Help with cervical cancer case

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napoleondynamite

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I have a very challenging mid-50's female, previously healthy and good performance status with FIGO Stage IIIB SCC of cervix. Disease extended to lower vagina and was wrapping around the uterus essentially and into the adnexa. By MRI, was intimately associated with both bladder and rectum, but no clear invasion by imaging nor by exam.

She was treated with 2c of Carbo/Taxol and had an excellent clinical response. Plan was for standard chemoRT and brachy, however she sought alternative therapies and has been very resistant to starting treatment..now nearly 2 months since completion of the 2c of chemo.

I saw her as a second opinion (I was not involved with the above) and the mere mention of brachy nearly had her run from the clinic. I emphasized that time is of the essence and she needs to start yesterday, last week, last month! She believes that the excellent clinical response she had was, of course not the chemo, but the alternative therapies she has been taking.

I think I can twist her arm to do chemoRT but no way on brachy. She just will not do it and I think would go AWOL on us if that is the only option. I have never had this happen, so would love to hear what others would do in this situation:

1) Present only the SOC option of chemoRT with brachy
2) Start with chemoRT and hope you can twist her arm for brachy after she earns your confidence, but also knowing that with this patient, it really does seem very unlikely
3) Start with chemoRT, boost what you can with EBRT afterward
4) other ideas?

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I would document the above discussion and cite the data showing poorer outcomes without brachy (there are papers floating around showing that, can't remember the specifics off the top of my head) as well as the patient agreeing to proceed with less efficacious Tx because of refusal to have brachy.... after all of that, I would do an IMRT boost to 60-70 as tolerated. The other option is to send her for a 3rd opinion to your local ivory tower cervix specialist and let them deal with her :)
 
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There is data on SBRT boosts. Not ideal, but similar in philosophy to brachytherapy, 25/5 fx seems reasonable, probably higher biologically than EBRT. Can get fiducials placed and fuse to MRI and tight margins. IMRT fine, too.

Can't make someone do something they don't want to do.. sad case.
 
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Induction chemo? Already off from the standard of care. I would prescribe 45 Gy and refer to a regional academic center while she is going though it. EBRT/SBRT boost does not work well.
 
I've had a couple of cases like this. No matter what you do, they invariably recur locally. There is a good reason that standard of care includes brachytherapy.

Agree with above posters - the best you can do is to document your recommendations, document her non-compliance, and try to do the best you can with conventional dose escalation or SBRT.
 
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What about 45Gy + Surgery? Though if she doesn't want brachy, she probably doesn't want a potentially curative surgery in this case.
 
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We get a lot of this type of crap in Florida. I am constantly being advised not to change your treatment approach because you have a difficult/stupid patient. She really needs MRI guided/interstitial brachy.

I have done 1 case in my career of an SBRT cervix boost in a frail patient who would not tolerate brachy. The biggest thing I learned after having to replan- make sure at time of sim and treatment, patient has empty rectum with enema/rectal tube. Because of the curvy relationship (on sagital) between rectum and cervix, change in rectum can easily put the rectum into your srs volume. (obviously, place fiducial and fuse mri)
 
We get a lot of this type of crap in Florida. I am constantly being advised not to change your treatment approach because you have a difficult/stupid patient. She really needs MRI guided/interstitial brachy.

I have done 1 case in my career of an SBRT cervix boost in a frail patient who would not tolerate brachy. The biggest thing I learned after having to replan- make sure at time of sim and treatment, patient has empty (reproducible) rectum with enema/rectal tube. Because of the curvy relationship (on sagital) between rectum and cervix, change in rectum can easily put the rectum into your srs volume. (obviously, place fiducial and fuse mri)
 
Obtain MRI before proceeding with chemo-XRT. Use vaginal contrast. Proceed with chemo-XRT. Obtain MRI near end of chemo-XRT. Try to convince to do brachy (badly needs interstitial, refer to RETRO-EMBRACE study). Why is she so scared of brachy? If still refuses, do SBRT (6x5) and fuse with MRI (do a EQD2 calc to try to get 85Gy to high risk CTV, intermediate risk CTV to 60s), need a very good bowel prep plus rectal tube (can use foley), fill bladder to a a known full amount each time before treatment and clamp foley. Be ready to re-sim and re-plan quick due to bowel gas. If uncomfortable, refer to ivory tower.
 
Unfortunately I see a fair number of flaky patients with very advanced disease and my experience has taught me almost without fail that all of the stress and thought that goes into formulating the best plan for these patients is useless. Either they don't complete treatment or their disease is so advanced they invariably met out (The last 2 patients I treated with cervix CA and adnexal involvement developed frank peritoneal carcinomatosis within a few months of treatment completion). I'm not saying you shouldn't develop a good plan, but in my experience, it almost never matters for reasons mentioned above.
 
Everyone seems to have a difficult cervical cancer patient or two in their logs. Patients who have zero desire to do recommended treatment, going instead for alternative therapies, or on their own schedule, who then don't do well.

You can try an EBRT boost with IMRT to 60+ Gy if adamantly against brachy. I would offer to at least get her treated with EBRT - discuss that it's not going to cure her and when she recurs she'll have to have an exenteration if she wants to continue living.
 
What about 45Gy + Surgery? Though if she doesn't want brachy, she probably doesn't want a potentially curative surgery in this case.
Since the lower vagina was initially involved, surgery would be mutilating.
You'd still need to resect down there, irrelevant of the response to neoadjuvant chemo.
 
Accept that you can't cure people that don't want to be cured, document it, and do the best you can. UTSW has an SBRT protocol if you want to use that as a guide but for very advanced disease like this she needs intracavitary and probably needs interstitial as well. In theory throwing in fiducials and fusing an MRI for SBRT sounds reasonable but it's quite difficult in practice, especially without a dedicated MR sim. I'm not sure how you do your brachy but perhaps she'd be willing to do it with an epidural.
 
Interesting....

"IMRT or SBRT boost resulted in inferior overall survival (hazard ratio, 1.86; 95% confidence interval, 1.35-2.55; P<.01) as compared with brachytherapy. In fact, the survival detriment associated with IMRT or SBRT boost was stronger than that associated with excluding chemotherapy (hazard ratio, 1.61' 95% confidence interval, 1.27-2.04' P<.01)."
 
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