A randomized controlled trial comparing concurrent chemoradiation versus concurrent chemoradiation followed by adjuvant chemotherapy in locally advanced cervical cancer patients: ACTLACC trial / 부인종양

OBJECTIVE: To compare response rate and survivals of locally advanced stage cervical cancer patients who had standard concurrent chemoradiation therapy (CCRT) alone to those who had adjuvant chemotherapy (ACT) after CCRT. METHODS: Patients aged 18–70 years who had International Federation of Gynecology and Obstetrics stage IIB–IVA without para-aortic lymph node enlargement, Eastern Cooperative Oncology Group scores 0–2, and non-aggressive histopathology were randomized to have CCRT with weekly cisplatin followed by observation (arm A) or by ACT with paclitaxel plus carboplatin every 4 weeks for 3 cycles (arm B). RESULTS: Data analysis of 259 patients showed no significant difference in complete responses at 4 months after treatment between arm A (n=129) and arm B (n=130): 94.1% vs. 87.0% (p=0.154) respectively. With the median follow-up of 27.4 months, 15.5% of patients in arm A and 10.8% in arm B experienced recurrences (p=0.123). There were no significant differences of overall or loco-regional failure. However, systemic recurrences were significantly lower in arm B than arm A: 5.4% vs. 10.1% (p=0.029). The 3-year progression-free survival (PFS) and 3-year overall survival (OS) of the patients in both arms were not significantly different. The hazard ratio of PFS and OS of arm B compared to arm A were 1.26 (95% CI=0.82–1.96; p=0.293) and 1.42 (95% CI=0.81–2.49; p=0.221) respectively. CONCLUSIONS: ACT with paclitaxel plus carboplatin after CCRT did not improve response rate and survival compared to CCRT alone. Only significant decrease of systemic recurrences with ACT was observed, but not overall or loco-regional failure. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02036164 Thai Clinical Trials Registry Identifier: TCTR 20140106001

Comparing treatment outcomes of stage IIIB cervical cancer patients between those with and without lower third of vaginal invasion / 부인종양

OBJECTIVE: To evaluate treatment outcomes between stage IIIB cervical cancer with and without lower third of vaginal invasion (LTI) in terms of response to treatment and overall survival (OS). METHODS: Matching one patient with LTI for 2 patients without LTI who had completed treatment between 1995 and 2012 were conducted by using treatment modalities (radiation therapy [RT] alone vs. concurrent chemoradiation therapy [CCRT]) and tumor histology (squamous cell carcinoma [SCC] vs. adenocarcinoma [ADC]). Treatment outcomes including complete response (CR) rate of RT/CCRT, patterns of treatment failure and survival outcomes were analyzed. RESULTS: Of 216 stage IIIB cervical cancer patients, 114 of them had no LTI and 72 had LTI. Most of the patients (83.8%) had tumor histology as SCC. The CR rates between stage IIIB without LTI and with LTI were 93.8% and 81.9% (p=0.009), and corresponding with disease progression at pelvis accounted for 18.2% and 34.4% (p=0.017), respectively. Distant metastasis was comparable between 2 groups of patients, 28.9% in patients without LTI and 29.5% in patients with LTI (p=0.988). The 2-year and 5-year OS of stage IIIB without LTI were 66.5% and 46.8% compared to stage IIIB with LTI which were 43.1% and 28.9% (p=0.004), respectively. For multivariable analysis, stage IIIB with LTI was only the influential factor on OS with hazard ratio (HR) of 1.63 (p=0.012) CONCLUSION: Stage IIIB cervical cancer patients with LTI have poorer treatment outcomes including response to treatment and survival outcomes than patients in the same stage without LTI.

