|Year : 2016 | Volume
| Issue : 1 | Page : 132-134
Resolving the brachytherapy challenges with government funded hospital
DS Nikam, AS Jagtap, R Vinothraj
Department of Radiotheraphy and Oncology, Cama and Albless Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||28-Apr-2016|
D S Nikam
Department of Radiotheraphy and Oncology, Cama and Albless Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study is to rationalize the feasibility and cost-effectiveness of high dose rate (HDR) cobalt 60 (Co-60) source versus 192-Iridium (192-Ir) source brachytherapy in government funded hospitals and treatment interruption gap because of exchange of sources. Materials and Methods: A retrospective study of gynecological cancer patients, treated by radiotherapy with curative intent between April 2005 and September 2012 was conducted. We analyzed the total number of patients treated for external beam radiotherapy (EBRT) and brachytherapy (Intracavitary brachytherapy or cylindrical vaginal source). The dates for 192-Ir sources installation and the last date and first date of brachytherapy procedure before and after source installation respectively were also analyzed and calculated the gap in days for brachytherapy interruptions. Results: The study was analyzed the records of 2005 to September 2012 year where eight 192-Ir sources were installed. The mean gap between treatment interruptions was 123.12 days (range 1-647 days). The Institutional incidence of gynecological cancer where radiotherapy was treatment modality (except ovary) is 34.9 percent. Around 52.25 percent of patients who received EBRT at this institute were referred to outside hospital for brachytherapy because of unavailability of Iridium source. The cost for 5 year duration for single cobalt source is approximately 20-22 lakhs while for 15 Iridium sources is approximately 52-53 lakhs. Conclusion: The combined HDR Co-60 brachytherapy and EBRT provide a useful modality in the treatment of gynecological cancer where radiotherapy is indicated, the treatment interruption because of source exchange is longer and can be minimized by using cobalt source as it is cost-effective and has 5 year working life. Thus, Co-60 source for brachytherapy is a feasible option for government funded hospitals in developing countries.
Keywords: Government funded hospital, gynecological cancer, high dose rate cobalt-60 brachytherapy, radiotherapy
|How to cite this article:|
Nikam D S, Jagtap A S, Vinothraj R. Resolving the brachytherapy challenges with government funded hospital. Indian J Cancer 2016;53:132-4
| » Introduction|| |
Carcinoma of the uterine cervix is the most common cancer in Indian women even though paradigm is shifting toward carcinoma of breast in urban India. Considering the fact, majority of Indian population is rural and carcinoma cervix is the most common cancer in rural Indian women. As India is having 120 million populations and increasing at fast rate hence the actual number of cases diagnosed as a cancer of the uterine cervix is significantly large. Cancer care facilities in India are provided by both private as well as government sector, but the private sector treatment is expensive and the majority of patients are not affordable hence the role of Government hospitals is significant in cancer care who provides treatment to the majority of patients.
Patients with carcinoma of the cervix are often diagnosed at late stages hence inoperable and treated with concurrent chemo-radiotherapy (pelvic external beam radiotherapy [EBRT]) and brachytherapy. It is emphasized that brachytherapy is a necessary component in the curative treatment of cervical cancers. Low dose rate (LDR) and high dose rate (HDR) are commonly used two mode of delivery of brachytherapy in after loading technique where HDR brachytherapy application has gain popularity owing to the advantages specifically out-patient department based treatment (lasting approximately 20-30 minutes), avoidance of long- term bed rest and avoidance of cervical dilation. Furthermore greater sparing of the rectum and bladder by temporary retraction, dose optimization and integration with EBRT to the pelvis are possible.
In HDR brachytherapy, the need for high specific activity limits the number of radioisotopes 192-Ir and 60 cobalt (60-Co) sources. 192-Ir is having 0.38 MeV average energy and 73.8 days half-life and available in small sizes (1 mm) seeds, which permit to more body sites through interstitial and intraluminal applications. 60-Co is having 1.25 MeV average energy and 5.26 years half-life and available in sizes more than twice as large as 192-Ir sources hence suitable only for intracavitary and some intraluminal treatments like esophagus. Iridium 192 (Ir-192) has to be exchanged for every 3-4 month, which requires 3-4 sources every year while cobalt sources can be utilized for 5-8 year once installed; hence, treatment can be delivered to patients without any interruption. Combined HDR Cobalt-60 (Co-60) brachytherapy and EBRT was a useful modality in the treatment of uterine cervical cancer.
Carcinoma of the cervix treated with definitive irradiation reported a major impact of the overall treatment duration on tumor control and overall survival. This may be related to biologic factors such as cell repopulation and increased proliferation during treatment interruptions, in addition to clonogenic cell burden hence the recommended total duration of treatment (EBRT and HDR) is less than 8 weeks.
| » Materials and Methods|| |
This study was performed at Radiotherapy and Oncology Department at Our Hospital. This is a state government funded hospital where women and children take treatment and has facilities of cobalt (Theratron), Simulator and HDR brachytherapy (Microselectron). 192-Ir is used for HDR brachytherapy that needs to be exchanged after every 4-5 month.
