Management Of Cervical Cancer Patients Research Articles

Rationality of FIGO 2018 IIIC restaging of cervical cancer according to local tumor size: A cohort study.

FIGO 2018 IIIC remains controversial for the heterogeneity of its prognoses. To ensure a better management of cervical cancer patients in Stage IIIC, a revision of the FIGO IIIC version classification is required according to local tumor size. We retrospectively enrolled cervical cancer patients of FIGO 2018 Stages I-IIIC who had undergone radical surgery or chemoradiotherapy. Based on the tumor factors from the Tumor Node Metastasis staging system, IIIC cases were divided into IIIC-T1, IIIC-T2a, IIIC-T2b, and IIIC-(T3a+T3b). Oncologcial outcomes of all stages were compared. A total of 63 926 cervical cancer cases were identified, among which 9452 fulfilled the inclusion criteria and were included in this study. Kaplan-Meier pairwise analysis showed that: the oncology outcomes of I and IIA were significantly better than of IIB, IIIA+IIIB, and IIIC; the oncology outcome of IIIC-(T1-T2b) was significantly better than of IIIA+IIIB and IIIC-(T3a+T3b); no significant difference was noted between IIB and IIIC-(T1-T2b), or IIIC-(T3a+T3b) and IIIA+IIIB. Multivariate analysis indicated that, compared with IIIC-T1, Stages T2a, T2b, IIIA+IIIB and IIIC-(T3a+T3b) were associated with a higher risk of death and recurrence/death. There was no significant difference in the risk of death or recurrence/death between patients with IIIC-(T1-T2b) and IIB. Also, compared with IIB, IIIC-(T3a+T3b) was associated with a higher risk of death and recurrence/death. No significant differences in the risk of death and recurrence/death were noted between IIIC-(T3a+T3b) and IIIA+IIIB. In terms of oncology outcomes of the study, FIGO 2018 Stage IIIC of cervical cancer is unreasonable. Stages IIIC-T1, T2a, and T2b may be integrated as IIC, and it might be unnecessary for T3a/T3b cases to be subdivided by lymph node status.

Abstract 53: Implementing Equitable Cancer Support Program: Lessons From Cervical Cancer Chemotherapy Access Program (C3AP)

Abstract Purpose: There is an inverse relationship between diagnosis to initiation of treatment interval and outcome of cancer treatment. A significant number of diagnosed cervical cancer patients don’t receive timely treatment in low resource settings. The Cervical Cancer Chemotherapy Access Program (C3AP) is one of End Cervical Cancer Nigeria Initiative’s interventions to IMProve Access to Cervical Cancer Treatment (IMPACT) in low resource settings. This report provides documentary evidence of the evolution of the implementation of the C3AP and highlights best practices that can be scaled up. Methods: The C3AP was conceptualized to increase the proportion of diagnosed cervical cancer patients that receive timely treatment by exploring adjuvant and neoadjuvant role of chemotherapy in the management of cervical cancer patients in settings where access to radiotherapy services can not be guaranteed. We instituted Plan Do Study and Act (PDSA) quality improvement cycle for the C3AP and used RE-AIM framework to study the implementation processes to be acted upon as part of the PDSA quality improvement process towards improving reach of the program. Results: The C3AP supported treatment of only 4 patients over the reporting period of 5months. Poor referral to the program is a major hurdle the program is battling. Only 2(17%) of the 12 confirmed cases of cervical cancer diagnosed in the facility within the 5month study period were able to access chemoradiation, suggesting a missed opportunity for 6/10(60%) that couldn’t afford chemoradiation. The program evolved over a PDSA cycle to eliminate social eligibility in the criteria to access the support thereby able to shorten application -support interval to same day with potential positive impact on prognosis. Conclusion: Providing equitable support for indigent cancer patients should be beyond the emotion to help humanity. We recommend the use of structured quality improvement for all programs providing support to indigent cancer patients to ensure implementation fidelity. Citation Format: Qudus Lawal, Kasimu Umar Adoke, Jummai Jimeta Tuko, Aminu Magashi Garba, Ishak K. Lawal. Implementing Equitable Cancer Support Program: Lessons From Cervical Cancer Chemotherapy Access Program (C3AP) [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 53.

