Elsevier

Gynecologic Oncology

Volume 141, Issue 3, June 2016, Pages 501-506
Gynecologic Oncology

Brachytherapy improves survival in primary vaginal cancer

https://doi.org/10.1016/j.ygyno.2016.03.011Get rights and content

Highlights

  • Utilization rates of brachytherapy in vaginal cancer are declining in the United States

  • Use of brachytherapy in vaginal cancer imparts a benefit in disease specific and overall survival

  • Larger tumors experienced the greatest benefit from brachytherapy

Abstract

Purpose

Prospective, randomized data does not exist to guide treatment in primary vaginal cancer (PVC). We evaluated the impact of brachytherapy on survival in women with PVC.

Methods and materials

Women who received radiotherapy for PVC were identified using the Surveillance, Epidemiology, and End Result database. Two retrospective cohorts were created; women who received external beam radiotherapy (EBRT) alone and those who received brachytherapy (alone or in combination of EBRT). Nearest-neighbor propensity score matching was used to balance the groups according to measured covariates. Cox proportional hazard regression modeling was used to estimate the effect of receipt of brachytherapy on survival.

Results

Two thousand five hundred seventeen vaginal cancer patients were identified. Squamous cell carcinoma made up 75% of tumors. Median overall survival (OS) for patients receiving EBRT alone was 3.6 years (95% CI, 3.0–4.2 years) versus 6.1 years (95% CI 5.2–7.2 years) for patients receiving brachytherapy (p = < 0.001). Cox proportional hazard model revealed decrease risk of death among patients that received brachytherapy in the matched cohort (HR 0.77; 95% CI 0.68–0.86). Brachytherapy reduced risk of death among patients in all stage groups. No patient demographic or tumor variables favored the use of EBRT alone. Brachytherapy was associated with a decreased risk of death for all FIGO stages. Brachytherapy benefited patients with squamous cell carcinoma (HR 0.80; 95% CI 0.70–0.92) and adenocarcinoma (HR 0.69; 95% CI 0.49–0.95). Tumors larger than 5 cm had the greatest benefit from brachytherapy (HR 0.68; 95% CI 0.50–0.91).

Conclusions

Brachytherapy should be encouraged for all suitable patients with PVC.

Introduction

Primary vaginal tumors are rare, comprising 2–3% of all gynecologic malignancies with an estimated 4070 new cases in the United States in 2015 [1]. Squamous cell carcinoma (SCC) is the most common histological variant accounting for up to 85% of vaginal cancer [2]. Human papilloma virus (HPV) infection is associated with up to 90% of all vaginal cancer, and is associated with improved survival outcomes [3], [4]. Vaginal cancer is a disease of older women; the median age of diagnosis in the United States is 69 years of age for HPV-associated vaginal cancer [5].

Prospective evaluation of vaginal cancer management is difficult due to its relative rarity. Surgical management of vaginal cancer poses challenges due to the close proximity of the vagina to other critical organs, such as the bladder and rectum. Retrospective studies have demonstrated successful treatment of vaginal cancer with definitive radiotherapy [3], [6], [7], [8], [9]. Treatment paradigms for primary vaginal cancer are often extrapolated from the cervical cancer data given the anatomic and histological similarities of the two diseases. A retrospective review of high dose rate (HDR) brachytherapy (BT) in treatment of primary or recurrent vaginal cancer demonstrated the efficacy of BT with a 2-year actuarial local control and cause-specific survival of 88% and 82.5%, respectively [10]. Although it has been shown that BT improves outcomes in cervical cancer, its use in both cervical and primary vaginal cancer has been declining as the rate of intensity-modulated radiation therapy (IMRT) utilization has increased [11], [12].

The purpose of this study was to evaluate the impact of BT on overall survival (OS) and disease-specific survival (DSS) in women with primary vaginal cancer.

Section snippets

Methods

The Surveillance, Epidemiology, and End Result (SEER) database is a population-based database that includes diagnostic, treatment and survival data for approximately 28% of all cancer patients treated in the United States. The database spans from years 1974 to 2011 and all available registries were utilized for this analysis. All SEER database information is de-identified; the study was submitted to the internal review board and was exempt from review.

The registry was queried for women who were

Results

A cohort including a total of 2517 vaginal cancer patients was identified from the SEER database. Of these women, 1294 had brachytherapy as a component of their definitive treatment and 1223 did not. The median age of the cohort was 67.0 years. The distribution of patients in the BT versus (vs.) no BT arms are summarized in Table 1. The majority of patients were ≥ 65 years old (54.1%), Caucasian (78.1%) and had an unknown insurance status (64.8%). Most tumors had SCC histology (74.9%) and were

Discussion

Due to the absence of prospective randomized data, current treatment recommendations for primary vaginal cancer are based primarily on retrospective single institutional series or extrapolation from management of other gynecologic cancers (e.g. cervical) for which large prospective and randomized studies are available. Previous research has shown that the use of BT is declining in the treatment of primary vaginal cancer [11], a result that is confirmed in this analysis. This is in spite of data

Conclusion

The use of BT, as a boost or as primary definitive treatment in appropriately selected patients, should be encouraged for all suitable patients. Neither FIGO stage IVA disease nor large tumor size should be considered contraindications to BT. Additional research into the interplay of the use of BT in the context of concurrent chemoradiation will help to further clarify the optimal treatment approach. Quality of life outcomes will also need to be assessed to ensure that a BT-based approach does

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Financial disclosures

None.

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    Precis: Utilization of brachytherapy in the treatment of primary vaginal cancer is declining. Analysis of the SEER database indicates that the use of brachytherapy imparts a survival benefit in women with this disease and should be considered for all suitable patients.

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