Brachytherapy: An overview for clinicians Chargari, Cyrus; Deutsch, Eric; Blanchard, Pierre ...
CA: a cancer journal for clinicians,
September/October 2019, Volume:
69, Issue:
5
Journal Article
Peer reviewed
Open access
Brachytherapy is a specific form of radiotherapy consisting of the precise placement of radioactive sources directly into or next to the tumor. This technique is indicated for patients affected by ...various types of cancers. It is an optimal tool for delivering very high doses to the tumor focally while minimizing the probability of normal tissue complications. Physicians from a wide range of specialties may be involved in either the referral to or the placement of brachytherapy. Many patients require brachytherapy as either primary treatment or as part of their oncologic care. On the basis of high‐level evidence from randomized controlled trials, brachytherapy is mainly indicated: 1) as standard in combination with chemoradiation in patients with locally advanced cervical cancer; 2) in surgically treated patients with uterine endometrial cancer for decreasing the risk of vaginal vault recurrence; 3) in patients with high‐risk prostate cancer to perform dose escalation and improve progression‐free survival; and 4) in patients with breast cancer as adjuvant, accelerated partial breast irradiation or to boost the tumor bed. In this review, the authors discuss the clinical relevance of brachytherapy with a focus on indications, levels of evidence, and results in the overall context of radiation use for patients with cancer.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
To determine the trends in brachytherapy use in cervical cancer in the United States and to identify factors and survival benefits associated with brachytherapy treatment.
Using the Surveillance, ...Epidemiology, and End Results (SEER) database, we identified 7359 patients with stages IB2-IVA cervical cancer treated with external beam radiation therapy (EBRT) between 1988 and 2009. Propensity score matching was used to adjust for differences between patients who received brachytherapy and those who did not from 2000 onward (after the National Cancer Institute alert recommending concurrent chemotherapy).
Sixty-three percent of the 7359 women received brachytherapy in combination with EBRT, and 37% received EBRT alone. The brachytherapy utilization rate has decreased from 83% in 1988 to 58% in 2009 (P<.001), with a sharp decline of 23% in 2003 to 43%. Factors associated with higher odds of brachytherapy use include younger age, married (vs single) patients, earlier years of diagnosis, earlier stage and certain SEER regions. In the propensity score-matched cohort, brachytherapy treatment was associated with higher 4-year cause-specific survival (CSS; 64.3% vs 51.5%, P<.001) and overall survival (OS; 58.2% vs 46.2%, P<.001). Brachytherapy treatment was independently associated with better CSS (hazard ratio HR, 0.64; 95% confidence interval CI, 0.57-0.71), and OS (HR 0.66; 95% CI, 0.60 to 0.74).
This population-based analysis reveals a concerning decline in brachytherapy utilization and significant geographic disparities in the delivery of brachytherapy in the United States. Brachytherapy use is independently associated with significantly higher CSS and OS and should be implemented in all feasible cases.
Radiation has many potential long-term effects on cancer survivors. Female cancer patients may experience decreased fertility depending on the site irradiated. Oncologists should be aware of these ...consequences and discuss options for fertility preservation before initiating therapy.
A comprehensive review of the existing literature was conducted. Studies reporting the outcomes for female patients treated with cranio-spinal, abdominal, or pelvic radiation reporting fertility, pregnancy, or neonatal-related outcomes were reviewed.
Cranio-spinal irradiation elicited significant hormonal changes in women that affected their ability to become pregnant later in life. Women treated with abdomino-pelvic radiation have an increased rate of uterine dysfunction leading to miscarriage, preterm labor, low birth weight, and placental abnormalities. Early menopause results from low-dose ovarian radiation. Ovarian transposition may decrease the rates of ovarian dysfunction.
There is a dose-dependent relationship between ovarian radiation therapy (RT) and premature menopause. Patients treated with RT must be aware of the impact of treatment on fertility and explore appropriate options.
To develop brachytherapy recommendations covering aspects of pretreatment evaluation, treatment, and dosimetric issues for locally advanced cervical cancer.
Members of the American Brachytherapy ...Society (ABS) with expertise in cervical cancer brachytherapy formulated updated recommendations for locally advanced (Federation of Gynecology and Obstetrics Stages IB2-IVA) cervical cancer based on literature review and clinical experience.
