E. MacDuffie1, C. Kernell2, J. George3, M. Nsingo4, L. Bazzett Matabele5, P. Vuylsteke5,6, M. Kassick7, and S. Grover6; 1Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 2University of Texas at Southwestern, Dallas, TX, 3Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA, 4Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana, 5University of Botswana, Gaborone, Botswana, 6Princess Marina Hospital, Gaborone, Botswana, 7Tufts University School of Medicine, Boston, MA
Purpose/Objective(s): While the standard treatment of locally advanced cervical cancer consists of chemoradiation (CRT), the benefit of induction chemotherapy (IC) is currently a topic of investigation. In Botswana, a sub-Saharan African low- and middle-income country (LMIC), standard treatment pathways were disrupted due to the COVID-19 pandemic. In response, patients were prescribed IC followed by radiotherapy (RT) or CRT in an effort to address these treatment delays. This study compares the outcomes of patients treated with IC compared to historical controls who received standard CRT, RT alone, or no treatment. Materials/
Methods: Women in Botswana presenting with locally advanced cervical cancer were enrolled in a prospective study.Overall survival (OS) was estimated using the Kaplan-Meier method. Multivariable Cox regression (aHR) adjusted for age, disease stage, HIV status, and treatment group were used to identify factors associated with OS. Results: Between 2019-2022, 91 patients were prescribed IC prior to RT or CRT. Treatment characteristics and outcomes were compared to those of 169 patients who received CRT or 111 patients who received RT alone between 2014-2019, and 134 patients who received no treatment between 2014-2022. The median age across cohorts was 49 years (IQR 42-61 years) and 68.7% (n=347) were living with HIV infection. FIGO stage III represented 45.7% of the cohort. Among those who were prescribed IC, 70.3% received =3 cycles and 7.7% received 1-3 cycles. After receipt of IC, 65.9% received RT alone and 6.6% received CRT with =1 cycle of concurrent chemotherapy. Among all patients, median follow-up was 22.1 months (95% CI 19.6-24.7 months) and 2-year OS was 55.6% (95% CI 50.9-60.8%). The 2-year OS rate was 80.0% (95% CI 74.0-86.4%), 31.2% (95% CI 23.0-42.4%), 69.2% (95% CI 59.8-80.2%), and 84.2% (95% CI 75.1-94.3%) for historical CRT patients, historical RT alone patients, those prescribed IC, and those who received IC followed by RT/CRT, respectively. Survival did not differ between those who received CRT and those prescribed IC (p=0.07) or those who received IC and RT/CRT (p=0.50). Those prescribed IC had improved survival over patients who received RT alone (p < 0.001) and those who received no treatment (p < 0.001). Among patients prescribed IC, stage III-IV (aHR 3.00, p=0.04) versus I-II disease increased the risk of mortality, while receipt of IC followed by RT/CRT (aHR 0.15, p<0.001) compared to those who did not receive any IC decreased the risk of the mortality. Among patients who received IC followed by RT/CRT, stage III-IV (aHR 12.92, p=0.02) versus I-II disease increased the risk of mortality. Conclusion: Patients prescribed IC experienced survival outcomes similar to historical controls who received standard CRT, and were at lower risk of mortality compared to historical controls who received RT alone or no treatment. This treatment pathway may provide an alternative option for providers in LMICs who experience delays in access to CRT.
