Abstract
BackgroundVaginal bleeding (VB) is common in women with gynecologic (GYN) malignancies. Radiation therapy (RT) is used for the definitive treatment of GYN cancers and palliation of bleeding. The historical dogma is that high dose-per-fraction radiation leads to more rapid bleeding cessation, yet there is scant data supporting this claim. We sought to examine the effect of RT fraction size on VB via retrospective analysis of patients receiving hypofractionated radiation (HFRT) compared to conventionally fractionated radiation (CFRT) for control of bleeding secondary to GYN malignancies.MethodsWe identified patients receiving external beam RT for continuous VB from GYN malignancy treated in our department from 2012 to 2020. RT was classified as HFRT (> 2.0 Gy/fx) or CFRT (1.8–2.0 Gy/fx). Demographic information, disease characteristics, and treatment details were collected. The primary endpoint was days from RT initiation until bleeding resolution. Characteristics between groups were compared via Fisher’s exact test. Time to bleeding cessation was assessed via Kaplan–Meier and log-rank test. Univariable and multivariable Cox-proportional hazards were used to identify factors associated with bleeding cessation.ResultsWe identified 43 patients meeting inclusion criteria with 26 and 17 patients receiving CFRT and HFRT, respectively. Comparison of baseline characteristics revealed patients receiving HFRT were older (p = 0.001), more likely to be post-menopausal (p = 0.002), and less likely to receive concurrent chemotherapy (p = 0.004). Time to bleeding cessation was significantly shorter for patients receiving HFRT (log-rank p < 0.001) with median time to bleeding cessation of 5 days (HFRT) versus 16 days (CFRT). Stratification by dose-per-fraction revealed a dose–response effect with more rapid bleeding cessation with increased dose-per-fraction. While HFRT, age, recurrent disease, prior pelvic RT, and prior systemic therapy were associated with time to bleeding cessation on univariable analysis, HFRT was the only factor significantly associated with time to bleeding cessation in the final multivariable model (HR 3.26, p = 0.008).ConclusionsPatients with continuous VB from GYN tumors receiving HFRT experienced more rapid bleeding cessation than those receiving CFRT. For patients with severe VB, initiation of HFRT to control malignancy related bleeding quickly may be warranted.
Highlights
Vaginal bleeding (VB) is common in women with gynecologic (GYN) malignancies
Bleeding is a common sequela of gynecologic (GYN) malignancies such as cervical cancer and endometrial cancer and in severe cases can lead to life-threatening anemia requiring transfusions
There have been multiple studies demonstrating the effectiveness of radiation to induce hemostasis with various fractionation and dosing schemes [2,3,4,5,6,7], there remains no consensus on the optimal radiation schedule for rapid and durable cessation of bleeding
Summary
Vaginal bleeding (VB) is common in women with gynecologic (GYN) malignancies. Radiation therapy (RT) is used for the definitive treatment of GYN cancers and palliation of bleeding. We sought to examine the effect of RT fraction size on VB via retrospective analysis of patients receiving hypofractionated radiation (HFRT) compared to conventionally fractionated radiation (CFRT) for control of bleeding secondary to GYN malignancies. Vaginal bleeding (VB) is a common presenting symptom for women with newly diagnosed GYN malignancies, especially endometrial and cervical cancer. For curative intent patients (e.g., patients with newly diagnosed locally advanced cervical cancer) with severe bleeding (e.g., requiring frequent transfusions), the optimal radiation regimen for both prompt bleeding cessation and long-term tumor control is not well defined. The merits of starting with a hypofractionated RT course to more rapidly halt bleeding followed later by more protracted, conventional fractionation to a curative intent RT dose (e.g., based on total biologically effective dose, BED) compared to delivering the entirety of the RT course with conventional fractionation is not well understood
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