An evidence-based estimate of the appropriate rate of utilization of radiotherapy for cancer of the cervix

Mapping of Radiation Oncology and Gynecologic Oncology Services Available to Treat the Growing Burden of Cervical Cancer in Africa

PURPOSE

To meet the demand for cervical cancer care in Africa, access to surgical and radiation therapy services needs to be understood. We thus mapped the availability of gynecologic and radiation therapy equipment and staffing for treating cervical cancer.

METHODS AND MATERIALS

We collected data on gynecologic and radiation oncology staffing, equipment, and infrastructure capacities across Africa. Data was obtained from February to July 2021 through collaboration with international partners using Research Electronic Data Capture. Cancer incidence was taken from the International Agency for Research on Cancer's GLOBOCAN 2020 database. Treatment capacity, including the numbers of radiation oncologists, radiation therapists, physicists, gynecologic oncologists, and hospitals performing gynecologic surgeries, was calculated per 1000 cervical cancer cases. Adequate capacity was defined as 2 radiation oncologists and 2 gynecologic oncologists per 1000 cervical cancer cases.

RESULTS

Forty-three of 54 African countries (79.6%) responded, and data were not reported for 11 countries (20.4%). Respondents from 31 countries (57.4%) reported access to specialist gynecologic oncology services, but staffing was adequate in only 11 countries (20.4%). Six countries (11%) reported that generalist obstetrician-gynecologists perform radical hysterectomies. Radiation oncologist access was available in 39 countries (72.2%), but staffing was adequate in only 16 countries (29.6%). Six countries (11%) had adequate staffing for both gynecologic and radiation oncology; 7 countries (13%) had no radiation or gynecologic oncologists. Access to external beam radiation therapy was available in 31 countries (57.4%), and access to brachytherapy was available in 25 countries (46.3%). The number of countries with training programs in gynecologic oncology, radiation oncology, medical physics, and radiation therapy were 14 (26%), 16 (30%), 11 (20%), and 17 (31%), respectively.

CONCLUSIONS

We identified areas needing comprehensive cervical cancer care infrastructure, human resources, and training programs. There are major gaps in access to radiation oncologists and trained gynecologic oncologists in Africa.

[Effect of waiting time for radiotherapy on five-year overall survival in women with cervical cancer, 1995-2010]

Overall 5-year survival and factors associated with death were evaluated in a cohort of 342 women with cervical cancer referred to radiotherapy in the Baixada Fluminense, in Greater Metropolitan Rio de Janeiro State, Brazil. Overall 5-year survival was 25.3%, reaching 60.8% in women with stage IIA or less. The model adjusted by extended Cox proportional regression showed an increase in mortality risk for patients with stages IIB-IIIB (HR = 1.89; 95%CI: 1.214; 2.957) and IVA-IVB (HR = 5.78; 95%CI: 2.973; 11.265). Cytology in asymptomatic women (HR = 0.58; 95%CI: 0.362; 0.961) and referral for first consultation in an oncology service in the Baixada Fluminense (HR = 0.60; 95%CI: 0.418; 0.875) were the main protective factors identified by the study. Waiting time (> 60 versus ≤ 60 days) was not statistically significant, but a delay of 4 days worsened the outcome. The 60-day limit for initiating radiotherapy should be respected, because delay greater than 64 days showed a significant association between all waiting time cut-off points and 5-year mortality risk.

Hierarchy of evidence referring to the central nervous system in a high-impact radiation oncology journal: a 10-year assessment. Descriptive critical appraisal study

CONTEXT AND OBJECTIVE

To the best of our knowledge, there has been no systematic assessment of the classification of scientific production within the scope of radiation oncology relating to central nervous system tumors. The aim of this study was to systematically assess the status of evidence relating to the central nervous system and to evaluate the geographic origins and major content of these published data.

DESIGN AND SETTING

Descriptive critical appraisal study conducted at a private hospital in São Paulo, Brazil.

METHODS

We evaluated all of the central nervous system studies published in the journal Radiotherapy & Oncology between 2003 and 2012. The studies identified were classified according to their methodological design and level of evidence. Information regarding the geographical location of the study, the institutions and authors involved in the publication, main condition or disease investigated and time of publication was also obtained.

RESULTS

We identified 3,004 studies published over the 10-year period. Of these, 125 (4.2%) were considered eligible, and 66% of them were case series. Systematic reviews and randomized clinical trials accounted for approximately 10% of all the published papers. We observed an increase in high-quality evidence and a decrease in low-quality published papers over this period (P = 0.036). The inter-rater reliability demonstrated significant agreement between observers in terms of the level of evidence.

