Differentiation of survival outcomes by anatomic involvement and histology with the revised 2023 International Federation of Gynecology and Obstetrics staging system for endometrial cancer

OBJECTIVES

The International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer underwent revision in 2023, incorporating histology, lymphovascular space invasion, and molecular classification. Herein, we compare overall survival (OS) outcomes by anatomic and histologic involvement for patients staged by the 2009 system versus 2023 system.

METHODS

The National Cancer Database (NCDB) was queried for patients with newly-diagnosed uterine adenocarcinoma from 2004 to 2015, with follow-up data extending through 2020. Stage was determined by both the 2009 and 2023 FIGO staging systems. Kaplan-Meier estimators and Cox proportional hazards models were used for survival analysis.

RESULTS

A total of 134,677 patients were analyzed. Per 2023 classification, patients with stage I disease decreased from 96,161 to 70,101 (-27.1%, p < 0.01), while stage II disease increased from 9295 to 36,294 (+390.5%, p < 0.01). Greatest OS change was observed for 2023 stage IA3 patients (low-risk, synchronous endometrial and ovarian tumors with a clonal relationship), whose 10-year OS was 73.4%, compared to 52.6% for 2009 stage IIIA disease. Ten-year OS for 2023 stage IIIB2 (pelvic peritoneal involvement), previously 2009 stage IVB, was 49.4%, compared to 18.7% for 2009 stage IVB patients. Akaike information criterion, Bayesian information criterion, and Harrel's concordance index were used to evaluate OS prognostication of each staging system across all stages, with likelihood ratio favoring the 2023 system (p = 0.020).

CONCLUSIONS

With FIGO's 2023 endometrial cancer anatomic and histologic staging system, stage migration is greatest in early-stage disease. New staging groups may offer more precise prognostication. These changes may affect future management.

Vulvar Cancer, Version 3.2024, NCCN Clinical Practice Guidelines in Oncology

Vulvar cancer is annually diagnosed in an estimated 6,470 individuals and the vast majority are histologically squamous cell carcinomas. Vulvar cancer accounts for 5% to 8% of gynecologic malignancies. Known risk factors for vulvar cancer include increasing age, infection with human papillomavirus, cigarette smoking, inflammatory conditions affecting the vulva, and immunodeficiency. Most vulvar neoplasias are diagnosed at early stages. Rarer histologies exist and include melanoma, extramammary Paget's disease, Bartholin gland adenocarcinoma, verrucous carcinoma, basal cell carcinoma, and sarcoma. This manuscript discusses recommendations outlined in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for treatments, surveillance, systemic therapy options, and gynecologic survivorship.

Survival Outcomes of Limited-Stage Diffuse Large B-Cell Lymphoma Treated With Radiation Therapy

BACKGROUND

Patients with favorable risk limited-stage (LS) diffuse large b-cell lymphoma (DLBCL) have shown excellent outcomes without radiotherapy (RT). However, the role of RT for the remainder of LS-DLBCL patients is less well defined. We aimed to investigate whether the addition of RT provided an overall survival (OS) benefit in a real-world cohort of LS-DLBCL patients based on primary site at presentation.

MATERIALS AND METHODS

Retrospective data from 39,745 patients with stage I and II DLBCL treated with front-line combination chemotherapy alone or followed by RT were identified using the National Cancer Database from 2004 to 2015.

RESULTS

The addition of RT was associated with improved 5-year OS for all LS patients as compared to those treated with chemotherapy alone (85% vs. 80%, P < .001). RT was associated with improved 5-year OS in both the nodal and extranodal disease patients (nodal: 85% vs. 80%, P < .001; extranodal: 83% vs. 79%; P < .001). Extranodal sites with prolonged OS from the addition of RT include skin and soft tissue, head and neck, testicular, and thyroid sites (all P < .02). Breast, bone, lung and gastrointestinal extranodal primary sites had no OS benefit from the inclusion of RT. In multivariate analysis, the addition of RT was an independent factor for improved survival for all LS patients ([HR] 0.84, 95% [CI] 0.81-0.88; P < .001).

CONCLUSION

Though there is no consensus on optimal treatment indications for RT in LS-DLBCL, these data suggest certain subgroups may have benefit when RT is added to front-line chemotherapy.

Image-guided preplanning workflow for high-dose-rate interstitial brachytherapy for gynecological malignancies

PURPOSE

To demonstrate image-guided preplan workflows for high-dose-rate (HDR) brachytherapy for advanced gynecological malignancies.

METHODS AND MATERIALS

Two different preplanning scenarios are presented: (1) CT- or MRI-based preplan with partial applicator in place; (2) Preplans generated from prior fractions. The first scenario can be applied to Syed-Neblett template-based implants or hybrid brachytherapy applicators, while the second scenario applies to hybrid applicators. Both scenarios use MRI or CT images acquired with the applicator in place to demonstrate tumor and applicator relative locations and therefore, provide the ability to show optimized suggested needle positions including the implant depths before the actual insertion.

RESULTS

The preplanning techniques have demonstrated feasibility and shown five areas of potential improvement: (1) shorter procedure time, (2) decreased number of total needles inserted, (3) shorter physician tumor contour time, (4) shorter planning time, and (5) evaluation of appropriateness for brachytherapy.

CONCLUSIONS

The use of image-guided brachytherapy preplanning improves clinical efficiency and is recommended for consideration for adaptation into clinical workflows for HDR interstitial and hybrid brachytherapy.

NCCN Guidelines® Insights: Cervical Cancer, Version 1.2024

The NCCN Guidelines for Cervical Cancer provide recommendations for all aspects of management for cervical cancer, including the diagnostic workup, staging, pathology, and treatment. The guidelines also include details on histopathologic classification of cervical cancer regarding diagnostic features, molecular profiles, and clinical outcomes. The treatment landscape of advanced cervical cancer is evolving constantly. These NCCN Guidelines Insights provide a summary of recent updates regarding the systemic therapy recommendations for recurrent or metastatic disease.

Multi-Institutional Analysis of Cancer Patient Exposure, Perceptions, and Trust in Information Sources Regarding Complementary and Alternative Medicine

PURPOSE

Complementary and alternative medicine (CAM) use during cancer treatment is controversial. We aim to evaluate contemporary CAM use, patient perceptions and attitudes, and trust in various sources of information regarding CAM.

METHODS

A multi-institutional questionnaire was distributed to patients receiving cancer treatment. Collected information included respondents' clinical and demographic characteristics, rates of CAM exposure/use, information sources regarding CAM, and trust in each information source. Comparisons between CAM users and nonusers were performed with chi-squared tests and one-way analysis of variance. Multivariable logistic regression models for trust in physician and nonphysician sources of information regarding CAM were evaluated.

RESULTS

Among 749 respondents, the most common goals of CAM use were management of symptoms (42.2%) and treatment of cancer (30.4%). Most CAM users learned of CAM from nonphysician sources. Of CAM users, 27% reported not discussing CAM with their treating oncologists. Overall trust in physicians was high in both CAM users and nonusers. The only predictor of trust in physician sources of information was income >$100,000 in US dollars per year. Likelihood of trust in nonphysician sources of information was higher in females and lower in those with graduate degrees.

CONCLUSION

A large proportion of patients with cancer are using CAM, some with the goal of treating their cancer. Although patients are primarily exposed to CAM through nonphysician sources of information, trust in physicians remains high. More research is needed to improve patient-clinician communication regarding CAM use.

Role of Brachytherapy in Adjuvant Radiation Practices for FIGO Stage II Endometrial Cancer

PURPOSE/OBJECTIVE(S)

FIGO stage II endometrial adenocarcinoma (EAC) involves the cervical stroma but is otherwise confined to the uterus. Management involves total hysterectomy and bilateral salpingo-oophorectomy (TH/BSO) followed by risk-adapted adjuvant therapy which may include radiation and chemotherapy (CHT). We sought to investigate whether patients with FIGO II EAC undergoing adjuvant radiation benefit from addition of vaginal cuff brachytherapy (VCB).

MATERIALS/METHODS

The National Cancer Database was queried to identify patients with FIGO II EAC diagnosed in 2010-2019 who received TH/BSO followed by adjuvant EBRT alone, VCB alone, or EBRT+VCB. Patients <18 years old or with <6 months follow-up were excluded. Clinical and demographic data were compared by treatment received using two-sided Z-tests and χ2 tests. Predictors of VCB were identified using multinomial logistic regression. Multivariate regression was used to identify predictors of death. Survival was evaluated with Kaplan-Meier estimators and Cox proportional hazards modeling.

