Socioeconomic characteristics of patients with squamous cell carcinoma of the uterine cervix treated with radiotherapy in the 1992 to 1994 patterns of care study

Molecular Heterogeneity of Cervical Cancer Among Different Ethnic/Racial Populations

The study aimed to find differential gene mutation profile and gene expression status among different ethnic/racial human populations relevant for cervical cancer pathogenesis. The study was based on freely available datasets of The Cancer Genome Atlas (TCGA) of cervical cancer samples in Genomic Data Commons (GDC) data portal. We identified that choline metabolism in cancer and Ras signaling pathways were significantly associated with the Hispanic and Latino group of cervical cancer patients. In these pathways, mutations in the PIK3CA gene, especially E545K, were significantly associated with the Hispanic and LATINO group. We found that AFF3 gene mutation was associated with downregulation of its expression only among the White racial category of cervical cancer cases. Additionally, hypomethylation of the CpG position in the S shore region of the PM20D1 gene was associated with overexpression among the Asian category of cervical cancer cases. Heterogeneity of the molecular profile of AFF3 and PM20D1 gene among racial groups reflects the potential of differential targeted therapy of cervical cancer.

The prognostic significance of pretreatment squamous cell carcinoma antigen levels in cervical cancer patients treated by concurrent chemoradiation therapy and a comparison of dosimetric outcomes and clinical toxicities between tomotherapy and volumetric modulated arc therapy

Background

To analyze the prognostic factors associated with stage IB-IVA cervical cancer in patients who underwent concurrent chemoradiation therapy (CCRT) and to compare the clinical toxicities and dosimetric parameters of organs at risk between the different radiotherapy techniques.

Methods

This retrospective study enrolled 93 patients with stage IB-IVA cervical cancer who underwent definitive CCRT between April 2009 and December 2017. Nine patients (9.7%) received 3DCRT, 43 patients (46.2%) underwent VMAT, and 41 patients (44.1%) received tomotherapy, and all of them followed by brachytherapy using a 2D planning technique. The treatment outcomes and related prognostic factors were analyzed. We also compared the clinical toxicities and dosimetric parameters between the different techniques used for the last 30 patients.

Results

With a median follow-up of 52.0 months, the 5-year overall survival (OS), progression-free survival (PFS), locoregional recurrence–free survival (LRRFS), and distant metastases–free survival (DMFS) were analyzed. In a Cox proportional hazards regression model, pretreatment SCC Ag > 10 ng/mL was a significant prognostic factor for PFS (hazard ratio [HR] 2.20; 95% confidence interval [CI] 1.03–4.70; P = 0.041), LRRFS (HR, 3.48; 95% CI 1.07–11.26; P = 0.038), and DMFS (HR 2.80; 95% CI 1.02–7.67; P = 0.045). Increasing the rectal volume receiving a radiation dose exceeding 30 Gy (V₃₀ of rectum; odds ratio [OR] 1.15; 95% CI 1.10–1.30; P = 0.03) was associated with a higher possibility of ≥ Grade 2 acute radiation therapy (RT)-related diarrhea. The median rectal V₃₀ values were 56.4%, 97.5%, and 86.5% for tomotherapy, 3-dimensional conformal radiation therapy (3DCRT), and volumetric modulated arc therapy (VMAT), respectively (P < 0.001). In addition, the chance of experiencing ≥ Grade 2 acute diarrhea were 10.0%, 66.7%, and 54.5% for tomotherapy, 3DCRT, and VMAT, respectively (P = 0.029).

Conclusions

Patients with pretreatment SCC Ag ≤ 10 ng/mL have better PFS, LRRFS, and DMFS than those with pretreatment SCC Ag > 10 ng/mL. The rectal V₃₀ is a significant predictor of severe acute diarrhea. Tomotherapy significantly decreased the rectal V₃₀, reducing the severity of acute RT-related diarrhea during external beam RT.

Trial registration This study was approved by the institutional review board at Kaohsiung Medical University Hospital. The registration number is KMUHIRB-E(I)-20190054 and retrospectively registered on 2019/3.