CONCLUSIONS

Increases in high-level evidence and in the total number of central nervous system papers were clearly demonstrated, although the overall number of such studies remained relatively small.

Indication of radiotherapy for women with cervical cancer in Rio De Janeiro, Brazil

The objective of this article was to analyze the treatment modalities used at the Brazilian National Cancer Institute, with particular emphasis on the use of radiotherapy (RT) and its indications in invasive cervical cancer, considering the staging and clinical epidemiological characteristics of the population. All cases of primary invasive tumors of the cervix (CID C53) registered at the institute and diagnosed between 1999 and 2004 were selected. The following variables were studied: (1) age, (2) year of diagnosis, (3) level of schooling, (4) race, (5) histopathologic subtype, (6) the staging of the tumor on diagnosis, and (7) the treatment modality initially offered. We analyzed 3509 cases of invasive disease, and 79.7% of them received RT. Based on the final logistic model, it was possible to construct a probabilistic model for the indication of RT in the subgroups formed by the combinations of the 3 highlighted variables (stage, age, and histological type). The likelihood varied from 22.5% in those with epidermoid carcinoma, stage I, younger than 55 years up to 100% in those with locally advanced disease and older than 65 years. These results indicate the importance of RT as a modality of treatment of invasive cervical cancer in Brazil, where a substantial proportion of the diagnoses are made in advanced stages. This set of information regarding this important center may help the long-term strategic planning and the allocation of funds that enable the high demand to be met in an optimized manner.

Estimating the lifetime utilization rate of radiotherapy in cancer patients: the Multicohort Current Utilization Table (MCUT) method

Extensive research has been carried out to establish the appropriate proportion of cancer patients requiring radiotherapy at some point during their illness. However, it is difficult to compare the actual rates against the appropriate rate, because calculating the actual rates requires life-long follow up of cancer patients. We have developed a method, referred to as the Multicohort Current Utilization Table (MCUT) method, to estimate the predicted lifetime utilization rates based on current medical practice. We implemented the method in SAS as a macro, and validated it by comparing the predicted and the actual utilization rates of radiotherapy in lung, breast, and prostate cancer cases diagnosed in Ontario, Canada. The MCUT method could be used to predict lifetime utilization rate of any medical services.

Defining the Need for Breast Cancer Radiotherapy in the General Population: a Criterion-based Benchmarking Approach

AIMS

Determining the appropriate rate of radiotherapy is important for ensuring optimal radiotherapy utilisation and accessibility. A criterion-based benchmark (CBB) was developed for estimating the need for radiotherapy in incident breast cancer cases. Our primary objective was to compare an evidence-based estimate (Ebest) of need against the CBB. These estimates were then compared with radiotherapy rates in Ontario, Canada and the USA. Surgical rates were also examined.

MATERIALS AND METHODS

Benchmarks were defined in Ontario as communities in proximity to cancer centres and without long waiting lists. Patient data from 1997 to 2001 were prospectively collected from radiotherapy cancer centres. Surgical data were obtained from the Canadian Institute for Health Information database. The public use file of Surveillance, Epidemiology and End Results (SEER) described treatment in the USA.

RESULTS

In total, 4241 cases of breast cancer were diagnosed in benchmark communities. The overall radiotherapy rate by Ebest was 64.0% (95% confidence interval: 58.1-69.8%) compared with the CBB of 60.7% (59.3-62.1%). In comparison, Ontario's overall radiotherapy rate was 55.6% (55.0-56.1%) and in SEER it was 49.3% (48.9-49.6%). Adjuvant radiotherapy rates after lumpectomy were 100% in Ebest and 83.6% (82.0-85.1%) by the CBB. The Ebest and CBB post-mastectomy rates were 21.9% (20.6-23.3%) and 34.6% (32.5-36.7%), respectively. Observed post-lumpectomy radiotherapy rates were 75.1% in Ontario and 65.3% in SEER. Post-mastectomy radiotherapy rates were 29.5% in Ontario and 17.0% in SEER.

CONCLUSIONS

CBB provides a reasonable estimate of the overall need for radiotherapy in breast cancer. Observed radiotherapy rates in Ontario and the USA suggest an age-related decrease in the use of radiotherapy. The benchmark estimate suggests a shortfall of adjuvant breast radiotherapy utilisation in Ontario.