Radiotherapy in the treatment of gynaecological cancers – moving forward
16-17 November 2023, Prague, Czech Republic
The Groupe Européen de Curiethérapie (GEC)-ESTRO gynae network meeting took place from the 16th to 17th November. In the first session, alternative brachytherapy fractionations were discussed in cervical cancer treatment. It was noted that the need for alternative fractionation schemes had increased during the COVID-19 pandemic. Professor Supriya Chopra shared the experience of staff at Tata Memorial Centre, Mumbai, where they use two implants with four fractions or a single implant with three fractions. It was noted that in high-volume centres where it is a challenge to comply with overall treatment time, a shorter fractionation may be particularly useful as it can lead to a 100% increase in treatment capacity and a 50% reduction in planning requirements.
In the second session, speakers presented data about hypofractionation in cervical cancer and post-operative endometrial cancers. In the phase II HYPOCx-iRex study, patients with locally advanced cervical cancer were randomised to hypofractionation (HYPO): 44Gy in 20 fractions (fx) to the whole pelvis and 53Gy in 20 fx (simultaneous integrated boost, SIB) to gross lymph nodes and consolidation volume radiation therapy: 45Gy and 55Gy in 25 fx, with concurrent weekly cisplatin 40mg/m2. No significant oncological outcome or pattern of failure differences was shown. Dr Lucas Mendez presented the preliminary results of the hypofractionated external beam radiotherapy for intact cervical cancer (HEROICC) trial. In the experimental arm, the patients with low-risk locally advanced cervical cancer were irradiated to a total dose of 40Gy and 45Gy in 15 fx (SIB) with weekly cisplatin 40mg/m2. Complete response and local control were excellent in both arms. Finally, Dr Eric Leung of the Odette Cancer Centre, Canada, shared the results of the stereotactic pelvic adjuvant radiation therapy in cancers of the uterus (SPARTACUS) trial. Post-operative uterine cancer patients with indications for adjuvant pelvic irradiation received stereotactic adjuvant pelvic radiation to a total dose of 30Gy in five fx administered every other day or once weekly. The trial results suggest that hypofractionated stereotactic radiotherapy is well tolerated by the time of short-term follow-up.
After the coffee break, Dr Chopra presented an update on the current status of the retro-characterising risk and biology of smouldering myeloma for early detection of symptomatic myeloma (COSMOS) study. The study was designed to determine the overall survival of patients with oligo-recurrent and oligo-metastatic cervical cancer who had been treated with local therapies with or without systemic therapy. The study is expected to run from 2023 to 2025 for active registration and to link further into prospective studies in these cohorts.
In the next session, speakers presented an update on ongoing studies, including EMBRAVE – a prospective, multi-centre study on the use of radiochemotherapy and image-guided adaptive brachytherapy to treat vaginal cancer, being conducted by Professor Remi Nout, head of radiotherapy at the Erasmus Medical Centre, The Netherlands, and Dr Henrike Westerveld of Amsterdam University Medical Centres, The Netherlands; and the EMBRACE low-risk study that is aimed to reduce rates of treatment-related acute and late morbidity in low-risk cervical cancer patients. The method under study is the de-escalation of the dose and volume of external beam radiotherapy (EBRT) and the combination of EBRT with brachytherapy, and the study is being performed by Professor Kari Tanderup (Aarhus University Hospital, Denmark) and Professor Nout.
The "hot topics" session raised molecular assessment and its impact on prognosis in endometrial and cervical cancer patients. Dr Nanda Horeweg of Leiden University Medical Centre, The Netherlands, presented a talk on the influence of molecular classification on radiotherapy response in endometrial cancer. Prof Nout gave some insight into the pilot BIO-EMBRACE study, which will focus on the identification of molecular markers of disease recurrence through tissue immunohistochemistry.
The third session of the workshop was dedicated to gynaecological cancers. The first talk ‑ "Sexual dysfunctions after radiochemotherapy in locally advanced cervix cancer: prevention and rehabilitation strategies" was presented by Professor Kathrin Kirchheiner of the Medical University of Vienna, Austria. Prof Kirchheiner found that sexual activity was a significant aspect of life for approximately 75% of cervical cancer patients. Around 40% of patients found sexual activity "not at all" or only "a little" enjoyable, and the same percentages reported that they "seldom" or "never" experienced sexual desire. Hormonal replacement therapy (HRT) was stated to be a safe treatment option for women diagnosed with cervical cancer. The administration of regular HRT in premenopausal patients at diagnosis of cervical cancer was associated with significantly less vaginal dryness and feelings of vaginal shortening, and a trend towards more sexual enjoyment, as reported by the patients. Bleeding due to contact during or after sexual activity was described as an important factor that in some cases induced recurrence anxiety. Therefore, there is a need to educate and reassure the patient. The frequently omitted subject of clitoral health was the critical point of the lecture. Pleasure-based approaches to sexual rehabilitation have been emphasised by numerous authors on account of their ability to enhance tissue oxygenation and thus increase blood flow in the pelvic region, facilitate tissue healing, and influence sexual desire and interest. Prof Kirchheiner concluded that sexual healthcare necessitated the use of a holistic strategy that extended beyond functional aspects and vaginal healthcare. She stated that healthcare professionals should adopt a proactive approach as numerous options for the prevention and management of sexual health issues occurred following pelvic radiotherapy.
The second talk – "Contouring of female sexual organs: which, why and how?" – was given by Professor Deborah Marshall of the Mount Sinai Health System in the USA. She is the main author of the article "A first radiotherapy application of functional bulboclitoris anatomy, a novel female sexual organ-at-risk and organ-sparing feasibility study". She presented the rules of contouring of female sexual organs and highlighted their roles, radiotherapy dose thresholds, primary dysfunctions and late toxicities. She emphasised that the effects of radiotherapy on the bulboclitoris were unknown, as the relationship between its structure and function and the effects of radiotherapy had yet to be described. The glandular domain, which includes the paraurethral glands responsible for arousal and orgasm, is not considered an organ-at-risk in radiotherapy and is not allocated any radiotherapy dose constraints. The musculature domain, whose sexual function is orgasm and receptive intercourse capability, is classified as an organ-at-risk but has no dose constraints. Prof Marshall said that radiation damage to female erectile tissue had not been considered sufficiently in the literature, and she emphasised the need to redefine functional sexual anatomy in terms of radiation therapy.
Emilia Staniewska, MD
Third Radiotherapy and Chemotherapy Department
Maria Skłodowska-Curie National Research Institute of Oncology
Gliwice, Poland