Cervix Cancer and HPV Tumor Discussion

[TheWallnerus]

“Easiest” way would be to increase brachytherapy requirements to the point where graduates would be technically competent in most brachy procedures. This will not happen for obvious reasons.

I wonder how many people would die from cancer in the year after brachytherapy were hypothetically to vanish

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[seper]

I wonder how many people would die from cancer in the year after brachytherapy were hypothetically to vanish

Not insignificant amount and more in years 2-5. There are data for that in cervical Ca literature, too lazy to calculate it for you

 

[RickyScott]

Not insignificant amount and more in years 2-5. There are data for that in cervical Ca literature, too lazy to calculate it for you

How many cervical cases are treated by xrt per year? 70gy without brachy delivers an overall cure rate of about 60%, but probably much higher for earlier stages when accounting for selection bias.

 

[TheWallnerus]

How many cervical cases are treated by xrt per year? 70gy without brachy delivers an overall cure rate of about 60%, but probably much higher for earlier stages when accounting for selection bias.

And it’s not like “brachy EBRT” is zero effective (regardless of my doubts that it is totes inferior to the century old standard!)

 

[seper]

And it’s not like “brachy EBRT” is zero effective (regardless of my doubts that it is totes inferior to the century old standard!)

I'm one of the busier cervical Ca guys and my estimate that durable remission rate is <30% without brachytherapy

 

[theradiator]

I'm one of the busier cervical Ca guys and my estimate that durable remission rate is <30% without brachytherapy

Anyone have any idea why anal cancer melts away with 54 Gy almost all of the time and oropharyngeal cancer radiation is being actively deescalated but that doesn't seem to work for cervix?

 

[deleted1111261]

Good question!

 

[RadRadRad]

Anyone have any idea why anal cancer melts away with 54 Gy almost all of the time and oropharyngeal cancer radiation is being actively deescalated but that doesn't seem to work for cervix?

Cervical cancers tend to be much larger. Often 6-8 cm. What is the control rate for T3 (over 5 cm anal). I think it’s only a little above 50% that don’t end up needing apr

 

[RadRadRad]

I should have said cervical cancers that we treat with radiation. Gyn onc typically operating on the smaller tumors

 

[OTN]

Anyone have any idea why anal cancer melts away with 54 Gy almost all of the time and oropharyngeal cancer radiation is being actively deescalated but that doesn't seem to work for cervix?

5FU and MMC (or platinum if you're at MDACC for God knows what reason- I mean "internal data") help that 54 Gy punch above its weight, and de-escalation of HPV+ OP RT hasn't been successful just yet.

 

[seper]

Cervical cancers that evade brachytherapy are usually huge (think > 8 cm actually) and node positive. Thus poor outcomes with EBRT

 

[deleted1111261]

5FU and MMC (or platinum if you're at MDACC for God knows what reason- I mean "internal data") help that 54 Gy punch above its weight, and de-escalation of HPV+ OP RT hasn't been successful just yet.

Maaaan .. the skin reaction is better with cis, I swear.

Act 2 was negative but I think it still showed less tox for Cis

 

[Ray D. Ayshun]

Are we on the verge of hypofrac'ing cervix? Like 40/15 or something. If there's a patient population that actually needs a shorter, less complicated treatment course, this is the one.

 

[NotMattSpraker]

Are we on the verge of hypofrac'ing cervix? Like 40/15 or something. If there's a patient population that actually needs a shorter, less complicated treatment course, this is the one.

A HEROICC Idea Hypofractionated External-beam RadiOtherapy for Intact Cervical Cancer (HEROICC-Trial): A Feasibility Study - Full Text View - ClinicalTrials.gov

There is a 5 fraction trial out there, but couldnt find it in my 3 minute google search

 

[Ray D. Ayshun]

Also, now that this has become a cervix thread, is anyone simming them prone, particularly post-op?