Revisiting Milan cervical cancer study: Do the original findings hold in the era of chemotherapy?

BACKGROUND

The primary treatment of early stage cervical carcinoma (IB-IIA) is either surgery or radiation therapy based on the pivotal Milan randomized study published twenty years ago. In the presence of high-risk features, the gold standard treatment is concurrent chemotherapy and radiation therapy (CRT) whether it is the in the postoperative or the definitive setting. Using the National Cancer Data Base (NCDB), the goal of our study is to compare the outcomes of surgery and radiation therapy in the chemotherapy era.

METHODS

Between 2004 and 2013, 5478 patients diagnosed with early stage cervical cancer were divided into 2 groups based on their primary treatment: non-surgical (n=1980) and surgical groups (n=3498). The distribution of patient/tumor characteristics and treatment variables with their relation to overall survival and proportional regression models were assessed to investigate the superiority of one approach over the other. Propensity score analysis adjusted for imbalance of covariates to create a well-matched-patient cohort.

FINDINGS

At 46months median follow-up, the 5-year overall survival was similar between both groups (73·8% vs. 75.7%; p=0.619) after applying propensity score analysis. On multivariate analysis, high Charlson comorbidity score, stage IIA disease, larger tumor size, positive lymph nodes and high-grade disease were significant predictors of poor outcome while older age and treatment approach were not.

INTERPRETATION

Our analysis suggests that surgery (followed by adjuvant RT or CRT) and definitive radiotherapy (with or without chemotherapy) result in equivalent survival. Prospective studies are warranted to establish this paradigm in the chemotherapy era.

Evaluation of Socio-demographic Factors for Non-compliance to Treatment in Locally Advanced Cases of Cancer Cervix in a Rural Medical College Hospital in India

Introduction:

Carcinoma cervix is a leading cause of cancer in India. However, majority of the patients face a problem of not being able to complete the treatment.

Aim:

This study was an attempt to find out the important causes of this non-compliance to treatment in a rural Medical College Hospital where majority of the cancer cases are of cervical cancer.

Results:

Out of 144 patients studied over 2 years 88 cases could not complete the treatment. The study revealed that due old age 58.33% cases were defaulters, having many children at home meant a burden to 76.92% cases and 63.89% cases had a problem of not been able to travel a far distance of more than 100 km from home to hospital for treatment.

Conclusion:

These were the important factors of non-compliance and suggested more important than the issues of literacy and poor socio-economic status.

Impact of sociodemographic factors on the radiotherapeutic management of lung cancer: Results of a Quality Research in Radiation Oncology survey

PURPOSE

The objective of this study is to describe the impact of sociodemographic (SOC) factors on the management of lung cancer patients treated at radiation therapy facilities participating in the Quality Research in Radiation Oncology survey.

METHODS AND MATERIALS

A 2-stage stratified random sample of lung cancer patients treated in 2006 to 2007 at 45 facilities yielded 340 stage I-III non-small cell lung cancer (NSCLC) and 144 limited-stage small cell lung cancer (LS-SCLC) cases. Five SOC variables based on data from the 2000 US Census were analyzed for association with the following clinical factors: patients living in urban versus rural settings (U/R); median household income (AHI); % below poverty level (PPV); % unemployed (PUE); and % with college education (PCE).

RESULTS

The 340 NSCLC patients were stage I, 16%; stage II, 11%; stage III, 62%; stage unknown, 11%. Histologic subtypes were adenocarcinoma, 31.8%; squamous cell carcinoma, 35.3%; large cell carcinoma, 3.2%; and NSCLC NOS, 27.7%. The median age was 66 years. Median Karnofsky performance status (KPS) was 80. The 144 LS-SCLC had a median age of 63; 73 were male (50.7%). Median KPS was 80. Stereotactic body radiation therapy (SBRT) and modern imaging utilization was associated with treatment at facilities located in higher SOC regions. SBRT was employed in 46.8% stage I NSCLC patients treated in centers where %PUE was below median versus 14.8% in centers where %PUE was above median (P = .02). Four-dimensional computed tomography was utilized in 14.2% of patients treated in centers located in regions with %PPV below median versus 3.7% in centers located in regions with %PPV above median (P < .01). SCLC patients were more likely to receive all of their planned RT when treated at centers located in regions with lower PPV (95.0% vs 79.1%; P = .04).

