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Dose and fractionation regimen for brachytherapy boost in cervical cancer in the US

Hsieh, Kristin; Bloom, Julie R; Dickstein, Daniel R; Hsieh, Celina; Marshall, Deborah; Ghiassi-Nejad, Zahra; Raince, Jagdeep; Lymberis, Stella; Chadha, Manjeet; Gupta, Vishal
PURPOSE/OBJECTIVE:Curative-intent radiotherapy for locally advanced and select early stage cervical cancer in the US includes external beam radiotherapy (EBRT) with brachytherapy. Although there are guidelines for brachytherapy dose and fractionation regimens, there are limited data on practice patterns. This study aims to evaluate the contemporary utilization of cervical cancer brachytherapy in the US and its association with patient demographics and facility characteristics. METHODS:We retrospectively analyzed clinical covariates of cervical cancer patients diagnosed and treated in 2018-2020 with curative-intent radiotherapy from the 2020 National Cancer Database. Associations between patient and institutional factors with the number of brachytherapy fractions were identified with logistic regression. Factors with association (p < 0.10) were then included in a multivariable logistic regression model. All tests were two-sided with significance <0.05 unless specified otherwise. RESULTS:Among the eligible 2517 patients, 97.3% received HDR or LDR and is further analyzed. More patients received HDR than LDR brachytherapy (98.9% vs 1.1%) and intracavitary than interstitial brachytherapy (86.4% vs 13.6%). The most common number of HDR fractions prescribed were 5 (51.0%), 4 (32.9%), and 3 (8.6%). After adjusting for the other variables in the model, ethnicity, private insurance status, overall insurance status, and facility type were the only factors that were significantly associated with the number of brachytherapy factions (p < 0.0001, p = 0.028, p = 0.001, and p < 0.0001, respectively, n = 2184). CONCLUSIONS:In the US, various HDR brachytherapy regimens are utilized depending on patient and institutional factors. Future research may optimize cervical cancer brachytherapy by correlating specific dose and fractionation regimens with patient outcomes.
PMID: 38052109
ISSN: 1095-6859
CID: 5595482

PO40 Presentation Time: 4:45 PM: Definitive Management of Cervical Cancer Patients at an Urban Institution During the COVID-19 Pandemic - Brachytherapy Treatment During the Surge [Meeting Abstract]

Lymberis, S C; Lee, S S; Boyd, L; Hacker, K E; Salame, G; Pothuri, B; Schiff, P B
Purpose: Locally advanced cervical cancer was defined by an international consensus panel as a high priority malignancy during the COVID-19 pandemic, recommending prompt initiation of definitive treatment and completion of treatment (PMID 32563593). The objective of this study was to study the clinical outcomes of patients (pts) with cervical cancer treated with definitive chemoradiation (CRT) and brachytherapy (BT) at our institution in 2019 (pre-COVID) and in 2020 (peri-COVID).
Material(s) and Method(s): This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/1/2019 to 12/31/2020. Pts received CRT followed by intracavitary brachytherapy (IC) with two operative insertions one week apart, or interstitial (IS) BT with one operative insertion. BT treatment was planned using image-guided CT or MR delineation. Pre-COVID was defined by initiation of CRT in 1/2019-12/2019, and peri-COVID was defined by initiation in 1/2020-10/2020. Process changes peri-COVID included limited on-site staff (e.g., minimal OR staff, no trainees, remote physics team), universal implementation of COVID-19 testing prior to surgery, and CT instead of MR-delineation based treatment. Outcomes of interest were time to treatment initiation and completion and differences in treatment planning modality or dosimetry. Fisher's exact and Mann Whitney U tests were used with significance p<0.05.
Result(s): Thirty-one pts were included, with 18 patients undergoing treatment pre-COVID and 13 peri-COVID. The median age at diagnosis pre-COVID was 57.7 (range 23-77) and for peri-COVID, 45.5 (range 28-62, p=0.06). There were no differences in non-English speaking pts (44% vs 59%, p=0.71) or uninsured pts (11% vs 33%, p=0.184) between the two cohorts. Median time to initiation of treatment from biopsy diagnosis was 52 days (range 13-209) in 2019 and for peri-COVID, 55.5 (range 20-173, p=0.71). During COVID, four pts had delayed initiation to treatment >100 days: two related to fertility, and one due to fear of COVID-19. For this pt, tumor size progressed from 2.3 cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts except one completed CRT with RT: 25 pts pelvic RT (45 Gy), 3 pelvic and para-aortic RT (45 Gy with 57.5 Gy concomitant boost to nodes), 8 pts pelvic RT (45Gy) with sequential parametrial boost (50.4-59.4 Gy) using IMRT with no dose differences between pre and peri-COVID (Table 1). No pts required treatment breaks and the median overall treatment time was 50 days (range 31-85) in 2019 vs 50 days (range 43-63) in 2020 (p=0.710).
Conclusion(s): Despite the significant burden of the COVID-19 pandemic on our health care system, all cervical cancer pts receiving CRT met standard of care including CRT and BT within the recommended time frame with no significant differences in dosimetric treatment parameters pre- and peri-COVID. Delays in treatment initiation of treatment initiation were seen in 30% of pts in the peri-COVID period, suggesting that patients may have had increased barriers to access care. More follow-up is needed to determine how the Covid pandemic impacted cervical cancer outcome measures.
ISSN: 1873-1449
CID: 5510352

