A retrospective review of outcomes in patients with node-negative stage IB cervical cancer treated with adjuvant standard pelvic field radiation versus small field pelvic field radiation

Objective: A retrospective review was conducted to ascertain whether there are differences in outcome or complications between node-negative patients with stage IB cervical cancer who were treated with adjuvant standard field as opposed to small pelvic field radiotherapy (RT). Study design: A retrospective observational study of patients with stage IB cervical cancer treated with radical surgery between 1984 and 2010 at Groote Schuur Hospital, Cape Town, South Africa. Two different pelvic radiation field sizes were used for adjuvant post-operative RT in node-negative patients during this period: standard whole pelvic fields (WPF), or with reduced-size, "small pelvic field" (SPF) RT since 1991. These two methods reflect changes in protocol over the period of this review. Cisplatin given concurrently with radiation has been used since 1999. Cancer control and grade 3 and 4 toxicities were compared between the two groups. The aim of this study was primarily to examine whether adjuvant SPF RT is a safe approach. A literature review was conducted on the subject of post-operative adjuvant RT, especially in node-negative patients; one aim was to discover how widely the SPF approach is used throughout the world. There was no indication in the literature that this approach has been used elsewhere in South Africa. Results: The SPF technique was first advocated by Prof Neville Hacker in Australia in 1991. The first publication by his group on SPF was in 1999, followed by several subsequent retrospective reports from Asian centers. In the current audit study, 31 patients were found in the WPF group, and 56 in the SPF group. The overall 5-year survival rate was 85%. No significant differences in survival rates were found between the WPF and SPF groups (log rank p=0.67) It was found that relapse patterns did not differ between the two groups and the same applied to the crude grade 3-4 treatment morbidity rates, although two patients in the WPF group (6%) died from their complications. Conclusions: The expected benefit of the SPF approach, which targets the central pelvic tumour bed, is a reduction in small bowel morbidity and lymphoedema. It is not possible to conclude from this study whether the SPF technique is unsafe by increasing out-of-field pelvic relapses, or whether it truly reduces complications. The literature review reveals that most studies of SPF involved relatively few patients and events were infrequent, whether recurrences or morbidity. A randomized controlled trial could theoretically settle this issue but it seems unlikely ever to be performed as a large sample size would be required. Intermittent single institution, or multi-institutional pooled comparisons, with historical WPF controls seem to be the best option

Advancing oncology drug therapies for sub-Saharan Africa.

Cancer incidence is rising across sub-Saharan Africa (SSA), and is often characterized by late-stage presentation, early age of onset and poor survival. While a number of oncology drugs are now improving the length and quality of life for cancer patients in high-income countries, significant disparities in access to a range of oncology therapeutics exist for SSA. A number of challenges to drug access such as drug costs, lack of infrastructure and trained personnel must be urgently addressed to advance oncology therapies for SSA. We present a review of selected oncology drug therapies that are likely to benefit cancer patients with a focus on common malignancies in SSA. We collate available data from seminal clinical trials in high-income countries to highlight the potential for these therapeutics to improve cancer outcomes. In addition, we discuss the need to ensure access to drugs within the WHO Model List of Essential Medicines and highlight therapeutics that require consideration. Available and active oncology clinical trials in the region is tabulated, demonstrating the significant gaps in access to oncology drug trials across much of the region. We issue an urgent call to action to address drug access due to the predicted rise in cancer burden in the region in coming years

Cervical cancer screening in HIV-endemic countries: An urgent call for guideline change