The ABS recommends the use of brachytherapy as a component of the definitive treatment of locally advanced cervical carcinoma. Precise applicator placement is necessary to maximize the probability of achieving local control without major side effects. The ABS recommends a cumulative delivered dose of approximately 80-90Gy for definitive treatment. The dose delivered to point A should be reported for all brachytherapy applications regardless of treatment-planning technique. The ABS also recommends adoption of the Groupe Européen Curiethérapie-European Society of Therapeutic Radiation Oncology (GEC-ESTRO) guidelines for contouring, image-based treatment planning, and dose reporting. Interstitial brachytherapy may be considered for a small proportion of patients whose disease cannot be adequately encompassed by intracavitary application. It should be performed by practitioners with special expertise in these procedures.
Updated ABS recommendations are provided for brachytherapy for locally advanced cervical cancer. Practitioners and cooperative groups are encouraged to use these recommendations to formulate their clinical practices and to adopt dose-reporting policies that are critical for outcome analysis.
To determine current practice patterns with regard to three-dimensional (3D) imaging for gynecologic brachytherapy among American Brachytherapy Society (ABS) members.
Registered physician members of ...the ABS received a 19-item survey by e-mail in August 2007. This report excludes physicians not performing brachytherapy for cervical cancer.
Of the 256 surveys sent, we report results for 133 respondents who perform one or more implantations per year for locally advanced cervical cancer. Ultrasound aids 56% of physicians with applicator insertion. After insertion, 70% of physicians routinely obtain a computed tomography (CT) scan. The majority (55%) use CT rather than X-ray films (43%) or magnetic resonance imaging (MRI; 2%) for dose specification to the cervix. However, 76% prescribe to Point A alone instead of using a 3D-derived tumor volume (14%), both Point A and tumor volume (7%), or mg/h (3%). Those using 3D imaging routinely contour the bladder and rectum (94%), sigmoid (45%), small bowel (38%), and/or urethra (8%) and calculate normal tissue dose-volume histogram (DVH) analysis parameters including the D2cc (49%), D1cc (36%), D0.1cc (19%), and/or D5cc (19%). Respondents most commonly modify the treatment plan based on International Commission on Radiation Units bladder and/or rectal point dose values (53%) compared with DVH values (45%) or both (2%).
More ABS physician members use CT postimplantation imaging than plain films for visualizing the gynecologic brachytherapy apparatus. However, the majority prescribe to Point A rather than using 3D image based dosimetry. Use of 3D image-based treatment planning for gynecologic brachytherapy has the potential for significant growth in the United States.
Radiation dose-volume effects of the urinary bladder Viswanathan, Akila N; Yorke, Ellen D; Marks, Lawrence B ...
International journal of radiation oncology, biology, physics,
03/2010, Volume:
76, Issue:
3 Suppl
Journal Article
Peer reviewed
Open access
An in-depth overview of the normal-tissue radiation tolerance of the urinary bladder is presented. The most informative studies consider whole-organ irradiation. The data on partial-organ/nonuniform ...irradiation are suspect because the bladder motion is not accounted for, and many studies lack long enough follow-up data. Future studies are needed.
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GEOZS, IJS, NUK, OILJ, UL, UM, UPUK
Our previous Surveillance, Epidemiology, and End Results (SEER) study revealed a concerning decline in brachytherapy utilization in the United States between 1988 and 2009. This study evaluates ...recent trends in brachytherapy utilization in cervical cancer and identifies factors and survival benefit associated with the use of brachytherapy treatment.
Using SEER data, 8500 patients with International Federation of Gynecologists and Obstetricians 2009 stage IB2-IVA cervical cancer treated with external beam radiation therapy (EBRT) between 2000 and 2020 were identified. Logistic regression analysis was performed on potential factors associated with brachytherapy use: age, marital status, race, ethnicity, income, metropolitan status, year of diagnosis, SEER region, histology, grade, and stage. To adjust for differences between patients who received brachytherapy and those who did not, propensity-score matching was used. Multivariable Cox regression analysis assessed the association of brachytherapy use with cervical cancer-specific mortality (CSM) and all-cause mortality (ACM) in the matched cohort.
