The hits keep coming (locally advanced cervical)

[communitydoc13]

In the spirit of SA breast and negative oligometastatic trials.

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(23)00531-4/fulltext

This stuff does affect morale...at least mine.

Always less and never more.

---

Members don't see this ad.

 

[ramsesthenice]

Hard to know what to make of this. The mark of success was partial response to 3 cycles of systemic therapy in treatment naive subjects. Thats not a very high bar. Hard to say just how promising the approach really is without knowing how they do in the long run. The only thing that caught my eye as particularly promising was the 30% pCR rate. But again...more information needed.

As an academic, the other depressing thing to me is the difference in the bar to publishing in top tier clinical journals. Let me repeat, its basically a phase 2 study showing that 80% of treatment naive subjects have any measurable response to therapy. IO might have made it better, but an astonishingly high percentage of subjects with metastatic cervical SCC initially have an objective response to doublet therapy. And this is in Lancet Oncology

 

[communitydoc13]

Hard to know what to make of this. The mark of success was partial response to 3 cycles of systemic therapy in treatment naive subjects. Thats not a very high bar. Hard to say just how promising the approach really is without knowing how they do in the long run. The only thing that caught my eye as particularly promising was the 30% pCR rate. But again...more information needed.

As an academic, the other depressing thing to me is the difference in the bar to publishing in top tier clinical journals. Let me repeat, its basically a phase 2 study showing that 80% of treatment naive subjects have any measurable response to therapy. IO might have made it better, but an astonishingly high percentage of subjects with metastatic cervical SCC initially have an objective response to doublet therapy. And this is in Lancet Oncology

To me, the main concern is a change in treatment strategy in entirety for locally advanced cervical CA. Agree, we need to see how the patients do, but 98% of their patients presumably were managed surgically and not with up front chemorads. In the community I'm in , GynOnc not eager to operate on locally advanced cervical cancer at all presently.

 

[ramsesthenice]

To me, the main concern is a change in treatment strategy in entirety for locally advanced cervical CA. Agree, we need to see how the patients do, but 98% of their patients presumably were managed surgically and not with up front chemorads. In the community I'm in , GynOnc not eager to operate on locally advanced cervical cancer at all presently.

Surgical rates were high, but not that high. Only about 80% had a response and went to surgery. Practice patterns in my area are the same as yours. It will take a pretty high bar to change practice.

 

[evilbooyaa]

Only the Asians AFAIK are still doing bashing their head against the neoadjuvant systemic followed by surgery paradigm for locally advanced cervix. Everyone else has seemingly bowed to chemoRT being the local modality of choice.

Thought this was gonna be about INTERLACE and was really worried that INTERLACE was going to make it into Lancet Oncology...

6 first authors on this paper, is that a record?

Authors are studying a chinese-made IT. Is it bad if a whole country (China) basically acts like a pharmaceutical company??

Literally no LR/PFS/OS outcomes. Big yawn.

 

[Bequerel]

Speaking of cervical cancer…I’ve never understood why we have never done randomized trials that looked to replace brachytherapy with external treatments. So many ways this could be done. BT is such a morbid procedure that I’m convinced will be looked at like it was crazy 50 years from now. Cervical cancer melts away during treatment the same way hpv+ oropharynx and anal cancers melt away but cervical needs highest EQD2Gy of any cancer we treat 🙄

 

[BobbyHeenan]

Speaking of cervical cancer…I’ve never understood why we have never done randomized trials that looked to replace brachytherapy with external treatments. So many ways this could be done. BT is such a morbid procedure that I’m convinced will be looked at like it was crazy 50 years from now. Cervical cancer melts away during treatment the same way hpv+ oropharynx and anal cancers melt away but cervical needs highest EQD2Gy of any cancer we treat 🙄

You may actually want to program your Ring camera to recognize when Patti Eifel or Beriwal show up to your house to take you to the re education camp for suggesting this. Maybe it can alert you quicker so you have a chance to run.

* I agree though, I'd like to see an SBRT vs. brachy trial at least for excellent responders.

 

[evilbooyaa]

Speaking of cervical cancer…I’ve never understood why we have never done randomized trials that looked to replace brachytherapy with external treatments. So many ways this could be done. BT is such a morbid procedure that I’m convinced will be looked at like it was crazy 50 years from now. Cervical cancer melts away during treatment the same way hpv+ oropharynx and anal cancers melt away but cervical needs highest EQD2Gy of any cancer we treat 🙄

There's a dose response based on EMBRACE. UTSW did a SBRT trial and it looked bad. Like real bad - A Phase II Trial of Stereotactic Ablative Radiation Therapy as a Boost for Locally Advanced Cervical Cancer - PubMed
Dosimetry is better for brachy than SBRT - Brachytherapy Versus Stereotactic Body Radiotherapy for Cervical Cancer Boost: A Dosimetric Comparison
Regular run of the mill ICBT isn't a morbid procedure if you're good at it. Replacing Gyn BT has been everyone's dream for most of their careers.

