Chemoradiation in Stage IIIB Cancer of the Uterine Cervix: A Review of the Zimbabwean Experience

Abstract

Purpose: Cervical cancer remains the leading cause of cancer morbidity and mortality among Zimbabwean women. Many patients present with stage IIIB disease. Although definitive concurrent chemoradiation (CCRT) is the standard of care, there is a paucity of data on the effect(s) of this intervention in resource-constrained and high HIV-prevalence settings. We investigated the differences in CCRT initiation practices, tolerability, and outcomes in this group.

Patients and methods: We performed a retrospective analysis of data from hospital records for patients with stage IIIB disease who were treated over a 2-year period at Parirenyatwa Group of Hospitals. Outcome measures were documented treatment-related adverse events and early clinical tumor response.

Results: One hundred twenty-eight (37%) of 346 patients received CCRT, and 65 (51%) of 128 patients were infected with HIV. CCRT was prescribed mostly in patients with less extensive disease-not involving lower third vaginal walls, minimal pelvic sidewall involvement (P = .002), and higher CD4⁺ count (P = .02). Eighteen percent of recorded adverse events were high grade (≥ 3). One patient did not complete treatment, and 68.5% achieved complete clinical tumor response at 3 months post-CCRT. A higher proportion of complete clinical tumor response was noted in those patients who were young, HIV uninfected, had less extensive disease, CD4⁺ of 500 cells/mm³ or greater, received four or more cycles of chemotherapy, received brachytherapy, and had no treatment breaks.

Conclusion: The study revealed that the use of CCRT to treat stage IIIB cervical cancer is low in Zimbabwe. Although several factors contribute, low CCRT uptake is mostly attributed to financial barriers. Well-selected patients tolerate the treatment and have good early clinical tumor response as expected. The role of CCRT for this patient group (and methods to make it available in resource-limited settings) must be further evaluated.

FIG 1

All consecutive records for patients with cervical cancer seen at Parirenyatwa Radiotherapy Centre during the study period were reviewed and stage IIIB cases were identified for analysis according to the eligibility criteria. Analysis for treatment tolerability and clinical tumor outcome was performed on patients who received definitive platinum-based concurrent chemoradiation, stratified by HIV status (n = 128).

FIG 2

HIV-infected patients who received definitive chemoradiation for stage IIIB cervical cancer had a mean CD4⁺ count of 526 cells/mm³ (± 233 cells/mm³ standard deviation) and a median of 534 cells/mm³ (range, 155-1,099 cells/mm³). This was higher than in patients who received radiotherapy only. The difference in the means of baseline CD4⁺ was statistically significant (P = .02).

FIG 3

Weekly mean creatinine clearance at week 6 decreased by an average of 12.5% from the pretreatment value in patients with stage IIIB cervical cancer without hydronephrosis who received definitive chemoradiation. The decrease was doubled in the group of patients with hydronephrosis.

FIG 4

Renal function was maintained at the pretreatment value until week 3 on definitive chemoradiation in patients with stage IIIB cervical cancer with unilateral hydronephrosis, decreasing by 25% at week 6. Marked fluctuations in the weekly mean creatinine clearance (CrCl) was noted in patients with bilateral hydronephrosis; the decrease at week 6 remained at the same level as with patients with unilateral hydronephrosis (n = 55).