 

[Ray D. Ayshun]

A HEROICC Idea Hypofractionated External-beam RadiOtherapy for Intact Cervical Cancer (HEROICC-Trial): A Feasibility Study - Full Text View - ClinicalTrials.gov

There is a 5 fraction trial out there, but couldnt find it in my 3 minute google search

I know it's out there, but the one time I discussed doing it with someone, the feeling was that it was quasi-palliative, when in fact it probably would've gotten the patient through with EBRT in 4 weeks instead of 7 (addiction issues...). Wondering when it will become "recommended."

 

[seper]

need weekly cisplatin for cervix, so shortening courses is tricky

 

[medgator]

need weekly cisplatin for cervix, so shortening courses is tricky

Same reasons we haven't seen it in locally advanced lung and h&n I'm guessing

 

[Lamount]

Same reasons we haven't seen it in locally advanced lung and h&n I'm guessing

Also, with high a/b ratio tumors, you lose ground with hypofrac when sensitive stuff is nearby (I know I know… many of you guys think LQM is witchcraft, but it is somewhat true-ish).

 

[madchemist89]

Head and neck cancers have cell loss factors of about 90%, so you only need to tip the equation so much to see them disappear. I also bet cervical cancer has a high degree of hypoxia.

 

[seper]

Same reasons we haven't seen it in locally advanced lung and h&n I'm guessing

There is a 5 week H&N regimen in European trials that will catch on, I bet

 

[evilbooyaa]

I'm one of the busier cervical Ca guys and my estimate that durable remission rate is <30% without brachytherapy

A Phase II Trial of Stereotactic Ablative Radiation Therapy as a Boost for Locally Advanced Cervical Cancer - PubMed

In this SAbR boost series suboptimal outcomes were probably related to patient selection and very large tumor volume. This approach may still be considered in patients with smaller tumors unable to undergo standard brachytherapy for cervix cancer.

pubmed.ncbi.nlm.nih.gov

2-year LC of 70% with SBRT boost, albeit it more toxic. Not good as brachy (and was said as much by the authors) but at least it's a data point.

5FU and MMC (or platinum if you're at MDACC for God knows what reason- I mean "internal data") help that 54 Gy punch above its weight, and de-escalation of HPV+ OP RT hasn't been successful just yet.

Lots of things to come at MDACC for doing things in the weird "MDACC way", won't disagree with you on that.

BUT, ACT-II literally had the exact same oncologic outcomes between 5-FU/MMC and 5-FU/Cis. Really between all 4 of the arms. The reason they probably like Cis more is because the MMC doesn't completely destroy counts the way MMC does.... the reason the UK authors felt MMC "won" is because "holding up a chair to give infusions and fluids rather than just a quick shot of MMC uses up too much resources" despite the increase in G3+ heme toxicity seen with MMC.

Full link for those interested: Mitomycin or cisplatin chemoradiation with or without maintenance chemotherapy for treatment of squamous-cell carcinoma of the anus (ACT II): a randomised, phase 3, open-label, 2×2 factorial trial

 

[evilbooyaa]

I have moved all the cervix cancer talk into its own thread to facilitate ongoing discussion without taking another thread off-topic.

 

[RadRadRad]

A Phase II Trial of Stereotactic Ablative Radiation Therapy as a Boost for Locally Advanced Cervical Cancer - PubMed

In this SAbR boost series suboptimal outcomes were probably related to patient selection and very large tumor volume. This approach may still be considered in patients with smaller tumors unable to undergo standard brachytherapy for cervix cancer.

pubmed.ncbi.nlm.nih.gov

2-year LC of 70% with SBRT boost, albeit it more toxic. Not good as brachy (and was said as much by the authors) but at least it's a data point.



Lots of things to come at MDACC for doing things in the weird "MDACC way", won't disagree with you on that.

BUT, ACT-II literally had the exact same oncologic outcomes between 5-FU/MMC and 5-FU/Cis. Really between all 4 of the arms. The reason they probably like Cis more is because the MMC doesn't completely destroy counts the way MMC does.... the reason the UK authors felt MMC "won" is because "holding up a chair to give infusions and fluids rather than just a quick shot of MMC uses up too much resources" despite the increase in G3+ heme toxicity seen with MMC.