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

<h3>Purpose</h3> 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). <h3>Materials and Methods</h3> 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. <h3>Results</h3> 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). <h3>Conclusions</h3> 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.

Integrative psychotherapy in stress management of cervical cancer patients at RSUD Dr. Moewardi Surakarta: A case study

Integrative psychotherapy in stress management of cervical cancer patients at RSUD Dr. Moewardi Surakarta: A case study

Can preoperative ureteral stents reduce the incidence of ureteral stricture after radiotherapy in patients with cervical cancer?

ObjectiveTo determine the impact of preoperative stent placement on postradiotherapy stricture rate in patients with cervical cancer after radical resection.MethodsThis study was a retrospective analysis of data collected from 55 cervical cancer patients treated with radiotherapy between June 2016 and June 2020. Patients were divided into the stent and control groups. After 3 months, the stricture rate and the complications related to stent placement between the two groups were compared.ResultsThere were 12 (46.2%) and 10 (34.5%) cases of ureteral stricture in the stent (n = 26) and control (n = 29) groups, respectively, three months after the end of radiotherapy. The incidence rates of ureter stricture in the two groups were not significantly different (P = 0.378). Moreover, there were 20 units (38.5%) and 15 units (25.9%) ureteral strictures in the stent and control groups, respectively. No significant difference in the incidence rates of ureteral strictures was found between the two groups (P = 0.157). There were 13 (50.0%) and 10 (34.5%) cases of ureteral stricture in the stent (n = 26) and control (n = 29) groups, respectively, six months after the end of the radiotherapy. The incidence rates of ureter stricture in the two groups were not significantly different (P = 0.244). Moreover, there were 21 units (40.4%) and 15 units (25.9%) ureteral strictures in the stent and control groups, respectively. No significant difference in the incidence rates of ureteral strictures was found between the two groups (P = 0.105). Complications related to stent placement such as urinary tract infections and bladder irritation were statistically significant (P = 0.006 and P = 0.036) between the two groups; while the other complications were not significantly different (P = 0.070, P = 0.092 and P = 0.586).ConclusionsUreteral stents may not reduce the incidence of ureteral stricture after radiotherapy in patients with cervical cancer. The stent needs to be replaced regularly, and the complications related to stent placement may occur at any time. Thus, preoperative stent placement should be cautious for the clinical management of cervical cancer patients treated with postoperative radiotherapy.

Association of a genetic variant in Interleukin-10 gene with increased risk and inflammation associated with cervical cancer.

Cervical-cancer is among the most commonly diagnosed cancers in women, and infection with human papillomavirus (HPV) is associated with an increased risk of cervical cancer and altered serum concentrations of inflammatory cytokines. We have explored the association between a genetic variation in the Interleukin-10 (IL-10) gene (rs1800896) and cervical cancer risk and its relationship with tissue Interferon gamma (IFN-γ), Transforming growth factor beta (TGF-β), Tumor necrosis factor alpha (TNF-α) concentrations in women with cervical cancer. A total of 315 women with, or without cervical cancer, were recruited into the study. DNA was extracted from cervical cells, and genotyping was undertaken using Taq-man real-time PCR. The genotype frequency and allele distribution were analyzed together with their association with pathological data. The association of the rs1800896 gene variation with tissue levels of the inflammatory cytokines was also investigated. Our data showed a significant association between the A allele of the rs1800896 gene variant and the presence of cervical cancer. In particular, patients with AG/AA genotypes had an increased risk of cervical cancer with an odds ratio of 1.929 (95% confidence interval [CI]: 0.879-4.23, P<0.001) in a recessive model, compared with the GG genotype. Also, the tissue concentrations of IFN-γ, TGF-β, and TNF-α in cervical tissues were significantly higher in women with cervical cancer (P<0.001) and were associated with the AA genotype. We have found an association between the polymorphism rs1800896 in the IL-10 gene and an increased risk of cervical cancer as well as a higher level of tissue inflammatory cytokines. Further investigations are necessary on the value of emerging biomarkers for the risk stratification for the management of cervical cancer patients.

