Kate Johnson

May 14, 2012

May 14, 2012 (Barcelona, Spain) — Image-guided adaptive brachytherapy (IGABT) with concomitant chemoradiation for cervical cancer is "highly effective, with acceptable side effects," and is poised to dramatically change the treatment of cervical cancer in Europe and North America, according to 2 studies presented here at ESTRO 31: European Society for Radiotherapy and Oncology 2012 Annual Conference.

"IGABT is the future of brachytherapy in cervical cancer," said Renaud Mazeron, MD, assistant professor at the Institut Gustave Roussy in Villejuif, France, who presented his institution's 3-year follow-up of the procedure.

The results of the study by Dr. Mazeron's team, as well as those from a second study — a multicenter analysis of IGABT in Europe — represent "a significant change in the standard management of cervical cancer and show the value of image-guided brachytherapy for cervical cancer patients," said Akila Viswanathan, MD, chair of the session, in an interview with Medscape Medical News.

The study by Mazeron's team involved 163 patients, (median age, 48 years) with stages I (27%), II (57%), III (12%), and IV (3%) cervical cancer. The majority (90%) received concomitant chemoradiation followed by image-guided brachytherapy using either magnetic resonance imaging (88%) or computed tomography (12%).

After brachytherapy, 63% of patients were assigned to observation, but 61 patients (37%) underwent hysterectomy a median of 10 weeks later. "At the beginning, this was done systematically for stage I and II patients," he said, but in light of new evidence favoring observation over hysterectomy, surgery became limited to salvage treatment only, he explained. Residual cancer was found in 13 of these patients.

After an average follow-up of 36 months, complete histologic response was observed in 64.4% of patients, macroscopic residual disease in 22%, and microscopic or uncertain residual disease in 13.6%, he reported.

A total of 45 patients relapsed (44.4% regional and 68.7% metastatic) and 38 died, with a median delay until progression of 12.5 months.

Local control was achieved in 92%, and overall survival at 3 years was 77%. The majority of patients (76.7%) experienced at least 1 morbid event, mostly grade 1 or 2, but 7.5% had severe gastrointestinal or genitourinary events. The incidence of this was much higher in patients who had undergone hysterectomy than in those treated with brachytherapy alone (14.8% vs 2.9%; P = .005), he said.

IGABT "provides excellent locoregional control rates with low treatment-related morbidity, justifying the elimination of radical hysterectomy in the absence of obvious local failure," he explained. "Hysterectomy does not seem to be useful unless there is proven failure, and it clearly adds severe morbidity to radiation therapy."

A separate multicenter analysis presented as an oral poster here at ESTRO 31 assessed IGABT in 454 patients (median age, 51 years) from 11 European centers. The findings were similar to the results reported by Dr. Mazeron.

In the cohort, 18% had stage IB cancer, 9% had stage IIA cancer, 51% had stage IIB cancer, 18% had stage IIIA to IIIB cancer, and 4% had stage IVA cancer.

At 36-month follow-up, the local control rate was 91.4%, with persistent local disease in 18 patients and local recurrence in 21 patients, reported Alina Sturdza, MD, from the Medical University of Vienna in Austria.

Systemic recurrence occurred in 24%, and 27% of patients died, she said.

According to Dr. Mazeron, IGABT with chemoradiation "achieves results far superior to the historical data...which show that local control of a stage I tumor was usually around 90%, from 60% to 87% for stage II, 44% to 66% for stage III, and 18% to 48% for stage IVA." This compares with IGABT local control results of 92% "of tumors at any stage," he said.

These results "will prevent unnecessary hysterectomies in young women with cervical cancer and will significantly reduce the resultant toxicities associated with the combination of surgery after chemoradiation," said Dr. Viswanathan, who is president-elect of the American Brachytherapy Society, director of gynecologic radiation oncology at the Dana-Farber/Brigham and Women's Cancer Center, and associate professor of radiation oncology at Harvard Medical School in Boston, Massachusetts.

In the United States, "most centers do not routinely do a hysterectomy after chemoradiation, although select institutions still do," she said.

Although she herself performs image-guided brachytherapy, this would be a new approach for many physicians in the United States, she said in an interview.

Dr. Mazeron and Dr. Viswanathan have disclosed no relevant financial relationships.

ESTRO 31: European Society for Radiotherapy and Oncology 2012 Annual Conference: Abstract OC-040, presented May 10, 2012; Abstract PD213, presented May 11, 2012.


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