title: Long-term result of high dose-rate afterloading brachytherapy in squamous cell carcinoma of the cervix: relationship between facility structure and outcome.
abstract: OBJECTIVE
  To compare outcome results for squamous cell carcinoma of the uterine cervix between patients treated in a single facility [single facility therapy: (SFT)] and others combined with external beam irradiation (EBRT) in a small facility and intracavitary brachytherapy in a central facility (combined facilities therapy: CFT).
  
  
  METHODS
  This is a retrospective analysis of 155 patients with histologically proven squamous cell carcinoma of the cervix radically treated by EBRT and high dose-rate (HDR) intracavitary brachytherapy from August 1995 to May 2000. The overall survival and cause-specific survival rates were calculated by using the Kaplan-Meier method. The endpoint was defined as death due to cervical cancer for the cause-specific survival. The log-rank test and the generalized Wilcoxon test were used to compare the survival curves between the two treatment groups.
  
  
  RESULTS
  Nine patients were lost, so 146 patients were retrospectively analyzed. There were 22 patients (15%) in stage I, 21 (14%) stage IIA, 51 (35%) stage IIB, 41 (28%) stage III, 11 (8%) stage IVA. The median age was 72 years (range, 30-89 years). The median follow-up time was 58 months. The proportion of patients treated with SFT was 23% (33/146) and CFT 77% (113/146). The overall survival rate was 62.3% and the cause-specific survival rate was 71.3%. The cause-specific survival rates for SFT and CFT were 87.9% and 66.4%, respectively; the difference between these two treatments was statistically significant (P = 0.024). The difference in the survival rate between these two treatments for stage III and IVA patients was also statistically significant (P = 0.021). However, no significant difference between these treatments was seen in the cause-specific survival rate for each stage. There was a significant difference between SFT and CFT in the incidence rate of severe late complications (grade 3-5) (P = 0.038). There was no significant difference in overall treatment times and total dose between the two groups; the applied photon beam energy showed a significant difference.
  
  
  CONCLUSIONS
  Our results suggest that the survival outcome will be aggravated by CFT. If the treatment process of using a lower photon beam energy were to be improved by the installation of a high-energy linear accelerator, CFT can be applied to patients with cervical cancer.
authors.affiliation: Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Japan. okuda@sc.dcns.ne.jp
authors.forename: Takahito
authors.initials: T
authors.lastname: Okuda
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Itho
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Ikeda
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Nakamura
authors.forename: Yoshimi
authors.initials: Y
authors.lastname: Horikawa
authors.forename: Shigeo
authors.initials: S
authors.lastname: Yanagawa
authors.forename: Takeo
authors.initials: T
authors.lastname: Ishigaki
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy; D002173:Cancer Care Facilities / Q000706:statistics & numerical data; D002294:Carcinoma, Squamous Cell / Q000401:mortality / Q000532:radiotherapy*; D019583:Dose Fractionation, Radiation; D004307:Dose-Response Relationship, Radiation; D005260:Female; D006801:Humans; D008875:Middle Aged; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D002583:Uterine Cervical Neoplasms / Q000401:mortality / Q000532:radiotherapy*