Think it should be eliminated because you can't or won't do it? Prove that it's equally effective and toxic (it won't be, basically ever), and until then, refer the patients to someone who can actually take care of them.

 

[TheWallnerus]

Regular run of the mill ICBT isn't a morbid procedure if you're good at it

I think I can 100% let you, or me, get away with this opinion after we’ve had a metal rod placed in our penile urethra for a good long stretch. While awake.

 

[OTN]

I think I can 100% let you, or me, get away with this opinion after we’ve had a metal rod placed in our penile urethra for a good long stretch. While awake.

 

[evilbooyaa]

I think I can 100% let you, or me, get away with this opinion after we’ve had a metal rod placed in our penile urethra for a good long stretch. While awake.

Place a tandem in a patient under anesthesia once and you'll NEVER do it without anesthesia ever again.

 

[Bequerel]

There's a dose response based on EMBRACE. UTSW did a SBRT trial and it looked bad. Like real bad - A Phase II Trial of Stereotactic Ablative Radiation Therapy as a Boost for Locally Advanced Cervical Cancer - PubMed
Dosimetry is better for brachy than SBRT - Brachytherapy Versus Stereotactic Body Radiotherapy for Cervical Cancer Boost: A Dosimetric Comparison
Regular run of the mill ICBT isn't a morbid procedure if you're good at it. Replacing Gyn BT has been everyone's dream for most of their careers.

Think it should be eliminated because you can't or won't do it? Prove that it's equally effective and toxic (it won't be, basically ever), and until then, refer the patients to someone who can actually take care of them.

Unfortunately, I’ve done more Brachy than any of my gyn attendings did during residency. Hence, my passion for getting rid of it. Just the dynamics of being only one in the region that does it. Definitely not by choice lol. I also have treated 10-15 patients with SBRT instead of BT because they were either unable to get smit sleeve due to GYO decision or were undocumented and there was no option. All of them NED with minimum of 3 years follow up and some 10 years out.

 

[NotMattSpraker]

There's a dose response based on EMBRACE. UTSW did a SBRT trial and it looked bad. Like real bad - A Phase II Trial of Stereotactic Ablative Radiation Therapy as a Boost for Locally Advanced Cervical Cancer - PubMed
Dosimetry is better for brachy than SBRT - Brachytherapy Versus Stereotactic Body Radiotherapy for Cervical Cancer Boost: A Dosimetric Comparison
Regular run of the mill ICBT isn't a morbid procedure if you're good at it. Replacing Gyn BT has been everyone's dream for most of their careers.

Think it should be eliminated because you can't or won't do it? Prove that it's equally effective and toxic (it won't be, basically ever), and until then, refer the patients to someone who can actually take care of them.

Cervical cancer will be eliminated from most of the US before brachytherapy is eliminated.

 

[communitydoc13]

Cervical cancer will be eliminated from most of the US before brachytherapy is eliminated.

My cervical patients are, by and large, late manifesting HPV in the elderly at this point. (But there are locales where this is not the case at all).

 

[NotMattSpraker]

My cervical patients are, by and large, late manifesting HPV in the elderly at this point. (But there are locales where this is not the case at all).

Wow. I was busy with cervix last year and only had 1 patient over 50.

I was being a little dramatic up there, but have been really impressed with the decreases in incidence we are already seeing with a pretty short run in thus far with vaccination. It hasnt even been 20 years since the first vax.

 

[TheWallnerus]

Unfortunately, I’ve done more Brachy than any of my gyn attendings did during residency. Hence, my passion for getting rid of it. Just the dynamics of being only one in the region that does it. Definitely not by choice lol. I also have treated 10-15 patients with SBRT instead of BT because they were either unable to get smit sleeve due to GYO decision or were undocumented and there was no option. All of them NED with minimum of 3 years follow up and some 10 years out.

Radiobiologists love this answer and of course gyn rad oncs do not. But I have had similar experience. Anecdotes, yay!

 

[NotMattSpraker]

because they were either unable to get smit sleeve due to GYO decision or were undocumented and there was no option.

Do you mean like you did the EBRT portion then you send them for brachy but they were turned away because of no insurance?

 

[Bequerel]

Do you mean like you did the EBRT portion then you send them for brachy but they were turned away because of no insurance?

I do the Brachy so I wouldn’t send them anywhere, unless they needed interstitial. The majority of the patients I treated with sbrt boost are undocumented patients so no gyo available for sleeve in the area. There have been a couple that were older and gyo declined placing sleeve, but I don’t recall the reason now as it’s been over 5 years.

