Patient preference for high or low dose rate brachytherapy in carcinoma of the cervix

doi:10.1016/0167-8140(94)90353-0

Radiotherapy and Oncology

Volume 33, Issue 3, December 1994, Pages 187-194

https://doi.org/10.1016/0167-8140(94)90353-0 Get rights and content

Abstract

High and low dose rate are two competing methods of brachytherapy. Existing data do not support choosing one method over the other for treating carcinoma of the uterine cervix. Arguments include clinical efficacy, monetary cost, radiation safety, and patient preference. There are no published data on patient preference. We developed a questionnaire to elicit patient preference and to measure its strength. Subjects received descriptions of both treatment options and their probable outcomes. We elicited preference for one low or three high dose rate fractions, and for two low or five high dose rate fractions, assuming both methods to be isoeffective. Strength of initial preference was measured by asking subjects how much of a change, in either the chances for cure or the chances for toxicity, would make them change preference. The questionnaire was completed by female staff at our centre (n = 90), by a group of previously treated patients (n = 18), and by a group of newly diagnosed patients (n = 20). When both methods were assumed to be isoeffective, only 34% of the 38 patients preferred three fractions of high dose rate to one fraction of low dose rate. However, when high dose rate was assumed to be 2% more curative, or 6% less toxic, a simple majority of 50% then said they would prefer high dose rate. Both preference and strength of preference for low dose rate were significantly associated with a greater travelling distance for treatments. Age, marital status, family structure, education, employment, and family income were not associated. In summary, a majority of our patients preferred low dose rate brachytherapy. Preference changed predictably with differences in fraction numbers, efficacy, toxicity, and travelling distance.

References (30)

K.K. Fu et al.
High dose rate versus low dose rate intracavitary brachytherapy for carcinoma of the cervix
Int. J. Radiat. Oncol., Biol. Phys.
(1990)
A. O'Connor
Effects of framing and level of probability on patient's preferences for cancer chemotherapy
J. Clin. Epidemiol.
(1989)
A. O'Connor et al.
Eliciting preferences for alternating drug therapies in oncology: Influence of treatment outcome description, elicitation technique and treatment experience on preferences
J. Chron. Dis.
(1987)
C. Orton et al.
Comparison of high and low dose rate remote afterloading for cervix cancer and the importance of fractionation
Int. J. Radiat. Oncol., Biol. Phys.
(1991)
P. Scalliet et al.
HDR versus LDR gynecological brachytherapy revisited
Radiother. Oncol.
(1993)
Y. Shigematsu et al.
Treatment of carcinoma of the uterine cervix by remotely controlled afterloading intracavitary radiotherapy with high-dose rate: a comparative study with a low-dose rate system
Int. J. Radiat. Oncol., Biol. Phys.
(1983)
V.E. Arterbery
High-dose rate brachytherapy for carcinoma of the cervix
Curr. Opinion Oncol.
(1993)
K. Bastin et al.
Resource utilization. High dose rate versus low dose rate brachytherapy for gynecologic cancer
Am. J. Clin. Oncol.
(1993)
D.J. Brenner et al.
Fractionated high dose rate versus low dose rate regimens for intracavitary brachytherapy of the cervix. I. General considerations based on radiobiology
Br. J. Radiol.
(1991)

CIBA-Geigy

E.L. Crow et al.

Statistics

L. Doss

Remote afterloading HDR brachytherapy

Cancer Consult

(July, 1990)

M. Drummond et al.

Clinical importance, statistical significance and the assessment of economic and quality-of-life outcomes

Health Econ.

(1993)

Cited by (21)