View attachment 361225

Full link for those interested: Mitomycin or cisplatin chemoradiation with or without maintenance chemotherapy for treatment of squamous-cell carcinoma of the anus (ACT II): a randomised, phase 3, open-label, 2×2 factorial trial

Agree
Acting like the act II arms are clinically different from efficacy standpoint has always perplexed me

 

[evilbooyaa]

Are we on the verge of hypofrac'ing cervix? Like 40/15 or something. If there's a patient population that actually needs a shorter, less complicated treatment course, this is the one.

You Canadian and UK bastards, stop hypofraccing my LIFE

There's post-op endometrial done in 5 fraction on phase I study from Canada (I think), but not enough late toxicity data to do anything besides wait.

Also, now that this has become a cervix thread, is anyone simming them prone, particularly post-op?

Haven't done prone back since I did a 3D Cervix patient as a PGY-2. I can get IMRT approved without insurance struggles at least at the institutions I've been at.

Also, with high a/b ratio tumors, you lose ground with hypofrac when sensitive stuff is nearby (I know I know… many of you guys think LQM is witchcraft, but it is somewhat true-ish).

The race to the bottom will continue, and there will be continued justification to continue shortening courses, whether it be increased acute or late toxicity.

 

[Ray D. Ayshun]

You Canadian and UK bastards, stop hypofraccing my LIFE

There's post-op endometrial done in 5 fraction on phase I study from Canada (I think), but not enough late toxicity data to do anything besides wait.


Haven't done prone back since I did a 3D Cervix patient as a PGY-2. I can get IMRT approved without insurance struggles at least at the institutions I've been at.


The race to the bottom will continue, and there will be continued justification to continue shortening courses, whether it be increased acute or late toxicity.

Closest uk to me is still my most despised NCAA bb team. I only want to hypofrac cervix given the frequently concurrent meth addiction in the patient population and the fact that 15 is less than 25, though we may need a trial to prove that.

 

[evilbooyaa]

Closest uk to me is still my most despised NCAA bb team. I only want to hypofrac cervix given the frequently concurrent meth addiction in the patient population and the fact that 15 is less than 25, though we may need a trial to prove that.

Not 'you' specifically, more so the general 'you' as in those folks running those trials

 

[Bequerel]

if we can give 80+ to a prostate with IMRT why can’t we give the same to cervical cancer patients. By the time we get to Brachy, the tumor should be <4cm unless we’re using needles. No reason to think we couldn’t resim and finish with external. I have a very busy general practice and am only guy in town who does brachy. I have around 10 patients a year with advanced cervical cancer. A couple a year are undocumented or have some other reason they can’t get to OR for smit sleeve so I just sbrt boost the remaining mri disease and document the hell out of why I’m deviated from soc. Probably 15 cases over my tenure here, some with 8 years of f/u. Everybody disease free and no significant side effects. I don’t buy into needing 100+ Gy to kill this cancer. I always think we will look back at this 50 years from now and think gyn brachy is barbaric.

 

[elementaryschooleconomics]

if we can give 80+ to a prostate with IMRT why can’t we give the same to cervical cancer patients. By the time we get to Brachy, the tumor should be <4cm unless we’re using needles. No reason to think we couldn’t resim and finish with external. I have a very busy general practice and am only guy in town who does brachy. I have around 10 patients a year with advanced cervical cancer. A couple a year are undocumented or have some other reason they can’t get to OR for smit sleeve so I just sbrt boost the remaining mri disease and document the hell out of why I’m deviated from soc. Probably 15 cases over my tenure here, some with 8 years of f/u. Everybody disease free and no significant side effects. I don’t buy into needing 100+ Gy to kill this cancer. I always think we will look back at this 50 years from now and think gyn brachy is barbaric.

PREACH

I look back on every gyn brachy case 50...milliseconds from reading your post and think it's barbaric.