CONCLUSIONS

SOC factors may impact use of modern treatment planning and delivery and multidisciplinary management of NSCLC and SCLC. These results may suggest an impact of these SOC factors on access to health care.

Socioeconomic position and survival after cervical cancer: influence of cancer stage, comorbidity and smoking among Danish women diagnosed between 2005 and 2010

Background:

In an attempt to decrease social disparities in cancer survival, it is important to consider the mechanisms by which socioeconomic position influences cancer prognosis. We aimed to investigate whether any associations between socioeconomic factors and survival after cervical cancer could be explained by socioeconomic differences in cancer stage, comorbidity, lifestyle factors or treatment.

Methods:

We identified 1961 cases of cervical cancer diagnosed between 2005 and 2010 in the Danish Gynaecological Cancer database, with information on prognostic factors, treatment and lifestyle. Age, vital status, comorbidity and socioeconomic data were obtained from nationwide administrative registers. Associations between socioeconomic indicators (education, income and cohabitation status) and mortality by all causes were analysed in Cox regression models with inclusion of possible mediators. Median follow-up time was 3.0 years (0.01–7.0).

Results:

All cause mortality was higher in women with shorter rather than longer education (hazard ratio (HR), 1.46; 1.20–1.77), among those with lower rather than higher income (HR, 1.32; 1.07–1.63) and among women aged<60 years without a partner rather than those who cohabited (HR, 1.60; 1.29–1.98). Socioeconomic differences in survival were partly explained by cancer stage and less by comorbidity or smoking (stage- and comorbidty- adjusted HRs being 1.07; 0.96–1.19 for education and 1.15; 0.86–1.52 for income).

Conclusion:

Socioeconomic disparities in survival after cervical cancer were partly explained by socioeconomic differences in cancer stage. The results point to the importance of further investigations into reducing diagnosis delay among disadvantaged groups.

Nomogram prediction of overall survival after curative irradiation for uterine cervical cancer

PURPOSE

The purpose of this study was to develop a nomogram capable of predicting the probability of 5-year survival after radical radiotherapy (RT) without chemotherapy for uterine cervical cancer.

METHODS AND MATERIALS

We retrospectively analyzed 549 patients that underwent radical RT for uterine cervical cancer between March 1994 and April 2002 at our institution. Multivariate analysis using Cox proportional hazards regression was performed and this Cox model was used as the basis for the devised nomogram. The model was internally validated for discrimination and calibration by bootstrap resampling.

RESULTS

By multivariate regression analysis, the model showed that age, hemoglobin level before RT, Fédération Internationale de Gynécologie Obstétrique (FIGO) stage, maximal tumor diameter, lymph node status, and RT dose at Point A significantly predicted overall survival. The survival prediction model demonstrated good calibration and discrimination. The bootstrap-corrected concordance index was 0.67. The predictive ability of the nomogram proved to be superior to FIGO stage (p=0.01).

CONCLUSIONS

The devised nomogram offers a significantly better level of discrimination than the FIGO staging system. In particular, it improves predictions of survival probability and could be useful for counseling patients, choosing treatment modalities and schedules, and designing clinical trials. However, before this nomogram is used clinically, it should be externally validated.

Concurrent chemoradiation in the routine management of patients with cervical cancer: does marital status matter?

OBJECTIVE

The aim of this study was to investigate the relationship between marital status and outcome in women treated with concurrent chemoradiation (CT-RT) for locally advanced cervical cancer.

METHODS

We reviewed the records of all women who received CT-RT for squamous or adenocarcinomas of the cervix at the M. D. Anderson Cancer Center between 1998 and 2005. Patients with extrapelvic disease, prior hysterectomy, concurrent second malignancies, or prior pelvic radiation therapy or chemotherapy were excluded. All patients received external beam and intracavitary radiation therapy with concurrent weekly cisplatin or cisplatin and 5-fluorouracil. Of 226 women, 117 were married (MPs; median follow-up, 41 months) and 109 were single, divorced, or separated (SPs; median follow-up, 42 months).

