The discussion revolved around the main issues that clinicians should know when dealing with moderately advanced cervical cancer, namely the type of imaging, when to order PET scans, when to order MRI, how to stage the patient and then moving to what is the standard of care using chemoradiation and the judicious usage of radiation in dosing and also in combination with chemotherapy. What is the best chemotherapy to be used and also the dosing of radiation, followed by an explanation and details about brachytherapy, which is internal radiation therapy for cervical cancer, and closing by discussing the role of surgery in countries or situations where we don't have brachytherapy available.
The physician is faced with the situation where they don't know how to close on the treatment because the external radiation part alone is not enough to cure a large proportion of patients. So what we usually recommend if there is no brachytherapy is after the external pelvic radiation part to move and consider surgery. But in situations where we don't have… the surgery is not possible because the tumour is extensive then the alternative is to proceed with more external radiation but it's focussed on the primary tumour. There are many ways of doing this; one way is the IMRT technology, which is intensity modulated radiation therapy, or better to use what we call SBRT, stereotactic body radiation therapy which delivers a higher dose of radiation and better gradient and differential in the low dose region than IMRT. But, again, those are only in situations where we cannot give brachy or we cannot do surgery and then we rely on this technology.
You need to repeat the MRI because after providing four or five weeks of external beam radiation to the pelvis with concurrent chemo the tumour changes in size and in shape so you have to repeat the imaging, ideally MRI, and if possible PET. PET is maybe borderline needed but MRI is definitely needed.
Does this affect standard of care?
Yes, the standard of care you don't change it but you have alternative approaches. When brachy is not available you use surgery if the tumour is amenable to surgical extraction. This is very critical - people who are experienced in deciding whether surgery is feasible. What I mean by feasible is that the tumour is not still extended beyond the cervix to the perimetrium, vagina or etc. and in this situation surgery would be harmful. So then we go to the third level of alternative therapy which is the focussed boosting with IMRT or SBRT, hoping that these centres would have this technology because this is important. If they don't have all of the above or surgery is not feasible then the only way left is to boost it with external 3D radiation which actually is the least preferred method for treatment.
The next actually steps to move forward would be to apply what we call volume based brachytherapy and this is an approach that has been gaining ground rapidly over the past several years. That's point one, the second point is hopefully to find some more powerful drugs to go along with radiation therapy. And the third maybe possibility of improvement could come from the addition of adjuvant chemotherapy, after all radiation is done the role of adjuvant radiation is still under study and this might add to the rate of cure of those patients.
