Disparities in Standard of Care Treatment and Associated Survival Decrement in Patients With Locally Advanced Cervical Cancer

Brachytherapy has been shown to increase survival in patients with cervical cancer when added to external beam radiation. Standard of care (SOC) treatment for locally advanced cervical cancer includes concurrent chemotherapy with external beam radiation therapy (EBRT) plus brachytherapy. The American Brachytherapy Society has recommended that all patients being treated with radiation for cervical cancer should receive brachytherapy as a component of their care (unless there is a contraindication). In recent years, however, use of brachytherapy has significantly declined. Large national database studies have shown that patients who receive a brachytherapy boost have superior survival than those receiving ERBT alone. It is unclear, however, whether there is a patient group not receiving a radiotherapy boost at all and, if so, how outcomes in this group compare to those in patients receiving EBRT boosts and brachytherapy boosts. This study examined national utilization trends and factors associated with receiving SOC therapy. The National Cancer Database was used to identify women with locally advanced cervical cancer treated with definitive radiation or chemoradiation therapy; patients were stratified by treatment received. Outcomes were compared for patients receiving SOC treatment with concurrent chemoradiation therapy including brachytherapy and for patients receiving alternate treatment. Multivariate analysis was used to adjust for covariables, including age, race, Charlson-Deyo combined comorbidity score, histology, stage, and chemotherapy. A total of 15,194 patients with cervical cancer diagnosed between 2004 and 2012were identified. Only 44.3% (n = 6724) of patients received full SOC treatment (with EBRT, chemotherapy, and brachytherapy); this group had significantly improved overall survival. An increased likelihood of receiving SOC was associated with high volume centers, academic centers, comprehensive community cancer centers, private insurance, and higher income, whereas black patients were less likely to receive SOC. Twenty-seven percent of patients received no radiation boost, 24% received an EBRT boost only, and 49.5% received EBRT with brachytherapy. Multivariate analysis showed that although an EBRT boost improved overall survival compared with no boost at all (adjusted hazards ratio, 0.720; P < 0.001), survival was superior in patients receiving brachytherapy (adjusted hazards ratio, 0.554; P < 0.001). Patients more likely to receive no radiotherapy boost were black, had lower incomes, Medicaid, were treated at low volume centers, or were treated at noncomprehensive community cancer centers. These findings show a significant survival advantage for patients with locally advanced cervical cancer who receive SOC therapy; however, less than half of these patients receive this treatment. The survival decrement from lack of brachytherapy as a component of definitive care cannot be made up by the addition of chemotherapy or sophisticated EBRT techniques (including intensity modulated radiation therapy or stereotactic body radiation therapy).