A Sexual and Gender Minority Inclusive Tool to Identify and Reduce Psychological Distress Related to Vaginal Brachytherapy Treatment

Domogauer, J D; Ganey-Aquino, S; Cabrera, A; Pietrzyk-Busta, B; Huppert, N E; Schiff, P B; Lymberis, S C
PURPOSE/OBJECTIVE(S): Evidence has shown treatments for gynecologic cancers can pose a significant impact to quality of life (QoL) and psychosocial functioning for cancer patients and cancer survivors, with very limited understanding of the impact of such treatments on the lesbian, gay, bisexual, transgender and queer/questioning community, also referred to as sexual and gender minorities (SGM), a diverse and medically underserved population. Specifically, intracavitary vaginal brachytherapy (ICVBT) for endometrial cancers can cause a negative impact on QoL and can even result in PTSD after treatment. Thus, better understanding a patient's unique identity and chosen sexual preferences, as well as assessing underlying anxiety, psychosocial issues, and/or prior non-consensual sexual encounter(s) can potentially alleviate distress during and after this sensitive treatment. Here, we present an innovative, SGM-inclusive assessment tool to identify potential risk factors for physical and/or psychosocial distress that may occur in patients undergoing ICVBT. MATERIALS/METHODS: We combined two previously published, validated tools to assess for urinary, bowel, and sexual symptoms in patients undergoing ICVBT. Next, as part of the ongoing LGBTQ initiative at our academic comprehensive cancer center, our department's LGBTQ Task Force, which is composed of volunteer patients, physicians, nurses, physicists, dosimetrists, and support staff reviewed the questionnaire and provided critical feedback for inclusivity. We subsequently had the questionnaire reviewed for health literacy by our Patient Education Liaisons.
RESULT(S): The task force recommended inclusion of sexual orientation and gender identity (SOGI) demographic questions to the survey, and adjustment of previous questions for improved inclusivity of SGM-identifying patients, especially those who identify as transgender, gender non-binary, and/or who choose to not engage in penetrative vaginal intercourse. Additionally, it was recommended to include a question that screens for a history of non-consensual sexual encounters to reduce triggering past trauma. The task force felt these items were important for the practitioner to discuss with their patient prior to the procedure, with the goal to reduce acute anxiety and possibly prevent acute and long-term negative physical and/or emotional outcomes.
CONCLUSION(S): Our ICVBT survey tool is designed to screen for "at-risk" patients, and provide a pathway for open dialogue between patients and physicians to potentially reduce undue harm during this important, yet sensitive treatment. To the best of our knowledge, this is the first such ICVBT survey tool to assess for a history of sexual trauma, and include SOGI and gender-inclusive questions. This adaptation has allowed our team to approach patients in a sensitive manner inclusive of their identity and prior experiences. Preliminary data is being collected and will be presented at the conference.
ISSN: 1879-355x
CID: 5077792

Treating through the surge: institutional experience of definitive management of cervical cancer patients at an urban institution during the COVID-19 pandemic [Meeting Abstract]

Lee, Sarah; Boyd, Leslie; Hacker, Kari; Salame, Ghadir; Pothuri, Bhavana; Schiff, Peter B. Schiff; Lymberis, Stella
ISSN: 0090-8258
CID: 4990762

Factors associated with delay in treatment initiation of locally advanced cervical cancer [Meeting Abstract]

Lee, S S; Berger, A A; Ishaq, O; Curtin, J P; Salame, G M; Pothuri, B; Schiff, P B; Boyd, L R; Lymberis, S
Objective: We aimed to explore the disparities associated with the delay of initiating chemoradiation therapy (CRT) and brachytherapy (BT) beyond the recommended 8 weeks for patients with cervical cancer and the effect on outcomes.
Method(s): Patients with FIGO stage IB2-IVA cervical cancer treated at an academic medical center and an urban public hospital by the same team of gynecologic and radiation oncologists with definitive CRT and BT from July 2009 to September 2017 were included. Patients received CRT followed by BT (7 Gy x 4 fractions) delivered via 2 insertions 1 week apart with image-guided CT/MR delineation. Patients who initiated CRT within 8 weeks from diagnosis as recommended (rCRT) were compared across demographic and cancer outcomes to patients who received delayed CRT after 8 weeks (dCRT). Disease-free survival (DFS) and overall survival (OS) were analyzed using adjusted Cox regression analysis (P < 0.05).
Result(s): In our cohort of 97 patients, 72 (75.0%) had rCRT and 24 (25.0%) had dCRT. At a median follow-up of 31.5 months, overall local control was achieved in 94.8% of patients. Patients with dCRT were more likely to be African-American (37.5% vs 17.8%, P = 0.046) and be uninsured or on Medicaid (87.5% vs 61.6%, P = 0.023). There were no differences in stage and grade. Patients with dCRT were more likely to recur or progress (OR = 2.65, 95% CI 1.02-6.86). Of those who recurred, 35.0% of rCRT patients had locoregional recurrence versus 66.7% of dCRT patients (P = 0.144). When controlling for age, race, insurance, referring hospital, and stage, patients with dCRT had lower DFS than patients with rCRT (50.6 vs 63.2 months, aHR = 6.11, 95% CI 2.00-18.62). However, there were no differences in OS.
Conclusion(s): Patients receiving delayed CRT tended to have worse recurrence and DFS than those initiating CRT by 8 weeks from diagnosis. African-American and uninsured patients were more likely to experience a delay in care. Navigator and social work services may help improve access to treatments for these patients.
ISSN: 0090-8258
CID: 4638422