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

Objectives:An international consensus panel has defined locally advanced cervical cancers as a high priority malignancy during the COVID-19 pandemic and recommends 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).Methods:This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/2019 to 10/2020. 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 between 1/2019-12/2019, and peri-COVID was defined by initiation between 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.Results:Thirty pts were included, with 18 patients undergoing treatment pre-COVID and 12 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, three 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 2.3cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts completed CRT with RT: 24 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).Conclusions: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 treatment parameters pre- and peri-COVID.

Eight-lncRNA signature of cervical cancer were identified by integrating DNA methylation, copy number variation and transcriptome data

BackgroundCopy number variation (CNV) suggests genetic changes in malignant tumors. Abnormal expressions of long non-coding RNAs (lncRNAs) resulted from genomic and epigenetic abnormalities play a driving role in tumorigenesis of cervical cancer. However, the role of lncRNAs-related CNV in cervical cancer remained largely unclear.MethodsThe data of messenger RNAs (mRNAs), DNA methylation, and DNA copy number were collected from 292 cervical cancer specimens. The prognosis-related subtypes of cervical cancer were determined by multi-omics integration analysis, and protein-coding genes (PCGs) and lncRNAs with subtype-specific expressions were identified. The CNV pattern of the subtype-specific lncRNAs was analyzed to identify the subtype-specific lncRNAs. A prognostic risk model based on lncRNAs was established by least absolute shrinkage and selection operator (LASSO).ResultsMulti-omics integration analysis identified three molecular subtypes incorporating 617 differentially expressed lncRNAs and 1395 differentially expressed PCGs. The 617 lncRNAs were found to intersect with disease-related lncRNAs. Functional enrichment showed that 617 lncRNAs were mainly involved in tumor metabolism, immunity and other pathways, such as p53 and cAMP signaling pathways, which are closely related to the development of cervical cancer. Finally, according to CNV pattern consistent with differential expression analysis, we established a lncRNAs-based signature consisted of 8 lncRNAs, namely, RUSC1-AS1, LINC01990, LINC01411, LINC02099, H19, LINC00452, ADPGK-AS1, C1QTNF1-AS1. The interaction of the 8 lncRNAs showed a significantly poor prognosis of cervical cancer patients, which has also been verified in an independent dataset.ConclusionOur study expanded the network of CNVs and improved the understanding on the regulatory network of lncRNAs in cervical cancer, providing novel biomarkers for the prognosis management of cervical cancer patients.

Completion of radical hysterectomy does not improve survival of patients with cervical cancer and intraoperatively detected lymph node involvement: ABRAX international retrospective cohort study.