RESULTS

The SPs were more likely to be African American (P < 0.001), be medically indigent (P < 0.001), and have used illicit drugs (P = 0.01). Married patients were more likely to have traveled to Houston for care; SPs were more likely to be permanent residents of Houston (61% vs 29.1%, P < 0.001). The SPs more often presented with tumors of 6.0 cm or more (P = 0.01) and stage II to IVA disease (P = 0.02). There were no other significant between-group differences in patient or tumor characteristics or CT-RT compliance. At 3 years, there were no significant between-group differences in disease-specific (80% in MPs vs 78% in SPs, P = 0.61) or pelvic relapse-free survival rates (88% in MPs vs 86% in SPs, P = 0.62).

CONCLUSIONS

Despite patient and tumor characteristics traditionally associated with poorer outcomes, SPs do not have significantly poorer treatment completion rates or outcomes after CT-RT. Further studies are needed to determine whether these trends hold true in other practice settings.

Racial differences in cervical cancer survival in the Detroit metropolitan area

BACKGROUND

African-American (AA) women have lower survival rates from cervical cancer compared with white women. The objective of this study was to examine the influence of socioeconomic status (SES) and other variables on racial disparities in overall survival among women with invasive cervical cancer.

METHODS

One thousand thirty-six women (705 white women and 331 AA women) who were diagnosed with primary invasive cancer of the cervix between 1988 and 1992 were identified through the Metropolitan Detroit Cancer Surveillance System (MDCSS), a registry in the Surveillance, Epidemiology, and End Results (SEER) database. Pathology, treatment, and survival data were obtained through SEER. SES was categorized by using occupation, poverty, and educational status at the census tract level. Cox proportional hazards models were used to compare overall survival between AA women and white women adjusting for sociodemographics, clinical presentation, and treatment.

RESULTS

AA women were more likely to present at an older age (P<.001), with later stage disease (P<.001), and with squamous histology (P=.01), and they were more likely to reside in a census tract categorized as Working Poor (WP) (P<.001). After multivariate adjustment, race no longer had a significant impact on survival. Women who resided in a WP census tract had a higher risk of death than women from a Professional census tract (P=.05). There was a significant interaction between disease stage and time with the effect of stage on survival attenuated after 6 years.

CONCLUSIONS

In this study, factors that affected access to medical care appeared to have a more important influence than race on the long-term survival of women with invasive cervical cancer.

Quality research in radiation oncology: a self-improvement initiative 30 years ahead of its time?

The quality of cancer care in the United States should be better than it is. Society has demanded improvement, but much work remains to be done to define and measure both the current quality of care and the steps needed to optimize such care. Various public and private organizations are directing early efforts toward attempts to determine the quality of selected oncology services as a first step in a broad-based quality improvement process. In contrast, the ACR Patterns of Care Study (PCS) for over 30 years has relied on exemplary voluntary engagement by American radiation oncologists in critical self-assessment and self-improvement as a highly effective pathway to improved practice quality. This article provides an overview of the documented historical and recent impact of PCS research findings on practice and describes the deliberate adaptation of the PCS identity and methodology to the quality-sensitive national environment with the new project name Quality Research in Radiation Oncology. The article concludes with a discussion of the rationale for continuing this unique quality improvement initiative and some of the challenges to this imperative that are being faced.

Advanced cervical cancer treatment in Harris County: Pilot evaluation of factors that prevent optimal therapy

OBJECTIVE

To document obstacles to completing outpatient treatment faced by indigent patients with cervical cancer and compare treatment costs.

METHODS

A retrospective pilot case series study assessed all indigent Harris County residents referred from Lyndon Baines Johnson Hospital (LBJ) to The University of Texas M. D. Anderson Cancer Center (M. D. Anderson) for advanced cervical cancer treatment between February 2001 and April 2004. Twenty-seven patients required hospital admission during the expected course of outpatient treatment and were identified as the study group. Nine patients, drawn from the same cohort but able to successfully complete the expected course of treatment as outpatients, were selected as the control group.

