Perioperative Morbidity, Long-term Outcomes, and Late Toxicity in Survivors of Carcinoma of the Cervix Treated With Brachytherapy

Abstract

Purpose/Objective(s): To evaluate perioperative morbidity and long-term outcome and quantify the incidence of late toxicity in patients with carcinoma of the cervix treated with a radical intent using brachytherapy. Materials/Methods: Two hundred and six consecutive patients with carcinoma of the cervix treated with a radical intent using brachytherapy at the 2 cancer centers serving our entire Health Authority region, from January 1998 to January 2013, were included in this study. Median age at diagnosis was 54 years, 29% of patients were single or separated, 82% had squamous cell carcinoma, 13% adenocarcinoma, and 1.5% had small cell carcinoma. Thirty-eight percent had FIGO stage I, 38% had stage II, 19% had stage II, and 5% had stage IV cancers. All patients underwent a combination of external beam RT and brachytherapy, and 77% of patients also had concurrent chemotherapy. The patients underwent a total of 602 brachytherapy procedures. While 75 (36.5%) patients had high-dose-rate (HDR) brachytherapy, 131(63.5%) were treated with low-dose-rate (LDR) brachytherapy. Results: After a median follow-up of 59.6 months, the 5-year local control rate, progression-free survival, and overall survival were 75.7%, 68.3%, and 66.9%, respectively. Age, histology, and stage were found to be significant prognostic factors. Marital status was found to strongly predict for improved outcomes: 5yr OS for married versus separated patients was 73.7% versus 45.3%, PZ.013. There was no statistically significant difference in outcomes for patients who received HDR versus LDR brachytherapy (5-year OS: 77.8% vs 65.2%, PZ.436), or for patients who did or did not receive concurrent chemotherapy (5-year OS: 77.9% vs 64.7%, PZ.908). The 3-year cumulative incidence of late grade 3-4 radiation proctitis and radiation cystitis for patients treated with HDR versus LDR brachytherapy were: 10.5% versus 9.3%, PZ.737, and 9.9% versus 5.7%, PZ.297, respectively. Six patients developed RT-related bowel obstruction or strictures for which surgery was required, 3 patients developed treatment-related fistulas, 4 had pelvic insufficiency fractures, 2 developed lumbosacral plexopathy, and 2 had second cancers. Perioperative morbidity for the 602 consecutive procedures included: 3 patients who developed deep vein thrombosis, 2 who had pulmonary embolism, 4 who had procedural perforation of the uterus, 2 who had significant hemorrhage requiring transfusion, 1 who had vaginal laceration requiring surgical repair, and one patient who died during the procedure from pulmonary embolism. Conclusion: There appears to be no significant difference in long-term outcomes or late toxicities with the use of HDR versus LDR brachytherapy techniques. Apart from known prognostic factors such as age, histology, and stage, we report a significant impact of the patients’ marital status on the results of treatment. Author Disclosure: G. Bahl: Independent Contractor; BC Cancer Agency. E. Woo: None. B. Lester: None. F. Wong: medical credentialing; BC Cancer Agency.