Women living with HIV (WLWH) are at an increased risk of developing HPV-related high grade cervical dysplasia and cervical cancer. Prior World Health Organization (WHO) screening guidelines recommended starting screening at age 30. We assessed characteristics of women diagnosed with cervical cancer to further inform and refine screening guidelines. We prospectively enrolled women diagnosed with cervical cancer from January 2015 to March 2020 at two tertiary hospitals in Gaborone, Botswana. We performed chi-square and ANOVA analyses to evaluate the association between age upon diagnosis and HIV status, CD4 count, viral load, and other sociodemographic and clinical factors. Data were available for 1130 women who were diagnosed with cervical cancer and 69.3% were WLWH. The median age overall was 47.9 (IQR 41.2–59.1), 44.6 IQR: 39.8 – 50.9) among WLWH, and 61.2 (IQR 48.6–69.3) among women living without HIV. There were 1.3% of women aged <30 years old, 19.1% were 30–39 and 37.2% were 40–49. Overall, 20.4% (n = 231) of cancers were in women <40 years. Age of cervical cancer diagnosis is younger in countries with higher HIV prevalence, like Botswana. Approximately 20% of the patients presented with cancer at <40 years of age and would have likely benefited from screening 10 years prior to cancer diagnosis to provide an opportunity for detection and treatment of pre-invasive disease

Vulvar cancer in Botswana in women with and without HIV infection: patterns of treatment and survival outcomes

ObjectivesVulvar cancer is a rare gynecological malignancy. However, the incidence of human papillomavirus (HPV)-associated vulvar disease is increasing, particularly in low- and middle-income countries. HIV infection is associated with an increased risk of HPV-associated vulvar cancer. We evaluated treatment patterns and survival outcomes in a cohort of vulvar cancer patients in Botswana. The primary objective of this study was to determine overall survival and the impact of treatment modality, stage, and HIV status on overall survival.MethodsWomen with vulvar cancer who presented to oncology care in Botswana from January 2015 through August 2019 were prospectively enrolled in this observational cohort study. Demographics, clinical characteristics, treatment, and survival data were collected. Factors associated with survival including age, HIV status, stage, and treatment were evaluated.ResultsOur cohort included 120 women with vulvar cancer. Median age was 42 (IQR 38-47) years. The majority of patients were living with HIV (89%, n=107) that was well-controlled on antiretroviral treatment. Among women with HIV, 54.2% (n=58) were early stage (FIGO stage I/II). In those without HIV, 46.2% (n=6) were early stage (stage I/II). Of the 95 (79%) patients who received treatment, 20.8% (n=25) received surgery, 67.5% (n=81) received radiation therapy, and 24.2% (n=29) received chemotherapy, either alone or in combination. Median follow-up time of all patients was 24.7 (IQR 14.2-39.1) months and 2- year overall survival for all patients was 74%. Multivariate analysis demonstrated improved survival for those who received surgery (HR 0.26; 95% CI 0.08 to 0.86) and poor survival was associated with advanced stage (HR 2.56; 95% CI 1.30 to 5.02). Survival was not associated with HIV status.ConclusionsThe majority of women with vulvar cancer in Botswana are young and living with HIV infection. Just under half of patients present with advanced stage, which was associated with worse survival. Improved survival was seen for those who received surgery

Ensuring Global Access to Cancer Medicines: A Generational Call to Action

Essential cancer treatments are not accessible, affordable, or available to patients who need them in many parts of the world. A new Access to Oncology Medicines (ATOM) Coalition, using public–private partnerships, aims to bring essential cancer medicines and diagnostics to patients in low- and lower middleincome countries

Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting

Delays in care for patients with cervical cancer in Botswana can be benchmarked using a multidisciplinary clinic model

Ensuring Global Access to Cancer Medicines: A Generational Call to Action

International audienceEssential cancer treatments are not accessible, affordable, or available to patients who need them in many parts of the world. A new Access to Oncology Medicines (ATOM) Coalition, using public–private partnerships, aims to bring essential cancer medicines and diagnostics to patients in low-and lower middle-income countries

Stage and outcomes of invasive cervical cancer patients in Botswana: A prospective cohort study from 2013 to 2020