The management of cervical cancer patients with intraoperative detection of lymph node involvement remains controversial. Since all these patients are referred for (chemo)radiation after the surgery, the key decision is whether radical hysterectomy should be completed as originally planned, taking into account an additional morbidity associated with extensive surgical dissection prior to adjuvant treatment. The ABRAX study investigated whether completing a radical uterine procedure is associated with an improved oncological outcome of such patients. We performed retrospective analyses of 515 cervical cancer patients (51 institutions, 19 countries) who were referred for primary curative surgery between 2005 and 2015 (stage IA-IIB, common tumour types) in whom lymph node involvement was detected intraoperatively. Patients were stratified according to whether the planned uterine surgery was completed (COMPL group, N=361) or abandoned (ABAND group, N=154) to compare progression-free survival. Definitive chemoradiation was given to 92.9% patients in the ABAND group and adjuvant (chemo)radiation or chemotherapy to 91.4% of patients in the COMPL group. The risks of recurrence (hazard ratio [HR] 1.154, 95% confidence intervals [CI] 0.799-1.666, P=0.45), pelvic recurrence (HR 0.836, 95% CI 0.458-1.523, P=0.56), or death (HR 1.064, 95% CI 0.690-1.641, P=0.78) were not significantly different between the two groups. No subgroup showed a survival benefit from completing radical hysterectomy. Disease-free survival reached 74% (381/515), with a median follow-up of 58 months. Prognostic factors were balanced between the two groups. FIGO stage and number of pelvic lymph nodes involved were significant prognostic factors in the whole study cohort. We showed that the completion of radical hysterectomy does not improve survival in patients with intraoperatively detected lymph node involvement, regardless of tumour size or histological type. If lymph node involvement is confirmed intraoperatively, abandoning uterine radical procedure should be considered, and the patient should be referred for definitive chemoradiation. NCT04037124.

Multimodal Therapy is a Better Choice for Patients with Brain Metastasis from Cervical Cancer.

ObjectiveTo evaluate the prognostic factors and optimal management of cervical cancer patients with brain metastasis (BM).Materials and MethodsWe retrospectively reviewed the medical records of 7098 consecutive patients with cervical cancer from January 2000 to December 2019. Data for a total of 24 BM patients with cervical cancer were analyzed retrospectively in the present study.ResultsThe incidence of BM from cervical cancer in our institution was 0.38%. The mean survival time was 7.2 months (median 6.2 months, 0.1–21.2 months). In the univariate analysis, the histopathology of neuroendocrine cancer, 2018 FIGO stage, Karnofsky performance status (KPS) at BM diagnosis, and treatment strategy were identified to be significant prognostic indicators for the survival of patients with BM from cervical cancer. In the multivariate analysis, KPS, chemotherapy, and radiotherapy were independent prognostic factors for survival. Recursive partition analysis (RPA) appeared to be a better prognostic tool than the other prognosis scoring classification systems.ConclusionWhen patients with BM from cervical cancer have good performance status and undergo comprehensive treatment, such as radiotherapy and chemotherapy, their survival time could be significantly prolonged. Patients with surgical indications may get better survival by postoperative radiotherapy and chemotherapy. Patients with BMs ≥3 may get better survival by whole-brain radiotherapy. But further studies are needed regarding the selection of surgical indications and radiotherapy modes. The prognosis scoring classification system for BM from cervical cancer needs to be improved.

Treatment Outcome of Cervical Cancer Patients Treated with Low-Versus High Dose Rate Brachytherapy after Concurrent Chemo-Radiation