Utility of MRI in the Definitive Treatment of Cervical Cancer [Meeting Abstract]

Lymberis, S.; Katz, L. M., Jr.; Wang, H.; Duckworth, T.; Kim, D.
ISSN: 0360-3016
CID: 4686292

Intraoperative Ultrasound Guided Intracavitary Brachytherapy: Improving Toxicity and Precision of Tandem Applicator Placement in Cervical Cancer [Meeting Abstract]

Domogauer, J. D.; Duckworth, T.; Osterman, S.; Pothuri, B.; Boyd, L.; Salame, G.; Kehoe, S.; Schiff, P. B.; Lymberis, S. C.
ISSN: 0360-3016
CID: 4686282

Gastrointestinal fistula formation in cervical cancer patients who received bevacizumab [Meeting Abstract]

Gerber, D; Curtin, J P; Saleh, M; Boyd, L R; Lymberis, S; Schiff, P B; Pothuri, B; Lee, J
Objective: The Gynecologic Oncology Group (GOG) study 240 demonstrated a 3.5-month improvement in overall survival when bevacizumab (bev) was added to a combination chemotherapy regimen. This study established a bev-containing regimen as standard therapy for women with recurrent, persistent, or metastatic cervical cancer (CC). Gastrointestinal fistula (GIF) formation is a known complication of bev, and the long-term data of GOG 240 reported that a GIF rate of 15% in women who were treated with bev compared to 1% in the control group women. We sought to evaluate our experience with women treated with bev for CC and to identify associated risk factors for GIF formation.
Method(s): All patients who have received bev for CC from 2012 to 2018 at two academic institutions were identified, and their records were reviewed. Standard two-sided statistical analyses were performed.
Result(s): A total of 43 women were treated with a bev-containing chemotherapy regimen; among them, 34 (79.1%) were treated for CC recurrence, and the remaining were treated for metastatic disease at initial presentation or persistent disease following primary treatment. Thirty-three women (76.6%) received prior radiation therapy (RT); of these, 10 (32.3%) received external beam radiation therapy (EBRT), and 21 (67.7%) had prior EBRT and brachytherapy (BT). The median dose of bev was 15 mg/kg for both EBRT only and EBRT and BT groups. Eleven women developed GIF after bev treatment (11/43, 25.6%). All 11 (100%) had been previously treated with RT, and six (54.5%) had received EBRT plus BT. This resulted in rates of 33.3% (11/33) for GIF formation among women who received EBRT, and 28.6% (6/21) for GIF formation among women who received EBRT plus BT. The median number of bev cycles prior to GIF development was 8 (1-29), and 7 (7/11, 63.6%) received the dose of bev (15 mg/kg) as prescribed in GOG 240. See Table 1.
Conclusion(s): In our cohort of women with CC who were treated with bev, over 25% developed GIF. This is more than expected based on the 15% seen in GOG 240. Notably almost all who developed GIF had recurrent disease and were treated with prior RT. A third of women treated with RT followed by bev formed GIF, representing a considerable proportion of the cohort. GIF development and the possibility of requiring a colostomy should be a part of counseling prior to bev initiation especially in those who have had prior RT. [Figure presented]
ISSN: 1095-6859
CID: 4005042

Experimental Verification of Dosimetric Uncertainty Related to Rotational Error of Single Isocenter for Multiple Targets Technique [Meeting Abstract]

Hu, L.; Zhang, J.; Wang, H.; Qu, T.; Barbee, D.; Lymberis, S. C.; Silverman, J. S.; Xue, J.
ISSN: 0360-3016
CID: 4112042

Effect of Insurance Status and Public versus Private Hospital on Cervical Cancer Outcomes [Meeting Abstract]

Berger, A. A.; Ishaq, O., Jr.; Curtin, J. P.; Pothuri, B.; Kehoe, S.; Schiff, P. B.; Boyd, L.; Lymberis, S. C.
ISSN: 0360-3016
CID: 4111362