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Treatment of locally advanced cervical cancer patients includes chemoradiation followed by brachytherapy. Our aim is to develop a delta radiomics (DRF) model from MRI-based brachytherapy treatment and assess its association with progression free survival (PFS). A retrospective analysis of FIGO stage IB- IV cervical cancer patients between 2012 and 2018 who were treated with definitive chemoradiation followed by MRI-based intracavitary brachytherapy was performed. Clinical factors together with 18 radiomic features extracted from different radiomics matrices were analyzed. The delta radiomic features (DRFs) were extracted from MRI on the first and last brachytherapy fractions. Support Vector Machine (SVM) models were fitted to combinations of 2–3 DRFs found significant after Spearman correlation and Wilcoxon rank sum test statistics. Additional models were tested that included clinical factors together with DRFs. A total of 39 patients were included in the analysis with a median patient age of 52 years. Progression occurred in 20% of patients (8/39). The significant DRFs using two DRF feature combinations was a model using auto correlation (AC) and sum variance (SV). The best performing three feature model combined mean, AC & SV. Additionally, the inclusion of FIGO stages with the 2- and 3 DRF combination model(s) improved performance compared to models with only DRFs. However, all the clinical factor + DRF models were not significantly different from one another (all AUCs were 0.77). Our study shows promising evidence that radiomics metrics are associated with progression free survival in cervical cancer. [ABSTRACT FROM AUTHOR]

Brachytherapy irradiation carries risks of both bleeding and venous thromboembolism (VTE). No screening or management recommendations for VTE in this setting have been developed. Our study aims to understand the incidence of VTE, compile published anticoagulation guidelines, and call for future guidelines to address thromboprophylaxis in this population. A retrospective, single institution study of patients undergoing brachytherapy irradiation between 2012 and 2022 was undertaken. We analyzed 2 cohorts: 87 patients undergoing brachytherapy with an inpatient admission, and 66 patients assessed for risk of VTE or bleeding after discharge from an inpatient admission for brachytherapy. Caprini risk scores were calculated for each patient, and statistical analyses were performed. Eighty-seven patients were included, and 25% had a VTE diagnosis. Forty-seven (54%) of patients included underwent brachytherapy as definitive treatment of cervical cancer, and 16 (18%) received brachytherapy irradiation to treat recurrent endometrial cancer. In the cohort of 66 patients assessed for risk of VTE or bleeding after brachytherapy discharge, 23 (34.8%) were discharged with thromboprophylaxis, and 43 (65.2%) were discharged without thromboprophylaxis. None of the patients discharged on thromboprophylaxis were diagnosed with a VTE within 90 days of discharge after brachytherapy, whereas 3 of 43 (7%) discharged without thromboprophylaxis were diagnosed with a VTE, OR and 95% CI: 0.25 (0.01–5.29), p = 0.37. Of the 23 patients discharged on thromboprophylaxis, 1 was readmitted for bleeding OR and 95% CI: 5.8 (0.22–155.18), p = 0.29. The median Caprini score was 11. VTE is a common occurrence in patients undergoing brachytherapy. Patients undergoing brachytherapy irradiation who require inpatient admission represent a unique population, and specialty organizations should develop consensus recommendations to address these clinical challenges. [ABSTRACT FROM AUTHOR]

Brachytherapy is an essential component of the cervical cancer treatment paradigm as it contributes to improved clinical outcomes and overall survival. Yet brachytherapy remains globally underutilized, with disparities in access at both national and international levels. The review explores current brachytherapy utilization practices and efforts being undertaken to address barriers to implementation in low-, middle-, and high-income countries, and how these efforts are projected to impact future brachytherapy access. The content presented is based on a review of published literature and the authors' collective clinical experiences. There exists a tremendous opportunity to expand access to essential brachytherapy services for women with cervical cancer. Many national and international brachytherapy efforts exist; yet it remains imperative that such focused efforts continue to grow and provide further access to this critical treatment modality for women in need worldwide. [ABSTRACT FROM AUTHOR]

