Cervical cancer patients at small facilities receive less than optimal care

Dec 5, 2004

Cervical cancer is generally viewed as a problematic disease restricted to developing nations. But even in the Western world, the management of cervical cancer may still be less than ideal.

Most recently, a report in the British Journal of Cancer urged Ireland to adopt a cervical screening program. The country currently has no screening program in place. As a result, the number of Irish women who die from cervical cancer every year has increased by 1.5% per year since 1978, according to the report (British Journal of Cancer, November 15, 2004, Vol. 91:10).

In the U.S., screening is standard and successful, but there are disparities with regard to cervical cancer treatment. Specifically, patients who undergo treatment at a larger, more sophisticated facility are more likely to receive better care, according to a patterns-of-care study in the International Journal of Radiation Oncology, Biology, Physics.

Dr. Patricia Eifel and colleagues set out to determine the influence of research findings and evolving technology on the practice of radiotherapy for cervical carcinoma. Eifel is from the M.D. Anderson Cancer Center in Houston. Her co-authors are from the Medical College of Wisconsin in Milwaukee and the American College of Radiology in Philadelphia.

"The most effective treatment (for cervical cancer) can be complex, involving careful interdigitation of external beam RT (EBRT), brachytherapy, and concurrent chemotherapy, and requiring experience and a team approach to management," the group explained (IJROBP, December 2004, Vol. 60:4, pp. 1144-1153).

They compared the results of a 1996-1999 survey to another one conducted from 1992-1994, honing in on changes in brachytherapy and multimodality therapy practices. They also compared practice patterns between small and large facilities in the U.S.

The institutions fell into four categories:

Twenty large academic centers with ≥ 500 new radiation oncology patients annually

Nineteen large nonacademic centers with ≥ 500 new radiation oncology patients annually

Two small academic centers with ≤ 500 new radiation oncology patients annually
Eighteen small nonacademic centers with ≤ 500 new radiation oncology patients annually

Overall, the median age of the patients was 56 years and the majority of these (40.5%) had stage IA-IIA intact cervical cancer, as well as squamous cell cancer (83%). CT was the most common method of nodal evaluation (79% of the patients). In total, 78% of the facilities practicing in the 1996-1999 time period treated less than 500 patients on a yearly basis.

Also, 93% of the patients had radiotherapy as their only local treatment and 6.7% had RT followed by hysterectomy. Overall, 34.6% of the women received chemotherapy with patients at stage IIB-IVA of the disease more likely to have it.

Breaking down the results by facility size, the authors found that only 39% of the small facilities that treated ≤ 2 eligible patients annually used brachytherapy. Other small facilities either treated with EBRT only, or sent their patient to another institution for brachytherapy. There was no change between the 1996-1999 survey and the 1992-1994 survey with regard to how many patients received treatment at two different facilities (13%).

At the smaller facilities, patients received significant lower radiation doses (< 80 Gy), were less likely to have brachytherapy as well as EBRT, and had a longer treatment time (> 70 days). However, these patients were more likely to undergo chemotherapy as part of their initial treatment.

"Disturbingly, the disparities between large and small facilities have increased," the authors stated. "Reports ... have emphasized a high rate of severe treatment protraction and encouraged physicians to work to reduce this problem. Comparisons between the 1992-1994 survey and the 1996-1999 survey suggest that practitioners in large facilities responded to this ... with a marked reduction in the number of patients who required greater than 10 weeks to complete RT."

In comparison, smaller facilities increased their radiation dose time and continued to treat with lower doses despite recent research, which has shown better local control and survival are correlated with greater total radiation dose and shorter treatment duration, they added. Finally, "small facilities tended to have very limited experiences with patients ... 37% treated an average of ≤ 2 patients annually."

The reasons why smaller facilities failed to offer brachytherapy services may include lack of capital, staff, and operating space. Clinicians at these institutions should consider referring patients to larger facilities with more technology and experience, Eifel's group said.

Other trends that the authors found noteworthy:

Details of chemotherapy treatment were rarely documents in the radiation oncologists' records or the hospital charts.

Although MRI provides better detail of the cervix and paracervical tissues, clinicians continue to rely on CT for pelvic and abdominal evaluation.

Results of multi-institutional trials are being incorporated into daily practice at larger facilities.

Finally, the group stressed that the "value of close communication among the members of the multidisciplinary team cannot be overestimated, particularly as the treatment of these patients becomes increasingly complex."

By Shalmali Pal
AuntMinnie.com staff writer
December 6, 2004

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