Brachytherapy improves survival in primary vaginal cancer
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.
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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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3D image-guided interstitial brachytherapy for primary vaginal cancer: A multi-institutional experience
2021, Gynecologic OncologyThe impact of brachytherapy boost and radiotherapy treatment duration on survival in patients with vaginal cancer treated with definitive chemoradiation
2021, BrachytherapyCitation Excerpt :The American Brachytherapy Society recommends that vaginal tumors receive a total equivalent dose in 2 Gy fractions of 70 Gy–85 Gy with a combination of EBRT and BT (26). However, given the absence of prospective data, the role of BT in vaginal cancer in the context of definitive chemoradiation has not been fully characterized (17). The treatment duration for cervix cancer is associated with overall survival (OS), and it has been reported that as treatment duration surpasses 9 weeks, OS significantly worsens (27).
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.