Abstract Purpose Concurrent chemoradiotherapy and brachytherapy is the standard of care for locally advanced cervical cancer. Brachytherapy is an integral part of treatment and has improved overall survival. Research is needed to ascertain the planning modalities and schedules to best use resources and optimize treatment time course. We hypothesized that MRI-based brachytherapy when delivered with the described regimen would not prolong, and potentially shorten, overall treatment time as compared with CT-based brachytherapy. Methods and Materials This study was a single-institution retrospective review within the years 2008 through 2018. Patients with cervical cancer of any stage who underwent definitive chemoradiotherapy and either CT- or MRI-based brachytherapy were included. The primary outcome variable for this study was time (in days). Overall treatment time was defined as the number of days from the first until the last day of radiotherapy. Univariate analysis was performed using Stata statistical software. Results External beam radiotherapy doses were generally 45–50.4 Gy. CT-based and MRI-based brachytherapy were performed in 55 and 49 patients, respectively. The median treatment time for brachytherapy with CT-based planning was 19.0 days and with MRI-based planning was 9.0 days (p < 0.001). The median treatment time for total radiation therapy with CT-based planning was 53 days, and with MRI-based planning was 50 days (p = 0.781). Conclusions This study found that MRI-based brachytherapy, when performed with the proposed regimen, did not prolong overall treatment time and significantly decreased time to complete brachytherapy in comparison with CT-based brachytherapy on nonconsecutive days. This regimen favorably impacts timely completion of treatment and uses MRI resources well within the construct of our institution. [ABSTRACT FROM AUTHOR]

Purpose: While Ir-192 remains the mainstay isotope for gynecologic high-dose-rate (HDR) brachytherapy in the U.S., Co-60 is used abroad. Co-60 has a longer half-life than Ir-192, which may lead to long-term cost savings; however, its higher energy requires greater shielding. This study analyzes Co-60 acceptability based on a one-time expense of additional shielding and reports the financial experience of Co-60 in Peru’s National Cancer Institute, which uses both isotopes. Material and methods: A nationwide survey was undertaken assessing physician knowledge of Co-60 and willingness-to-pay (WTP) for additional shielding, assuming a source more cost-effective than Ir-192 was available. With 440 respondents, 280 clinicians were decision-makers and provided WTPs, with results previously reported. After completing a shielding report, we estimated costs for shielding expansion, noting acceptability to decision makers’ WTP. Using activity-based costing, we note the Peruvian fiscal experience. Results: Shielding estimates ranged from $173,000 to $418,000. The percentage of respondents accepting high-density modular or lead shielding (for union and non-union settings) were 17.5%, 11.4%, 3.9%, and 3.2%, respectively. Shielding acceptance was associated with greater number of radiation oncologists in a respondent’s department but not time in practice or the American Brachytherapy Society membership. Peru’s experience noted cost savings with Co-60 of $52,400 annually. Conclusions: By comparing the cost of additional shielding for a sample institution’s HDR suite with radiation oncologists’ WTP, this multi-institutional collaboration noted < 20% of clinicians would accept additional shielding. Despite low acceptability in the US, Co-60 demonstrates cost-favorability in Peru and may similarly in other locations. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the survival endpoints in women with International Federation of Gynecology and Obstetrics (FIGO) stage II endometrial cancer who received adjuvant vaginal brachytherapy (VBT) alone using multi-institutional pooled data.Methods and Materials: We performed a multi-institutional analysis of surgically staged patients with FIGO stage II endometrioid-type endometrial cancer treated with VBT alone. Patient, tumor, and treatment characteristics were collected and analyzed. Univariable and multivariable frailty survival models were performed to assess clinicopathologic risk factors for recurrence and death.Results: One hundred six patients were included (92 VBT alone and 14 VBT with chemotherapy) with median follow-up of 39.0 months. Pelvic node dissection was performed in 89.6% of patients. One hundred four patients (98.1%) and 2 patients (1.9%) had microscopic and macroscopic cervical stromal invasion, respectively. Grade 1 or 2 disease occurred in 88.6% of patients. For patients treated with VBT without chemotherapy, the 5-year estimates of vaginal failure, pelvic nodal failure, and distant metastases were 2.6%, 4.2%, and 7.2%, respectively. Five-year progression-free survival and overall survival were 74.0% and 76.2%, respectively. On univariable and multivariable models for progression-free survival, increasing age and lack of pelvic node resection were hazardous (P < .05).Conclusions: Vaginal and pelvic failure rates were low in this selected population of stage II patients receiving adjuvant VBT without external beam radiation therapy. It is reasonable to consider adjuvant VBT alone in selected patients with grade 1 or 2 disease and microscopic cervical stromal invasion who underwent pelvic lymphadenectomy. [ABSTRACT FROM AUTHOR]