RESULTS

A total of 6152 women with FIGO II EAC met inclusion criteria. After TH/BSO, 1792 (29%) patients received EBRT alone, 2428 (40%) received VCB alone, and 1923 (31%) received EBRT+VCB. Lymphovascular space invasion (LVSI) was present in 2224 (36%) patients, of which 751 (34%) received EBRT alone, 698 (31%) received VCB alone, and 775 (35%) received EBRT+ VCB. CHT was given to 548 (31%) treated with EBRT alone, 248 (16%) with VCB alone, and 414 (21%) with EBRT+VCB. Positive surgical margins (+SM) were present in 211 patients (3%), of which 92 (44%) were treated EBRT alone and 70 (33%) with EBRT+VCB. Compared to EBRT alone, relevant relative risk ratios (RRR) of receiving VCB alone include grade 2 (RRR -0.25, p = 0.020) or 3 (RRR -0.41, p = 0.004) disease, single agent CHT (RRR -0.83, p = 0.001), and LVSI (RRR -0.56, p<0.001). RRR of receiving EBRT+VCB include age>70 (RRR -0.37, p = 0.022), grade 3 disease (RRR 0.30, p = 0.024), and single (RRR -0.42, p = .046) or multi- (RRR -0.24, p = 0.026) agent CHT. Predictors of death in the study cohort include age 50-69 (OR 1.8, p<0.001) and >70 (OR 4.1, p<0.001), Charlson-Deyo Comorbidity Index ≥1 (OR 1.4, p<0.001), grade 2 (OR 1.8, p<0.001) or 3 (OR 3.0, p<0.001) disease, cervical stromal invasion (OR 1.4, p = 0.001), and LVSI (OR 1.5, p<0.001). Compared to EBRT alone, both VCB alone (OR 0.81, p = 0.023) and EBRT+VCB (OR 0.70, p<0.001) were associated with decreased risk of death. Five-year overall survival in patients receiving EBRT alone was 77.9% (95% CI 75.8-79.8%), whereas VCB alone and EBRT+VCB were 84.8% (83.2-86.2%, log rank p<0.001) and 82.9% (81.0-84.6%, log rank p<0.001) respectively. Survival differences remained significant when isolating patients with LVSI, grade 3, and +SM.

CONCLUSION

VCB as monotherapy or in combination with EBRT in patients with FIGO II EAC was associated with improved survival. Inclusion of adjuvant VCB maintains an important role in treating patients with FIGO II EAC.

Risk of Cardiac-Specific Mortality in Patients with Lymphoma Treated with Radiotherapy

PURPOSE/OBJECTIVE(S)

The mainstays of treatment for Non-Hodgkin (NHL) and Hodgkin (HL) lymphoma are chemotherapy, radiotherapy (RT), or a combination of both. Thanks to improvements in treatment options many patients outlive their diagnosis by several decades. As treatments are de-intensified and cardiac sparing techniques have improved, the impact of RT on cardiac mortality should be re-visited. In this study, we sought to investigate the potential association between thoracic irradiation and cardiac-specific mortality (CSM) in patients with lymphoma. We hypothesized that receipt of RT would be associated with higher risk of cardiac death.

MATERIALS/METHODS

The Surveillance Epidemiology and End Results (SEER) database was queried to identify all patients with HL and NHL with a thoracic primary site from 1975 to 2018. Kaplan Meier estimators were used to analyze cardiac-specific survival. Cohorts were balanced using inverse probability treatment weighing (IPTW). Hazard ratios were calculated using multivariate cox regression analysis. The following treatment eras were defined for analysis: pre-1995, 1995-2003, post-2003, to roughly correspond to the adoption of 3D conformal RT (3DCRT) and intensity-modulated RT (IMRT).

RESULTS

We identified 10,602 patients, of which 8,088 (76%) had NHL and 2,514 (24%) had HL. Seventy-three percent of patients received chemotherapy and 38% received RT. Median follow up was 11.2 years. Forty-eight percent of patients were alive at last follow up, 6.6% had died from cardiac-specific causes, and 45% had died of other causes. Patients who received RT were had a lower risk of CSM (HR = 0.64, p < 0.01). However, IPTW survival analysis revealed no difference in the risk of cardiac death between the treatment cohorts (HR = 1.00, p = 0.99). Multivariate cox regression analysis identified female sex (HR = 0.73, p <0.01), age younger than 40 (HR = 0.27, p <0.01), and diagnosis after 1995 (HR = 0.31, p <0.01) to be associated with a lower CSM. In patients who received RT, we found that the risk of CSM was a higher (HR = 2.66, p <0.01) in those treated in the pre-1995 era and lower (HR = 0.32, p < 0.01) in the post-2003 era when compared to patients treated between 1995-2003. Additionally, receipt of RT was associated with a lower risk of all-cause mortality (HR 0.82, p<0.01).

CONCLUSION

Our IPTW analysis shows that patients with thoracic lymphoma treated with RT have a similar risk of cardiac death to patients who did not receive RT, and an improved OS. Known cardiovascular risk factors like male sex and older age were associated with higher risk of cardiac death in patients receiving RT. We also found that patients treated with RT pre-1995 had higher CSM compared to those treated in 1995-2003 and those treated after 2003 had the lowest CSM, possibly in part attributable to the adoption of newer RT techniques. These findings may help clinicians counsel patients with lymphoma on the optimal modality of therapy and the possibility for late treatment effects in the modern era.

Financial Improvements from Short Course Adjuvant Vaginal Cuff Brachytherapy (VCB) in Early Endometrial Cancer Compared to Standard of Care, "SAVE" Trial

PURPOSE/OBJECTIVE(S)

Early-stage endometrial cancer is often managed with hysterectomy followed by adjuvant VCB. Financial toxicity from cancer treatment is a strong driver of adherence. The SAVE trial is a multicenter, prospective randomized trial of standard of care (SoC) VCB doses delivered in 3-5 fractions per physician discretion compared to a 2-fraction course. We report on secondary cost endpoints, quantifying the financial impacts of shorter treatment courses on institutions and participating patients.

MATERIALS/METHODS

Technical (TechCs), professional (PCs), and total charges (TotCs) were collected prospectively and are reported as raw and Medicare-adjusted charges per patient. Geographic variations were standardized with CMS Geographic Practice Cost Indices (GPCI), and inflation was adjusted using the Consumer Price Index (CPI): Medical Care. Distance to treatment center was calculated from the patient's zip code to the corresponding treatment center. Cost of commutes was estimated through round-trip travel distance multiplied by average gas MPG for new vehicles by treatment year and state. Median income for each patient's zip code was estimated using 5-year Household income in 2021 inflation-adjusted dollars from the US Census. Mann-Whitney U, T- and Chi-square tests were used to compare characteristics between the two groups.

RESULTS

One hundred eight patients were analyzed. SoC VCB was delivered in 3, 4 and 5 fractions for 27/54 (50%), 11/54 (20%), and 16/54 (30%), respectively. Median total distance traveled per patient for SoC vs. experimental arms was 213 vs 137 miles (p = .12), and median cost of commute for patients was 36.3 vs 18.0 USD (p = .11). Compared to 2-fraction treatment, 5-fraction treatment resulted in longer travel distances (median 462 vs. 137 miles, p < 0.01) and increased travel costs (median 59.3 v. 18.0 USD, p = < 0.01). Median income by zip code for SoC v. experimental arms was 79,704 vs. 79,671 USD (p = 1.0). For SoC v. experimental arms, 11 (20%) vs 7 (13%) of patients had zip codes with median income in the lowest or second lowest quintiles (p = 0.5). Adjusted raw PCs per patient did not differ between SoC vs. experimental arms (9,159$ vs. 7,532$, p = 0.19). TechCs were significantly higher on the SoC arm (35,734$ vs. 24,696$ p = < 0.01), as were TotCs (44,892$ vs. 32,228$, p < 0.01;). Medicare-adjusted PCs, TechCs, and TotCs were higher for the SoC arm (Table 1).

CONCLUSION

Two-fraction VCB resulted in fewer treatments per patient, reduced cost of travel compared to longer courses, and an adjusted reduction in healthcare expenditures compared to standard of care. Ongoing work will include assessment of patient-reported financial toxicities.

Short Course Adjuvant Vaginal Cuff Brachytherapy (VCB) in Early Endometrial Cancer: Primary Endpoint Results of the SAVE Randomized Clinical Trial

PURPOSE/OBJECTIVE(S)

Prospective trials in early stage endometrial cancer demonstrate increased locoregional control with adjuvant radiotherapy for patients with high risk features. VCB is widely utilized, yet there is substantial practice variation and limited randomized data examining optimal dose/fractionation. We aimed to study the safety and efficacy of short course VCB compared to commonly used regimens.

MATERIALS/METHODS

We conducted a prospective, randomized, multicenter trial examining short course adjuvant VCB (11 Gy x 2 fractions at the surface) compared with other standard regimens (7 Gy x 3 fractions at 0.5 cm depth, 6 Gy x 5 fractions at the surface, or 5-5.5 Gy x 4 fractions at 0.5 cm depth). Eligible patients underwent hysterectomy and had pathologically confirmed endometrioid adenocarcinoma, serous, clear cell, or carcinosarcoma. Patients with stage I and II cancers were included, with lymphovascular invasion (LVI) required for stage IAG1. The primary outcome was Global Health Status measured by the EORTC QLQ-C30 with a pre-specified non-inferiority margin of 15 points. Secondary outcomes included patient-reported outcomes, toxicities as assessed by CTCAEv5, and patterns of recurrence. Data were collected at each brachytherapy fraction and at 1-, 6-, and 12-month follow-up.