RESULTS

The median total treatment costs per patient in the study group (n = 27) was 28,892 US dollar more than the median treatment costs for the patients in the control group (n = 9) (P = 0.01). Median number of inpatient days in the study group was 19.6. Social factors identified as significantly different between the study and control groups included transportation difficulties (P = 0.006) and lack of social support (P = 0.08). Additional factors identified in the study group may have social significance such as accessible local housing (11% vs. 0%, P = 0.56) and noncompliance with treatment (37% vs. 11%, P = 0.22).

CONCLUSION

A combination of the lack of adequate methods of transportation and social support may contribute to the high cost of treating indigent patients with cervical cancer in Harris County, Texas.

A population-based study of racial and ethnic differences in survival among women with invasive cervical cancer: analysis of Surveillance, Epidemiology, and End Results data

OBJECTIVE

The incidence of cervical cancer is higher in Hispanic than in non-Hispanic or African American women in the United States, but few studies have examined differences in survival between these groups. The objective of this study was to examine racial/ethnic differences in survival after diagnosis with invasive cervical cancer in a population-based sample of patients while adjusting for patient and tumor characteristics and treatment types.

METHODS

We identified 7267 women (4431 non-Hispanic Caucasians, 1830 Hispanic Caucasians, and 1006 non-Hispanic African Americans) diagnosed with primary invasive cervical cancer from 1992 to 1996 (with follow-up through 2000) from the Surveillance, Epidemiology and End Results (SEER) Program. Kaplan-Meier and Cox proportional hazards survival methods were used to assess differences in survival by race/ethnicity.

RESULTS

After adjusting for age at diagnosis, histology, stage, first course of cancer-directed treatment (surgery and radiation therapy), and SEER registry, Hispanic Caucasian women were at 26% decreased risk of death from any cause (hazard ratio (HR) = 0.74, 95% confidence interval (CI): 0.66-0.83) and non-Hispanic African American women were at 19% increased risk of death (HR = 1.19, 95% CI: 1.06-1.33) compared to non-Hispanic Caucasian women over the follow-up period.

CONCLUSION

Analysis of population-based SEER data indicates significant survival differences by race/ethnicity for women with invasive cervical cancer. Hispanic Caucasian women in SEER had improved survival compared to non-Hispanic Caucasian or non-Hispanic African American women.

The med AUSTRON / ÖGRO patterns of care study on radiotherapy indications in Austria

PURPOSE

In Austria a national survey was conducted by Med AUSTRON/Osterreichische Gesellschaft for Radio--Onkologie, Radiobiologie und Medizinische Radiophysik (OGRO) in order to estimate the indications, patient numbers and radiotherapy treatment planning procedures and performances at all Austrian radiotherapy institutes. Results were correlated with incidence rates (Austrian cancer registry) to determine patterns of radiotherapy practice in Austria.

MATERIAL AND METHODS

At 12 radiotherapy departments of Austria data of all patients receiving irradiation within a 3 months (2002/2003) period were assessed. On the basis of a questionnaire number of treated patients, indications, and parameters of disease (stage, histology) and treatment modalities were evaluated. Results were analysed with regard to different tumour groups, according to academic and non academic hospitals, and correlated with epidemiological data on cancer incidence.

RESULTS

In total, 3783 patients were registered within this period. According to the different tumour entities percentages of patients receiving radiotherapy within initial treatment varied from 3% to 90 % (e.g. brain tumours: 77%, breast cancer: 90%, prostate cancer: 35%). The most frequent indications to radiotherapy per radiotherapy department were breast cancer (range 22%-35%; mean 26%), urological tumours (range 6%-27%; mean 12%) and bone metastases (mean 10%, range 3%-17%).

CONCLUSION

In Austria breast cancer, urological tumours and bone metastases are representing the most common indications to radiotherapy. Among the different departments variations in indications to radiotherapy were observed. Our study is the first evaluation of radiotherapeutic management in Austria.