Cervical cancer (CC) is the commonest gynecological cancer seen in the Ghanaian woman. Majority of patients here present with locally advanced diseases due poor screening practices aimed at detecting and treating precancerous conditions. The current standard curative treatment for locally advanced CC is concurrent cisplatin-based chemo-radiation plus intracavitary brachytherapy. The brachytherapy (BT) component has been Low-Dose Rate (LDR) BT for almost a century now until a few decades ago when High-Dose Rate (HDR) BT was developed to overcome disadvantages of LDR BT such as long treatment duration. In October 2014, HDR BT was introduced as the BT technique for the management of CC patients at this Centre, after several years of using LDR BT. The hypothesis for this study was that there was no difference in the treatment outcomes of CC patients treated with HDR BT compared with those who received LDR BT at this center. The aim of this study was to compare the treatment outcomes and toxicity of CC patients treated with LDR BT versus HDR BT treated at this Centre. Patients with histologically confirmed CC treated from January 2008 to December 2017 were enrolled after applying the inclusion and exclusion criteria. Information regarding patient demographics, stage of disease, type of BT received, total radiation dose received, response to treatment and treatment related toxicities experienced were extracted from the medical records of the patients. The primary end points of the study included local control (LC), disease free survival (DFS) and overall survival (OS) all at 2 years. Toxicities were also assessed. Primary endpoints were estimated using the Kaplan-Meier method. Comparisons between treatment groups were performed using the log-rank test and Cox proportional hazards models. Over the 10-year period, 284 LDR (2008 –mid-2014) and 136 HDR (mid-2014-2017) patients fit the inclusion criteria. The median follow-up was 22 months (1-132months) vs. 11 months (1-41months) in LDR vs. HDR group respectively. For stages IB, IIA, IIB, IIIA and IIIB disease, the 2-year LC rates for LDR vs. HDR were 63 % vs. 61% p = 0.348, 86% vs. 90% p = 0.680, 86% vs. 88% p = 0.829, 66% vs. 60% p = 0.556 and 77% vs. 40% p = 0.005 respectively. The 2-year DFS for LDR vs. HDR BT were 64% vs. 61% p = 0.495, 81% vs. 69% p = 0.179, 81% vs. 80% p = 0.540, 62% vs. 33%, p = 0.818, and 71% vs.30%, p = 0.001 for stages IB, IIA, IIB, IIIA and IIIB respectively. The OS were comparable in both treatment groups stage for stage. Frequencies of acute and chronic toxicities for LDR vs. HDR were 22.6 % vs. 23.5%, and 3.9% vs. 6.9%, respectively. Comparable LC, DFS and OS were observed for IB, IIA, IIB and IIIA patients treated with LDR vs. HDR BT. HDR BT for the treatment of CC is therefore an acceptable alternative to LDR BT. However, the poorer LC and DFS rates observed for IIIB patients, and the higher frequencies of toxicities in the HDR BT cohort highlights the need for refining the HDR BT techniques at the Centre.

SIRT2 expression exhibits potential to serve as a biomarker for disease surveillance and prognosis in the management of cervical cancer patients.

This study aimed to compare the sirtuin 2 (SIRT2) expression between tumor tissue and adjacent tissue, and to investigate the association of tumor SIRT2 expression with clinical characteristics and survival profiles in cervical cancer patients.One hundred ninety-one cervical cancer patients were reviewed in this retrospective study. All patients underwent surgical resection and had well-preserved tumor tissue and adjacent tissue, which were obtained for SIRT2 expression detection by immunohistochemistry (IHC). Clinical parameters were obtained. Disease free survival (DFS) and overall survival (OS) were calculated.Both SIRT2 expression by IHC score (P < .001) and the percentage of SIRT2 high expression (defined as IHC score >3) (P < .001) were declined in tumor tissue compared with paired adjacent tissue. In addition, SIRT2 expression in tumor tissue was negatively correlated with tumor size (P = .047), lymph node metastasis (P = .009) and FIGO stage (P = .001). And the DFS (P = .007) as well as OS (P = .008) were better in patients with SIRT2 high expression compared with patents with SIRT2 low expression. Univariate Cox's proportional hazards regression model analyses revealed that high SIRT2 expression in tumor tissue was a predictive factor for more prolonged DFS (P = .009) and OS (P = .011), while multivariate Cox's proportional hazards regression model analysis disclosed that it lacks independent predictive value for DFS (P = .084) or OS (P = .132).SIRT2 expression exhibits potential to serve as a biomarker for disease surveillance and prognosis in the management of cervical cancer patients.

