A study presented by Dr. Renaud Mazeron at the World Congress of Brachytherapy reveals that many cases of hysterectomy, as well as recurrence and spreading of cancer of the cervix can be controlled effectively by delivering radiotherapy directly to the cancer with 3-D imaging techniques.
After reviewing using 3-D image guided adaptive brachytherapy (IGABT) in 163 patients who received a course of concomitant chemoradiation, i.e. chemotherapy combined with radiotherapy at the Institut Gustave Roussy in Villejuif, France between 2004 to 2009, Dr. Mazeron and his team observed far superior results, compared with previous cases that used different therapies.
They observed that aside from IGABTs efficacy in tumor control the therapy also had more acceptable adverse effects.
Currently, no conclusive evidence exists as to whether women with cervical cancer, particular those of advanced stage, i.e. stage IB to IIB should undergo hysterectomies in order to prevent a recurrence of the cancer or prevent it from metastasizing. According to these findings, unless the cancer has recurred and invaded the womb, there is no reason for the majority of women to undergo a hysterectomy.
Dr Mazeron, an assistant professor of the Institut Gustave Roussy's radiation oncology department explained:
"IGABT is a three dimensional technique of brachytherapy allowing a much better adaptation of treatment to the target area, while preserving healthy organs at risk from radiation. Our department has been one of the pioneers of this technique and we already have accumulated significant experience. Our current study does not formally show that surgery is unnecessary, since we did not conduct a randomized comparison, but it shows that IGABT combined with chemoradiation achieves results far superior to the historical data, with high rates of control at the site of the primary tumor."
"In our institute, surgeons have been convinced to abandon systematic surgery by the advances in concomitant chemoradiation and IGABT, and the conjunction of both. Historical data based on classical techniques, which gave external radiation without chemotherapy and X ray-based brachytherapy which did not allow to adapt the treatment to each case, show that local control of a stage I tumor was usually around 90%, between 60 to 87% for stage II, 44 to 66% for stage III and 18-48% for stage IVA. In this study, we report a rate of 92% in a large group of patients with tumors at any stage."
The cancer stages of the 163 study participants included 27% of patients with stage I cervical cancer, 57% who had stage II and 12% who suffered from stage III, as well as 3% who had stage IV cervical cancer. All patients' received concomitant chemoradiation. After the chemoradiation, 88% of patients had magnetic resonance imaging (MRI) scans and 12% a computerized tomography (CT) in order to administer brachytherapy to the correct location. Even though 61 women or 37% underwent a radical hysterectomy, only 13 cases were observed to have residual cancer cells. According to Dr Mazeron, the operations were partly conducted because the study covered a pivotal period when surgeons discontinued to routinely perform surgery on cervical cancer patients.
"At present, surgery is proposed in case of obvious residual tumor after chemoradiation and IGABT. It is sometimes difficult to define complete remission, and thus some patients in the study were operated due to clinical or imaging suspicion of residual tumor, but finally were found to be in complete pathological remission. Currently, surgeons at our institute practice radical hysterectomy following chemoradiotherapy and IGABT only a few times per year, after a biopsy has confirmed that part of the tumor remains. However, in another study, we have shown a worse prognosis, despite surgery, for patients who do not respond completely to radiotherapy or brachytherapy due to a higher risk of metastases."
At the average 36-month follow-up, the team noted a relapse in 45 patients, including one woman who had had a hysterectomy. 70.4% of these patients had distant metastases.
"This clearly shows that distant metastases are the primary cause of relapse."
The overall survival and disease-free survival rate was 84% and 73% respectively at three years, whilst tumor control at its primary site (local control) shrunk 97% for less than 5 cm compared with the initial width of the tumor, 91% for 5 to 6 cms and 81% for 6 cms or larger. 74.5 patients were observed to suffer more severe adverse effects classed as grade 3 to 4 and 9 of these 12 patients underwent a hysterectomy after their radiotherapy.
Dr. Mazeron comments:
"This represents a strong argument for not performing surgery in patients in complete remission after treatment with concomitant chemoradiation and IGABT."
He states that these findings should be confirmed by two international studies, one of which will be presented at the parallel ESTRO 31 conference in Barcelona due to the fact that IGABT is an emerging technology, and concluded:
"IGABT is the future of brachytherapy in cervical cancer. Potential financial investments should not discourage radiation oncologists. It costs less than Intensity-Modulated Radiation Therapy, a technique of external beam radiotherapy that has become a standard in the treatment of some cancers. We must keep in mind that cervical cancer is a public health problem in developing countries where it is the second most common cancer in women following breast cancer. IGABT represents a significant improvement in results, and some centers are already practicing this technique in India and Southeast Asia."
Chairperson of the World Congress of Brachytherapy, Dr Christine Haie-Meder, who is a radiation oncologist at the Institut Gustave Roussy, added:
"Image-guided adaptive brachytherapy has recently been implemented in cervix cancer patients. Results are in favor of a significant improvement in local control. The present series also contribute to show improvement in local control with IGABT. Within this context, complementary surgery does not bring any further contribution to local control improvement, and hysterectomy may even increase the risk of complications."
Written By Petra Rattue