The radiation oncology department is structured in terms of both service, education and research. As far as cervix cancers are concerned there is a lot of service going on for cancers of the cervix. We have a two accelerator department and with the entire spectrum of radiation oncology that can be offered but the fact that we have technology doesn’t mean that we have to use it so we optimise the use of technology across patients. High end technology for cancer of the cervix does have its own niche but it is still being tested in prospective controlled randomised trials. There’s enough evidence that technology does good in terms of increasing cure by increasing doses of radiotherapy as well as reducing or optimising morbidity by addressing organs at risk in a very proper fashion. So that’s what we do in the hospital, we evaluate every patient that is referred to us from the main surgical division and then we take a call.
What do you recommend is the best imaging work up?
Although the FIGO staging guidelines do not recommend standard axial imaging across patients, that’s because we have to have a staging system that is applicable across countries, across social divisions. But it encourages axial imaging and in our hospital all patients undergo a pelvic MR apart from a good clinical examination and an EUA if required, a proper clinical staging. All patients are considered for MR of the pelvis and a CT of the upper abdomen with contrast because we do see a few motion artefacts with MR of the upper abdomen that might miss small nodes. We consider a simple radiograph of the chest and any other site directed imaging if at all it is required, after which if a patient is not suitable for surgery, it’s beyond a surgical stage, we have an ongoing Government of India funded clinical trial that’s testing PET in a very prospective fashion. So a certain select subgroup of patients after proper informed consent in a language that they understand are recruited into the study for an integration of metabolic imaging with or without dose escalation for radiation oncology.
What techniques do you have available at the hospital?
We do have the entire pallet of radiation oncology available at Tata Medical Centre, right from standard 3D conformal radiation therapy to image-guided high end technology. We are also happy because we’ve got a system called the TomoTherapy system that can seamlessly treat long fields of treatment because a finite percentage of our patients have para-aortic nodal invasion and they needed extended field treatments respecting bowel tolerance so that we don’t give them a lot of bowel morbidity. However, we do not treat all patients with intensity modulation. Our standard approach is to treat patients with good 3D conformal radiotherapy with imaging for positioning and response assessment, follow it up with brachytherapy as an integral modality. Only patients who go on to the metabolic imaging trial are treated with intensity modulated radiotherapy.
How would you treat cervical carcinomas?
Any carcinoma of the cervix that is being treated with radiation therapy with a curative intention should receive weekly platinum based on all the studies that have been published in the literature because it adds to about a 12% survival benefit with the addition of platinum. Although very ironically maximum benefit, if you look at all the studies, is mostly seen in the earlier stages, 2bs and 2as rather than advanced 3bs and 4as. So all our patients get platinum, cisplatin that is, at the dose of 40mg/m2; we cap it to 70mg a week and then modify doses depending upon their creatinine clearance and their tolerance to treatment.
Do you perform any post-radiation, post-chemotherapy or palliative care?
Palliative radiation therapy again forms a certain percentage of the practice. Special references come in for haemostatic radiation at times or they come in for painful lymph nodes compressing on certain structures or locally advanced disease that’s beyond a curative intent. For the haemostatic set-up we usually don’t give haemostatic in a curative setting, we straight away begin with the curative chemo-radiation so that we don’t compromise radiation doses in future. For the others, yes, palliative radiotherapy as a weekly high dose fractionation or quick short course fractionation to give them relief is definitely considered for patients who need them.