Various substitutes of brachytherapy boost after neoadjuvant chemoradiation for locally advanced cervical cancer. Literature Review

Abstract

Objective: Concurrent chemoradiotherapy (CCRT) is widely regarded as the gold standard for locally advanced cervical cancer (LACC). Radio Therapy encompasses pelvic external beam radiation therapy (EBRT), followed by intracavitary brachy therapy (BT) to boost the cervix. However, in developing countries, there is a tendency to prefer surgery over other types of treatments for several reasons - surgery is easily obtainable, more acceptable, and understandable culturally. On the other hand, in developed countries, The utilization of brachy therapy (BT) to boost the cervix in patients with Cervical Cancer (CC) has been gradually declined because of the advent of sophisticated techniques for EBRT. Recently, the treatment of LACC has been a point of controversy. We have no prospective data to justify that surgery or modern EBRT can be used in place of intracavitary BT boost in women with locally advanced CC. This study aims to review existing information about brachytherapy alternatives after neoadjuvant chemoradiation. Material and Methods: An electronic search of the PubMed database was conducted to obtain key cervical cancer literature. The MEDLINE/PubMED (www.ncbi.nlm.nih.gov) database was chosen as it remains the most widely used resource for medical literature. Additional records were searched in other resources. Results: The first phase of screening identified 18 articles for the first search term (“Adjuvant hysterectomy” AND “Cervical Cancer”), 10 article for the second search term (“IMRT boost” AND Cervical cancer”) and 11 articles for the third search term (“SBRT” AND “Cervical Cancer”). In sum 39 articles were identified to be relevant for the second phase of screening. Studies that included less than five patients with investigated intervention or did not provided enough information about at least one primary endpoint were excluded. A total of 20 (11-adjuvant hysterectomy, 4-IMRT boost, 5-SBRT boost) papers met the selection criteria and were found eligible for this review.  Conclusion: When all these alternative approaches to ICB are evaluated, adjuvant hysterectomy appears to have treatment outcomes comparable to standard of care, while SBRT appears to have only modest yearly results. As a result, the majority of writers believe that neoadjuvant chemoradiation followed by radical surgery or SBRT may be a realistic therapeutic option for patients with LACC, not merely when ICB is unavailable, technically impractical, or rejected. Large, randomized-controlled trials are required to conclusively demonstrate or invalidate non-ICB alternatives for cervical cancer treatment.