Definitive treatment for patients diagnosed with locally advanced cervical cancer includes chemoradiation and image-based brachytherapy. This requires significant multidisciplinary and intradepartmental coordination. Our goal was to assess and share gynecologic brachytherapy best practices from high volume brachytherapy centers within the United States and Canada. A brachytherapy best practices survey was developed using our institution's Qualtrics software. The survey was sent to 42 centers that perform a high volume of complex gynecologic brachytherapy procedures. Complex brachytherapy was defined as non-vaginal cylinder intracavitary and interstitial brachytherapy. Data was analyzed and descriptive statistics were performed using Excel. Responses were collected from 32/42 (76%) institutions. 41% of responding institutions perform >100 complex brachytherapy procedures per year, 26% perform 51-100, 29% perform 11-50 and 3% perform 1-10. 97% of surveyed centers receive 25-75% of their complex brachytherapy patients as referrals from an in-network satellite or out of network facility. External beam plan acquisition from referring institutions was viewed as important but difficult to consistently coordinate. Most departments have >1 brachytherapist performing procedures. 85% of respondents complete 1-2 complex brachytherapy procedures per day, 59% complete all their own cases and 59% perform complex brachytherapy procedures 2 days per week. The majority have specified days of the week that are devoted to brachytherapy (65%), though most respondents see patients in clinic on their procedure days (74%). 91% of departments have dedicated nurses, physicists, and other staff devoted to brachytherapy, which is pivotal for a successful program. Scheduling includes a combination of brachytherapy coordinators (33%), nursing staff (20%), department schedulers (20%), physicians (16%), and advanced practice practitioners (7%), and requires physicians to enter orders for each procedure. Respondents spend a median of 30 minutes on scheduling per week. 56% of tandem-based intracavitary procedures and 52% of interstitial hybrid procedures take place in a brachytherapy suite within a department while 50% of interstitial template procedures take place in an operating room. Surveyed institutions use MRI (35%), CT (24%) or a combination (24%) for treatment planning. 88% of respondents use sedation for tandem based procedures which include general (28%), MAC (23%), epidural/spinal (15%), oral medication (11%) and paracervical block (5%). Coordination with Anesthesiology and Gyn Onc is variably approached but an essential component of a successful program. Respondents cite high complexity of care, insufficient reimbursement, untimely referrals from external beam radiation oncologists, shared operative and clinical duties, expensive applicator acquisition and complex scheduling as the most challenging aspects of providing brachytherapy services. Conversely, respondents cite a dedicated team, a departmental brachytherapy suite, well organized coordination of procedures and personnel, anesthesia support, a full range of applicators, image-based planning near the department and supportive administration as integral components in providing high volume complex brachytherapy. Most institutions performing a high volume of complex gynecologic brachytherapy have >1 brachytherapist who perform 1-2 procedures per day and a dedicated brachytherapy space and team that assists with coordination and scheduling efforts. A well supported multidisciplinary team is vital to ensure state of the art brachytherapy which is essential in curing these challenging malignancies. [ABSTRACT FROM AUTHOR]