 

[RadOncDoc21]

Anecdotal evidence here as well, I had to do SBRT on 2 patients and they are so far doing well, 4 yrs out. I stopped doing brachytherapy about 2 yrs again and sending them all out. Let’s just say I don’t miss it at all.

 

[Tigerstang]

Unfortunately, I’ve done more Brachy than any of my gyn attendings did during residency. Hence, my passion for getting rid of it. Just the dynamics of being only one in the region that does it. Definitely not by choice lol. I also have treated 10-15 patients with SBRT instead of BT because they were either unable to get smit sleeve due to GYO decision or were undocumented and there was no option. All of them NED with minimum of 3 years follow up and some 10 years out.

Same

 

[communitydoc13]

Surgical rates were high, but not that high. Only about 80% had a response and went to surgery. Practice patterns in my area are the same as yours. It will take a pretty high bar to change practice.

We'll see where we stand in 10 years.

Maybe I'm reading the abstract wrong. They selected for PDL-1 positive patients (about 80%), and of those, I believe at least partial response was remarkably high.

I agree the bar is high, but this is a perfect example regarding how every disease site is contextualized by the systemic tools available...and unfortunately, that context almost never indicates new or more indications regarding XRT. (There have historically been examples of the converse, with combined modality therapy improving organ preservation with regard to anal, H&N and more recently rectal. We are all a little confused about how this context impacts our role in the metastatic setting, but we are not driving this and we are not getting a clearly positive answer.)

Stage III lung is the classic recent example, where depending on where you are, practice patterns may have already significantly changed. I could see academic GYN departments adopting this approach fairly readily (or accruing patients on trial) under the premise that avoiding XRT in the pelvis is universally good and surgery without XRT for limited burden disease is associated with better long term QOL.

We need to be creative to have any stake in a world of diminishing returns. An example would be an early stage trial incorporating limited XRT with chemoimmuno to improve downstaging and facilitate limited surgery if outcomes for these patients look good or to allow for surgical surveillance only if a complete response on clinical exam (as per the recent SANO esophageal trial).

 

[ramsesthenice]

We need to be creative to have any stake in a world of diminishing returns. An example would be an early stage trial incorporating limited XRT with chemoimmuno to improve downstaging and facilitate limited surgery if outcomes for these patients look good or to allow for surgical surveillance only if a complete response on clinical exam (as per the recent SANO esophageal trial).

I won't dox myself, but you just described my current trial profile

 

[IonsAreOurFuture]

We need to be creative to have any stake in a world of diminishing returns. An example would be an early stage trial incorporating limited XRT with chemoimmuno to improve downstaging and facilitate limited surgery if outcomes for these patients look good or to allow for surgical surveillance only if a complete response on clinical exam (as per the recent SANO esophageal trial).

We need to be creative.

I couldn't agree more. When did the 5 trials come out showing a benefit to adding chemo to RT for most disease sites? It's been 20 to 40 years, eg Nigro protocol was published in 1974. How many of us were even alive then?

In the meantime, there's been a revolution in biologics, immunotherapy and targeted therapies, and we have largely watched from the sidelines.

We need to innovate or die

 

[RadOncDoc21]

We need to be creative.

I couldn't agree more. When did the 5 trials come out showing a benefit to adding chemo to RT for most disease sites? It's been 20 to 40 years, eg Nigro protocol was published in 1974. How many of us were even alive then?

In the meantime, there's been a revolution in biologics, immunotherapy and targeted therapies, and we have largely watched from the sidelines.

We need to innovate or die

We’re blockbuster, biologics is Netflix… I’m liquidating my assets!

 

[TheWallnerus]

We’re blockbuster, biologics is Netflix… I’m liquidating my assets!

Son: "Dad, tell me about cervical cancer, brachytherapy, and the heydays of radiotherapy"

Me:

 

[Upgrayedd]

i’m

I think I can 100% let you, or me, get away with this opinion after we’ve had a metal rod placed in our penile urethra for a good long stretch. While awake.

The risk we are mitigating is disease specific death. Like; not other outcomes, not biochemical progression. Death.

Sometimes I think some rad onc’s should repeat an MS3 surgery elective to remind themselves most of medicine is a contact sport.

 

[Ray D. Ayshun]

Son: "Dad, thanks for describing the excitement you had when you saw a high risk prostate or stage III lung consult on the printer. What was it like hearing you had a cervix cancer patient coming?"

Me:

 

[evilbooyaa]

Unfortunately, I’ve done more Brachy than any of my gyn attendings did during residency. Hence, my passion for getting rid of it. Just the dynamics of being only one in the region that does it. Definitely not by choice lol. I also have treated 10-15 patients with SBRT instead of BT because they were either unable to get smit sleeve due to GYO decision or were undocumented and there was no option. All of them NED with minimum of 3 years follow up and some 10 years out.