Association of hemoglobin level with survival in cervical carcinoma patients treated with concurrent cisplatin and radiotherapy: a Gynecologic Oncology Group Study

OBJECTIVES

To determine if there is an association of hemoglobin level before or during concurrent cisplatin and radiotherapy (RT) with disease outcome in women with locally advanced cervical cancer, and to assess if the association is particularly significant at a specific interval or time during treatment.

METHODS

A retrospective review of 494 patients treated on two consecutive prospective Gynecologic Oncology Group (GOG) trials was conducted. Demographic data, pathologic information, treatment-related factors, and hemoglobin values at baseline and during each week of therapy were collected. Cox proportional hazards model was performed to evaluate the impact of hemoglobin level on progression-free survival (PFS).

RESULTS

Of the combined patients, 278 (56%) and 216 (44%) were diagnosed with Stage II and Stage III/IV disease, respectively. Controlling for age, race, performance status, disease stage, tumor size, cell type, and duration of radiotherapy, mean hemoglobin values during treatment were predictive of disease progression (P < 0.0001). The pretreatment level was not significant when hemoglobin levels during treatment were included in the multivariate analysis. When the 6-week treatment course was divided into 2-week periods (early, middle, and late), analysis revealed hemoglobin values during the late period were the most predictive of disease progression (P = 0.0289).

CONCLUSIONS

Hemoglobin levels during combined radiotherapy and cisplatin were independent predictors of treatment outcome in advanced cervical carcinoma. The pretreatment level was not a significant predictor of outcome when hemoglobin levels during treatment were included in the multivariate regression model. Levels in the last part of treatment were the most predictive of disease recurrence and survival.

Stage IIB-IVA Cancer of the Cervix

Stage IIB-IVA cancer of the cervix represents locally advanced-stage disease that has extended beyond the cervix without clinical evidence of extrapelvic metastasis. Localized surgery is seldom used as the extent of the disease precludes and an adequate surgical margin. Both sophisticated imaging and surgical staging have been utilized to accurately assess the extent of disease for treatment planning. Careful attention to radiation technique and the use of brachytherapy impact survival and treatment morbidity. Concurrent cisplatin-based chemotherapy has become the accepted standard based on randomized clinical trials (level 1 evidence). Further improvements may be achieved with combination chemotherapy, hyperthermia or prophylactic extended field radiation. However, these improvements, currently practiced in developed countries, must be implemented in underdeveloped countries which have the greatest burden of this disease.

Cervical cancer outcomes analysis: impact of age, race, and comorbid illness on hospitalizations for invasive carcinoma of the cervix

OBJECTIVE

The aim of this study was to evaluate the association of age, race, and comorbid illness with procedures and complications in hospitalized patients with invasive carcinoma of the cervix in a statewide population-based database over a 3-year period.

METHODS

Hospitalizations were classified into homogeneous subgroups based on a diagnosis of invasive cervical cancer. Cancer-related complications and comorbid diseases were evaluated. chi(2) and t tests determined differences in means or proportions. Linear regression techniques were applied to build models for hospitalization charges and lengths of stay (LOS).

RESULTS

There were 1009 admissions. The mean age was 49.5, with a median age of 46 (21-100, SD 15.4). Of the total, 606/1009 (60%) were white, 354/1009 (35%) were African-American (AA), and 5% were "other" races. AAs were more likely to have Medicaid or be uninsured (44% vs 23%, P = 0. 001) and were more likely to be admitted for an emergency (unadjusted odds ratio (OR) = 1.6; 1.2-2.2), to have a comorbid illness (P = 0.001), to be admitted for a cancer-related complication (P = 0.036), to be admitted for a transfusion (P = 0. 01), and to be admitted for radiation therapy rather than surgery (P = 0.001). The following were associated with LOS and higher hospital costs: emergency admissions for complications of cancer, comorbid illness, and older age.

CONCLUSIONS

Racial differences exist in patterns of admission, type of therapy, and severity of illness; however, there were no differences in charges or LOS for similar procedures. The large percentage of African-Americans uninsured or insured by government-supported programs indicates the potential impact of public policy on the care of these patients. Socioeconomic status rather than phenotypic appearance may be a more important determinant of outcome.