RESULTS

One hundred eight patients were enrolled, 54 in each study arm. Data completion was 94%, 91%, and 77% at 1 month, 6 months, and 12 months, respectively. 70% of patients had endometrioid adenocarcinoma, 18% serous carcinoma, and 12% other histologies. 23% were FIGO grade 1, 33% grade 2, and 43% grade 3 or high risk histologies. The majority of patients were stage I (56% IA, 38% IB). 22% of patients had LVI. The QLQ-C30 Global Health Status for the experimental arm was within the predefined boundary and thus 2 fractions were non-inferior to standard of care at one month (p = 0.000005) and 12 months (p = 0.0005). Using EORTC EN24 for patient reported vaginal/sexual, urologic, and gastrointestinal symptoms, the change in mean patient reported symptom score from baseline to 1 month and baseline to 12 months were not significantly different between arms. Using CTCAEv5, 51 patients experienced short-term AEs related to study treatment, 20 in the experimental arm and 31 in the control arm (p = 0.053). All study treatment-related AEs were grade 1-2, except for two grade 3-4 AEs, both on the control arm. At median follow-up of 19 months, the isolated vaginal control rate in each arm was 100%. There was no significant difference in the total number of recurrences between study arms, with 3 distant and 3 distant/pelvic/vaginal recurrences in the experimental arm, and 2 distant, 2 pelvic, and 1 pelvic/vaginal recurrence in the control arm.

CONCLUSION

Short course VCB is safe with acceptable acute toxicity and non-inferior patient reported outcomes. Short course VCB improves patient convenience and may improve access to care for rural or underserved populations while providing similar local control.

Dosimetric Evaluation of Organs at Risk From SAVE Protocol

PURPOSE

The objective of this work was to evaluate dosimetric characteristics to organs at risk (OARs) from short-course adjuvant vaginal cuff brachytherapy (VCB) in early endometrial cancer compared with standard of care (SOC) in a multi-institutional prospective randomized trial.

METHODS AND MATERIALS

SAVE (Short Course Adjuvant Vaginal Brachytherapy in Early Endometrial Cancer Compared to Standard of Care) is a prospective, phase 3, multisite randomized trial in which 108 patients requiring VCB were randomized to an experimental short-course arm (11 Gy × 2 fractions [fx] to surface) and SOC arm. Those randomized to the SOC arm were subdivided into treatment groups based on treating physician discretion as follows: 7 Gy × 3 fx to 5 mm, 5 to 5.5 Gy × 4 fx to 5 mm, and 6 Gy × 5 fx to surface. To evaluate doses to OARs of each SAVE cohort, the rectum, bladder, sigmoid, small bowel, and urethra were contoured on planning computed tomography, and doses to OARs were compared by treatment arm. Absolute doses for each OAR and from each fractionation scheme were converted to 2 Gy equivalent dose (EQD23). Each SOC arm was compared with the experimental arm separately using 1-way analysis of variance, followed by pairwise comparisons using Tukey's honestly significant difference test.

RESULTS

The experimental arm had significantly lower doses for rectum, bladder, sigmoid, and urethra compared with the 7 Gy × 3 and 5 to 5.5 Gy × 4 fractionation schemes; however, the experimental arm did not differ from the 6 Gy × 5 fractionation scheme. For small bowel doses, none of the SOC fractionation schemes were statistically different than the experimental. The highest EQD23 doses to the examined OARs were observed to come from the most common dose fractionation scheme of 7 Gy × 3 fx. With a short median follow-up of 1 year, there have been no isolated vaginal recurrences.

CONCLUSIONS

Experimental short-course VCB of 11 Gy × 2 fx to the surface provides a comparable biologically effective dose to SOC courses. Experimental short-course VCB was found to reduce or be comparable to D2cc and D0.1cc EQD23 doses to rectum, bladder, sigmoid, small bowel, and urethra critical structures. This may translate into a comparable or lower rate of acute and late adverse effects.

Improvement in radiation techniques for locally advanced cervical cancer during the last two decades

Since the National Cancer Institute (NCI) alert of concurrent chemoradiotherapy, radiotherapy has been changed from external beam radiotherapy plus brachytherapy to platinum-based concurrent chemoradiotherapy. Therefore, concurrent chemoradiotherapy plus brachytherapy has become a standard treatment for locally advanced cervical cancer. Simultaneously, definitive radiotherapy has been changed gradually from external beam radiotherapy plus low-dose-rate intracavitary brachytherapy to external beam radiotherapy plus high-dose-rate intracavitary brachytherapy. Cervix cancer is uncommon in developed countries; hence, international collaborations have been critical in large-scale clinical trials. The Cervical Cancer Research Network (CCRN), created from the Gynecologic Cancer InterGroup (GCIG), has investigated various concurrent chemotherapy regimens and sequential methods of radiation and chemotherapy. Most recently, many clinical trials of combining immune checkpoint inhibitors with radiotherapy have been ongoing for sequential or concurrent settings. During the last decade, the method of standard radiation therapy has changed from three-dimensional conformal radiation therapy to intensity-modulated radiation therapy for external beam radiotherapy and from two-dimensional to three-dimensional image-guided approaches for brachytherapy. Recent improvements include stereotactic ablative body radiotherapy and MRI-guided linear accelerator (MRI-LINAC) using adaptive radiotherapy. Here we review the current progress of radiation therapy during the last two decades.

Adjuvant chemotherapy following chemoradiotherapy as primary treatment for locally advanced cervical cancer versus chemoradiotherapy alone (OUTBACK): an international, open-label, randomised, phase 3 trial

BACKGROUND

Standard treatment for locally advanced cervical cancer is chemoradiotherapy, but many patients relapse and die of metastatic disease. We aimed to determine the effects on survival of adjuvant chemotherapy after chemoradiotherapy.

METHODS

The OUTBACK trial was a multicentre, open-label, randomised, phase 3 trial done in 157 hospitals in Australia, China, Canada, New Zealand, Saudi Arabia, Singapore, and the USA. Eligible participants were aged 18 year or older with histologically confirmed squamous cell carcinoma, adenosquamous cell carcinoma, or adenocarcinoma of the cervix (FIGO 2008 stage IB1 disease with nodal involvement, or stage IB2, II, IIIB, or IVA disease), Eastern Cooperative Oncology Group performance status 0-2, and adequate bone marrow and organ function. Participants were randomly assigned centrally (1:1) using a minimisation approach and stratified by pelvic or common iliac nodal involvement, requirement for extended-field radiotherapy, FIGO 2008 stage, age, and site to receive standard cisplatin-based chemoradiotherapy (40 mg/m2 cisplatin intravenously once-a-week for 5 weeks, during radiotherapy with 45·0-50·4 Gy external beam radiotherapy delivered in fractions of 1·8 Gy to the whole pelvis plus brachytherapy; chemoradiotherapy only group) or standard cisplatin-based chemoradiotherapy followed by adjuvant chemotherapy with four cycles of carboplatin (area under the receiver operator curve 5) and paclitaxel (155 mg/m2) given intravenously on day 1 of a 21 day cycle (adjuvant chemotherapy group). The primary endpoint was overall survival at 5 years, analysed in the intention-to-treat population (ie, all eligible patients who were randomly assigned). Safety was assessed in all patients in the chemoradiotherapy only group who started chemoradiotherapy and all patients in the adjuvant chemotherapy group who received at least one dose of adjuvant chemotherapy. The OUTBACK trial is registered with ClinicalTrials.gov, NCT01414608, and the Australia New Zealand Clinical Trial Registry, ACTRN12610000732088.

FINDINGS

Between April 15, 2011, and June 26, 2017, 926 patients were enrolled and randomly assigned to the chemoradiotherapy only group (n=461) or the adjuvant chemotherapy group (n=465), of whom 919 were eligible (456 in the chemoradiotherapy only group and 463 in the adjuvant chemotherapy group; median age 46 years [IQR 37 to 55]; 663 [72%] were White, 121 [13%] were Black or African American, 53 [6%] were Asian, 24 [3%] were Aboriginal or Pacific islander, and 57 [6%] were other races) and included in the analysis. As of data cutoff (April 12, 2021), median follow-up was 60 months (IQR 45 to 65). 5-year overall survival was 72% (95% CI 67 to 76) in the adjuvant chemotherapy group (105 deaths) and 71% (66 to 75) in the chemoradiotherapy only group (116 deaths; difference 1% [95% CI -6 to 7]; hazard ratio 0·90 [95% CI 0·70 to 1·17]; p=0·81). In the safety population, the most common clinically significant grade 3-4 adverse events were decreased neutrophils (71 [20%] in the adjuvant chemotherapy group vs 34 [8%] in the chemoradiotherapy only group), and anaemia (66 [18%] vs 34 [8%]). Serious adverse events occurred in 107 (30%) in the adjuvant chemotherapy group versus 98 (22%) in the chemoradiotherapy only group, most commonly due to infectious complications. There were no treatment-related deaths.