Anecdotal evidence here as well, I had to do SBRT on 2 patients and they are so far doing well, 4 yrs out. I stopped doing brachytherapy about 2 yrs again and sending them all out. Let’s just say I don’t miss it at all.

Same

All you guys routinely doing cervix SBRT, are you following these patients 5 years out? No toxicities? Or is this the "I saw em once at 3 months and d/c them back to their GynOnc or their Ob/Gyn, so it's totally reasonable"? In which case, enjoy your head in the sand.

You guys should publish on your patients so we can see how barbaric the rest of the folks nationwide are.

If you think you NEED a GynOnc to place a Smit sleeve otherwise you can't even ATTEMPT a tandem brachy case - just refer it out, mang. Feel free to message me where you are, and I will try to find you someone nearby who can appropriately take care of the patient.

Cowboy level stuff here. Hope none of these patients have their cancer come back or have a high grade toxicity...

 

[RadOncDoc21]

All you guys routinely doing cervix SBRT, are you following these patients 5 years out? No toxicities? Or is this the "I saw em once at 3 months and d/c them back to their GynOnc or their Ob/Gyn, so it's totally reasonable"? In which case, enjoy your head in the sand.

You guys should publish on your patients so we can see how barbaric the rest of the folks nationwide are.

If you think you NEED a GynOnc to place a Smit sleeve otherwise you can't even ATTEMPT a tandem brachy case - just refer it out, mang. Feel free to message me where you are, and I will try to find you someone nearby who can appropriately take care of the patient.

Cowboy level stuff here. Hope none of these patients have their cancer come back or have a high grade toxicity...

I mean 2 patients in more then 10 yrs of practicing doesn’t seem crazy to me. Especially when they refused or wasn’t a candidate for brachy.

Also, kinda judgy… not cool!

 

[NotMattSpraker]

I mean 2 patients in more then 10 yrs of practicing doesn’t seem crazy to me. Especially when they refused or wasn’t a candidate for brachy.

Its not crazy, it would just be helpful if you guys published your experience because the current published outcomes are horrible.

This came up once for me last year. The reason we were considering bailing on brachy was because of social/compliance issues and the first (aborted) fraction was a nightmare. I instead elected to admit the patient, reduce the number of fractions, and do BID.

If I had better data to lean on, even retrospective, I could see that conversation going differently.

 

[Upgrayedd]

Its not crazy, it would just be helpful if you guys published your experience because the current published outcomes are horrible.

This came up once for me last year. The reason we were considering bailing on brachy was because of social/compliance issues and the first (aborted) fraction was a nightmare. I instead elected to admit the patient, reduce the number of fractions, and do BID.

If I had better data to lean on, even retrospective, I could see that conversation going differently.

Super reasonable IMO. Its still good care; just not as food as HDR; but when there are mitigating factors some treatment is better than no treatment.

 

[RadOncDoc21]

Its not crazy, it would just be helpful if you guys published your experience because the current published outcomes are horrible.

This came up once for me last year. The reason we were considering bailing on brachy was because of social/compliance issues and the first (aborted) fraction was a nightmare. I instead elected to admit the patient, reduce the number of fractions, and do BID.

If I had better data to lean on, even retrospective, I could see that conversation going differently.

I can’t speak for everyone but I’m sure nobody is advocating that this should be the new standard of care. I think it does deserve some more investigation and can be an option for some patients if brachy isn’t an option for whatever reason.

I’m just unsure of why do we have to take everything so personal when it comes to a difference of practice or opinions on here and how everything has so much certainty when we all know the practice of medicine has many variables in play.

I won’t be publishing anything anytime soon and I’m hoping there will be good data that becomes available in our field that is indeed practice changing and makes an impact for our patients instead of the same omission trials and protons vs. 2D garbage I see out there now.

 

[Bequerel]

All you guys routinely doing cervix SBRT, are you following these patients 5 years out? No toxicities? Or is this the "I saw em once at 3 months and d/c them back to their GynOnc or their Ob/Gyn, so it's totally reasonable"? In which case, enjoy your head in the sand.

You guys should publish on your patients so we can see how barbaric the rest of the folks nationwide are.

If you think you NEED a GynOnc to place a Smit sleeve otherwise you can't even ATTEMPT a tandem brachy case - just refer it out, mang. Feel free to message me where you are, and I will try to find you someone nearby who can appropriately take care of the patient.

Cowboy level stuff here. Hope none of these patients have their cancer come back or have a high grade toxicity...