Cost-utility analysis of treatments for stage IB cervical cancer / 부인종양

OBJECTIVE: To analyze the cost-utility of two common clinical practices for stage IB cervical cancer patients from provider and societal viewpoints. METHODS: A decision tree model was conducted to examine value for expenditure between the following: (1) radical hysterectomy with pelvic lymph node dissection (RHPLND) with or without postoperative adjuvant therapy according to the risk of recurrence and (2) concurrent chemoradiotherapy (CCRT). The relevant studies were identified to extract the probability data, and meta-analysis was performed. Direct medical costs were estimated from hospital database and medical records review. Direct non-medical costs and utility parameters were obtained through interviews with patients to estimate quality-adjusted life years (QALYs) outcome. The time horizon was according to the life expectancy of Thai women. RESULTS: From provider viewpoint, RHPLND and CCRT resulted in approximate costs of US $5,281 and US $5,218, respectively. The corresponding costs from societal viewpoint were US $6,533 and US $6,335, respectively. QALYs were 16.40 years for RHPLND and 15.94 years for CCRT. The estimated incremental cost effectiveness ratio of RHPLND in comparison to CCRT from provider and societal viewpoints were US $100/QALY and US $430/QALY, respectively. RHPLND had more cost-effectiveness than CCRT if patients did not need adjuvant therapy. The most effective parameter in model was a direct medical cost of CCRT. At the current ceiling ratio in Thailand, RHPLND provides better value for money than CCRT, with a probability of 75%. CONCLUSION: RHPLND is an efficient treatment for stage IB cervical cancer. This advantage is only for patients who require no adjuvant treatment.

Computed Tomography Evaluation of Paraaortic Lymph Nodes in Locally Advanced Cervical Cancer

Abstract Computed Tomography Evaluation of Paraaortic Lymph Nodes in Locally Advanced Cervical Cancer Kanyarat              Katanyoo               MD* Arcom                   Rangtaid                MD** Marisa                   Jongthanakorn     MD* Thanatip               Tantivattana         MD* * Radiation Oncology Section, Department of Radiology, BMA Medical College and Vajira Hospital ** Diagnostic Radiology Section, Department of Radiology, BMA Medical College and Vajira Hospital Objectives: To evaluate paraaortic lymph node metastatic rate in locally advanced cervical cancer by computed tomography and outcomes of treatment in the patients with paraaortic lymph nodes metastasis. Study design: Descriptive study. Subjects: All 81 patients with locally advanced cervical cancer (IIB-IVA) who were evaluated by computed tomography of whole abdomen and treated at BMA Medical College and Vajira Hospital between January 2006 - June 2008. Methods: Medical records of the patients including radiation oncology records, out-patient charts and computerized database of the institution were reviewed. Patients' age, histologic type and size of tumor, stage, computed tomography of whole abdomen reports, type of radiation therapy and results of treatment were recorded. Main outcome measures: Paraaortic lymph node metastatic rate by computed tomography, 1-year and 2-year survival rate. Results: Mean age of 81 patients was 54.5 + 10.8 years. Histopathology of cervical cancer were squamous cell carcinoma in 82.7% and adenocarcinoma in 17.3%. Clinical stage of diseases were stage IIB and IIIB in 51.9% and 48.1% respectively. Rate of paraaortic lymph node metastasis by computed tomography was 4.9%. Patients who did not have evidence of paraaortic lymph node metastasis had higher survival rate than the patients who had evidence of paraaortic lymph node metastasis with the 1-and 2-year survival rates of 93.3% and 80.4% compared to 75.0% and 0% respectively (p-value = 0.001). Conclusion: The rate of paraaortic lymph node metastasis by computed tomography of whole abdomen was 4.9%. Overall 1-and 2-year survival rates of these patients were 75.0% and 0 % respectively. Key words: cervical cancer, advanced, computed tomography, paraaortic lymph nodes metastasis, survival rate   Vajira Med J 2009 ; 54 : 33 - 40  

