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Radiotherapy

Radiotherapy

Brachytherapy proves safe for cervical cancer

21 Apr 2018 Tami Freeman
Lars Fokdal

Ureteral stricture – a narrowing of the tube that takes urine from the kidneys to the bladder – is a rare but potentially serious complication following radiation treatment for cervical cancer. The stricture can lead to kidney damage and sometimes life-threatening infections.

Previously, concerns have been raised that brachytherapy might increase the risk of ureteral stricture, although the treatment itself is associated with better survival. However, research presented today at the ESTRO 37 conference in Barcelona shows that intracavitary and interstitial (IC/IS) brachytherapy is safe and does not increase the risk of ureteral stricture.

Intracavitary brachytherapy involves placing an applicator in the uterus, while interstitial brachytherapy involves inserting needles directly into the tumour. The appropriate radiation dose is then delivered to the cancer via one or both of these approaches.

Lars Fokdal, from Aarhus University Hospital, and colleagues examined data from 1772 patients with locally advanced cervical cancer enrolled in two international trials: the retrospective RetroEMBRACE and the prospective EMBRACE studies. Image-guided brachytherapy (IGBT) was delivered with the combined IC/IS technique in 36% of patients.

The team followed up the patients treated with IC/IS IGBT for between one and 163 months. At a median follow-up of 29 months, 36 patients were diagnosed with severe grade 3-4 ureteral stricture. The overall risk of developing grade 3-4 ureteral stricture was 2% after three years and 3.2% after five years. The risk was lowest (1.3% at five years) in patients with small, stage 1-2 tumours and slightly higher in those with stage 3-4 tumours (1.8%/4.8% at three/five years).

The highest risk was seen among patients with advanced cancer who also had swollen ureters (hydronephrosis) at diagnosis. In these patients, the risk of ureteral stricture was 13.6% and 23.4%, at three and five years, respectively.

“The incidence of ureteral stricture in cervical cancer patients generally is between 2-3%, so the overall risk of developing the complication after IC/IS IGBT compares well,” explained Fokdal. “It is good to know that the interstitial component of IGBT does not increase the risk of this complication. However, the risk is more pronounced in patients with advanced stage and hydronephrosis at diagnosis.”

One strategy to avoid ureteral stricture in higher-risk patients could be closer observation following IC/IS IGBT so that ureteral strictures could be detected earlier before they become too severe. Another option could be insertion of ureteral stents before radiotherapy to visualize the organ on imaging and reduce the delivered dose.

“Results from the RetroEMBRACE and EMBRACE trials have also shown that IC/IS image-guided brachytherapy is associated with a better outcome for patients in terms of survival and adverse side-effects,” Fokdal added. “The increased, but targeted radiation dose to the tumour controls the cancer better without adversely affecting nearby organs and tissues. Taking all these results together, we have growing evidence in favour of IC/IS IGBT for treating cervical cancer.”

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