We analyzed data from January 2005 to September 2012 where new patients registered as gynecological malignancy where radiotherapy is indicated (except ovarian cancer). We compared the actual patients were treated on cobalt machine versus brachytherapy.
Being a Government hospital, it is difficult to mobilize 192-Ir sources every 4-5 monthly without interruption of treatment because of policy issue. We analyzed the data regarding installation, treatment gap between last treatment done before source installation and first treatment after source installation.
| » Results|| |
- Total new patients registered: 6157
- Total registered gynecological patients (except carcinoma ovary) 2149 (47.75 percent)
- 35 percent of patients registered are of Carcinoma of the uterine cervix.
- The total patients enrolled for EBRT from 2005 to September 2012: 1663
- The total patients enrolled for brachytherapy from 2005 to September 2012: 794
- The number of patients treated for EBRT versus Brachytherapy hence the average percentage of patients are treated with brachytherapy at our institute - 47.75 percent and the percentage of patients are referred to outside hospital for brachytherapy - 52.25 percent [Figure 1].
Gap calculation in days
From 2005 to September 2012, eight Ir-192 sources were installed in our department. We calculated the average gap in days between date of brachytherapy done before and after installation of Iridium sources. The mean (average) gap in source installation is 123.16 days (17 weeks) [Figure 2].
Iridium sources needs to be replaced every 4-5 monthly hence for 5 year duration around 15 sources are required to give treatment uninterrupted. The approximate cost for 15 sources is 52-53 lakhs. Co-60 source is having 5.26 year half-life hence can be used for 5-6 year without treatment interruption. The cost for single source is approximately 20-22 lakhs hence the cost saving will be approximately 30-32 lakhs [Table 1].
| » Discussion|| |
The carcinoma of the uterine cervix is the most common cancer in India hence the actual cases diagnosed is very high. The clinical presentation is usually at a late stage hence majority of them are treated with radiotherapy. Our retrospective analysis also shows that around 35 percent of patients registered are of Carcinoma of the uterine cervix. The concurrent chemotherapy and radiotherapy remains the standard of treatment for inoperable cases. Concomitant chemotherapy and radiotherapy improves overall and progression-free survival also reduces local and distant recurrence in selected patients. Curative intent of radiotherapy is EBRT with Brachytherapy.
In our institute, around 47.75 percent of registered patients are gynecological malignancies where radiation treatment (which includes both EBRT and brachytherapy) was advised. This incidence is higher than usual as this is exclusive women and children tertiary referral hospital.
At present, 137 Cs is the most commonly used source for LDR and 192-Ir source for HDR brachytherapy while recently 60-Co sources for HDR is gaining popularity. The physical differences in dose distribution around the Co-60 and Ir-192 sources have a negligible effect on the resulting clinical treatment plan quality parameters, especially when dwell optimization through inverse planning techniques is used. However, Co-60 will deliver higher doses than Ir-192 along the extension of the source axis due to anisotropy differences, > percent at 5 cm distal to the applicator. Combined teletherapy along with HDR Co-60 brachytherapy of 850 cGy/fraction, weekly to point A for two fractions for the uterine cancer demonstrated a slightly higher incidence of grade 2 radiation proctitis.
Use of Co-60 source brachytherapy in Indian patients is well-documented by Balsundaram, who concludes that this is the ideal system for after loading brachytherapy system for carcinoma of the uterine cervix. The complications occurred within 3 years were low and acceptable limit if rectal dose monitored closely.
The prolongation of treatment time has a significant impact on pelvic tumor control and cause specific survival regardless tumor size and stage. Delivery of brachytherapy within 4-5 weeks from initiation of irradiation yielded lower pelvic failure rates (8.8 percent vs. 18 percent in stage IIB; P < 0.01). The overall survival depends upon the entire treatment duration (including EBRT and Brachytherapy) and should be less than 8 weeks. In addition, the time gap between teletherapy and brachytherapy in most patients was reported to be more than 2 weeks and was due to limitation of hospital facilities.,
In our analysis, the average gap between EBRT and Brachytherapy is more than 3 weeks (when source installed) and was due to the large number of patients where brachytherapy is indicated and limited hospital facility. Only 47.75 percent of patients who took EBRT at our institute are treated for brachytherapy, remaining 52.25 percent patients we referred to outside hospital. The average gap between EBRT and Brachytherapy because of delay in source installation is 123.16 days (17 week).
