Brachytherapy plays an established role in managing locally advanced cervical cancer, but its use has been in decline since the widespread adoption of intensity-modulated radiation therapy (IMRT). Two recently published consensus statements clarify the roles of brachytherapy in the treatment of primary cervical cancer and recurrent disease.
Cervical cancer is diagnosed in an estimated 528,000 women worldwide each year, and another 266,000 die annually.1 The current standard of radiation oncology care for women with stage IB-IVA locoregional cervical cancer involves external beam radiotherapy (EBRT) plus concurrent cisplatin-based chemotherapy and brachytherapy.1 Image-guided or adaptive brachytherapy employs sequential re-imaging with each brachytherapy treatment session to adapt brachytherapy dose and placement as tumors regress and change shape, sparing nontarget, healthy tissue from irradiation.1
Despite brachytherapy’s longstanding role in cervical cancer management, its use has declined markedly over recent years, with the increasing availability of highly conformal EBRT techniques such as IMRT and stereotactic body radiation therapy (SBRT).1-3 (The same is true for prostate cancer, for which critics have claimed IMRT is overutilized, partly because of more attractive reimbursements.3,4) The US Centers for Medicaid & Medicare Services (CMS) does not reimburse brachytherapy as well as IMRT; brachytherapy is more time-consuming than IMRT or 3-dimensional conformal radiotherapy and reimbursement rates do not always cover costs, meaning that brachytherapy can become a source of financial loss to radiation oncology departments.3 Radiation oncology centers are increasingly managed as community-based hospital-owned satellite facilities, as well; smaller centers with fewer radiation oncologists are less equipped for the time demands and complexity of integrated cervical brachytherapy.3
Some might argue that the supplantation of brachytherapy by IMRT makes clinical sense. IMRT allows sharp anatomic irradiation gradients, with higher radiation doses delivered to target tumor tissue while sparing adjacent, nontarget tissue. IMRT has allowed dose escalation in cervical cancer radiotherapy.1 But recent declines in brachytherapy for locally advanced cervical cancer have been accompanied by a decline in survival for these patients, raising concerns that patients might frequently be denied brachytherapy even when it might improve their survival times.1-3 Evidence also shows that declines in the use of brachytherapy for locally advanced cervical cancer has hit African American and Native American women particularly hard, with these patients being even less likely than others to receive brachytherapy, possibly helping to explain racial disparities in cervical cancer survival rates.1,5 Authors of one recently published retrospective study of more than 16,000 patients concluded that improved access to brachytherapy might improve overall survival rates and help to ameliorate racial disparities in cervical cancer outcomes.5
Support for Brachytherapy
A recent survey of 81 members of the American Brachytherapy Society (ABS) suggested that cervical brachytherapy is widely underutilized, in part because of inadequate training of medical residents and inadequate maintenance of brachytherapy skills.2 The increased time requirements of brachytherapy planning and delivery were also seen as potential barriers to use by many survey respondents.2
The Society of Gynecologic Oncology (SGO) and the ABS recently released a statement emphasizing brachytherapy’s continued, critical role as a component of primary radiation therapy for women with cervical cancer.1
“Despite insufficient evidence that IMRT or SBRT constitute an equivalent technique to brachytherapy, national database studies indicate a disturbingly high rate of their usage in lieu of brachytherapy and thus nonadherence to established criteria for high-quality primary radiation treatment for cervical cancer,” they wrote.1 “[E]xternal beam radiation therapy combined with high-quality brachytherapy has been an established treatment course for women with locoregional cervical cancer for nearly 100 years. Advances in the use of chemotherapy and image-guided brachytherapy have shown promise to increase the number of women cured and decreased the number of women harmed. Despite this, recent data has suggested that other modalities unproven to be equivalent to these tried-and-true techniques are being increasingly utilized in some centers.”