br National guidelines to complete treatment within weeks
National guidelines to complete treatment within 8 weeks are based on improved pelvic control and disease specific survival noted in older studies prior to the combined chemo-radiation era [4,13–15]. There is limited data regarding the importance of time to completion of radiation after the introduction of sensitizing chemotherapy. Some studies suggest that prolonged treatment may impact both progression free survival (PFS) and overall survival (OS) , while others found it only impacts pelvic control . Shaverdian et al. found that with the addition of che-motherapy, treatment duration did not impact treatment efficacy . A large data 1331891-93-0 study found that there was no survival benefit to complet-ing treatment in 8 weeks, but that women who had radiation treatment duration N10 weeks and N12 weeks had a 15% and 23% higher risk of death . Our study did demonstrate significantly decreased recurrence rates in the group that received all of their RT at the PI. Five year survival
Fig. 3. Overall survival; OLF: outlying facility; PI: primary institution.
data also demonstrated a trend towards improved survival in this group, but this did not meet statistical significance. In this study observed differ-ences in stage and nodal status may have contributed to improved overall survival without significant improvement in progression free survival, which was limited by sample size.
It has been established that the addition of brachytherapy signifi-cantly improves outcomes [3,20,21]. Brachytherapy treatment in com-bination with EBRT is associated with significantly higher cause specific survival (64.3% vs 51.5%) as well as overall survival rates (58.2% vs 46.2%) when compared to EBRT alone . Interestingly, while there has been a clear and proven benefit of brachytherapy in the treatment of locally advanced cervical cancer, compliance rates for this treatment modality have decreased over a similar time frame. In a recent study, Han et al. demonstrated that brachytherapy use decreased from 83% in 1980 to 58% in 2009 with a demonstrated sharp decline of 23% in 2003 . We found that even patients treated at outlying facili-ties received standard brachytherapy dosing, just with a longer treat-ment duration. However, there was an increased utilization of IMRT at outlying facilities. These patients received IMRT instead of standard BT which some studies suggest could affect PFS and OS.
While coordination of care seems to be a component, there are other factors that likely affect this observed difference. As a large referral cen-ter many patients are travelling long distances to the PI to see a gyneco-logic oncologist. Some patients traveled as far as 106 miles to their BT facility and 80.8 miles to their EBRT facility. BT was only performed cen-trally, as the smaller outlying facilities were not equipped to treat pa-tients with this modality of RT. EBRT, on the other hand, was often performed at several smaller towns/cities remote from the PI. These pa-tients often opt to have their EBRT closer to home and therefore un-dergo at least one component of their RT at an OLF. It is difficult, therefore, to determine if decreased compliance rates in these situations are due to a lack of coordinated care or are due to constraints with trav-elling long distances for BT treatments such as coordinating travel with a caregiver that might have delayed treatment.
Our study has several limitations. Data was collected from a single institution which may limit generalizability of results. However, most gynecologic oncologists see patients from a large geographic area, and therefore need to coordinate care between multiple sites. Additionally, this is a small retrospective study. While data regarding overall survival did demonstrate a trend towards better five year survival, our study was underpowered to demonstrate a statistically significant difference among the two groups. Patients who received all or part of their RT at an OLF were significantly older and the data suggested a trend towards more advanced disease with lymph node involvement. It is possible that these patients may not have been as compliant with screening guide-lines and therefore had more advanced disease, but that information was not available in this data analysis.
Despite the limitations of our study we found a strong correlation between treatment location and time to completion of therapy. Moving forward, it is critical that these patients are recognized at the beginning of their care and efforts are made to ensure timely and coordinated care in order to improve compliance rates with RT. Using cancer navigators to help coordinate care between multiple sites and providers, providing patients with a treatment plan outline, and encouraging patients to meet with the radiation oncologist who will perform their brachyther-apy at the start of therapy may help close the treatment duration gap. Several studies have noted improvement in care coordination with the use of cancer navigators including improved adherence to cancer ap-pointments . Multi-institution studies are necessary to confirm this finding, and to further evaluate treatment duration on recurrence rates and disease specific survival.