Significant cost savings may be achieved with Co-60 since source replacements are required every 4-5 years compared with Ir-192 where new sources are needed every 3-4 months. Equipment down-time and physics support time is also reduced by around 40 percent with Co-60 in comparison with Ir-192. The average cost for single Ir-192 source is Rs. 350,000 which has to be replaced by every 3-4 month hence the average cost of 15 sources for 5 year is Rs. 5,250,000. Although the cost for single Co-60 source is Rs. 2,000,000. The cost saving for 5 year period with cobalt source is approximately Rs. 3,250,000.
| » Conclusion|| |
The combined HDR Co-60 brachytherapy and EBRT provide a useful modality in the treatment of gynecological cancer where radiotherapy is indicated. The treatment interruption because of source exchange is longer in a government hospital due to procedural delay. Cobalt source with 5 year working life is cost-effective; thus it is a feasible option for government funded hospital set up in developing countries.
| » Acknowledgments|| |
The authors are extremely thankful to Dr. R.D. Katke, superintendent, Cama and Albless Hospital, Dr. J.P. Agarwal, Professor and HOU, Tata Hospital, for their valuable guidance.
| » References|| |
Nag S, Erickson B, Thomadsen B, Orton C, Demanes JD, Petereit D. The American brachytherapy society recommendations for high-dose-rate brachytherapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2000;48:201-11.
Pesee M, Krusun S, Padoongcharoen P. High dose rate cobalt-60 afterloading intracavitary therapy for cervical carcinoma in Srinagarind Hospital-analysis of survival. Asian Pac J Cancer Prev 2010;11:1469-71.
Green JA, Kirwan JM, Tierney JF, Symonds P, Fresco L, Collingwood M, et al
. Survival and recurrence after concomitant chemotherapy and radiotherapy for cancer of the uterine cervix: A systematic review and meta-analysis. Lancet 2001;358:781-6.
Palmer A, Mzenda B. Performance assessment of the BEBIG multisource high dose rate brachytherapy treatment unit. Phys Med Biol 2009;54:7417-34.
Balasundaram V. 5-year results and complications of treatment of carcinoma of the cervix using the cathetron in rural India. Sonderb Strahlenther Onkol 1988;82:147-50.
Perez CA, Grigsby PW, Castro-Vita H, Lockett MA. Carcinoma of the uterine cervix. I. Impact of prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy. Int J Radiat Oncol Biol Phys 1995;32:1275-88.
Tangvoraphonkchai V, Pesee M, Boonvisuth V. Tumor registry: An overview of problems shooting in radiotherapy. Thai J Radiol 1989;26:95-8.
Pesee M, Tangvoraphonkchai V, Reamsiri T. Low dose rate brachytherapy caesium-137 after loading in the treatment of carcinoma of uterine cervix in Srinagarind Hospital: Analysis of actuarial survival rate. Thai J Radiol 1995;1:125-30.
[Figure 1], [Figure 2]
|This article has been cited by|
||One thousand cases of cobalt-based high dose rate brachytherapy treated at a tertiary care center: A retrospective study
| ||Janaki Manur Gururajachar, Revathy Thangaraj, Arul Ponni Thiruraju, Kirthi Koushik Agrahara Srinivasa, Ram Charith Alva, Mohan Somashekhar Kumar |
| ||Brachytherapy. 2020; 19(4): 457 |
|[Pubmed] | [DOI]|
||Brachytherapy in India: Learning from the past and looking into the future
| ||Anuj Kumar, Supriya Chopra, Umesh Mahantshetty, Vijay Anand Reddy |
| ||Brachytherapy. 2020; 19(6): 861 |
|[Pubmed] | [DOI]|
||Meeting report, “First Indian national conference on cervical cancer management - expert recommendations and identification of barriers to implementation”
| ||K. S. Tewari,A. Agarwal,A. Pathak,A. Ramesh,B. Parikh,M. Singhal,G. Saini,P. V. Sushma,N. Huilgol,S. Gundeti,S. Gupta,S. Nangia,S. Rawat,S. Alurkar,V. Goswami,B. Swarup,B. Ugile,S. Jain,A. Kukreja |
| ||Gynecologic Oncology Research and Practice. 2018; 5(1) |
|[Pubmed] | [DOI]|
||Treatment outcomes of high-dose-rate intracavitary brachytherapy for cervical cancer: a comparison of Ir-192 versus Co-60 sources
| ||Thanatip Tantivatana,Kanisa Rongsriyam |
| ||Journal of Gynecologic Oncology. 2018; 29(5) |
|[Pubmed] | [DOI]|
||Peer-assisted Learning: Intensity-modulated Radiotherapy Transition in Developing Countries
| ||I. Mohamad,A. Salem,T. Abu Hejleh,S. Wadi-Ramahi,M. Qandeel,S. El Khatib,W. Asha,S. Mhied,O. Al Saraireh,W. Al-Gargaz,H. Abdulelah,A. Hosni,A. Al Mousa |
| ||Clinical Oncology. 2017; 29(10): 689 |
|[Pubmed] | [DOI]|