As stated in my previous post…I have extended follow up on these patients. I follow all these patients for as long as they remain in the area, some have 10 years of follow-up. A few sneak up to me because they know we take care of undocumented patients and then head back to Mexico directly afterwards. At most 15 patients over 10 years. I document the heck out of it in my consult and informed consent. Your “cowboy” level stuff, is just my working within the system and providing best possible care for undocumented women who would otherwise get nothing. Believe me, when I moved here I tried to refer these patients, but surely you wouldn’t find it surprising that large academic tertiary centers like MDACC won’t see undocumented women? And if they did, these women don’t have the means to travel and receive treatment. For the record, I wasn’t ever advocating that SBRT should currently be used in lieu of HDR. I was sharing my anecdotal experiences and suggesting an HDR Vs SBRT randomized trial be performed instead of all the omission trials that are being done.

 

[communitydoc13]

Super reasonable IMO. Its still good care; just not as food as HDR; but when there are mitigating factors some treatment is better than no treatment.

https://www.practicalradonc.org/article/S1879-8500(23)00280-1/fulltext

There's ton's of data out there that outcomes without brachy can be good. The Timmerman trial is a bit of an outlier and included some absurd cancers (SBRTing Syed type patients with 28/4 and closed after 15 patients).

In my career, I have had several patient's who were not good candidates for brachytherapy or SBRT.

I have cured several very locally advanced cervical cancers with ~60-66 Gy with chemo.

I have had durable control with 50 Gy in patients who stop treatment or refuse brachy.

Of course intuition and anecdotes are not very valuable for determining relative efficacy.

My belief is that 66Gy standard fractionation with radiosensitizing cisplatin in the IMRT era in a modern center is far better than the outcomes published from places with marginal resources 10+ years ago...I am not eager for this trial and offer this only to very old and frail patients or patients who refuse other options and are not candidates for hypofractionated boost due to anatomy.

My belief also is that an SBRT target for intact cervix is very mobile and hard to define radiographically. I suspect that there is a judicious choice of margins/technique/dose out there that can get close to brachy at some point.

The most remarkable thing about the PRO article above (a good article) is the significant number of early stage or institutional trials with variable dosimetric goals and very low accrual goals out there. This is an example of US academic radonc at it's finest. Clearly SBRT to an intact cervix is not quite the same as SBRT to a brain met, lung lesion, adrenal lesion or kidney lesion.

Academic places are treating significant numbers of patients without brachytherapy, presumably for good reasons and sometimes for small phase trials that are at times dubious.

I'm pretty sure no one on this board is substituting external beam radiation for brachy at this juncture for medically fit and willing patients.

We all should be considering induction chemo at this point for medically fit locally advanced cervical cancer patients.

Induction chemo...induction chemo/IO...if outcomes good enough...changes or de-escalation in local management.

Happens every time.

 

[RickyScott]

I have tried sbrt in one or 2 cases over my career. The key is to cath/enema the pt and have very reproducible rectal and bladder filling. Otherwise, am with evilboya on this. Procedure is so much easier under anesthesia, although this ends up taking up your whole morning.

 

[evilbooyaa]

I mean 2 patients in more then 10 yrs of practicing doesn’t seem crazy to me. Especially when they refused or wasn’t a candidate for brachy.

Also, kinda judgy… not cool!

How many cervix patients did you get to HDR (either by yourself or referred out appropriately in that same time frame? 2 patients in 10 years doesn't matter if you only saw 10 cervix patients (a definite possibility) in that time frame.

If it's 2 out of 100-200 patients, then yeah, sure, I get it.

As stated in my previous post…I have extended follow up on these patients. I follow all these patients for as long as they remain in the area, some have 10 years of follow-up. A few sneak up to me because they know we take care of undocumented patients and then head back to Mexico directly afterwards. At most 15 patients over 10 years. I document the heck out of it in my consult and informed consent. Your “cowboy” level stuff, is just my working within the system and providing best possible care for undocumented women who would otherwise get nothing. Believe me, when I moved here I tried to refer these patients, but surely you wouldn’t find it surprising that large academic tertiary centers like MDACC won’t see undocumented women? And if they did, these women don’t have the means to travel and receive treatment. For the record, I wasn’t ever advocating that SBRT should currently be used in lieu of HDR. I was sharing my anecdotal experiences and suggesting an HDR Vs SBRT randomized trial be performed instead of all the omission trials that are being done.

You're saying you've done SBRT on 15 patients in 10 years? Given your reported high-volume practice, would you presume > 300 HDR patients over those 10 years? That ratio would be reasonable.

I can’t speak for everyone but I’m sure nobody is advocating that this should be the new standard of care. I think it does deserve some more investigation and can be an option for some patients if brachy isn’t an option for whatever reason.

I’m just unsure of why do we have to take everything so personal when it comes to a difference of practice or opinions on here and how everything has so much certainty when we all know the practice of medicine has many variables in play.

