Cervical Cancer Outcomes in Elderly Women Treated with EBRT and Brachytherapy +/- Concurrent Chemotherapy

Abstract

Cervical cancer is commonly viewed as a cancer affecting middle-aged women. However, more than 15% of cervical cancer cases occur in women over age 65. It is uncertain whether literature from trials, in which older women are a minority of the study population, appropriately guides their treatment and describes their natural history. The goal of this study was to evaluate cervical cancer treatment patterns and outcomes in older women in order to better counsel patients and optimize management. We performed a retrospective institutional analysis on women 69 and above with primary cervical cancer treated from 1999 - 2018. Included patients were treated with definitive, curative intent radiotherapy. We excluded patients with distant metastases, those treated palliatively, and those receiving surgery as primary treatment. We evaluated overall patient survival, use of chemotherapy, and recurrence patterns. This study was IRB approved. 65 eligible patients were included. Median age was 77 years (range 69-88), ranging in stage from IB1 to IIIB (IB1: 15 pts; IB2: 6 pts; IIA (NOS): 6 pts; IIA1: 3 pts; IIA2: 3 pts, IIB: 17 pts; IIIA: 2 pts, IIIB: 13 pts). Most were squamous cell carcinoma (83.1%), followed by adenocarcinoma (13.9%) and other (3%). Median external beam radiation (EBRT) dose was 45 Gy and median brachytherapy (BT) dose was 27.5 Gy. BT varied by era, but the majority were treated with HDR BT, with 53/65 (81.5%) HDR, 10/65 (15.4%) LDR, and 2/65 (3.1%) discontinuing treatment prior to brachytherapy. 86.2% received intracavitary BT and 10.8% received combined intracavitary/interstitial BT. Median total duration of therapy (EBRT + BT) was 50 days. The vast majority of women completed their intended course of radiation therapy, with a completion rate of 90.8%. 37 pts (56.9%) received concurrent chemotherapy, most commonly weekly cisplatin. Of those women, 5 (13.5%) discontinued chemotherapy due to adverse effects. With a median follow up of 24 months, 15 pts (24.6%) developed a recurrence, with 3 relapsing locally, 1 relapsing regionally, 9 relapsing with distant metastases only, and 2 relapsing both distantly and regionally. The 2-year local control rate was 91.4% and the loco-regional control rate was 82.9%. The 2-year overall survival was 75.1%. The 2-year disease-free survival was 61.4%. Due to small patient numbers and imbalance in stage between those receiving/not receiving concurrent chemotherapy, no conclusions can be made about the impact of chemotherapy on disease outcomes. The outcomes of elderly patients treated with definitive radiotherapy for cervical cancer are comparable to those of younger women, with the vast majority of patients able to complete therapy, resulting in 2-year loco-regional control rates over 80%. In conclusion, definitive radiation therapy, including brachytherapy, should be encouraged for older women presenting with cervical cancer.