Vaginal Toxicity Management in Patients with Locally Advanced Cervical Cancer following Exclusive Chemoradiation-A Nationwide Survey on Knowledge and Attitudes by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Gynecology Study Group

Abstract

Background and Objective: Exclusive radiotherapy, including external beam radiotherapy (EBRT) and interventional radiotherapy/brachytherapy (IRT/BT), with concurrent cisplatin-based chemotherapy, represents the standard of care in patients with locally advanced cervical cancer (LACC). The emerging topic of vaginal toxicity has become a key endpoint in LACC management, although different approaches and non-standardized procedures were available. Our aim was to analyze a nationwide study of the attitudes of Italian gynecological radiation oncology teams in the management of LACC patients' vaginal toxicities. Methods: A nationwide survey of radiation oncologists specializing in the treatment of gynecological malignancies was performed, using the free SurveyMonkey platform, consisting of 26 items. The questionnaire was proposed by the Italian Association of Radiation Oncologists (AIRO) gynecological working group to all 183 Italian radiation oncology institutions, as per AIRO's website. Results: Fifty-eight questionnaires (31%) were completed and returned. The assessment of acute and late vaginal toxicities was systematic in 32 (55.2%) and 26 (44.8%) centers, respectively. In the case of EBRT, 70.7% of centers, according to the contouring and treatment plan data, did not contour the vagina as an organ at risk (OAR). Vaginal dose constraints were heterogeneous for both EBRT and IRT/BT. Local treatment to prevent vaginal toxicity was prescribed by 60.3% of radiation oncologists, mostly vaginal hyaluronic acid cream, and one center recommended vaginal estrogen preparations. During follow-up visits, vaginal toxicity was considered an issue to be investigated always (n = 31) or in sexually active women only (n = 11). Conclusions: This survey showed that wide variation exists with regard to recording and treating vaginal toxicity after exclusive chemoradiation for cervical cancer, underscoring the need to develop more comprehensive guidelines for contouring e-dose reporting of the vagina, so as to implement clinical approaches for vaginal toxicity.

Keywords: locally advanced cervical cancer; survey; vaginal toxicity.

Figure 1

Distribution of centers (radiation oncologists who are experts in gynecological malignancy management) that completed the survey.

Figure 2

Distribution of the Italian LACC radiation oncology teams who participated in the national survey according to the number of LACC treated per year. The x-axis refers to the number (range) of treated LACC patients per year in the center; the y-axis refers to the center. For instance, the first bar indicates that approximately 80% of centers (y-axis) treats 0–20 LACC patients per year (x-axis).

Figure 3

Distribution of reported acute and late vaginal toxicity. The x-axis refers to the percentage of patients (range) who referred vaginal toxicity; the y-axis refers to the center. For instance, the first two bars indicate that approximately 40% and 60% of centers (y-axis) report up to 20% of patients (x-axis) who experienced acute (dark-gray bar) and late (light-gray bar) vaginal toxicity, respectively.