Treatment Outcomes of Radiation Therapy for Locally Advanced Cervical Cancer

Abstract Treatment Outcomes of Radiation Therapy for Locally Advanced Cervical Cancer Thanatip     Tantivattana        MD Kanyarat    Katanyoo             MD Marisa        Jongthanakorn    MD Radiation Oncology Section, Department of Radiology, BMA Medical College and Vajira Hospital Objective: To study the results of radiation therapy in locally advanced cervical cancer (IIB-IVA) in terms of 2- and 5- year survival rates. Prognostic factors and complications of radiation therapy were also evaluated. Study design: Descriptive study. Subjects: A total of 420 patients with locally advanced cervical cancer (IIB-IVA), who were treated by radiation with or without concurrent chemotherapy at Radiation Oncology section, BMA Medical College and Vajira Hospital between January 1998 and December 2005. Methods: Medical records of the patients including radiation oncology records, out-patient charts and computerized data base of the institution were reviewed. Patients' age, histologic type, size of tumor, stage, computed tomography of whole abdomen results, anemia during treatment, types of radiation therapy, complications and results of treatment were recorded. Main outcome measures: Overall 2-and 5-year survival rates. Results: Mean age of 420 patients was 51.8 ± 11.7 years. Cervical cancer histopathology were squamous cell carcinoma in 78.8%, while the rest were adenocarcinoma or adenosquamous cell carcinoma. Clinical stage of diseases were stage IIB 51.4%, IIIA 1.0%, IIIB 45.0% and IVA 2.6%. The overall 2-and 5-year survival rates for all patients were 78.4% and 64.8% respectively. The only significant prognostic factor associated with survival rate from multivariable analysis was tumor stage. Patients in stage IIB had higher survival rate than the patients in stage III (IIIA and IIIB) and IVA with the 5-year survival rate of 72.2%, 56.2% and 47.0% respectively (p-value = 0.001). The late complication of bowel and bladder grade 3-4 were 4.1% and 0.7% respectively. Conclusion: The overall 2- and 5-year survival rates of patients with locally advanced cervical cancer treated with radiation therapy were 78.4% and 64.8% respectively. Tumor stage was the only significant prognostic factor for survival. Vajira Med J 2009 ; 53 : 121-129

Prevalence of Malnutrition in New Cancer Patients at Radiation Oncology Unit, BMA Medical College and Vajira Hospital

Abstract   Prevalence of Malnutrition in New Cancer Patients at Radiation Oncology Unit, BMA Medical College and Vajira Hospital   Kanyarat    Katanyoo               MD Marisa        Jongthanakorn      MD Thanatip     Tantivattana        MD   Department of Radiology, BMA Medical College and Vajira Hospital   Objective: To evaluate the prevalence of malnutrition and its associating factors in new cancer patients at Radiation Oncology unit, BMA Medical College and Vajira Hospital.   Study design: Descriptive study.   Subjects: One hundred and six new cancer patients at Radiation Oncology unit, BMA Medical College and Vajira Hospital during May and July 2008 were enrolled.   Methods: Data including sex, types and stages of cancer, previous treatment, febrile status, serum albumin level, percentage of blood lymphocyte and other symptoms which may be associated with malnutrition were recorded. The nutritional status was evaluated using the nutritional screening questionnaire which consisted of data on body mass index, performance status, quantity of food intake and presence of co-morbidity or other treatments.   Main outcome measures: Prevalence of malnutrition in new cancer patients. Results: Out of 106 new cancer patients, 21.7% had malnutrition. The five most common cancers associated with malnutrition were cancers of hepatobiliary system, esophagus, male genitourinary tract, pancreas and head and neck. Factors which significantly associated with the nutritional status were sex, types and stages of cancer. Male and female cancer patients had malnutrition in 35.4% and 10.3% respectively. Malnutrition in early, locally advanced and metastatic stage were 0%, 15.9% and 50.0% respectively. Other factors associated with malnutrition were low serum albumin level and low percentage of blood lymphocyte, in which malnutrition were found in 40.4% and 42.9% respectively. Symptoms of mucositis, taste and food aversion, anorexia, fatigue, pain and dyspnea were also associated with malnutrition in new cancer patients. Conclusion: The prevalence of malnutrition in new cancer patients was 21.7%. Sex, types, stages of cancer, serum albumin level, percentage of blood lymphocyte, mucositis, taste and food aversion, anorexia, fatigue, pain and dyspnea were associated with malnutrition. Vajira Med J 2009 ; 53 : 59 - 67