High versus low-dose rate brachytherapy for cervical cancer
2015, Gynecologic Oncology
Citation Excerpt :
While LDR brachytherapy has been in use for several decades, utilization of HDR therapy offers a number of advantages for patients and providers. Compared to LDR therapy, HDR brachytherapy allows outpatient treatment, requires shorter times, is associated with greater patient convenience, allows individualized treatment planning and source optimization, and may allow greater safety for treatment personnel [2,28,29]. Importantly, our data suggest that outcomes of HDR and LDR brachytherapy among patients in the United States are similar and provide support for use of HDR therapy.
Brachytherapy plays an important role in the treatment of cervical cancer. While small trials have shown comparable survival outcomes between high (HDR) and low-dose rate (LDR) brachytherapy, little data is available in the US. We examined the utilization of HDR brachytherapy and analyzed the impact of type of brachytherapy on survival for cervical cancer.
Women with stages IB2–IVA cervical cancer treated with primary (external beam and brachytherapy) radiotherapy between 2003–2011 and recorded in the National Cancer Database (NCDB) were analyzed. Generalized linear mixed models and Cox proportional hazards regression were used to examine predictors of HDR brachytherapy use and the association between HDR use and survival.
A total of 10,564 women including 2681 (25.4%) who received LDR and 7883 (74.6%) that received HDR were identified. Use of HDR increased from 50.2% in 2003 to 83.9% in 2011 (P < 0.0001). In a multivariable model, year of diagnosis was the strongest predictor of use of HDR. While patients in the Northeast were more likely to receive HDR therapy, there were no other clinical or socioeconomic characteristics associated with receipt of HDR. In a multivariable Cox model, survival was similar between the HDR and LDR groups (HR = 0.93; 95% CI 0.83–1.03). Similar findings were noted in analyses stratified by stage and histology. Kaplan–Meier analyses demonstrated no difference in survival based on type of brachytherapy for stage IIB (P = 0.68), IIIB (P = 0.17), or IVA (P = 0.16) tumors.
The use of HDR therapy has increased rapidly. Overall survival is similar for LDR and HDR brachytherapy.
Patient preference to use a questionnaire varies according to attributes
2011, Patient Education and Counseling
Citation Excerpt :
We also developed a Prototype Toxicity Assessment (PTA) for direct comparison with ESAS (Appendix C). The PTA was compared to ESAS using previously reported methods [18–20] to assess within-person consistency in how attributes in-the-aggregate predict preference when several attributes are simultaneously adjusted. Participants were asked to choose between tools and further to decide whether they would use both.
Health care professionals may assume questionnaires are burdensome to patients, and this limits their use in clinical settings and promotes simplification. However, patient adherence may improve by optimizing questionnaire attributes and contexts.
This cross-sectional survey used Contingent Valuation methods to directly elicit patient preference for conventional monitoring of symptoms, versus adding a tool to monitoring. Under explicit consideration was the 10-question Edmonton Symptom Assessment System (ESAS). In the questionnaire, attributes of ESAS were sequentially altered to try and force preference reversal. A separate group of participants completed both questionnaire and interviews to explore questionnaire reliability, and extend validity.
Overall, 24 of 43 participants preferred using ESAS. Most important attributes to preference were frequency, specificity, and complexity. Where preference is initially against ESAS, it may reverse by simplifying the tool and its administrative processes. Interviews in 10 additional participants supported reproducibility and validity of the questionnaire method.
Preference for using tools increases when tools are made relevant and used more appropriately.
Questionnaires completed by patients as screening tools or aids to communication may be under-utilized. Optimization of ESAS and similar tools may be guided by empirical findings, including those obtained from Contingent Valuation methodologies.
Brachytherapy for Cervix Cancer: Time for Change
2010, Clinical Oncology
Radiation Therapy for Gynecologic Malignancies
2006, Hematology/Oncology Clinics of North America
The emergence of advanced brachytherapy techniques for common malignancies
2006, Hematology/Oncology Clinics of North America
Phase III randomized trial comparing LDR and HDR brachytherapy in treatment of cervical carcinoma
2004, International Journal of Radiation Oncology Biology Physics
Intracavitary brachytherapy plays an important role in the treatment of cervical carcinoma. Previous results have shown controversy between the effect of dose rate on tumor control and the occurrence of complications. We performed a prospective randomized clinical trial to compare the clinical outcomes between low-dose-rate (LDR) and high-dose-rate (HDR) intracavitary brachytherapy for treatment of invasive uterine cervical carcinoma.
A total of 237 patients with previously untreated invasive carcinoma of the uterine cervix treated at King Chulalongkorn Memorial Hospital were randomized between June 1995 and December 2001. Excluding ineligible, incomplete treatment, and incomplete data patients, 109 and 112 patients were in the LDR and HDR groups, respectively. All patients were treated with external beam radiotherapy and LDR or HDR intracavitary brachytherapy using the Chulalongkorn treatment schedule.
The median follow-up for the LDR and HDR groups was 40.2 and 37.2 months, respectively. The actuarial 3-year overall and relapse-free survival rate for all patients was 69.6% and 70%, respectively. The 3-year overall survival rate in the LDR and HDR groups was 70.9% and 68.4% (p = 0.75) and the 3-year pelvic control rate was 89.1% and 86.4% (p = 0.51), respectively. The 3-year relapse-free survival rate in both groups was 69.9% (p = 0.35). Most recurrences were distant metastases, especially in Stage IIB and IIIB patients. Grade 3 and 4 complications were found in 2.8% and 7.1% of the LDR and HDR groups (p = 0.23).
Comparable outcomes were demonstrated between LDR and HDR intracavitary brachytherapy. Concerning patient convenience, the lower number of medical personel needed, and decreased radiation to health care workers, HDR intracavitary brachytherapy is an alternative to conventional LDR brachytherapy. The high number of distant failure suggests that other modalities such as systemic concurrent or adjuvant chemotherapy might lower this high recurrence, especially in Stage IIB and IIIB.

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Original paperPatient preference for high or low dose rate brachytherapy in carcinoma of the cervix

Abstract

Int. J. Radiat. Oncol., Biol. Phys.

J. Clin. Epidemiol.

J. Chron. Dis.

Int. J. Radiat. Oncol., Biol. Phys.

Radiother. Oncol.

Int. J. Radiat. Oncol., Biol. Phys.

High-dose rate brachytherapy for carcinoma of the cervix

Curr. Opinion Oncol.

Resource utilization. High dose rate versus low dose rate brachytherapy for gynecologic cancer

Am. J. Clin. Oncol.

Fractionated high dose rate versus low dose rate regimens for intracavitary brachytherapy of the cervix. I. General considerations based on radiobiology

Br. J. Radiol.

Statistics

Remote afterloading HDR brachytherapy

Cancer Consult

Clinical importance, statistical significance and the assessment of economic and quality-of-life outcomes

Health Econ.

Original paper
Patient preference for high or low dose rate brachytherapy in carcinoma of the cervix