Patterns of Radiotherapy Practice for Patients Treated for Intact Cervical Cancer in 2005-2007: A QRRO Study

Reviewer: Lara Bonner Millar, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: November 3, 2010

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Authors: P. J. Eifel1, N. Khalid2, B. Erickson3, C. Crozier2, J. Owen2, J. F. Wilson3
Institution
1 M.D. Anderson Cancer Center, Houston, TX
2 ACR Clinical Research Center, Philadelphia, PA
3 Medical College of Wisconsin, Milwaukee, WI

Background

  • Cervical cancer represents a worldwide problem, and is the third most common gynecologic cancer in the United States.
  • When screening is not undertaken, patients often present with locally advanced disease that is treated primarily with radiation.
    • Generally, this consists of a combination of external beam radiotherapy and brachytherapy.
  • The Quality Research in Radiation Oncology (QRRO), part of the American College of Radiology Clinical Research Center, has the overall goal of improving the care received by cancer patients throughout the USA.
    • QRRO conducts national surveys to determine structure, process, and outcome of care.
    • Surveys are designed to emphasize practice setting, new technologies, and other factors likely to influence outcome.
    • One survey focus is disease sites, such as cervix, for which radiation is a primary treatment modality, and for which further improvements nationwide are needed.
  • This QRRO study was conducted to assess practice patterns and compliance with clinical performance measures for patients treated with radiation for intact carcinoma of the cervix.

Materials and Methods

  • 106 US facilities were randomly selected after stratification by practice type and size.
    • 42 facilities participated: 14 academic, 9 small non academic (1 linac) , 7 medium non academic (2 linacs), 12 large non academic (3+ linacs). 
  • Trained research associates reviewed the records of 239 randomly selected patients from 42 facilities.  6 facilities had no eligible pts.
    • Up to 10 pts were reviewed per facility.
  • Patients who received radiation therapy (RT) for carcinoma of the cervix between 2005 and 2007 were eligible if they had not undergone initial hysterectomy, had no distant metastases and had no history of other malignancies or prior pelvic RT.
  • Practice patterns with regard to treatment duration, brachytherapy use and technique, administration of chemotherapy, and monitoring of hemoglobin levels were analyzed based on this sample of medical records.

Results

  • The median patient age was 50 years. 59% were white, 21% black and 4% Asian; 15% were Hispanic.
  • FIGO Stages were I (33%), IIA (8%), IIB (27%), III (21%) and IVA (3%). 227 patients were treated with definitive intent.
    • For these 227, the median duration of RT was 56 days; however, 25% required more than 66 days (9.4 wks) and another 33 patients (14%) failed to complete the planned course of RT.
    • Over 80% staged with were CT, up from less than 80% accompanied by increase in use of PET and MRI since the last survey done in the late 1990s
  • Most facilities treated 3 or fewer pts with an intact cervix each year. 25 treated less than 10 pts over 3 years; no small or medium non-academic facilities treated more than 10 pts over 3 years.
  • The median treatment duration was longer for patients treated in non-academic centers [59 days (75% quartile, 73 days)] than for those treated in academic centers [53 days (75% quartile, 63 days)].
    • Only 56% of pts in non academic facilities completed RT in less than 10 weeks, however even in academic facilities about a quarter failed to complete on time. The rate of prolonged or incomplete RT correlated inversely with the number of patients treated.
  • Overall, 27/ 227 patients (12%) did not receive any brachytherapy. Patients treated in academic facilities were more likely to receive brachytherapy than those treated in non-academic facilities (94% vs. 82%).
    • Academic centers rarely referred to other centers for brachytherapy. In small and medium non academic facilities, more were referred to other centers for brachytherapy, however 2/3 still received it at the home facility.
  • Of the 187 patients who received brachytherapy, 103 (55%) were treated with intracavitary HDR, 82 (44%) with LDR/PDR intracavitary and 2 with interstitial brachytherapy. This represents a significant shift in practice toward the use of HDR since the 1994-1999 survey.  Interstitial treatment decreased from 7% to 1% between the two studies.
  • Of 224 patients treated with definitive intent for stage IB or greater cervical cancer, 166 (74%) were said to have received cisplatin-based concurrent chemotherapy; however verification of chemotherapy delivery was inconsistently documented in weekly management notes. The number of cycles was not often recorded in treatment notes.
  • Two additional measures were studied to assess the level of documentation in the clinical charts of patients who received RT for cervical cancer: 1) Hg level and 2) brachytherapy dose to normal tissue.
    • Of patients treated with brachytherapy, 29% did not have normal tissue doses recorded for all brachytherapy treatments.
    • Documentation of hemoglobin levels in weekly management notes was also poor–only 41% of patients had a mention of the patient's hemoglobin level in 4 or more notes.

Author's Conclusions

  • Survey results indicate a high rate of non-compliance with established criteria for high-quality care of patients with cervical cancer.
  • Gaps in the documentation of important aspects of treatment (chemotherapy, brachytherapy dose) raise questions about the quality of communication and the consistency of care within the multidisciplinary teams that are responsible for these complex treatments.
    • Incomplete RT was not related to facility size in non academic centers.
  • Careful review of the process of care to improve treatment delivery is warranted in the future.

Clinical Implications

  • Organized team support is critical in providing multi-modality treatment. Logistical difficulties may be barriers to delivering the treatment as planned. For facilities with a low volume of intact cervix patients, which, in this survey, was most small and medium non academic centers, processes may not be adequate for streamlined coordination external beam, chemotherapy, and brachytherapy.
  • Lack of infrastructure also contributes to prolongation of treatment time.
  • With regard to brachytherapy, several patient benefits have been cited as a justifying the use of HDR over LDR brachytherapy.
    • These include increased patient convenience, as well as lower risk of DVT and hospital acquired infection. Because most HDR is done on-site, it may be easier to deliver on schedule since inpatient logistics are avoided.
    • Despite the increased convenience and use of HDR, treatment prolongation and incomplete treatment is still a problem. Both academic and non-academic facilities should establish a work-flow whereby the patient's care path is mapped out early on to avoid delays and missed treatments.



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