Sixty-four percent of the 8500 women received brachytherapy in combination with EBRT; 36% received EBRT alone. The brachytherapy utilization rate declined sharply in 2003/2004 (lowest rate 44% in 2003) and then gradually improved especially in 2018 to 2020 (76%). Factors associated with higher odds of brachytherapy use included younger age, married (vs single), later years of diagnosis, certain SEER regions, and earlier stage. In the propensity-score matched cohort, brachytherapy treatment was associated with lower 4-year cumulative incidence of cancer death (32.1% vs 43.4%; P < .001) and better overall survival (64.0% vs 51.4%; P < .001). Brachytherapy treatment was independently associated with lower CSM (hazard ratio, 0.70; 95% CI, 0.64-0.76; P < .001) and ACM (hazard ratio, 0.72; 95% CI, 0.67-0.78; P < .001).
Brachytherapy utilization among SEER regions has improved since 2004 in patients with stage IB2-IVA cervical cancer. Brachytherapy use remains independently associated with significantly lower CSM and ACM and is an essential component of treatment for patients with locally advanced cervical cancer.
To provide an update of the 2007 American brachytherapy survey on image-based brachytherapy, which showed that in the setting of treatment planning for gynecologic brachytherapy, although computed ...tomography (CT) was often used for treatment planning, most brachytherapists used point A for dose specification.
A 45-question electronic survey on cervical cancer brachytherapy practice patterns was sent to all American Brachytherapy Society members and additional radiation oncologists and physicists based in the United States between January and September 2014. Responses from the 2007 survey and the present survey were compared using the χ(2) test.
There were 370 respondents. Of those, only respondents, not in training, who treat more than 1 cervical cancer patient per year and practice in the United States, were included in the analysis (219). For dose specification to the target (cervix and tumor), 95% always use CT, and 34% always use MRI. However, 46% use point A only for dose specification to the target. There was a lot of variation in parameters used for dose evaluation of target volume and normal tissues. Compared with the 2007 survey, use of MRI has increased from 2% to 34% (P<.0001) for dose specification to the target. Use of volume-based dose delineation to the target has increased from 14% to 52% (P<.0001).
Although use of image-based brachytherapy has increased in the United States since the 2007 survey, there is room for further growth, particularly with the use of MRI. This increase may be in part due to educational initiatives. However, there is still significant heterogeneity in brachytherapy practice in the United States, and future efforts should be geared toward standardizing treatment.
Radiation therapy (RT) refusal is known to have deleterious effects on survival for multiple cancer types. Factors associated with RT refusal by patients with gynecologic malignancies have not been ...well described. This study aimed to examine factors associated with and the survival impact of documented RT refusal among patients with gynecologic cancers.
This study analyzed data from the National Cancer Database (NCDB) of patients with gynecologic cancers diagnosed between 2004 and 2020. Patients were included if they had complete survival data and a documented RT recommendation by their treating physician in the NCDB. Patients coded as received RT were compared with those coded as refused RT in the NCDB using a multivariate log binomial regression with robust variance to yield incidence rate ratios (IRR). Overall survival was analyzed using a multivariate (MV) Cox proportional hazards model to yield hazard ratios.
This study identified 209,976 patients. A total of 5.75% (n = 12,081) patients were coded as refusing RT. Multivariable IRR showed that documentation of RT refusal was positively associated with older age (MV IRR, 1.04; 95% CI, 1.041-1.045), Native Hawaiian Pacific Islander race (1.72 1.27-2.32), and increased morbidity (score = 1: 1.06 1.02-1.11; score = 2: 1.20 1.12-1.29; score ≥3: 1.26 1.14-1.38). Negative associations were seen with Hispanic ethnicity (0.74 0.67-0.80), having insurance (0.58 0.53-0.63), and annual income >$74,063 (0.85 0.81-0.90). During the 16-year period, a statistically significant test for trend (P = .001) for increasing RT refusal was noted. RT refusal was associated with a significantly higher risk of death (MV hazard ratio, 1.59 1.55-1.63).
For patients with gynecologic malignancies diagnosed from 2004 to 2020, an increase in documented RT refusal is associated with decreased overall survival in all disease types. Targeted interventions aimed at mitigating potential sociodemographic barriers to receipt of RT are warranted.
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