External beam radiotherapy for cervical cancer with Cobalt-60 in Ethiopia

Cervical cancer is the second most commonly diagnosed cancer among females in Ethiopia. Data on outcome of radiotherapy for cervical cancer patients in Ethiopia and other parts of sub-Saharan Africa are limited. In Ethiopia, radiotherapy is only available at the University Hospital in Addis Ababa. The purpose of this study is to describe the current practice of radiotherapy for cervical cancer patients at the Radiotherapy Center of Tikur Anbessa Hospital and analyse overall survival of cervical cancer patients according to whether they completed or discontinued radiotherapy. This unicentric cohort study reports on retrospectively analysed data of all patients diagnosed with cervical cancer by biopsy and treated with radiotherapy 2008-2012 at Tikur Anbessa Hospital, Addis Ababa. Brachytherapy was not available, therefore all patients received external beam radiotherapy by Cobalt-60 according to guidelines based on stage of FIGO. Data on adverse e ects and survival were obtained from clinical records and telephone interviews. The multivariate Cox proportional hazards regression was used to estimate hazard ratios. Adjustment was done for total dose of radiotherapy, HIV status, estimated glomerular ltration rate, ECOG score and grade of anemia. Within the framework of this study, the o cal translation of the EORTC Quality of Life questionnaires for cervical cancer patients into the Amharic language was conducted. Out of 1009 cases, 788 patients were scheduled for radiotherapy according to guidelines. Adverse e ects were common (e.g., proctitis and incontinence in 29% and 22% respectively). After guidelineconform assignment, patients, who completed radiation treatment had better outcome than those, who discontinued. One-year overall survival after radical radiotherapy (n=180) for FIGO stage IIA-IIIA was 89% and 96% (hazard ratio 1.3, 95% con dence interval 0.5-3.3) for discontinuation (<72 Gy) and completion (≥72 Gy) respectively. One-year overall survival after non-radical radiotherapy (n=389) for FIGO stage IIIB and IVA was 71% if discontinued compared to 88% after minimum recommended dose of 44 Gy (hazard ratio 3, 95% con dence interval 1.4-6.7). One-year overall survival after monthly single fractions of 10 Gy for FIGO IVB (n=219) was 14% after 1 and 76% after 2 single fractions (hazard ratio 5.4, 95% con dence interval 1.8-16). This study provides the rst data on outcome of cervical cancer patients after receiving radiotherapy in Ethiopia. Completion of guideline-conform radiotherapy resulted in more favourable OS. This may re ect a true dose-e ect or, possibly, a selection of tter patients, who did not discontinue radiotherapy due to less aggressive tumours. Better supportive care, higher adherence to protocols, radical radiotherapy for patients staged FIGO IIIB and IVA, brachytherapy services, a second radiotherapy machine to secure availability and socioeconomic support would probably add lifetime to the patients. Further research on Quality of Life of cervical cancer patients treated with radiotherapy in Ethiopia is necessary. The respective questionnaires are now available in Amharic language. Mölle, Ulrike: External beam radiotherapy for cervical cancer with Cobalt-60 in Ethiopia Adherence to therapy, adverse e ects and overall survival of 1009 patients 2008-2012, Halle (Saale), University, Faculty of Medicine, Dissertation (2016), pp. 1-80