I won’t be publishing anything anytime soon and I’m hoping there will be good data that becomes available in our field that is indeed practice changing and makes an impact for our patients instead of the same omission trials and protons vs. 2D garbage I see out there now.

The issue is that most 'retrospective studies' in this space is because people are offering women awake T&O and when they 'don't tolerate' defaulting to going 'not a good candidate for brachy' and gambling with their lives (or at least their bladder/rectum if they need an exent at the time of their local recurrence).

So sure, open to it being evaluated in a proper trial, but to ignore the prospective data that has already been published on it is wrong to me. I won't sit here and be nice about that. It's cowboy mentality, and all I can hope is that you continue to only do it on those who truly have their eyes open to what the prospective data shows - worse oncologic outcomes and worse toxicity - compared to HDR.

The reason people are so interested in doing SBRT for gyn is because SBRT has (mostly) replaced brachy in prostate, and people want to do similarly. I get it. It's easier to do SBRT. You don't have to refer it out. You get to keep the RVUs. Good for the physician. Good for the patient that they don't have to travel for a procedure too.

No data that it is as good for the patient.

https://www.practicalradonc.org/article/S1879-8500(23)00280-1/fulltext

There's ton's of data out there that outcomes without brachy can be good. The Timmerman trial is a bit of an outlier and included some absurd cancers (SBRTing Syed type patients with 28/4 and closed after 15 patients).

In my career, I have had several patient's who were not good candidates for brachytherapy or SBRT.

I have cured several very locally advanced cervical cancers with ~60-66 Gy with chemo.

I have had durable control with 50 Gy in patients who stop treatment or refuse brachy.

Of course intuition and anecdotes are not very valuable for determining relative efficacy.

My belief is that 66Gy standard fractionation with radiosensitizing cisplatin in the IMRT era in a modern center is far better than the outcomes published from places with marginal resources 10+ years ago...I am not eager for this trial and offer this only to very old and frail patients or patients who refuse other options and are not candidates for hypofractionated boost due to anatomy.

My belief also is that an SBRT target for intact cervix is very mobile and hard to define radiographically. I suspect that there is a judicious choice of margins/technique/dose out there that can get close to brachy at some point.

The most remarkable thing about the PRO article above (a good article) is the significant number of early stage or institutional trials with variable dosimetric goals and very low accrual goals out there. This is an example of US academic radonc at it's finest. Clearly SBRT to an intact cervix is not quite the same as SBRT to a brain met, lung lesion, adrenal lesion or kidney lesion.

Academic places are treating significant numbers of patients without brachytherapy, presumably for good reasons and sometimes for small phase trials that are at times dubious.

I'm pretty sure no one on this board is substituting external beam radiation for brachy at this juncture for medically fit and willing patients.

We all should be considering induction chemo at this point for medically fit locally advanced cervical cancer patients.

Induction chemo...induction chemo/IO...if outcomes good enough...changes or de-escalation in local management.

Happens every time.

Couple of things.
The guideline paper you linked SPECIFICALLY excludes SBRT for primary cervical cancer. Does not recommend. Says don't do it. Yes, people have done it, as per the table, with either 100% LC and ZERO toxicity (what is the likelihood of that?) or 15-25% G3+ toxicity, which is higher than what anyone would expect with HDR-BT.

They say to CONSIDER SBRT in primary medically inpoerable endometrial cancer, which I get, because appropriately covering the tumor volume in medically inoperable uterine cancer per traditional guidelines can be quite difficult, even in experienced brachy hands.

Maybe induction chemo will be the answer, but the low brachy doses in both INTERLACE and the newest KEYNOTE study are concerning as control arm did pitifully in both and I (personally) am awaiting full papers before making any decisions.

 

[brushbeamscanning]

All you guys routinely doing cervix SBRT, are you following these patients 5 years out? No toxicities? Or is this the "I saw em once at 3 months and d/c them back to their GynOnc or their Ob/Gyn, so it's totally reasonable"? In which case, enjoy your head in the sand.

You guys should publish on your patients so we can see how barbaric the rest of the folks nationwide are.

If you think you NEED a GynOnc to place a Smit sleeve otherwise you can't even ATTEMPT a tandem brachy case - just refer it out, mang. Feel free to message me where you are, and I will try to find you someone nearby who can appropriately take care of the patient.

Cowboy level stuff here. Hope none of these patients have their cancer come back or have a high grade toxicity...

I was taught to place my own Smit Sleeves during residency but I was wondering if this was common? My assumption at the time was that it was relatively rare when talking to other residents from different training programs?

 

[drowsy12]

I’m happy to refer my cervix patients out. I don’t want to do the brachy. I can’t send them away fast enough.

