Will MR image-guided brachytherapy be a standard of care for cervical cancer in future? An Indian perspective

Magnetic Resonance Image Guided Adaptive Brachytherapy in Locally Advanced Cervical Cancer: An Experience From a Tertiary Cancer Center in a Low and Middle Income Countries Setting

PURPOSE

To determine the clinical impact of magnetic resonance image guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC) (stages II and III) in a tertiary care cancer hospital in a low and middle income countries setting.

METHODS AND MATERIALS

Ninety-four LACC patients enrolled in a prospective EMBRACE (An International Study on MRI-Guided Brachytherapy in Locally Advanced Cervical Cancer) protocol treated with external radiation therapy (45 Gy in 25 fractions) with or without weekly cisplatin, followed by magnetic resonance IGABT (4 fractions of 7 Gy), were analyzed in detail for dosimetric and clinical outcomes including late toxicities.

RESULTS

The mean (± standard deviation) high-risk clinical target volume (HR-CTV) at the first session of brachytherapy and at the second session of brachytherapy for the current study cohort was 46.94 ± 24.6 cm³ and 42.7 ± 22.5 cm³, respectively, with mean minimum dose received by 90% volume (D₉₀) of 88.3 ± 4.4 equivalent 2-Gy fractionation (Gy_EQD2). At median follow-up (39 months), the local control rate (LCR) and overall progression-free survival rate were 90.1% ± 3.4% and 72.1% ± 4.8%, respectively, with grade 3 bladder toxicity in 3% of patients and rectum toxicity in 9%. The LCR at 39 months was significantly better in patients with stage IIB and IVA disease versus stage IIIB disease (100% vs 85%, P=.013). Local failures were limited to stage IIIB only and were associated with significantly larger HR-CTVs at brachytherapy (70 ± 25.7 cm³ vs 44.3 ± 21.9 cm³, P=.01) but not with HR-CTV D₉₀ doses (which were similar for patients who had local failures vs those who did not: 86.3 ± 3.9 α/β equal to 10 Gy (Gy₁₀) vs 88.5 ± 5 α/β equal to 10 Gy, P=.987).

CONCLUSIONS

IGABT leads to a significant improvement in LCR and overall progression-free survival in LACC and should be considered for wider implementation in developing countries to improve outcomes.

Income generated by women treated with magnetic resonance imaging-based brachytherapy: A simulation study evaluating the macroeconomic benefits of implementing a high-end technology in a public sector healthcare setting

PURPOSE

To estimate the difference in income generated if all women presenting in our institute over a 5-year period were treated with MRI-based image-guided brachytherapy (MR-IGBT) instead of conventional radiograph-based brachytherapy (CR-BT).

METHODS AND MATERIALS

Outcome data from 463 patients (94 treated with MR-IGBT) treated in our institute was used to simulate cumulative women-days of work and cumulative income over 5 years for 5526 patients expected to be treated in this period. The average daily income for a woman was derived from the National Sample Survey Organization (NSSO) survey data. Outcomes from both unmatched and propensity score-matched data sets were simulated.

RESULTS

The cumulative income in 5 years ranged between Rs 101-168 million if all patients presenting at our institute underwent MR-IGBT. The simulated excess income ranged from Rs 4-45 million after 5 years, which represented 6-66% of the expenditure incurred for acquiring the required equipment and manpower for practicing exclusive MR-IGBT.

CONCLUSIONS

Using outcome data from a prospective cohort of patients treated with MR-IGBT in our institute, we demonstrated that significant economic gains may be realized if MR-IGBT was used instead of CR-BT.

Brachytherapy in India - a long road ahead

Brachytherapy can play a very important role in the definitive cure by radiation therapy in India. However, except for in a handful of centres, the majority of hospitals use it only for intracavitary treatment. The most probable reasons for such are the lack of logistical resources in terms of trained personal and supporting staff, rather than lack of radiotherapy machines and equipment. In this article, the authors look into the various aspects of brachytherapy in India: from its beginning to present days. The authors point out the resources available, shortcomings, and some possible solutions to make use of brachytherapy more popular and effective. Apart from presenting a picture of the present scenario, the article pays attention to the positive signs of brachytherapy becoming more popular in the near future.