It defies logic that we can treat EVERY OTHER TYPE OF CANCER with modern EBRT except for JUST THIS.

 

[evilbooyaa]

if we can give 80+ to a prostate with IMRT why can’t we give the same to cervical cancer patients. By the time we get to Brachy, the tumor should be <4cm unless we’re using needles. No reason to think we couldn’t resim and finish with external. I have a very busy general practice and am only guy in town who does brachy. I have around 10 patients a year with advanced cervical cancer. A couple a year are undocumented or have some other reason they can’t get to OR for smit sleeve so I just sbrt boost the remaining mri disease and document the hell out of why I’m deviated from soc. Probably 15 cases over my tenure here, some with 8 years of f/u. Everybody disease free and no significant side effects. I don’t buy into needing 100+ Gy to kill this cancer. I always think we will look back at this 50 years from now and think gyn brachy is barbaric.

It literally was evaluated prospectively by UTSW (Timmerman senior author!) and found to have poor outcomes and increased toxicity to brachy. To do it the rare times when a patient is not a candidate for brachy either medically or socially, then OK. But it is not as conformal as brachy is. And even if it looks similar on the computer, the results in a patient are worse than brachy.

If you can't do T&O and you don't offer Hybrid/interstitial you should make a timely referral to a center that does. Not saying that's you specifically, but more of a general 'you' for those folks who are seeing cervical cancer patients but don't offer brachy beyond T&O.

If anyone reading this is struggling to get in touch with somebody to do interstitial on their patient, feel free to PM me and I am happy to help identify folks that could at least try to help in your region.

 

[Bequerel]

It literally was evaluated prospectively by UTSW (Timmerman senior author!) and found to have poor outcomes and increased toxicity to brachy. To do it the rare times when a patient is not a candidate for brachy either medically or socially, then OK. But it is not as conformal as brachy is. And even if it looks similar on the computer, the results in a patient are worse than brachy.

If you can't do T&O and you don't offer Hybrid/interstitial you should make a timely referral to a center that does. Not saying that's you specifically, but more of a general 'you' for those folks who are seeing cervical cancer patients but don't offer brachy beyond T&O.

If anyone reading this is struggling to get in touch with somebody to do interstitial on their patient, feel free to PM me and I am happy to help identify folks that could at least try to help in your region.

Those tumor volumes were huge. There are a few retrospective publications with similar number of patients that show good outcomes with sbrt in “non-brachy” candidates. I’m not advocating for people to not treat with SOC Brachy. I just feel it’s barbaric and very 1970’s of us. In this era of de-escalation and non-inferiority studies, I think there should be a non-inferiority study of appropriate cervical tumor sizes randomized to brachy Vsexternal boost technique. If people give 75 Gy in 25 fractions (BED 97.5) for pancreas with a loop of small bowel as dose limiting structure, isn’t it reasonable to hypothesize that one could safely give similar BED with bladder and rectum as rate limiting structure?

 

[evilbooyaa]

Those tumor volumes were huge. There are a few retrospective publications with similar number of patients that show good outcomes with sbrt in “non-brachy” candidates. I’m not advocating for people to not treat with SOC Brachy. I just feel it’s barbaric and very 1970’s of us. In this era of de-escalation and non-inferiority studies, I think there should be a non-inferiority study of appropriate cervical tumor sizes randomized to brachy Vsexternal boost technique. If people give 75 Gy in 25 fractions (BED 97.5) for pancreas with a loop of small bowel as dose limiting structure, isn’t it reasonable to hypothesize that one could safely give similar BED with bladder and rectum as rate limiting structure?

Links to those retrospective pubs, please.

I think there's too much non-inferiority study already in Rad Onc, and it does a disservice.

Cervix patients who receive chemoRT do well in regards to LR but frequently don't do well in other schema. It's not like HPV+ OPhx where we are curing SO many of them with such high toxicity (given improvements in CT and MRI based planning for cervix patients) that we're really ready to start figuring out safety of de-escalation and non-inferiority at this time, IMO.

