Phase II study of concurrent cisplatinum with ifosfamide and radiotherapy in locally advanced squamous cell cervical carcinoma.

Objective: To evaluate the efficacy and toxicities of cisplatinum and ifosfamide administered concomitantly with radiation therapy in the treatment of locally advanced squamous cell cervical carcinoma (LASCC). Methods: Twenty patients with biopsy-proven squamous cervical carcinoma, FIGO stage II A to III B were entered into this study. All patients received standard radiotherapy (50 Gy in 25 fractions and brachytherapy at a dose of 268-28 Gy). Cisplatinum 70 mg/m2 plus ifosfamide 3 gm/m2 were administered totally for three cycles on Day 1, 21 and 42, concomitant with the radiotherapy schedule. Response and toxicities of treatment were evaluated and long term follow up was performed for disease free survival. Results: All patients received a course of concomitant chemoradiotherapy. Sixteen patients (80%) were able to receive a full course of chemotherapy, the remaining received 1-2 courses because of severe toxicities. The clinical complete response rate was 90% and overall 4 years survival rate was 85%. Grade 3 and 4 leucopenia occurred in 2 cases with one febrile neutropenia. Late complication revealed 2 cases of grade 3 cystitis. Conclusion: This study showed that concomitant chemoradiotherapy with cisplatinum plus ifosfamide was feasible for patients with LASCC. Further study of this regimen should be compared in randomized control trial (RCT) with cisplatinum alone and in the other histologic type of cervical cancer such as adenocarcinoma.

Prevalence incidence and management of anemia in cancer patients treated in the radiation oncology division, Siriraj Hospital.

Objective: This study was designed to find the prevalence of anemia in cancer patients before radiotherapy and the incidence of anemia during radiotherapy treatment. The study also planned to identify factors that affect the incidence and prevalence of anemia and the management of anemia in the radiation oncology division, Siriraj Hospital. Methods: This study is designed prospectively to collect hemoglobin level and factors that might cause anemia in patients whom were treated with radiotherapy at Siriraj Hospital during April - June 2006. The eligible criteria were patients age > 18 years old, had a pathology confirmed to be malignancy, and had never been treated with radiotherapy before. Patients were excluded if they were not treated with radiotherapy, had skin/central nervous system or hematologic malignancies. In this trial, anemia was defined as Hb level < 12 g/dl for both genders. Results: It was found that the prevalence of anemia within 30 days before starting radiotherapy was 54.4% and the incidence of anemia during radiotherapy was 34.3%. The frequency of anemia, defined as the number of patients in the study in whom Hb <12.0 g/dL were found at least once either at enrollment or during the survey, was 66%. Previous chemotherapy was the main predicting factor for anemia before radiotherapy. Concurrent chemo-radiotherapy patients developed a higher incidence of anemia during the survey than patients with radiotherapy alone. The incidence of anemia was highest in gynecologic malignancy patients. Only 25/112 (22.3%) of anemic patients at initial evaluation received treatment for anemia. Most of the patients were treated with a blood transfusion and none was treated with erythropoietin. Our mean trigger hemoglobin level for treatment of anemia was 9.3 g/dl. Conclusion: Anemia is common in the patients who are treated with radiotherapy in our institute with the prevalence of anemia before starting radiotherapy as high as 54.4% especially in patients previously treated with chemotharapy. One-thirds of patients developed anemia during radiotherapy, with a higher incidence in gynecologic malignancy patients and patients who receive combined chemo-radiotherapy. The total frequency of anemia in patients treated in the Division of Radiation Oncology, Siriraj Hospital was as high as 66% before and during radiotherapy.

Breast cancer: A cost analysis study.

