Factors associated with completion of intracavitary brachytherapy: do socio-demographic factors play a role?

Objectives: Despite new developments in the treatment of cervical cancer, intracavitary brachytherapy (ICBRT) continues to be part of the standard of care treatment for locally advanced cervical cancer. The objective of our study was to evaluate clinical and socio-demographic factors associated with not receiving indicated ICBRT and its impact on overall survival (OS) in women with locally advanced cervical cancer. Methods: Patients diagnosed with cervical cancer between 1993-2017 receiving care at 2 large academic centers were included in this retrospective case control study. Demographic and clinical data were retrospectively abstracted. Data analysis was done using Mann-Whitney U test, Fischer's Exact test, logistic regression. Kaplan-Meier curves were constructed for OS and the log rank test was utilized to detect differences in OS. Results: Of 274 patients with cervical cancer, 130 were candidates to receive ICBRT. Mean age was 50.19 (±12.6). The majority of patients included were underrepresented minorities including 60.8% White-Hispanic patients and 30.8% Black. Spanish was identified as the primary language for 48.5% of women. The average median household income based on zip code was $45,387 (± $17,135) for the cohort. A total of 50.5% of subjects were foreign born with only 11.5% identified as USA born. Squamous cell carcinoma was the most common histologic type in the group at 86.2%. Majority of subjects included in cohort (53.8%) were Stage IIB at time of diagnosis. ECOG performance status was 0 in 72% of the subjects included. On univariate analysis, older patients (55.52±11.7years, p=0.012) (OR 0.957 [0.924, 990], p=0.012), those with ECOG PS 4cm), country of birth, BMI, and histologic type were not associated with completion of ICBRT (all p > 0.05). On multivariate analysis, Black race OR 0.216 CI (0.091-0.579) and Medicare status OR 0.039 CI (0.14-2.085) continued to be significantly associated with lack of receipt of brachytherapy. A total of 29 (22.3%) subjects did not complete the indicated ICBRT as part of their treatment. Among the reasons for not receiving ICBRT included distorted anatomy (17%), poor response to EBRT (28%), patient refusal or noncompliance (17%), ICBRT not available at the institution (7%), and inability to achieve desired dose (10%). Women who did not receive ICBRT were more likely to die of disease with a HR of 2.85 [1.071, 7.617], p=0.046, even when external beam boost was performed. On Cox proportional-hazard analysis, receipt of ICBRT continued to be associated with OS. Receipt of intensity-modulated radiation therapy (IMRT) boost instead of ICBRT did not improve survival. Conclusions: While ICBRT remains the standard of care for locally advanced cervical cancer, 22.3% of subjects (93% minority patients) did not receive it for various reasons. Sociodemographic and clinical factors are both associated with receipt of brachytherapy. Regardless of the reasons for not receiving, and even when external beam boost is given in an effort to compensate for lack of receipt of brachytherapy, patients who do not receive ICBRT have a lower OS.