INTERPRETATION

Adjuvant carboplatin and paclitaxel chemotherapy given after standard cisplatin-based chemoradiotherapy for unselected locally advanced cervical cancer increased short-term toxicity and did not improve overall survival; therefore, it should not be given in this setting.

FUNDING

National Health and Medical Research Council and National Cancer Institute.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Evaluating patterns of care for early-stage low-grade follicular lymphoma in the rituximab era

Radiotherapy (RT) utilization for early-stage, low-grade follicular lymphoma (FL) is low despite treatment guideline recommendations. We compare treatment trends for early-stage FL in the era of involved-site RT and rituximab. We identified 11,645 patients in the National Cancer Database (NCDB) with stage I-II, grade 1-2 nodal or extranodal FL diagnosed 2011-2017, with median follow-up of 44 months. From 2011 to 2017, RT utilization rates decreased from 33.4% to 22.4%, observation decreased from 65.3% to 49.7%, chemoimmunotherapy increased from 0.5% to 15.0%, immuno-monotherapy increased from 0.6% to 10.2%, and RT + systemic therapy increased from 0.6% to 2.5%. RT utilization remains low in the involved-site RT and rituximab era.

Patterns of care and outcomes of early stage I-II Hodgkin lymphoma treated with or without radiation therapy

Omission of radiotherapy in the upfront management of early-stage classic Hodgkin lymphoma (cHL) has become more common with time. We report patterns of care and outcomes of stage I-II cHL treated with chemotherapy (CT) only versus CT and radiotherapy (combined modality therapy, CMT). From the National Cancer Database, we identified 28,327 early-stage cHL patients treated with CT (n = 15,798) or CMT (n = 12,529) from 2004 to 2018. CMT utilization declined over the period from 58% to 34%. With median follow-up of 6.2 years, the 5- and 10-year overall survival for CT versus CMT was 93.3% versus 96.9% (p < 0.001) and 88.7% versus 93.5% (p < 0.001), respectively. On multivariable analysis, uninsured (OR 0.75, p < 0.001) and Black patients (OR 0.86, p = 0.02) were less likely to receive CMT, and treatment with CT was predictive of death (OR 2.0, p < 0.001). This report highlights real-world outcomes in early-stage cHL, with worse survival with CT and notable disparities in CMT utilization.

Radical trachelectomy and adjuvant vaginal brachytherapy to preserve fertility in pediatric cervical adenocarcinoma

PURPOSE

This case report describes the use of a trachelectomy and adjuvant vaginal brachytherapy for pediatric clear cell adenocarcinoma as definitive fertility-sparing treatment.

METHODS AND MATERIALS

A previously healthy 8-year-old female presented with abdominal cramping and heavy vaginal bleeding. Diagnostic imaging revealed a 3.5 cm circumscribed cervical mass, with subsequent biopsy revealing clear cell adenocarcinoma. Fertility preserving treatment was requested.

RESULTS

The patient underwent a radical trachelectomy, with final pathology demonstrating a close radial margin. Due to close margin, adjuvant radiotherapy with a vaginal cylinder was delivered to a total dose of 18 Gray in three fractions prescribed to a depth of 5 mm from the vaginal surface using iridium-192. With 2 years of follow-up, the patient continues to do well with no evidence of recurrence or late toxicity from treatment.

CONCLUSIONS

Pediatric clear cell adenocarcinoma of the cervix is a rare occurrence that lacks clinical trials to guide effective treatment. Adjuvant vaginal brachytherapy following trachelectomy in a pediatric patient with clear cell adenocarcinoma of the cervix is feasible and well-tolerated.

Racial and Ethnic Health Disparities in Delay to Initiation of Intensity-Modulated Radiotherapy

PURPOSE

Delays in initiation of radiotherapy may contribute to inferior oncologic outcomes that are more commonly observed in minoritized populations in the United States. We aimed to examine inequities associated with delayed initiation of intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

The National Cancer Database was queried to identify the 10 cancer sites most commonly treated with IMRT. Interval to initiation of treatment (IIT) was broken into quartiles for each disease site, with the 4th quartile classified as delayed. Multivariable logistic regression for delayed IIT was performed for each disease site using clinical and demographic covariates. Differences in magnitude of delay between subsets of patients stratified by race and insurance status were evaluated using two-sample t-tests.

RESULTS

Among patients (n = 350,425) treated with IMRT between 2004 and 2017, non-Hispanic Black (NHB), Hispanic, and Asian patients were significantly more likely to have delayed IIT with IMRT for nearly all disease sites compared with non-Hispanic White (NHW) patients. NHB, Hispanic, and Asian patients had significantly longer median IIT than NHW patients (NHB 87 days, P < .01; Hispanic 76 days, P < .01; Asian 74 days, P < .01; and NHW 67 days). NHW, Hispanic, and Asian patients with private insurance had shorter median IIT than those with Medicare (P < .01); however, NHB patients with private insurance had longer IIT than those with Medicare (P < .01).

CONCLUSION

Delays in initiation of IMRT in NHB, Hispanic, and Asian patients may contribute to the known differences in cancer outcomes and warrant further investigation, particularly to further clarify the role of different insurance policies in delays in advanced modality radiotherapy.

Intensity-Modulated Radiation Therapy Reduces Patient-Reported Chronic Toxicity Compared With Conventional Pelvic Radiation Therapy: Updated Results of a Phase III Trial

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The purpose of this update was to determine differences in patient-reported chronic toxicity and disease outcomes with intensity-modulated radiation therapy (IMRT) compared with conventional pelvic radiation. Patients with cervical and endometrial cancers who received postoperative pelvic radiation were randomly assigned to conventional radiation therapy (CRT) or IMRT. Toxicity and quality of life were assessed using Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, Expanded Prostate Cancer Index Composite (EPIC) bowel and urinary domains, and Functional Assessment of Cancer Therapy-General. Between 2012 and 2015, 279 eligible patients were enrolled to the study with a median follow-up of 37.8 months. There were no differences in overall survival (P = .53), disease-free survival (P = .21), or locoregional failure (P = .81). One year after RT, patients in the CRT arm experienced more high-level diarrhea frequency (5.8% IMRT v 15.1% CRT, P = .042) and a greater number had to take antidiarrheal medication two or more times a day (1.2% IMRT v 8.6% CRT, P = .036). At 3 years, women in the CRT arm reported a decline in urinary function, whereas the IMRT arm continued to improve (mean change in EPIC urinary score = 0.5, standard deviation = 13.0, IMRT v -6.0, standard deviation = 14.3, CRT, P = .005). In conclusion, IMRT reduces patient-reported chronic GI and urinary toxicity with no difference in treatment efficacy at 3 years.

Secondary malignancies in non-Hodgkin lymphoma survivors: 40 years of follow-up assessed by treatment modality

BACKGROUND

Survivors of non-Hodgkin lymphoma (NHL) have increased secondary malignancy (SM) risk. We quantified this risk by patient and treatment factors.

METHODS

Standardized incidence ratios (SIR, observed-to-expected [O/E] ratio) were assessed in 142,637 NHL patients diagnosed from 1975 to 2016 in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Comparisons were made between subgroups in terms of their SIRs relative to respective endemic populations.

RESULTS

In total, 15,979 patients developed SM, more than the endemic rate (O/E 1.29; p < 0.05). Compared with white patients, relative to respective endemic populations, ethnic minorities had a higher risk of SM (white O/E 1.27, 95% CI 1.25-1.29; black O/E 1.40, 95% CI 1.31-1.48; other O/E 1.59, 95% CI 1.49-1.70). Relative to respective endemic populations, patients who received radiotherapy had similar SM rates to those who did not (O/E 1.29 each), but irradiated patients had increased breast cancer (p < 0.05). Patients who received chemotherapy had higher SM rates than those who did not (O/E 1.33 vs. 1.24, p < 0.05) including more leukemia, Kaposi sarcoma, kidney, pancreas, rectal, head and neck, and colon cancers (p < 0.05).

CONCLUSIONS

This is the largest study to examine SM risk in NHL patients with the longest follow-up. Treatment with radiotherapy did not increase overall SM risk, while chemotherapy was associated with a higher overall risk. However, certain subsites were associated with a higher risk of SM, and they varied by treatment, age group, race and time since treatment. These findings are helpful for informing screening and long-term follow-up in NHL survivors.

Mental health disorders are more common in patients with Hodgkin lymphoma and may negatively impact overall survival

BACKGROUND

Long-term mental health outcomes were characterized in patients who were diagnosed with Hodgkin lymphoma (HL), and risk factors for the development of mental health disorders were identified.

METHODS

Patients who were diagnosed with HL between 1997 and 2014 were identified in the Utah Cancer Registry. Each patient was matched with up to five individuals from a general population cohort identified within the Utah Population Database, a unique source of linked records that includes patient and demographic data.

