In this interview we discuss treatment disparities and the impact on survival among patients with locally advanced cervical cancer with Christine M. Fisher, MD, MPH, a radiation oncologist at the University of Colorado in Denver. Dr. Fisher and her colleagues recently published a paper that analyzed differences in treatment and survival results among cervical cancer patients.
—Interviewed by Anna Azvolinsky
Cancer Network: What was the impetus to study the national trends of the use of standard of care treatment in cervical cancer patients? Is there data already to suggest that not all patients receive the standard of care based on current guidelines?
Dr. Fisher: The impetus is that we are still seeing women present with advanced cervical cancer, recurrent cervical cancer, and even dying from cervical cancer, which is ultimately a preventable disease. Worldwide, the burden on young women is quite high with about half a million cases per year. In my own practice, as a cervical cancer specialist, I have seen women come in, in a recurrent setting, who haven’t had all of the components of standard of care upfront, and I was suspicious and concerned that this may lead to poorer outcomes in terms of survival for these patients.
For locally advanced patients I am looking to see that they got external beam radiation, brachytherapy or internal radiation, and a form of concurrent chemotherapy. In terms of the middle component, brachytherapy, there is data that that is declining as a modality, and I think that is primarily due to the time and expertise required. We have data suggesting that this skillset of being a brachytherapist is declining, and we don’t have a good substitute for that in cervical cancer. That said, a broad description of the standard of care in cervical cancer patients and the utilization across the country—which would include external beam radiation, chemotherapy, and brachytherapy—had not been previously undertaken. We wanted to really understand what those patterns were across the country and see how that might impact survival.
Cancer Network: Could you describe the patient dataset you analyzed and what you found in this study?
Dr. Fisher: Absolutely. We used a dataset called the National Cancer Database (NCDB), so this is done as a collaboration between the American Cancer Society and the American College of Surgeons. This database is pretty incredible in that it captures almost three-quarters of all cancer centers across the United States, so this allows us to look at a snapshot of cancer care across the country. This is not just large academic, comprehensive cancer centers like the University of Colorado, but also much smaller centers in a diversity of settings—so this is pretty unique rather than looking at data from one single cancer center—to actually see how different populations, different approaches to care can impact outcomes.
The other important thing besides patients’ patterns of care is that it provides overall survival. So one can look at different approaches and modalities and see if any differences in overall survival exist based on what approaches are used. So our goal in this study was to look at outcomes regarding use of radiation after the initial external beam radiation—this is referred to in the paper as a boost, and that could be done with brachytherapy. Unfortunately, for some patients there was no boost at all. So that was the first component of our question and the second was whether sensitizing chemotherapy, which demonstrated a survival benefit in randomized clinical trials, was being used optimally in a localized cancer population.
Within the dataset, we looked at patients with cervical cancer from 2004 to 2012 and excluded those with early disease or metastatic disease, so focusing on the locally advanced population. These are women that can be cured with the best approach, despite having very large or locally advanced tumors, but often won’t be cured if one or all of the critical components of care is not used. That is to say that these are the women where the best approach has the best impact on surviving cancer. Overall, we found that under half the women get all of the components of standard care treatment.
Those who did get the best treatment, all three critical modalities, were generally treated at academic centers, high-volume centers, or comprehensive cancer centers where the expertise in cervical cancer and brachytherapy, in particular, exist. Those that did not get standard of care treatment (particularly with no boost documented at all) were those treated at smaller centers, those who may have been underinsured, low income patients, and black patients. The overall survival that we looked at was directly impacted by treating with the standard of care. So looking at a 5-year outcome, there were about twice as many women alive when treated with the standard of care vs those that got only external beam, which is a huge difference in terms of outcomes.
Cancer Network: Any of the results that were particularly surprising to you?
Dr. Fisher: I expected a small percentage of women to not get the standard of care therapy. For a variety of reasons I was really surprised to learn that more than half the women treated in the United States fell into this category. In our country where we have access to the most advanced technology innovation, and often are developing it, it is disappointing to see that many women are suffering and dying due to potentially inadequate treatment. It also confirmed prior studies that have been done as well as experience showing that the addition of brachytherapy and chemotherapy are really irreplaceable in this subset of patients. Overall, it was surprising that we have this preventable loss of young women’s lives by really adhering to the standard of care therapies.
Cancer Network: What’s next? Are you and your colleagues now trying to understand how to help improve cervical cancer patient care across the United States?
Dr. Fisher: Absolutely. I think for those with a cervical cancer diagnosis, they should really aim to be seen at a comprehensive cancer center, an academic center, or at least try to seek out a high-volume center near where they live. Asking their oncologist about their experience and comfort with cervical cancer and brachytherapy is appropriate. Patients, their families, and even their primary care physicians can all help ensure that each woman gets the best possible care for the best outcomes.
Globally though, much of the responsibility and privilege of helping cervical cancer patients really rests on our primary care colleagues, including gynecologists, who can actually help prevent these women from becoming a cancer patient in the first place. I have served personally as the vice chair of the Colorado Department of Public Health board that looks at cervical cancer screening and prevention and we really focused on getting good screening across Colorado. So that group focuses on human papilloma virus (HPV) testing and PAP testing to ensure secondary prevention—that is, picking up early changes that may occur from a viral infection before cancer has time to develop. Even better though, would be to actually prevent the infection and those cellular changes from starting in the first place. We have an HPV Task Force in Colorado where we work to target counties with populations that don’t have good rates of screening and have higher rates of invasive cervical cancer. We can actually work to generate heat maps where we can best put resources for vaccination and screening, and really target the women and populations that are not well plugged into the healthcare system. So, overall, vaccination and prevention of this cancer is by far the best way to help women in the United States and worldwide.
Cancer Network: Thank you so much for joining us today, Dr. Fisher.
Dr. Fisher: Thank you for having me.