 

[deleted1111261]

I had a PA request for SBRT for cervix.

Asked for more info, thinking it was something reasonable.

Essentially, this insurance would pay for the EBRT but not brachy (?? Flori-duh). I said had to refer out, then, that it was a bad reason to treat with SBRT, especially in a high-density metro area. So, they did that and hopefully patient got appropriate care.

(This is one of those double-edged swords about PA; I think I did the right thing and did right by patient, but can certainly be accused of 'playing doctor by remote')

 

[communitydoc13]

Says don't do it.

Say's don't do it in lieu of brachy...not don't do.

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

Background and purpose Chemoradiotherapy (CRT) followed by a brachytherapy (BT) boost is the standard of care for patients with locally advanced or recurrent gynecological cancer (LARGC). However, not every patient is suitable for BT. Therefore, we investigated the feasibility of an MR-guided...

ro-journal.biomedcentral.com

Thinking we need to get a some salvage Viewray hardware to @Bequerel.

Viva la revolution!

 

[RadOncDoc21]

How many cervix patients did you get to HDR (either by yourself or referred out appropriately in that same time frame? 2 patients in 10 years doesn't matter if you only saw 10 cervix patients (a definite possibility) in that time frame.

If it's 2 out of 100-200 patients, then yeah, sure, I get it.

I’ll say 2 out of approximately 100 but again there were no other options for them. They are still alive, disease free going on +5 yrs now…. And yes I followed them.

Am I ok to continue to practice medicine now? Yes, I’m being snarky.

 

[ramsesthenice]

surprised to see how many people are using Smit sleeves. I personally hate them but I do a ton of implants. I'll admit, Im a weird case. I usually don't use a speculum to insert the tandem either. Easiest way I find to do it is slide my left index finger just behind the base of the os and slide the tandem along my finger to guide it in. Usually way less poking and prodding on my end this way.

 

[RadOncDoc21]

surprised to see how many people are using Smit sleeves. I personally hate them but I do a ton of implants. I'll admit, Im a weird case. I usually don't use a speculum to insert the tandem either. Easiest way I find to do it is slide my left index finger just behind the base of the os and slide the tandem along my finger to guide it in. Usually way less poking and prodding on my end this way.

You sound like a gentleman!

 

[evilbooyaa]

I was taught to place my own Smit Sleeves during residency but I was wondering if this was common? My assumption at the time was that it was relatively rare when talking to other residents from different training programs?

Would be a great skill to learn, but not one that I was taught during residency. Throwing sutures within the vaginal vault is generally a pretty tight squeeze, and not one that I would feel comfortable winging on my own when I have supportive Gyn/Oncs. Alternatively, tandem can be placed without a Smit sleeve with an abdominal US for at least the first fraction (ideally, IMO, for each fraction) to confirm proper placement.

Say's don't do it in lieu of brachy...not don't do.

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

Background and purpose Chemoradiotherapy (CRT) followed by a brachytherapy (BT) boost is the standard of care for patients with locally advanced or recurrent gynecological cancer (LARGC). However, not every patient is suitable for BT. Therefore, we investigated the feasibility of an MR-guided...

ro-journal.biomedcentral.com

Thinking we need to get a some salvage Viewray hardware to @Bequerel.

Viva la revolution!

Primary management of cervical cancer is chemoRT + brachy. I don't understand your first line. When are you going to SBRT in this scenario if not in lieu of brachytherapy?

Are we supposed to be happy with EQD2 of 73.6Gy for definitive management of cervical cancer? That's all they could get given their need to respect OAR constraints. So we're already punting 10-15% local control per below dose response curve.

I get that these are cases specifically deemed not candidates. But it's just not as good as brachy. Having to turn the dose down and having median 9 month f/u so too early to see local recurrences...


Locally recurrent disease not amenable to exent? Sure, go ahead, SBRT whatever you want.

I’ll say 2 out of approximately 100 but again there were no other options for them. They are still alive, disease free going on +5 yrs now…. And yes I followed them.

Am I ok to continue to practice medicine now? Yes, I’m being snarky.

Great to hear that 1) your patients are doing well and 2) your rate of SBRT usage is so low. Carry on. Never let someone limit your snarkiness!

surprised to see how many people are using Smit sleeves. I personally hate them but I do a ton of implants. I'll admit, Im a weird case. I usually don't use a speculum to insert the tandem either. Easiest way I find to do it is slide my left index finger just behind the base of the os and slide the tandem along my finger to guide it in. Usually way less poking and prodding on my end this way.

Your cervical cancer patients still have an intact os and normal feeling anatomy on digital exam? Most of mine have pretty toast local anatomy unfortunately.... The IB2 and below are going for hysterectomy near ubiquitously. If not doing a Smit sleeve I'm doing US guided. Lower uterine segment can be quite friable and you can go right through especially with the small caliber metal tandem from Varian's T&O kit.