RESULTS

In total, 795 patients who had HL were matched with 3575 individuals from the general population. Compared with the general population, patients who had HL had a higher risk of any mental health diagnosis (hazard ratio, 1.77; 95% confidence interval, 1.57-2.00). Patients with HL had higher risks of anxiety, depression, substance-related disorders, and suicide and intentional self-inflicted injuries compared with the general population. The main risk factor associated with an increased risk of being diagnosed with mental health disorders was undergoing hematopoietic stem cell transplantation, with a hazard ratio of 2.06 (95% confidence interval, 1.53-2.76). The diagnosis of any mental health disorder among patients with HL was associated with a detrimental impact on overall survival; the 10-year overall survival rate was 70% in patients who had a mental health diagnosis compared with 86% in those patients without a mental health diagnosis (p < .0001).

CONCLUSIONS

Patients who had HL had an increased risk of various mental health disorders compared with a matched general population. The current data illustrate the importance of attention to mental health in HL survivorship, particularly for patients who undergo therapy with hematopoietic stem cell transplantation.

Complementary and alternative medicine exposure in oncology (CAMEO) study: A multi-institutional cross-sectional analysis of patients receiving cancer treatment

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Background: Compared to standard of care treatments, complementary and alternative medicine (CAM) use has been associated with decreased survival in cancer patients. CAM includes a broad range of treatments including vitamins/minerals, herbs/supplements, special diets, and mind/body interventions. An improved understanding of contemporary prevalence, predictors and intended goals of CAM use is needed to improve the cancer patient experience and guide shared decision-making regarding risks and benefits of their use. Methods: A cross-sectional survey of prospectively enrolled adult cancer patients treated at a large regional non-profit cancer center and an NCI-Designated Comprehensive Cancer Center between 2020 and 2021 was collected. Patients receiving cancer treatment were selected for analysis and grouped based on reported CAM use. Differences between CAM users and nonusers were assessed by chi-squared for categorical and two-sample t-test for continuous variables. Predictors of CAM use were identified with univariable and multivariable logistic regression. Results: Of 749 respondents, 83.31% had heard of or been recommended a CAM. Rates of CAM use during cancer treatment were highest for vitamins/minerals (56%), mind/body (52%), herbs/supplements (38%), special diets (30%), and other (12%). In the most common primary cancers, overall rates of CAM use were high (Breast: 84%, prostate: 66%, lung: 79%). Most patients (91%) use CAM in addition to conventional treatments. The intended goal of CAM therapy was most often management of symptoms (42%), treatment of cancer (30%), and mental health (15%). CAM users were younger than non-users (median age 62 years [y] vs 65y, p = 0.03). Females had higher rates of CAM use compared to males (86% vs. 78%, p < 0.01). Patients with incurable cancer had higher rates of CAM use than those with curable cancer (82% vs. 72%, p < 0.01). Predictors of CAM use on multivariable model include female gender (OR 2.5, p < 0.01) and incurable cancer (OR 2.5, p < 0.01). During cancer treatment, patients using CAM used multiple therapies and therapy types, including an average of 3.3 vitamins/minerals, 3.1 herbs/supplements, 2.5 mind/body exercises, and 1.6 special diets. Conclusions: CAM use is common among cancer patients receiving radiation, chemotherapy, and or surgery. Many patients are taking multiple CAM therapies during treatment with one third of patients using CAM with the intended goal of treating their cancer. This data provides details about and predictors of CAM use and provides information to guide patient-physician discussions.

Shifting perceptions of alternative therapies in cancer patients during the COVID-19 pandemic: Results from the Complementary and Alternative Medicine Exposure in Oncology (CAMEO) Study

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Background: Complementary and alternative medicine (CAM) use has been associated with worse survival outcomes in cancer patients compared to standard of care therapies. CAM has received a significant increase in public awareness and interest in the COVID-19 pandemic era. We sought to understand how the COVID-19 pandemic affected CAM use and perceptions in cancer patients. Methods: Data was collected from adult cancer patients prospectively enrolled on a cross-sectional survey conducted at an NCI-designated cancer center and a comprehensive cancer center between 2020 and 2021. The survey included questions assessing changes in patient attitude towards CAM and likelihood of using CAM, both relative to prior to COVID-19. Analyzed CAM users included those taking vitamin, mineral and herbal supplements, alternative medicines and special diets, and excluded mind-body practices as the focus of this analysis was on enteral and parenteral CAM therapies. Differences in the impact of COVID-19 on CAM use beliefs and practices between CAM users and non-users were analyzed with χ2 and two-sample t-tests. Results: Out of 749 respondents, 578 (77%) used any CAM and 470 (63%) used enteral or parenteral CAM. Results shown in table. Compared to prior to COVID-19, CAM users were more likely to view CAM more favorably (12% vs 5%, p < 0.01), while non-users were more likely to have an unchanged opinion (90% vs 84%, p = 0.03). Females had higher rates of viewing CAM more favorably than males (80% vs 58%, p = 0.04). Patients who viewed CAM more favorably had higher rates of self-reported incurable cancer (36% vs 11%, p = 0.04), declining recommended hormone therapy (22% vs 0%, p < 0.01), and higher trust of social media (19% vs 0%, p = 0.02) and websites (24% vs 0%, p < 0.01). Since the start of COVID-19, CAM users were more likely to report increased likelihood of using CAM (12% vs 6%, p = 0.01). Patients who were more likely to use CAM had higher rates of declining recommended chemotherapy (12% vs 0%, p = 0.02), and higher trust of social media (15% vs 2%, p = 0.01) and websites (28% vs 7%, p < 0.01). Conclusions: During the COVID-19 pandemic, attitudes on CAM use in oncology patients have become increasingly polarizing. Patients with favorable attitudes toward CAM were likely to decline recommended standard of care therapy and more like to use CAM since COVID-19. This data helps characterize shifting attitudes toward CAM and may help guide shared decision-making between physician and patient.[Table: see text]

Staging locally advanced cervical cancer with FIGO 2018 versus FIGO 2008: Impact on overall survival and progression-free survival in the OUTBACK trial (ANZGOG 0902, RTOG 1174, NRG 0274)

5531

Background: The International Federation of Obstetrics and Gynecology staging system for cervical cancer (FIGO 2008) was revised in 2018 to incorporate lymph node involvement (FIGO 2018). OUTBACK is an international, randomized phase 3 trial of adjuvant chemotherapy versus observation after standard of care treatment with chemoradiation for women with locally advanced cervical cancer. OUTBACK found no benefit from the addition of adjuvant chemotherapy. We evaluated the effects of classifying participants with these 2 staging systems in the OUTBACK trial population. Methods: OUTBACK recruited April 2011 to June 2017 and staged participants according to FIGO 2008. Lymph node status, smoking status, age, race and histological subtype were documented at trial entry as important prognostic factors. We assessed the effects of stage grouping into stage I, II, and III/IVa with FIGO 2008 versus FIGO 2018, on progression-free survival (PFS) and overall survival (OS) at 5 years using Kaplan-Meier estimates, and in univariable proportional-hazards regression analyses, and in multivariable analyses adjusting for important prognostic factors and randomly allocated treatment. Results: All 919 study participants had complete data for staging according to the 2 staging systems and most prognostic factors for adjustment. Among all participants, the 5-year outcomes were PFS = 62% and OS = 72%. Classification according to FIGO 2018 rather than FIGO 2008 yielded higher 5-year PFS and OS in each stage group (see table for numbers of participants, PFS and OS for each stage group). Predictors of PFS in multivariable analysis included squamous vs non-squamous histology (HR 0.71 for FIGO 2008 and 0.74 for FIGO 2018), but not nodal involvement when FIGO 2018 was used. Both staging systems were the only independently significant prognostic factors in both univariable and multivariable analyses (all p < 0.0001) for both PFS and OS. Conclusions: Compared to FIGO 2008, reclassifying pts by FIGO 2018 staging resulted in more pts being classified as stage 3 due to the incorporation of nodal status. Staging locally advanced cervical cancer using FIGO 2018 rather than FIGO 2008 resulted in higher PFS and OS in each stage grouping that reflected stage migration, not a true improvement in outcomes. FIGO stage remains the strongest predictor of overall survival after CRT but survival outcomes by stage in trials using the old vs new staging system are not comparable. Clinical trial information: ACTRN12610000732088. [Table: see text]

Off study utilization of an unpublished trial regimen: A real-world analysis of GOG258-eligible cohorts