EP-1506 Multi-institutional treatment and management of cervical cancer patients

EP-1506 Multi-institutional treatment and management of cervical cancer patients

Assessment of Health Related Quality of Life in Cervical Cancer Patients in Western Kenya

Health Related Quality of Life (HRQoL) is an important health outcome in the holistic management of patients especially those suffering from life limiting conditions such as cervical cancer. In Kenya, Cervical cancer is the most frequent cancer among women. However, little is known and documented on HRQoL of cervical cancer patients. This study assessed HRQoL of cervical cancer patients in western Kenya. A cross-sectional study involving 334 cervical cancer patients was conducted in Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) in Kisumu from September 2014 to February 2015. FACT-Cx (The Functional Assessment of Chronic Illness Therapy –for measuring Quality of Life in cervical cancer patients) Version 4 and a structured questionnaire were used to collect data. Quantitative data was analyzed using Statistical Package for Social Scientists (SPSS) Version 20 and Statistical Application Software (SAS) version 9.2 at a statistical significance of P ≤ 0.05, descriptive and inferential statistics were performed. The mean HRQoL was 35.35 (SD=13.21). More than half of the respondents experienced poor functional and physical wellbeing, 221 (66%) and 201 (60%) respectively and no patient experienced good functional and physical wellbeing. While 189 (57%) experienced fair overall quality of life. Multiple cumulative logistic regression analysis between cancer stage and treatment had statistically significant association with overall quality of life (X2 = 105.34 and 70.72; with df=3 and 6; p-values = 0.0001 and 0.0001, respectively); also between age, marital status, level of education and religion showed positive influence on overall quality of life except for religion (X2 = 21, 11, 113 and 4 with df=3 for all and p-values = 0.0001, 0.0121, 0.0001, 0.2563 respectively). Cervical cancer patients do fairly better with emotional and social wellbeing, while they experience poor functional and physical wellbeing due to large proportion of patients presenting at stage IV and III of the disease. There is a need to include HRQoL assessment in routine management of cervical cancer patients to enhance their quality of life.

Is neo-adjuvant chemotherapy a better option for management of cervical cancer patients of rural India?

To explore alternate modality of treatment in patients of advanced cancer cervix by neo-adjuvant chemotherapy (NACT) followed by External Beam Radiotherapy (ERT) and Brachytherapy (BT). Short- (6 months) and long- (12 months) term follow-up data from these patients were compared with the retrospective data from an urban cancer centre, where standard protocol of concurrent chemo-radiotherapy is practiced. Two hundred patients of advanced cervical cancer, treated at our rural cancer centre between January 2007 and December 2007, were included in the study arm (Group A). These patients received three cycles of neo-adjuvant chemotherapy with Cisplatin, Bleomycin, and Vincristine before External-Beam Radiotherapy (EBT) followed by brachytherapy. Patients in the control arm (Group B) of an urban cancer centre, received EBT with weekly concomitant Cisplatin, followed by brachytherapy. Short- (6 months) and long- (12 months) term follow-up data from our patients were compared with the retrospective data from the urban cancer centre. Complete response rate was comparatively higher among patients of Group A, also correspondingly proportion of patients showing progressive disease and stable disease was lower among them. Local treatment failure was 87.5% among patients from Group A and 94.4% in Group B patients. Concomitant chemoradiation (CRT) was associated with more GI toxicities. Our result suggests NACT arm is as effective as CRT arm in respect of complete response with less pelvic failure and G.I toxicities. Further follow-up data are needed before arriving at a definite conclusion.

EGFR Promoter Methylation, EGFR Mutation, and HPV Infection in Chinese Cervical Squamous Cell Carcinoma.