ObjectiveTo present the stage distribution, patterns of care, and outcomes of patients from Botswana with invasive cervical cancer, living with or without HIV.MethodsBetween 2013 and 2020, women with cervical cancer were prospectively enrolled in an observational cohort study.ResultsA total of 1,043 patients were enrolled; 69% were women living with HIV. The median age of the cohort was 47&nbsp;years (interquartile range [IQR] 40-58 years), with women living with HIV presenting at a younger age compared to women without HIV (44 versus 61 years, p&nbsp;&lt;&nbsp;0.001). Among women living with HIV, the median CD4 count at the time of cancer diagnosis was 429.5 cells/μL (IQR 240-619.5 cells/μL), 13% had a detectable viral load, and 95% were on antiretroviral therapy. In regard to treatment, 6% (n&nbsp;=&nbsp;58) underwent surgery, 33% (n&nbsp;=&nbsp;341) received radiation therapy, 51% (n&nbsp;=&nbsp;531) received chemoradiation, and 7% (n&nbsp;=&nbsp;76) did not receive treatment. Stage distribution in the cohort was as follows: I 17% (n&nbsp;=&nbsp;173), II 37% (n&nbsp;=&nbsp;388), III 35% (n&nbsp;=&nbsp;368), and IV 8% (n&nbsp;=&nbsp;88). For all patients, 2-year OS was 67%. In multivariable Cox regression, worse OS was associated with stage: II (HR 1.91, p&nbsp;=&nbsp;0.007), III (HR 3.99, p&nbsp;&lt;&nbsp;0.001), and IV (HR 5.06, p&nbsp;&lt;&nbsp;0.001) compared to stage I. Improved OS was associated with hemoglobin&nbsp;&gt;&nbsp;10&nbsp;g/dL (HR 0.51, p&nbsp;&lt;&nbsp;0.001) compared to Hb&nbsp;≤&nbsp;10&nbsp;g/dL.ConclusionsAmong women in Botswana with cervical cancer, most patients presented with stage II or III disease warranting radiation therapy or chemoradiation. While two-thirds of cervical cancer patients were women living with HIV, HIV did not impact OS

Chemoradiation versus radiation alone in stage IIIB cervical cancer patients with or without human immunodeficiency virus

ObjectiveCervical cancer remains the most common cancer among women in sub-Saharan Africa and is also a leading cause of cancer related deaths among these women. The benefit of chemoradiation in comparison with radiation alone for patients with stage IIIB disease has not been evaluated prospectively in women living with human immunodeficiency virus (HIV). We assessed the survival of chemoradiation versus radiation alone among stage IIIB cervical cancer patients based on HIV status.MethodsBetween February 2013 and June 2018, patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IIIB cervical cancer with or without HIV and treated with chemoradiation or radiation alone, were prospectively enrolled in an observational cohort study. Overall survival was evaluated using the Kaplan-Meier method. Cox proportional hazards modeling was used to analyze associations with survival.ResultsAmong 187 patients, 63% (n=118) of women had co-infection with HIV, and 48% (n=69) received chemoradiation. Regardless of HIV status, patients who received chemoradiation had improved 2 year overall survival compared with those receiving radiation alone (59% vs 41%, p&lt;0.01), even among women living with HIV (60% vs 38%, p=0.02). On multivariable Cox regression analysis, including all patients regardless of HIV status, 2 year overall survival was associated with receipt of chemoradiation (hazard ratio (HR) 0.63, p=0.04) and total radiation dose ≥80 Gy (HR 0.57, p=0.02). Among patients who received an adequate radiation dose of ≥80 Gy, adjusted overall survival rates were similar between chemoradiation versus radiation alone groups (HR 1.07; p=0.90). However, patients who received an inadequate radiation dose of &lt;80 Gy, adjusted survival was significantly higher in chemoradiation versus radiation alone group (HR 0.45, p=0.01).ConclusionsAddition of chemotherapy to standard radiation improved overall survival, regardless of HIV status, and is even more essential in women who cannot receive full doses of radiation