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Background: Practice patterns in the management of advanced endometrial cancer are widely variable and treatment paradigms are rapidly changing given the evolving clinical trial landscape. Prior studies have demonstrated “medical reversals” where clinicians favor or utilize the experimental approach only to find inferiority on publication of results. The objective of this study was to examine the utilization of the GOG 258 arms-- (adjuvant chemotherapy (CT) vs chemoradiotherapy (CRT)-- for patients with advanced or high-risk endometrial cancer. Methods: Patients 18 years or older who underwent staging surgery with stage III/IVA endometrial carcinoma of any histology or stage I/II clear cell or serous histologies with positive washings diagnosed between 2004 and 2018 were identified in the National Cancer Database. Utilization of adjuvant CT and CRT were examined in the pre-GOG 258 era (before 2009), during GOG 258 enrollment (2010-2017), and after publication of results (2018). Two-sided Cochrane-Armitage test assessed trends over time. T-test and chi-square tests assessed differences in groups receiving CT alone vs CRT. Multivariable logistic regression assessed factors associated with receipt of CRT. Propensity score matching accounted for baseline differences in groups receiving CT vs CRT. Results: 40,028 patients were included. 16,342 (41%) received adjuvant CT and 23,686 (59%) received adjuvant CRT. The majority of patients (39,185, 98%) were advanced stage and 19,616 (49%) were endometrioid histology. 90% of patients receiving both CT and CRT received multiagent therapy. Utilization of CRT was 54% before GOG 258 opening, 60% during GOG 258 enrollment, and 67% after publication of results (p < 0.001). Factors associated with receipt of CT alone were age greater than 70 (adjusted odds ratio [aOR] 0.68, 95% confidence interval [CI] 0.46-0.99), non-Hispanic Black race (aOR 0.84, CI 0.77-0.92), serous and clear cell histologies (aOR 0.68, CI 0.59-0.77; aOR 0.74, CI 0.57-0.95), living greater than 50 miles from treatment facility (aOR 0.84, CI 0.77-0.92), and receiving care in the Midwest, South, and West regions (aOR 0.84, CI 0.78-0.90; aOR 0.69, CI 0.64-0.76; aOR 0.72, CI 0.66-0.78). Compared to an academic medical center, receiving care at a comprehensive community cancer center was associated with receipt of CRT (aOR 1.2, CI 1.2-1.3). Compared to pre-GOG 258 opening in 2009, patients were more likely to receive CRT during GOG 258 enrollment (aOR 1.2, CI 1.1-1.3) and immediately after results announcement in 2018 (aOR 1.7, CI 1.5-1.8), despite results showing that CRT was not associated with longer relapse-free or overall survival. Conclusions: For patients with advanced endometrial cancer, there was significant use of both study arms with increases in CRT use during the study enrollment period and immediately after reporting of GOG 258 results, despite lack of benefit in the CRT arm.

Worsening racial disparities in utilization of intensity modulated radiotherapy

Purpose

The benefits of intensity modulated radiation therapy (IMRT) compared with standard 3-dimensional conformal radiation therapy have been demonstrated in many cancer sites and include decreased acute and late toxicity, improved quality of life, and opportunities for dose escalation. Limited literature suggests non-white patients may have lower utilization of IMRT. We hypothesized that as the use of IMRT has increased in recent years, racial inequities have persisted and disproportionately affect non-Hispanic Black (NHB) patients. We aim to evaluate temporal trends in IMRT utilization focusing on disparities among minoritized populations.

Methods and Materials

The National Cancer Database was queried to identify the 10 disease sites with the highest total number of cancer patients treated with definitive intent IMRT in 2017, the most recent year for which data are available. Exclusions included stage IV, age <18 years, unknown insurance status, unknown race, and palliative intent radiation. Race and ethnicity variables were combined and classified as non-Hispanic White, Hispanic, NHB, Asian, Native American/Eskimo, and Hawaiian/Pacific Islander. Multivariable logistic regression for IMRT utilization was performed for each disease site for both early (2004-2010) and contemporary (2011-2017) cohorts, adjusting for clinical and demographic covariates.

Results

Among the 10 selected disease sites, 1,010,292 patients received radiation therapy as part of definitive treatment between 2004 and 2017. Overall IMRT utilization rates increased from 22.0% in 2004 to 57.8% in 2017. After adjustment and compared with non-Hispanic White patients, NHB patients were significantly less likely to receive IMRT in 1 of 10 disease sites in the 2004 to 2010 cohort, and 5 of 10 disease sites in the 2011 to 2017 cohort.

Conclusions

Despite greater awareness of racial disparities in cancer care and outcomes, this study demonstrates worsening disparities in the use of IMRT, particularly for NHB patients. These differences may exacerbate racial disparities in cancer outcomes; therefore, identification of underlying drivers of differential IMRT utilization is warranted.

Cervix Cancer in Sub-Saharan Africa: An Assessment of Cervical Cancer Management

PURPOSE

Underdeveloped nations carry the burden of most cervical cancer, yet access to adequate treatment can be challenging. This report assesses the current management of cervical cancer in sub-Saharan Africa to better understand the needs of underdeveloped nations in managing cervical cancer.

METHODS

A pre- and postsurvey was sent to all centers participating in the Cervical Cancer Research Network's 4th annual symposium. The pre- and postsurvey evaluated human papillomavirus and HIV screening, resources available for workup and/or treatment, treatment logistics, outcomes, and enrollment on clinical trials. Descriptive analyses were performed on survey responses.

RESULTS

Twenty-nine centers from 12 sub-Saharan countries saw approximately 300 new cases of cervical cancer yearly. Of the countries surveyed, 55% of countries had a human papillomavirus vaccination program and 30% (range, 0%-65%) of women in each region were estimated to have participated in a cervical cancer screening program. In the workup of patients, 43% of centers had the ability to obtain a positron emission tomography and computed tomography scan and 79% had magnetic resonance imaging capabilities. When performing surgery, 88% of those centers had a surgeon with an expertise in performing oncological surgeries. Radiation therapy was available at 96% of the centers surveyed, and chemotherapy was available in 86% of centers. Clinical trials were open at 4% of centers.

CONCLUSION

There have been significant advancements being made in screening, workup, and management of patients with cervical cancer in sub-Saharan Africa; yet, improvement is still needed. Enrollment in clinical trials remains a struggle. Participants would like to enroll patients on clinical trials with Cervical Cancer Research Network's continuous support.

NCCN Guidelines Insights: Cervical Cancer, Version 1.2020

The NCCN Guidelines for Cervical Cancer provide recommendations for diagnostic workup, staging, and treatment of patients with the disease. These NCCN Guidelines Insights focus on recent updates to the guidelines, including changes to first- and second-line systemic therapy recommendations for patients with recurrent or metastatic disease, and emerging evidence on a new histopathologic classification system for HPV-related endocervical adenocarcinoma.

NCCN Guidelines® Insights: Uterine Neoplasms, Version 3.2021

The NCCN Guidelines for Uterine Neoplasms provide recommendations for diagnostic workup, clinical staging, and treatment options for patients with endometrial cancer or uterine sarcoma. These NCCN Guidelines Insights focus on the recent addition of molecular profiling information to aid in accurate diagnosis, classification, and treatment of uterine sarcomas.

Risk of secondary malignancies in ovarian cancer survivors: 52,680 patients analyzed with over 40 years of follow-up

OBJECTIVE

Survivors of ovarian cancer are at risk of developing a secondary malignancy (SM). We sought to evaluate the risk of developing SM, stratified by treatment modality.

METHODS

Standardized incidence ratios (SIR, observed-to-expected [O/E] ratio) were assessed in 52,680 patients diagnosed with ovarian cancer between 1975 and 2016 in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program.

RESULTS

Of the 52,680 patients, 3366 patients (6.4%) developed SM, which was more than the endemic rate (O/E 1.13; p < .05). Patients who received any radiation (RT) had an increased risk of overall SM compared to those who didn't (O/E 1.42 vs 1.11; p < .05), and specifically, in the bladder (O/E 2.81). Patients who received any chemotherapy (CT) had an increased risk of leukemia (O/E 3.06), and a similar risk of overall SM compared to those not treated with CT (O/E 1.11 vs 1.14; p < .05). The excess risk of developing a solid tumor SM was greatest at latencies of 10-20 years. Patients younger than 50 had the highest risk of developing SM. Non-White patients had a higher risk of SM compared to White patients.

CONCLUSIONS

This is the largest study to examine the risk of SM in patients with ovarian cancer and has the longest follow-up. Risk of SM was increased after ovarian cancer and varied with treatment modality, race, latency, and age. These results may help inform SM screening protocols for women diagnosed with ovarian cancer.

