Dr. Rajagopalan and colleagues conducted a study examining trends in the use of brachytherapy boost for vaginal cancer treatment between 2004 and 2011. They found a significant decrease in the use of brachytherapy boost from 87.7% in 2004 to 68.6% in 2011. Factors associated with lower odds of receiving brachytherapy boost included higher disease stage, advanced patient age, and treatment at smaller, nonacademic facilities. However, brachytherapy boost remained critical for achieving sufficient radiation doses without overexposure of surrounding organs. The authors conclude that further efforts are needed to emphasize brachytherapy's importance and ensure expertise and access for optimal gynecologic cancer treatment.

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Decreased Use of Brachytherapy Boost for Vaginal Cancer
Brachytherapy boost for the treatment of vaginal cancer is on the decline,
researchers report in a retrospective cohort study examining the trends of
the use of this modality.
An uncommon cancer, vaginal cancer occurs in less than 2% of gynecologic
cancers, with 2890 cases and 840 deaths reported in the United States in
2013. Radiation therapy is the usual treatment.
“Surgery may be an option for some patients with early stage disease,
but it is often precluded due to the vagina’s close proximity to critical
organs including the rectum, bladder, and the urethra,” write Malolan S.
Rajagopalan, MD, from the University of Pittsburgh Cancer Institute
in Pittsburgh, Pennsylvania, and colleagues. “Therefore, the mainstay of
treatment is radiation therapy.”
Such therapy involves external beam radiation therapy (EBRT) and a
brachytherapy boost after EBRT. The ideal total dose is in equivalent 2 Gy
fractions of 70 to 85 Gy, and EBRT followed by a brachytherapy boost is
required to achieve this high dose. Therefore, brachytherapy is a vital part
of the treatment process to “ensure that a curative dose is delivered to the
tumor,” the authors explain.
With brachytherapy being such a necessity in vaginal cancer treatment, why
the apparent decrease in its use?
Philip Villiotte, MD, Radiation Oncologist and Medical Director
of the Cancer Care Center of York County in Sanford is pleased to
announce the appointment of Amy Kane, R.T.T. as senior radiation
therapist at the Center starting January 2015. With 21 years of
experience, Amy attended Southern Maine Technical College in
South Portland, Thomas Jefferson University in Philadelphia and
Bloomsburg University in Pa. Amy most recently worked at the
Center for Cancer Care at Griffin Hospital in Connecticut and at
the Southwestern Vermont Regional Cancer Center as the Director
of Cancer Services. Amy is excited to be back in Maine stating “As a
radiation therapy graduate from Southern Maine Technical College
and having lived, vacationed and spent considerable time visiting
with her immediate family who resides in Maine, I am happy to
permanently relocate our family back to southern Maine.” Amy has
been involved in a number of leadership roles in community outreach
events that include American Cancer Society’s Relay for Life,
VT-NH Komen Race for the Cure Coordinator and Team Captain, Nationally recognized Delta Society
Pet Partner Team Program, guest speaker - Radiation Therapy/Coding, Improvement of Environment
of Care for patients, and author of Health Matters and Technology that makes cancer treatment more
effective.
For more information please contact Karen Pierce-Stewart, Executive Director, Cancer Care Center of
York County at 207-459-1606.
Amy Kane, RTT
new senior
radiation therapist
Spotlight
Cancer news and information from the Cancer Care Center of York County
SUMMER 2015
ChangingtheFaceofCancer
ChangingtheFaceofCancer

2. Dr. Rajagopalan and colleagues suspect that radiation oncologists may be steering away
from brachytherapy because the modality requires technical expertise and specialized
resources. Also, nonbrachytherapy methods such as intensity-modulated radiation
therapy (IMRT) and stereotactic body radiation therapy (SBRT) are being used more
often; are less invasive; and, unlike brachytherapy, do not require the patient to travel
to another facility to receive this phase of treatment. In addition, the authors noted a
recent report of decreased brachytherapy use for cervical cancer within the last 10 years
and aimed to determine if this same trend was occurring in vaginal cancer.
Using the National Cancer Data Base (NCDB), the researchers sought out 4669
women who were diagnosed with vaginal cancer between 2004 and 2011. Because they
wanted to determine the rate of brachytherapy boost, they only included women with a
recorded boost modality (n = 1530).
The authors performed multivariable logistic regression analysis to pinpoint factors
independently linked with brachytherapy boost. Such factors included age, year
of diagnosis, Charlson/Deyo comorbidity score, stage, histologic features, race,
brachytherapy applicator technique, treatment facility volume, and chemotherapy use.
Significant Decrease
Of the 1530 patients who underwent a boost with either EBRT or brachytherapy,
1178 (77%) received brachytherapy boost and 353 (23%) received EBRT boost. The
rate of brachytherapy boost declined from 87.7% in 2004 to 68.6% in 2011 (P < .001).
Interestingly, though, the use of IMRT rose sharply during the same study period
(from 4.5% in 2004 to 23.5% in 2011)—the greatest increase noted compared with
other nonbrachytherapy modalities.
Multivariate analysis demonstrated that patients with higher disease stage (odds
ratio [OR], 0.2) and advanced patient age (OR, 0.5) were less likely to receive
brachytherapy boost. Also, brachytherapy boost was less likely to be used in smaller,
nonacademic facilities. On the other hand, use of the modality was more common in
facilities with higher volume (OR, 2.3), which was the strongest predictor of the use of
brachytherapy boost. Academic centers tended to use brachytherapy boost more often
than community cancer programs (79.1% vs 69.6%).
Histologic features, chemotherapy use, race, and Charlson/Deyo comorbidity score
were not significantly linked with the use of brachytherapy boost.
There’s No Substitute for Brachytherapy
“Using the NCDB, we identified a concerning decline in the utilization of
brachytherapy boost for those with vaginal cancer and a corresponding increase
in IMRT boost technique,” Dr. Rajagopalan and colleagues state. In light of this
observation, they stress that IMRT should not be a substitute for brachytherapy.
Despite its technical challenges, the authors maintain that “no other technique is
capable of reproducing brachytherapy’s high doses to the target with sharp falloff
of dose to the critical structures.”Therefore, in the 100 years since its discovery,
brachytherapy has been a critical component of care for gynecologic cancers,
particularly cervical and vaginal cancer.
Therefore, “[f]urther education of trainees and practicing radiation oncologists is
required to emphasize the importance of brachytherapy in gynecologic cancers,” the
authors conclude. “Furthermore, efforts to deliver brachytherapy or refer patients to
centers where such expertise is available are paramount in the optimal treatment of
these patients.”
The authors report no conflicts of interest related to this study.
Pract Radiat Oncol. 2015;5:56-61.