Patterns of radiotherapy practice for patients with squamous carcinoma of the uterine cervix: Patterns of care study

Purpose: To determine the impact of research findings and evolving technolo gy on the patterns of radiotherapy practice for patients with carcinoma of the uterine cervix. Methods and Materials: Sixty-two radiation therapy facilities participated in the study after having been selected from a random sample, proportionall y stratified according to practice type, of all United States facilities. E ach facility submitted a list of patients treated during 1992-1994 with rad iation for squamous carcinoma of the cervix. Cases for review were randomly selected from each institution after excluding those of patients who had d istant metastases or initial hysterectomy. A total of 471 patients' records were reviewed in the treating institutions to obtain information about pat ients' characteristics, diagnostic evaluation, tumor extent, treatment appr oach, and radiotherapy techniques. Results: Of the 61 facilities that treated eligible cases of intact cervica l cancer during the 3-year survey period, 35 (57%) treated fewer than three eligible patients per year. Thirty-four (83%) of 41 non-academic facilitie s vs. 1 (5%) of 20 academic facilities treated fewer than three patients pe r year. FIGO stages were I, II, III, and IV in 32%, 40%, 24%, and 3% of pat ients, respectively. Computed tomography (CT) was the most common method of lymph node evaluation, but surgical evaluation, which was performed in 76 (16%) patients, had increased from previous surveys. Fields were designed u sing a dedicated simulator in 95% of patients; a dedicated CT unit was used for treatment planning in 119(30%) cases. External beam irradiation was mo st often given using a four-field technique at 180 cGy per day on a 10-20 M V linear accelerator. The average daily fraction size had decreased from pr evious surveys, and 13% of patients were treated with daily doses of 170 cG y or less. Most patients were treated with a combination of external beam a nd low dose-rate (LDR) intracavitary irradiation. Of 425 patients who had t reatment with curative intent that included brachytherapy, 362 (85%) had LD R brachytherapy, 45 (11%) had high dose-rate (HDR) brachytherapy, 3 had a c ombination of HDR and LDR, and 15 had incomplete information about the brac hytherapy dose-rate. Forty-six (23%) of 197 patients with Stages I-IIA dise ase were treated with radiation followed by extrafascial hysterectomy. Of 1 11 patients treated with curative intent for Stage III-IV disease, 72 (65%) had a combination of external beam and intracavitary radiation therapy, 22 (20%) had external beam plus interstitial brachytherapy, and 17 (15%) were treated with external beam irradiation only. For patients who completed tr eatment with curative intent and did not have adjuvant hysterectomy or HDR brachytherapy, the median total dose at point A was 82.5 Gy. For all patien ts who completed treatment with radiation alone, the median total duration of treatment was 63 days; more than 70 days were taken to complete treatmen t in 33% of cases. Twenty-nine percent of patients received chemotherapy, u sually concurrent with their radiation therapy. Only 27% of these patients were on investigational protocols. Conclusions: Greater participation in well-designed prospective trials migh t help clinicians address important clinical questions and reduce current i nconsistencies in the use of adjuvant treatments. Radiation oncologists sho uld take steps to avoid unnecessary treatment protraction and to improve pa tient compliance. Future studies will be needed to determine whether the sm all number of cases being treated in most nonacademic facilities will influ ence the outcome for patients with invasive cervical carcinoma. (C) 1999 El sevier Science Inc.