapy. The frequency of vaginal recurrence suggests a role for incorporating vaginal brachytherapy in the adjuvant management of this disease.