Objectives: There are significant disparities in access to care and treatment among cervical cancer patients. Less than half of patients with locally advanced cervical cancer receive the standard of care therapy consisting of concurrent chemoradiation, followed by brachytherapy, despite significantly improved overall survival based on an analysis of the National Cancer Database. The recommended time to complete radiation therapy in advanced cervical cancer patients is < 56 days, with both pelvic control and survival decreasing when the duration of treatment is lengthened. This study explored the relationship between social vulnerability and clinical variables, including radiation treatment duration in cervical cancer patients undergoing definitive chemoradiation, including brachytherapy over a nine-year period at a single institution. Methods: By querying a cohort discovery tool, data were obtained from 108 patients with cervical cancer from 2012 to 2021 who received brachytherapy in addition to external beam radiation. Patients' census tracts were matched to indices from the Centers for Disease Control's (CDC) Social Vulnerability Index (SVI). The SVI rankings range from least vulnerable, 0, to most vulnerable, 1, for four themes: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Clinical data, such as stage, histology, and demographic factors, were investigated. Results were analyzed using the Kruskal-Wallis rank-sum test Fisher's exact test, and Spearman's correlation. Results: Of patients included, 69% were Caucasian, 20% African American, 6.5% Hispanic, 1.9% Asian, and 1.9% American Indian/ Alaskan Native. The median SVI value when comparing patients to all census tracts in the United States was 0.43 (range: 0.0001-0.9907) in this population. Median SVI values suggested that African American patients were most vulnerable with an SVI of 0.86 (Interquartile Range [IQR]: 0.77-0.94), followed by Hispanic 0.59 (IQR: 0.46-0.79), American Indian or Alaska Native 0.56 (IQR: 0.43-0.69), Asian 0.33 (IQR: 0.22-0.44), and Caucasian 0.31 (IQR: 0.11-0.53) (p <0.001). Using 2018 FIGO staging, 58% of patients were stage III. Stage IV patients had the highest social vulnerability (0.77, IQR: 0.6-0.9). In a subset analysis of radiation treatment duration, the median time from start to end of radiation was 53 days (range: 35-127 days). There was no significant difference in length of time of radiation treatment by race (p=0.3) or stage (p>0.9). There was no relationship between SVI and radiation treatment duration (Rs =0.1). Conclusions: While social vulnerability appears to impact cervical cancer patients in regards to race and stage, increased social vulnerability was not associated with increased radiation treatment duration. Other factors, such as time to diagnosis, initiation of treatment, or accessibility to follow-up, may be more reflective of social vulnerability than treatment duration when a committed team works to mitigate obstacles to care during the course of radiation. [ABSTRACT FROM AUTHOR]

Purpose: To provide an update of the 2007 American brachytherapy survey on image-based brachytherapy, which showed that in the setting of treatment planning for gynecologic brachytherapy, although computed tomography (CT) was often used for treatment planning, most brachytherapists used point A for dose specification.Methods and Materials: A 45-question electronic survey on cervical cancer brachytherapy practice patterns was sent to all American Brachytherapy Society members and additional radiation oncologists and physicists based in the United States between January and September 2014. Responses from the 2007 survey and the present survey were compared using the χ(2) test.Results: There were 370 respondents. Of those, only respondents, not in training, who treat more than 1 cervical cancer patient per year and practice in the United States, were included in the analysis (219). For dose specification to the target (cervix and tumor), 95% always use CT, and 34% always use MRI. However, 46% use point A only for dose specification to the target. There was a lot of variation in parameters used for dose evaluation of target volume and normal tissues. Compared with the 2007 survey, use of MRI has increased from 2% to 34% (P<.0001) for dose specification to the target. Use of volume-based dose delineation to the target has increased from 14% to 52% (P<.0001).Conclusion: Although use of image-based brachytherapy has increased in the United States since the 2007 survey, there is room for further growth, particularly with the use of MRI. This increase may be in part due to educational initiatives. However, there is still significant heterogeneity in brachytherapy practice in the United States, and future efforts should be geared toward standardizing treatment. [ABSTRACT FROM AUTHOR]

Purpose Report current practice patterns for postoperative endometrial cancer emphasizing vaginal brachytherapy (VBT). Methods and Materials A 38-item survey was e-mailed to 1,598 American Brachytherapy Society (ABS) members and 4,329 US radiation oncologists in 2014 totaling 5,710 recipients. Responses of practitioners who had delivered VBT in the previous 12 months were included in the analysis. Responses were tabulated to determine relative frequency distributions. χ 2 analysis was used to compare current results with those from the 2003 ABS survey. Results A total of 331 respondents initiated the VBT survey, of whom 289 (87.3%) administered VBT in the prior 12 months. Lymph node dissection and number of nodes removed influenced treatment decisions for 90.5% and 69.8%, respectively. High-dose-rate was used by 96.2%. The most common vaginal length treated was 4 cm (31.0%). Three-dimensional planning was used by 83.2% with 73.4% of those for the first fraction only. Doses to normal tissues were reported by 79.8%. About half optimized to the location of dose specification and/or normal tissues. As monotherapy, the most common prescriptions were 7 Gy for three fractions to 0.5-cm depth and 6 Gy for five fractions to the surface. As a boost, the most common prescriptions were 5 Gy for three fractions to 0.5-cm depth and 6 Gy for three fractions to the vaginal surface. Optimization points were placed at the apex and lateral vagina by 73.1%. Secondary quality assurance checks were performed by 98.9%. Conclusions VBT is a common adjuvant therapy for endometrial cancer patients, most commonly with HDR. Fractionation and planning processes are variable but generally align with ABS recommendations. [ABSTRACT FROM AUTHOR]