Cervix cancer is one of the commonest cancers in Indian women. Every year close to 90,000 women are diagnosed with this cancer in India. Women who present with early stage cervix cancer often undergo surgery. Removal of uterus and other affected organs and lymph nodes leaves the pelvic cavity with extra space and intestines fall into this space. After surgery, women who have some additional risk factors need further treatment with radiation. While radiation delivered after surgery leads to improvement in cancer related outcomes and survival, it also leads to some long standing side effects to intestines.
In 2011, investigators at Tata Memorial Centre started a large phase III randomized study (PARCER) that tested advanced and highly precise technique in radiation technology like Image guided intensity modulated radiotherapy (IG-IMRT) for their ability to reduce long term radiation changes to intestines. The study has received international acclaim and was recently published in Journal of Clinical Oncology (American Society of Clinical Oncology). Overall 300 patients who underwent surgery for cervical cancer were randomized to receive either standard radiation (three dimensional conformal radiation) or IG-IMRT. At a follow up of 4 years after treatment, the use of IG-IMRT lead to a major reduction in moderate (from 42% to 21%) and severe (15.5% to 2.9%) intestinal late side effects.
This is the first major study internationally that clearly demonstrates benefit of advanced radiation techniques for gynecological cancers. Previously a study led by MD Anderson Cancer hospital across various centres in USA did not demonstrate sustained long term beneficial effects of IGIMRT, though it was considered to be of short term benefit. The results of the Tata Memorial Centre study will change the way women with cervical cancer are treated worldwide. These results have already been presented by lead author Professor Supriya Chopra at the Clinical Trials session at the American Society for Radiation Oncology (ASTRO) Annual Meeting 2020 and at the plenary session of Society of Gyncology Oncology, USA in 2021.
These results are very timely and relevant. Many new technical advances in cancer management are thought to be more effective. However, robust head to head comparison with established techniques are often limited. For e.g. in the gynecological surgical field, more advanced techniques like laparoscopic (or key hole) surgery for cervix cancer were compared with open surgery in randomized study in recent years. Contrary to the expectations, laparoscopic surgery fared worse than open surgery for cervix cancer in terms of cancer recurrence. However, in this study the use of IG-IMRT (a more precise and advanced radiation technique) was associated with equal cancer survival as standard radiation (3DCRT) albeit with lesser side effects. Therefore the advanced IG-IMRT technique is not only safe but associated with long term reduction in side effects that are caused due to cancer treatment.
As newer cancer treatments continue to report improved outcomes, it is more and more important that survivors lead a normal life. Women diagnosed with cervix cancer are generally in their very active phase of life and highly effective and safe and effective treatments like IG-IMRT bring a new ray of hope.
The investigators also note that implementing advanced technologies on a national and global scale can be challenging. However the results of studies like these provide strong reason for governments and new cancer centres to invest in advanced radiation technology.