Adjuvant chemotherapy following chemoradiation as primary treatment for locally advanced cervical cancer compared to chemoradiation alone: The randomized phase III OUTBACK Trial (ANZGOG 0902, RTOG 1174, NRG 0274)

LBA3

Background: Cervical cancer is a common cause of cancer-related death among women worldwide. Standard treatment for locally advanced disease is chemoradiation. However, a significant percentage of women still relapse and die from the development of distant metastatic disease. OUTBACK was designed to determine the effects of giving adjuvant chemotherapy after chemoradiation on survival. Methods: OUTBACK is an international randomized phase III trial of the Gynecologic Cancer InterGroup (GCIG). Participating groups (countries) included ANZGOG (Australia and New Zealand), NRG (USA, Saudi Arabia, Canada, China), and Singapore. Eligible women had locally advanced cervical cancer (FIGO 2008 stage IB1 and node positive, IB2, II, IIIB or IVA) that was suitable for primary treatment with chemo-radiation with curative intent. Women were randomly assigned to either standard cisplatin-based chemo-radiation (control) or standard cisplatin-based chemo-radiation followed by adjuvant chemotherapy (ACT) with 4 cycles of carboplatin and paclitaxel, after stratification for nodal status, participating site, FIGO stage, age, and planned extended-field radiotherapy. The primary end point was overall survival (OS) at 5 years. Secondary endpoints included progression-free survival (PFS); adverse events (AE); and patterns of disease recurrence. The target sample size of 900 provided 80% power with 95% confidence to detect an improvement in OS at 5 years from 72% (control) to 80% (ACT), with some over-accrual to account for non-compliance with ACT and loss to follow-up. Results: 919 of 926 women recruited from April 2011 to June 2017 were eligible and included in the primary analysis: 463 assigned ACT, 456 control. ACT was started in 361 (78%) women assigned to receive it. Median follow-up was 60 months (IQR 45-65). OS at 5 years was similar in those assigned ACT versus control (72% vs 71%, difference <1%, 95% CI -6 to +7; P = 0.91). The hazard ratio for OS was 0·91, (95% CI 0.70 to 1.18). PFS at 5 years was similar in those assigned ACT versus control (63% vs 61%, difference 2%, 95% CI -5 to +9; P = 0.61). The hazard ratio for PFS was 0·87, (95% CI 0.70 to 1.08). AE of grade 3-5 within a year of randomisation occurred in 81% who were assigned and received ACT versus 62% assigned control. There was no evidence of differences between treatment groups in AE beyond 1 year of randomisation. Patterns of disease recurrence were similar in the two treatment groups. Conclusions: Adjuvant chemotherapy given after standard cisplatin-based chemoradiation for women with locally advanced cervical cancer did not improve OS or PFS. Clinical trial information: ACTRN12610000732088.

Risk of secondary malignancies in non-Hodgkin lymphoma survivors: 40 years of follow-up assessed by treatment modality

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Background: Survivors of non-Hodgkin lymphoma (NHL) are at increased risk of secondary malignancies (SM). We quantified this risk in survivors with over 40 years of follow-up, and evaluated differences in risk by treatment modality. Methods: Standardized incidence ratios (SIR, observed-to-expected [O/E] ratio), which accounts for patient years at risk, and absolute excess risk of SM were assessed in 142,837 patients diagnosed with NHL as a first malignancy between 1975 and 2016 in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Follow up was available through 2016. Non-melanoma skin cancers were not counted as SM. SIRs were also evaluated for patients stratified by age at and latency from diagnosis. Results: In all, 14,101 patients received radiotherapy alone (RT), 68,424 received chemotherapy alone (CT), and 18,339 received chemotherapy and radiation (CRT). In total, 15,979 patients (11%) developed SM, more than the endemic rate (O/E 1.29; P < .01). Overall, patients treated with any RT (RT+CRT) had a similar risk of SM as those who did not receive RT (O/E 1.29 for both compared to endemic rate). Patients treated with RT had more risk of female breast cancer and less risk of leukemia than unirradiated patients (P < .05). Patients treated with any CT (CT+CRT) had increased SM rates compared with those who did not receive CT [O/E 1.33 (95% CI 1.30-1.35) vs 1.24 (95% CI 1.21-1.26), respectively], which included increased risks of leukemia, Kaposi sarcoma, kidney, pancreas, rectal, head and neck, and colon cancers and decreased risk of prostate cancer (P < 0.05). When stratified by four treatment groups (no CT or RT, RT alone, CT alone, CRT), there were no differences in SM rates between the no therapy and RT alone groups (O/E 1.24 95% CI 1.21-1.27 and O/E 1.23 95% CI 1.18-1.28 respectively). CT alone and CRT were associated with increased risk of secondary malignancy compared to the no therapy group (O/E 1.32 95% CI 1.29-1.35 and O/E 1.35 95% CI 1.29-1.40 respectively). CT alone was also associated with increased risk of leukemia, Kaposi sarcoma, kidney, head and neck and thyroid cancers, and a decreased risk of prostate cancer (P < .05). CRT was associated with increased risk of head and neck and female breast cancers (P < .05). There was no difference in the overall risk of SM between the CT alone and CRT groups and female breast cancer was the only site at which CRT was associated with higher risk than CT alone. Of note, female breast cancer risk was highest in those diagnosed under 25 years of age and at latencies of greater than 10 years. Conclusions: This is the largest study to examine secondary malignancy risk in patients with NHL and has the longest follow-up. Patients treated with RT alone did not have an increased SM risk compared to those who received no RT or CT. The risk of SMs was increased overall for NHL survivors and varied with treatment modality.

Radiation therapy and secondary malignancy in Li-Fraumeni syndrome: A hereditary cancer registry study

Background

Li‐Fraumeni Syndrome (LFS) is a rare cancer‐predisposing condition caused by germline mutations in TP53. Conventional wisdom and prior work has implied an increased risk of secondary malignancy in LFS patients treated with radiation therapy (RT); however, this risk is not well‐characterized. Here we describe the risk of subsequent malignancy and cancer‐related death in LFS patients after undergoing RT for a first or second primary cancer.

Methods

We reviewed a multi‐institutional hereditary cancer registry of patients with germline TP53 mutations who were treated from 2004 to 2017. We assessed the rate of subsequent malignancy and death in the patients who received RT (RT group) as part of their cancer treatment compared to those who did not (non‐RT group).

Results

Forty patients with LFS were identified and 14 received RT with curative intent as part of their cancer treatment. The median time to follow‐up after RT was 4.5 years. Fifty percent (7/14) of patients in the curative‐intent group developed a subsequent malignancy (median time 3.5 years) compared to 46% of patients in the non‐RT group (median time 5.0 years). Four of seven subsequent malignancies occurred within a prior radiation field and all shared histology with the primary cancer suggesting recurrence rather than new malignancy.

Conclusion

We found that four of14 patients treated with RT developed in‐field malignancies. All had the same histology as the primary suggesting local recurrences rather than RT‐induced malignancies. We recommend that RT should be considered as part of the treatment algorithm when clinically indicated and after multidisciplinary discussion.

NRG Oncology/RTOG Consensus Guidelines for Delineation of Clinical Target Volume for Intensity Modulated Pelvic Radiation Therapy in Postoperative Treatment of Endometrial and Cervical Cancer: An Update

PURPOSE

Accurate target definition is critical for the appropriate application of radiation therapy. In 2008, the Radiation Therapy Oncology Group (RTOG) published an international collaborative atlas to define the clinical target volume (CTV) for intensity modulated pelvic radiation therapy in the postoperative treatment of endometrial and cervical cancer. The current project is an updated consensus of CTV definitions, with removal of all references to bony landmarks and inclusion of the para-aortic and inferior obturator nodal regions.

METHODS AND MATERIALS

An international consensus guideline working group discussed modifications of the current atlas and areas of controversy. A document was prepared to assist in contouring definitions. A sample case abdominopelvic computed tomographic image was made available, on which experts contoured targets. Targets were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation with kappa statistics as a measure of agreement between observers.

RESULTS

Sixteen participants provided 13 sets of contours. Participants were asked to provide separate contours of the following areas: vaginal cuff, obturator, internal iliac, external iliac, presacral, common iliac, and para-aortic regions. There was substantial agreement for the common iliac region (sensitivity 0.71, specificity 0.981, kappa 0.64), moderate agreement in the external iliac, para-aortic, internal iliac and vaginal cuff regions (sensitivity 0.66, 0.74, 0.62, 0.59; specificity 0.989, 0.966, 0.986, 0.976; kappa 0.60, 0.58, 0.52, 0.47, respectively), and fair agreement in the presacral and obturator regions (sensitivity 0.55, 0.35; specificity 0.986, 0.988; kappa 0.36, 0.21, respectively). A 95% agreement contour was smoothed and a final contour atlas was produced according to consensus.

CONCLUSIONS

Agreement among the participants was most consistent in the common iliac region and least in the presacral and obturator nodal regions. The consensus volumes formed the basis of the updated NRG/RTOG Oncology postoperative atlas. Continued patterns of recurrence research are encouraged to refine these volumes.

Radiation therapy for gynecologic malignancies during the COVID-19 pandemic: International expert consensus recommendations

OBJECTIVE

To develop expert consensus recommendations regarding radiation therapy for gynecologic malignancies during the COVID-19 pandemic.

METHODS

An international committee of ten experts in gynecologic radiation oncology convened to provide consensus recommendations for patients with gynecologic malignancies referred for radiation therapy. Treatment priority groups were established. A review of the relevant literature was performed and different clinical scenarios were categorized into three priority groups. For each stage and clinical scenario in cervical, endometrial, vulvar, vaginal and ovarian cancer, specific recommendations regarding dose, technique, and timing were provided by the panel.

RESULTS

Expert review and discussion generated consensus recommendations to guide radiation oncologists treating gynecologic malignancies during the COVID-19 pandemic. Priority scales for cervical, endometrial, vulvar, vaginal, and ovarian cancers are presented. Both radical and palliative treatments are discussed. Management of COVID-19 positive patients is considered. Hypofractionated radiation therapy should be used when feasible and recommendations regarding radiation dose, timing, and technique have been provided for external beam and brachytherapy treatments. Concurrent chemotherapy may be limited in some countries, and consideration of radiation alone is recommended.