Therapy strategy toward epidermal growth factor receptor (EGFR) inhibition in cervical cancer has been ongoing. EGFR promoter methylation status and EGFR tyrosine kinase inhibitor-sensitive mutations in cervical cancer may be significant for clinical outcome prediction using anti-EGFR treatment. In this study, EGFR tyrosine kinase inhibitor-sensitive mutations, EGFR exons 18, 19, and 21 mutations, were detected by sequencing in a total of 293 Chinese cervical squamous cell carcinoma tissue samples. EGFR promoter methylation status was detected by an EGFR asymmetric PCR and hybridization-fluorescence polarization assay and sequencing in 293 Chinese cervical squamous cell carcinoma tissue samples. High-risk human papillomavirus (HPV) genotypes in 293 Chinese cervical squamous cell carcinoma tissue samples were detected by an asymmetric GP5+/6+ PCR and hybridization-fluorescence polarization assay. No EGFR exons 18, 19, and 21 mutations were detected, EGFR promoter methylation status was identified in 98 samples, and HPV 16 infection was the first frequent HPV genotype. The methylated EGFR promoter was identified most frequently in cervical squamous cell carcinoma samples with HPV 16 infection (53.4%). Statistical significant difference of EGFR promoter methylation prevalence was found between HPV 16 and other HPV genotypes (P<0.01). This study suggested that there was no EGFR tyrosine kinase inhibitor-sensitive mutation in EGFR exons 18, 19, and 21 in Chinese cervical squamous cell carcinoma tissue samples. EGFR promoter methylation was common and it might be associated with HPV 16 infection in Chinese cervical squamous cell carcinoma. The results provided a novel understanding and an applicable pharmacogenomic tool for individualized management of cervical cancer patients.

Effect of changes in treatment practice on survival for cervical cancer: results from a population-based study in Manitoba, Canada.

BackgroundResults from clinical trials in the 1990s led to changes in the recommended treatment for the standard therapy for stage IIB-IVA cervical cancer from radiotherapy alone to chemo-radiotherapy. We conducted the first population-based study in Canada to investigate temporal treatment patterns for cervical cancer and long-term survival in relation to these changes in the treatment guidelines.MethodsDetailed information on stage and treatment for 1085 patients diagnosed with cervical cancer in 1984–2008 and identified from the population-based Manitoba Cancer Registry (MCR) in Canada was obtained from clinical chart review and the MCR. Factors associated with receiving guideline treatment were identified using logistic regression. All cause and cervical cancer specific survival were compared in patients who were and were not treated as recommended in the guidelines, using Cox proportional hazards models.ResultsThe median follow-up time was 6.4 years (range: 0.05–26.5 years). The proportion of women who received guideline treatment was 79 % (95 % confidence interval [CI]: 76–81 %). However, the likelihood of being treated according to the guidelines over time was modified by age (p < 0.0001) and tumour stage at diagnosis (p = 0.002). Women who were treated according to the guidelines after the change in recommended clinical practice (1999–2008) had a significantly lower risk of death from all causes and from cervical cancer. This was driven by lower mortality rates in cases with stage IIB-IVA tumours (all causes of death: hazard ratio [HR] = 0.60, 95 % CI: 0.43–0.82, p = 0.002; cervical cancer related death: HR = 0.64, 95 % CI: 0.44–0.93, p = 0.02).ConclusionsThe management of cervical cancer patients in Manitoba, Canada was in good agreement with treatment guidelines although reasons for departure from the guideline recommendations could not be examined further due to lack of data. Treatment of stage IIB-IVA cervical cancers with recommended concurrent chemo-radiotherapy, which is now standard practice, was associated with substantially increased survival, although the effect of changes in clinical practice including maintenance of haemoglobin levels on improved survival cannot be ruled out as a contributing factor.

Patient side cost and its predictors for cervical cancer in Ethiopia: a cross sectional hospital based study