A T&O done under at least moderate sedation is not really barbaric. Doing it in an awake woman just medicated with orals (see recent thread in private forum), sure yes, not ideal. Sure, Syed interstitial cases are a different beast, won't argue regarding the barbarity of that either.

 

[Bequerel]

Links to those retrospective pubs, please.

I think there's too much non-inferiority study already in Rad Onc, and it does a disservice.

Cervix patients who receive chemoRT do well in regards to LR but frequently don't do well in other schema. It's not like HPV+ OPhx where we are curing SO many of them with such high toxicity (given improvements in CT and MRI based planning for cervix patients) that we're really ready to start figuring out safety of de-escalation and non-inferiority at this time, IMO.

A T&O done under at least moderate sedation is not really barbaric. Doing it in an awake woman just medicated with orals (see recent thread in private forum), sure yes, not ideal. Sure, Syed interstitial cases are a different beast, won't argue regarding the barbarity of that either.

Stereotactic body radiotherapy for pelvic boost in gynecological cancer patients with local recurrence or unsuitable for intracavitary brachytherapy - PubMed

In gynecological cancer patients with recurrent pelvic tumors or intact uterus unsuitable for brachytherapy, local dose escalation with SBRT resulted in an initial response rate of 72% with acceptable early toxicities. A long-term follow-up is required to assess the impact on local control or...

pubmed.ncbi.nlm.nih.gov

Long-term results of robotic radiosurgery for non brachytherapy patients with cervical cancer - PubMed

Brachytherapy remains the standard of care for patients diagnosed with cervical cancer and indication for primary chemoradiation. In terms of local control, CyberKnife®-based boost concepts provide excellent local control. It can be an alternative for patients who cannot receive adequate...

pubmed.ncbi.nlm.nih.gov

Stereotactic Body Radiation Therapy Boost in Patients With Cervical Cancer Ineligible for Brachytherapy - PubMed

SBRT boost in patients with cervical cancer ineligible for BT led to acceptable survival outcomes and a safe toxicity profile.

pubmed.ncbi.nlm.nih.gov

Long-term results of robotic radiosurgery for non brachytherapy patients with cervical cancer - PubMed

Brachytherapy remains the standard of care for patients diagnosed with cervical cancer and indication for primary chemoradiation. In terms of local control, CyberKnife®-based boost concepts provide excellent local control. It can be an alternative for patients who cannot receive adequate...

pubmed.ncbi.nlm.nih.gov

Intensity modulated radiation therapy boost in locally-advanced cervical cancer in the absence of brachytherapy - PubMed

The combination of external beam radiotherapy and brachytherapy remains the standard of care, however our preliminary data show the feasibility of IMRT boost in terms of toxicity with promising results in terms of local control and overall survival.

pubmed.ncbi.nlm.nih.gov

MR-guided SBRT boost for patients with locally advanced or recurrent gynecological cancers ineligible for brachytherapy: feasibility and early clinical experience - PubMed

These early results report the feasibility of an MRg-SBRT boost approach in patients with LARGC, who were not candidates for BT. When classical BT-OAR constraints are followed, the therapy was well tolerated. Long-term follow-up is needed to validate the results.

pubmed.ncbi.nlm.nih.gov

 

[seper]

Take well-trained staff + Smit sleeves + outpatient suite, and your GYN brachytherapy is entirely tolerable experience

 

[Bequerel]

Take well-trained staff + Smit sleeves + outpatient suite, and your GYN brachytherapy is entirely tolerable experience

I have a Brachy-suite, smit sleeve, conscience sedation team and a well-trained staff. It’s definitely “tolerable”, but is it all necessary?

 

[seper]

I have a Brachy-suite, smit sleeve, conscience sedation team and a well-trained staff. It’s definitely “tolerable”, but is it all necessary?

Yes. I have a personal experience similar to what you've described, and EBRT does not approach brachytherapy in efficacy.