 

[evilbooyaa]

I had a PA request for SBRT for cervix.

Asked for more info, thinking it was something reasonable.

Essentially, this insurance would pay for the EBRT but not brachy (?? Flori-duh). I said had to refer out, then, that it was a bad reason to treat with SBRT, especially in a high-density metro area. So, they did that and hopefully patient got appropriate care.

(This is one of those double-edged swords about PA; I think I did the right thing and did right by patient, but can certainly be accused of 'playing doctor by remote')

Thank you for helping that patient.

But, why is the insurance paying for EBRT and not brachy??

 

[ramsesthenice]

Would be a great skill to learn, but not one that I was taught during residency. Throwing sutures within the vaginal vault is generally a pretty tight squeeze, and not one that I would feel comfortable winging on my own when I have supportive Gyn/Oncs. Alternatively, tandem can be placed without a Smit sleeve with an abdominal US for at least the first fraction (ideally, IMO, for each fraction) to confirm proper placement.



Primary management of cervical cancer is chemoRT + brachy. I don't understand your first line. When are you going to SBRT in this scenario if not in lieu of brachytherapy?

Are we supposed to be happy with EQD2 of 73.6Gy for definitive management of cervical cancer? That's all they could get given their need to respect OAR constraints. So we're already punting 10-15% local control per below dose response curve.
View attachment 379705

I get that these are cases specifically deemed not candidates. But it's just not as good as brachy. Having to turn the dose down and having median 9 month f/u so too early to see local recurrences...


Locally recurrent disease not amenable to exent? Sure, go ahead, SBRT whatever you want.


Great to hear that 1) your patients are doing well and 2) your rate of SBRT usage is so low. Carry on. Never let someone limit your snarkiness!


Your cervical cancer patients still have an intact os and normal feeling anatomy on digital exam? Most of mine have pretty toast local anatomy unfortunately.... The IB2 and below are going for hysterectomy near ubiquitously. If not doing a Smit sleeve I'm doing US guided. Lower uterine segment can be quite friable and you can go right through especially with the small caliber metal tandem from Varian's T&O kit.

Typically anatomy is not normal, but normal enough. Or so bad it’s a full interstitial implant ☹️

 

[deleted1111261]

Thank you for helping that patient.

But, why is the insurance paying for EBRT and not brachy??

I think some of these cut rate ones want something site specific for procedures - like maybe the ambu center is cheaper (or more expensive) than hospital?

 

[Aphtalyfe]

Overall this is a great discussion. As someone who does a lot of brachy I would be more than happy to do less brachy if it was better for the patient(s).

Unfortunately, multiple studies have shown that EBRT/SBRT boost in lieu of brachytherapy is inferior. I didn't see anyone link the NCBD and SEER analysis.

Furthermore, a phase III study would be difficult to run due to most physicians having a strong/polarized opinion on brachytherapy. I could not out of good conscience enroll patients on a cervix trial comparing SBRT to brachy boost.

 

[deleted1111261]

Overall this is a great discussion. As someone who does a lot of brachy I would be more than happy to do less brachy if it was better for the patient(s).

Unfortunately, multiple studies have shown that EBRT/SBRT boost in lieu of brachytherapy is inferior. I didn't see anyone link the NCBD and SEER analysis.

Furthermore, a phase III study would be difficult to run due to most physicians having a strong/polarized opinion on brachytherapy. I could not out of good conscience enroll patients on a cervix trial comparing SBRT to brachy boost.

I think the lower outcomes are in some way influenced by selection and worse brachy candidates tend to get SBRT (not always).

I lean towards thinking brachy >> SBRT, but in selected patients, I think a study may provide some helpful information, if done well.

I don't know enough about gyn any more to know WHO would be the right ones to select for a study, though.

Maybe you're right and it is literally nobody.

 

[Palex80]

I don't know enough about gyn any more to know WHO would be the right ones to select for a study, though.

The two main indications for brachytherapy in cervical are stage driven:
1. cN1 disease (or pN1 on staging lymphadenectomy)
2. Local disease >cT2a

Patients with bulky tumors or tumors infiltrating the vagina/bladder are not good SBRT candidates.
So, the sweet spot may be cN1/pN1 disease with rather smaller primaries. These patients may benefit the most from an induction chemotherapy phase (like shown in the INTERLACE trial) to combat distant recurrences, then undergo EBRT and then, finally, SBRT may be as good as brachytherapy, because: a) the primary was small and may have shrunk even more / disappeared with all the therapy you have already given and b) local control may not be the predominant site of potential failure.

DISCLAIMER: I have zero experience with cervical cancer SBRT. We do brachy in all cases.