Objective : To compare the unit cost and the reimbursement calculated by Thai Diagnosis Related Group (DRG) version 3 of breast cancer treatments. Methods: thirty nine breast cancer patients who were underwent surgery during1 March 2001 to 30 April 2001 were sequentially selected. Hospital charts were reviewed. History before diagnosis, type of treatments, laboratory details, hormonal therapy and other costs were recorded. Labor cost, material cost and capital cost were calculated as direct cost which also included the cost of doctor visits. Indirect costs included the cost of the facility. Unit cost of each patent was calculated and compared to the reimbursement calculated by Thai DRG version 3 (September 2002). Results : Of 39 breast cancer patients, total Relative Weight (RW) was 54.37 (mean + SD=1.39+0.23) with full cost being 849,377.52 baht (mean + SD = 21,778.91+8,890.46). The total calculated reimbursement was 869,868.80 baht (men + SD 22,304.33 + 3,635.17). Calculation of reimbursement was based on the initial agreement that the university hospital would receive 16,000 baht in payment per 1 RW. Overall reimbursement was slightly higher than cost. Our study resulted in the classification of patients into 4 DRG groups as follows :1) DRG 09010 (Total mastectomy for malignancy, no complication), 2) DRG 09012 (Total mastectomy for malignancy, with mild to moderate complication),3) DRG 09014 (Total mastectomy for malignancy, with severe complication) and 4) DRG 09020 (Subtotal mastectomy for malignancy, no complication or Conservative breast surgery).Reimbursement was lower than cost in groups 2 and 4. In group 2,1 out of 2 patients had a long hospital stay which resulted in a high average cost. Conversely, unit cost of group 4 was not different from other groups but the RW given was lowest, which made the reimbursement much lower than real cost. Conclusion : In conservative breast surgery (group 4), patients must receive both surgical and radiation treatment to decrease the morbidity which increases the cost of treatment. An increased RW should be specially considered for this group.

Results of cervical cancer patients treated according to clinical practice guideline in Siriraj Hospital.

Patients with cervical cancer stage Ib-IVa treated with curative intent at Siriraj Hospital between January and December 2002 were included in the study. There were 362 patients with an age range of 26-86 years old. We found that 65.3% of the patients were treaded according to Siriraj Hospital’s clinical practice guideline (CPG) and 34.7% were not treated according to the CPG. Early results of the treatment showed that 70.4% of the patients treated according to the CPG had complete response at 3 months. After further follow up and salvage treatments, five more patients treated according to CPG accomplished complete responses. The overall results of CPG treatment were comparable to the result of cervical cancer treatment in the literature.

Hemostatic control for intractable bleeding from advanced cancer of the uterine cervix by collagen fleece coated with fibrin glue: A report of 3 cases.

We report 3 cases of advanced cervical cancer with intractable vaginal bleeding. They had all been initially managed by vaginal packing which had failed on 2 occasions. In all cases, bleeding could be controlled by a collagen fleece coated with fibrin glue (Tacho Combฎ) without adverse side effect. Applying a collagen fleece coated with fibrin glue may be an alternative method of bleeding control in selected patients.

Oral mitomycin C and UFT concomitant with irradiation in carcinoma of the cervix, stage IIb and stage IIIb.

Mitomycin C and UFT were given orally, concomitant with irradiation to patients with squamous and adeno-squamous cell carcinoma of the cervix, stages IIb and IIIb, at Siriraj Hospital between June 1993 and June 1994. All patients had tumours larger than 5 cm in diameter. The result showed that the patients were 100 percent disease-free for carcinoma of the cervix stage IIb and 60 percent for stage IIIb.

Simultaneous oral 5-fluorouracil, mitomycin C and radiation therapy in the treatment of localy advanced carcinoma of uterine cervix.

Locally advanced carcinoma of the uterine cervix usually has a poor prognosis with high incidence of persistent disease and local recurrence which contributes to distressing symptoms and poor survival rates. The poor prognosis in this group of patient has remained unchanged over the last decade in spite of the additional of other therapeutic measures. Between January 1993 and June 1994, 20 patients with locally advanced carcinoma of the uterine cervix were treated with oral 5-fluorouracil, oral mitomycin C, simultaneously with radiotherapy. While another group of 18 patients, during the same period, were treated by conventional radiotherapy alone. The result of this study indicate an improvement in local control using the combined therapy: 83.33% vs 66.66% in stage IIB and 78.57% vs 41.66% in stage IIIB. The toxicity and side effects of the combination therapy were minimal. The result suggest that a combination of chemotherapy together with radiotherapy can be an improved method of treatment for locally advanced carcinoma of the uterine cervix.