CONCLUSIONS

The expert consensus recommendations provide guidance for delivering radiation therapy during the COVID-19 pandemic. Specific recommendations have been provided for common clinical scenarios encountered in gynecologic radiation oncology with a focus on strategies to reduce patient and staff exposure to COVID-19.

Cervical Cancer, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Cervical cancer is a malignant epithelial tumor that forms in the uterine cervix. Most cases of cervical cancer are preventable through human papilloma virus (HPV) vaccination, routine screening, and treatment of precancerous lesions. However, due to inadequate screening protocols in many regions of the world, cervical cancer remains the fourth-most common cancer in women globally. The complete NCCN Guidelines for Cervical Cancer provide recommendations for the diagnosis, evaluation, and treatment of cervical cancer. This manuscript discusses guiding principles for the workup, staging, and treatment of early stage and locally advanced cervical cancer, as well as evidence for these recommendations. For recommendations regarding treatment of recurrent or metastatic disease, please see the full guidelines on NCCN.org.

Executive summary of the American Radium Society® Appropriate Use Criteria for management of uterine carcinosarcoma

OBJECTIVE

Uterine carcinosarcomas (UCS) represent a rare but aggressive subset of endometrial cancers, comprising <5% of uterine malignancies. To date, limited prospective trials exist from which evidence-based management of this rare malignancy can be developed.

METHODS

The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines developed by a multidisciplinary expert panel for management of women with UCS. An extensive analysis of current medical literature from peer-reviewed journals was performed. A well-established methodology (modified Delphi) was used to rate the appropriate use of imaging and treatment procedures for the management of UCS. These guidelines are intended for the use of all practitioners who desire information about the management of UCS.

RESULTS

The majority of patients with UCS will present with advanced extra uterine disease, with 10% presenting with metastatic disease. They have worse survival outcomes when compared to uterine high-grade endometrioid adenocarcinomas. The primary treatment for non-metastatic UCS is complete surgical staging with total hysterectomy, salpingo-oophorectomy and lymph node staging. Patients with UCS appear to benefit from adjuvant multimodality therapy to reduce the chance of tumor recurrence with the potential to improve overall survival.

CONCLUSION

Women diagnosed with uterine UCS should undergo complete surgical staging. Adjuvant multimodality therapies should be considered in the treatment of both early- and advanced stage patients. Long-term surveillance is indicated as many of these women may recur. Prospective clinical studies of women with UCS are necessary for optimal management.

Improvement in Patient-Reported Outcomes With Intensity-Modulated Radiotherapy (RT) Compared With Standard RT: A Report From the NRG Oncology RTOG 1203 Study

PURPOSE

In oncology trials, the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) is the standard tool for reporting adverse events (AEs), but it may underreport symptoms experienced by patients. This analysis of the NRG Oncology RTOG 1203 compared symptom reporting by patients and clinicians during radiotherapy (RT).

PATIENTS AND METHODS

Patients with cervical or endometrial cancer requiring postoperative RT were randomly assigned to standard 4-field RT or intensity-modulated RT (IMRT). Patients completed the 6-item patient-reported outcomes version of the CTCAE (PRO-CTCAE) for GI toxicity assessing abdominal pain, diarrhea, and fecal incontinence at various time points. Patients reported symptoms on a 5-point scale. Clinicians recorded these AEs as CTCAE grades 1 to 5. Clinician- and patient-reported AEs were compared using McNemar's test for rates > 0%.

RESULTS

Of 278 eligible patients, 234 consented and completed the PRO-CTCAE. Patients reported high-grade abdominal pain 19.1% (P < .0001), high-grade diarrhea 38.5% (P < .0001), and fecal incontinence 6.8% more frequently than clinicians. Similar effects were seen between grade ≥ 1 CTCAE toxicity and any-grade patient-reported toxicity. Between-arm comparison of patient-reported high-grade AEs revealed that at 5 weeks of RT, patients who received IMRT experienced fewer GI AEs than patients who received 4-field pelvic RT with regard to frequency of diarrhea (18.2% difference; P = .01), frequency of fecal incontinence (8.2% difference; P = .01), and interference of fecal incontinence (8.5% difference; P = .04).

CONCLUSION

Patient-reported AEs showed a reduction in symptoms with IMRT compared with standard RT, whereas clinician-reported AEs revealed no difference. Clinicians also underreported symptomatic GI AEs compared with patients. This suggests that patient-reported symptomatic AEs are important to assess in this disease setting.

Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.

Uterine Neoplasms, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology

Endometrial carcinoma is a malignant epithelial tumor that forms in the inner lining, or endometrium, of the uterus. Endometrial carcinoma is the most common gynecologic malignancy. Approximately two-thirds of endometrial carcinoma cases are diagnosed with disease confined to the uterus. The complete NCCN Guidelines for Uterine Neoplasms provide recommendations for the diagnosis, evaluation, and treatment of endometrial cancer and uterine sarcoma. This manuscript discusses guiding principles for the diagnosis, staging, and treatment of early-stage endometrial carcinoma as well as evidence for these recommendations.

Expanded validation of the EPIC bowel and urinary domains for use in women with gynecologic cancer undergoing postoperative radiotherapy

OBJECTIVE

Women with endometrial or cervical cancer at risk for recurrence receive postoperative radiation therapy (RT). A patient reported outcomes (PRO) instrument to assess bowel and urinary toxicities is the Expanded Prostate Cancer Index Composite (EPIC), which has been validated in men with prostate cancer. As this instrument specifically measures bowel toxicity and the degree to which this is a problem, it was used in NRG Oncology/RTOG 1203 to compare intensity modulated RT (IMRT) to standard RT. This paper reports on the expanded validation of EPIC for use in women receiving pelvic RT.

METHODS

In addition to the EPIC bowel domain, urinary toxicity (EPIC urinary domain), patient reported bowel toxicities (PRO-CTCAE) and quality of life (Functional Assessment of Cancer Therapy (FACT)) were completed before, during and after treatment. Sensitivity, reliability and concurrent validity were assessed.

RESULTS

Mean bowel and urinary scores among 278 women enrolled were significantly worse during treatment and differed between groups. Acceptable to good reliability for bowel and urinary domain scores were obtained at all time points with the exception of one at baseline. Correlations between function and bother scores within the bowel and urinary domains were consistently stronger than those across domains. Correlations between bowel domain scores and PRO-CTCAE during treatment were stronger than those with the FACT.

CONCLUSION

Correlations within and among the instruments indicate EPIC bowel and urinary domains are measuring conceptually discrete components of health. These EPIC domains are valid, reliable and sensitive instruments to measure PRO among women undergoing pelvic radiation.

Do vaginal recurrence rates differ among adjuvant vaginal brachytherapy regimens in early-stage endometrial cancer?

PURPOSE

We sought to retrospectively examine clinical outcomes for three adjuvant vaginal high-dose-rate (HDR) brachytherapy regimens after hysterectomy for early-stage endometrial cancer.

METHODS

Included were women of all ages from two independent hospital systems diagnosed with Stage I-II endometrial cancer of any grade between 2000 and 2016 who underwent hysterectomy followed by adjuvant vaginal cylinder HDR brachytherapy with either 7.0 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, 6.5 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, or 6.0 Gy × 5 fractions prescribed to the vaginal surface. Outcomes included vaginal recurrence (VR), pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival.

RESULTS

Of the 348 women, 45 (13%) received 7.0 Gy × 3 fractions, 259 (74%) received 6.5 Gy × 3 fractions, and 44 (13%) received 6.0 Gy × 5 fractions. Women receiving 5-fraction brachytherapy were more likely to be younger with a higher performance status. At a median follow-up of 4.5 years, VR rates were 2.2%, 0.8%, and 4.5%, respectively. Multivariate analysis revealed no significant differences in the risks for VR among brachytherapy regimens. Risks for VR, pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival did not differ between propensity score-matched five- and 3-fraction brachytherapy cohorts.

CONCLUSIONS

VR rates after hysterectomy and adjuvant vaginal brachytherapy for early-stage endometrial cancer were low and not significantly different by HDR dose fractionation.

Too many women are dying from cervix cancer: Problems and solutions

One woman dies from cervix cancer every 2 min, adding up to over 270,000 deaths globally per year. This cancer affects a young population, and hence, the loss of life is staggering. There are many aspects of prevention, screening, and care that are suboptimal. A great deal is known about HPV induced carcinogenesis, yet clinical outcomes have been stagnant over decades. There has been no improvement in cervix cancer survival in the US since the mid-1970s [1]. With increased knowledge of the disease and greater worldwide resources including prevention, screening, and improved therapeutics, there is significant promise for fewer women to die from this virally induced cancer. We focus here on the major problems in prevention, screening, and delivery of care for cervix cancer and provide concrete solutions. With appropriate focus, a major improvement in survival from cervix cancer could be achieved in a short time span.