BackgroundCervical cancer is a leading cause of death from cancer among women in low-resource settings, affecting women at a time of life when they are critical to social and economic stability. In addition, the economic burden is important for policy formulation. The aim of this study is to estimate patient side cost and to determine predictors of its variation for the treatment of cervical cancer.MethodsAnalytic cross sectional study involving 227 cervical cancer cases at Tikur Anbessa Hospital, Ethiopia was conducted. Cost estimation was based on patients' perspective and using the prevalence-based model as a time frame. Productivity losses were estimated from lost working days.ResultsThe mean outpatient cost per patient for cervical cancer was $407.2 (Median = $206.9). Direct outpatient cost (Mean = $334.2) takes the largest share compared with the indirect counterpart ($150). The outpatient cost for half of the respondent falls in a range between $93.7 and $478. The mean inpatient cost for hospitalized patients was $404.4. The average direct inpatient cost was $329 (74% medical costs and 26% non medical costs). The mean value for total inpatient cost for half of the respondents was in the range of $133.5 and $493.9. For every additional day of inpatient hospital stay, there is a daily incremental inpatient cost of $4.2.ConclusionAs has been found in other studies, our findings revealed that cervical cancer creates an immense financial burden on patients. Primary prevention measures, vaccination against HPV and screening, should be initiated and expanded to reduce morbidity from cervical cancer and subsequent costs in both human lives and money resources. Control of co-morbidity and complication should be emphasized during management of cervical cancer patients. Capacitating regional hospitals and provision of low cost or fee exemption schemes should be arranged and strengthened.

Management of cervical cancer patients with isolated para-aortic lymph node metastases

To the editor: For patients with locally advanced cervical cancer, the current guidelines recommend primary chemoradiation [1]. Therefore, pretherapeutic staging has an important role in the management of female patients with locally advanced cervical cancer. Assessment of the nodal involvement of the para-aortic lymph node (PALN) is critical for determining the field of radiation therapy (RT). Extended-field RT, concurrent cisplatin-containing chemotherapy, and brachytherapy should be considered in the case of PALN metastasis. Jang et al. [2] report the outcomes of 40 cervical cancer patients with isolated PALN metastases at initial diagnosis. This interesting and valuable article demonstrates the association between treatment outcomes and the features of PALN metastasessuch as size, site, and number. The number and size of PALNs were shown to correlate with progression-free survival. The authors suggest that the radiologic features of PALN can be used to determine the prognosis of patients with isolated PALN metastases. As the authors define PALN involvement based on imaging, the criteria for lymph node involvement should be clarified. In addition, it should also be noted that there are limitations including the false-positive and false-negative results of conventional imaging studies (magnetic resonance imaging or computed tomography) in detecting PALN metastases. It makes hard for clinicians to determine whether to perform extended-field RT based solely on imaging studies. It would be even more interesting if the authors were to show the correlation between the radiologic and pathologic findings in seven patients who underwent radical hysterectomy. In recent years, positron emission tomography/computed tomography (PET/CT) has been recommended for stage IB2 or advanced disease as it is considered to be more sensitive than conventional imaging studies in detecting node or distant metastases [3]. Future studies based on PET/CT are required in order to identify prognostic factors and treatment outcomes for locally advanced cervical cancer. Furthermore, survival data for patients with PALN metastases detected surgically and treated by extended-field RT in a randomized trial setting is rare [4]. Therefore, the impact of surgical staging in women with locally advanced cervical cancer should be evaluated in future trials, considering the high rate of false-negative PALN involvement from imaging studies. Bearing in mind that postoperative complications and the delay of definite chemoradiation can occur from nodal staging surgery, a comprehensive cost-effective analysis is required to clarify the best treatment strategy for locally advanced stage cervical cancer.

Spiritual Meanings of Illness in Patients with Cervical Cancer

In a health crisis such as diagnosis with cancer and its subsequent treatment, patients may draw on spirituality to attach meanings to the illness. In South Africa, patients' meanings of chronic illness may also be shaped by a specific African religious context. To describe psychological understandings of chronic illness, 16 patients diagnosed with cervical cancer for six months or longer were interviewed at a South African hospital, and the qualitative data were subjected to thematic analysis. This paper reports on spiritual meanings, as one component of these psychological understandings that get attached to living with cervical cancer. For holistic management of cervical cancer patients, and by extension for palliative care, spiritual dimensions should not be neglected; all members of any multi-disciplinary oncology team should be alerted to these dimensions to provide adequate care.