Disparities in standard of care treatment and associated survival decrement in patients with locally advanced cervical cancer

Published:September 16, 2016DOI:


      • Less than half of patients with locally advanced cervix cancer receive SOC therapy despite a substantial OS benefit.
      • Management per SOC guidelines was associated with private insurance, higher income, and higher volume centers.
      • Patients with lower incomes and those treated at low volume centers were more likely to receive no radiotherapy boost.



      Standard of care (SOC) treatment for locally advanced cervical cancer includes pelvic external beam radiation (EBRT) with chemotherapy and interdigitated brachytherapy. We evaluated national utilization trends and factors associated with receiving SOC therapy.

      Materials and methods

      We utilized the National Cancer Database (NCDB) to identify women with locally advanced cervical cancer treated with definitive radiation or chemoradiation therapy and stratified these patients by treatment received.


      We identified 15,194 patients. Only 44.3% of patients received SOC treatment and this group had significantly improved OS. High volume centers, academic centers, comprehensive community cancer centers, private insurance, and higher income, were all associated with an increased likelihood of receiving SOC, whereas Black patients were less likely to receive SOC. We found 26.8% of patients received no radiation boost, 23.8% received an EBRT boost only, and 49.5% of patients received EBRT with brachytherapy. Although an EBRT boost was advantageous over no boost at all (HR 0.720, p < 0.001), OS was superior in patients who received brachytherapy (HR 0.554, p < 0.001). Patients were more likely to receive no radiotherapy boost if they had lower incomes, Medicaid, were treated at low volume centers, or were treated at non-comprehensive community cancer centers.


      SOC for locally advanced cervical cancer offers superior outcomes, yet less than half of patients receive SOC and there are disparities in which patients receive SOC treatment. No additional treatment, including sophisticated EBRT techniques including IMRT or SBRT, can make up for the survival decrement from lack of brachytherapy as a component of definitive care.


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        • Coia L.
        • Won M.
        • Lanciano R.
        • Marcial V.A.
        • Martz K.
        • Hanks G.
        The Patterns of Care Outcome Study for cancer of the uterine cervix. Results of the Second National Practice Survey.
        Cancer-Am. Cancer Soc. 1990; 66: 2451-2456
        • Hanks G.E.
        • Herring D.F.
        • Kramer S.
        Patterns of care outcome studies. Results of the national practice in cancer of the cervix.
        Cancer-Am. Cancer Soc. 1983; 51: 959-967
        • Lanciano R.M.
        • Won M.
        • Coia L.R.
        • Hanks G.E.
        Pretreatment and treatment factors associated with improved outcome in squamous cell carcinoma of the uterine cervix: a final report of the 1973 and 1978 patterns of care studies.
        Int. J. Radiat. Oncol. Biol. Phys. 1991; 20: 667-676
        • Montana G.S.
        • Martz K.L.
        • Hanks G.E.
        Patterns and sites of failure in cervix cancer treated in the U.S.A. in 1978.
        Int. J. Radiat. Oncol. Biol. Phys. 1991; 20: 87-93
        • Han K.
        • Milosevic M.
        • Fyles A.
        • Pintilie M.
        • Viswanathan A.N.
        Trends in the utilization of brachytherapy in cervical cancer in the United States.
        Int. J. Radiat. Oncol. Biol. Phys. 2013; 87: 111-119
        • Lin J.F.
        • Berger J.L.
        • Krivak T.C.
        • Beriwal S.
        • Chan J.K.
        • Sukumvanich P.
        • et al.
        Impact of facility volume on therapy and survival for locally advanced cervical cancer.
        Gynecol. Oncol. 2014; 132: 416-422
        • Viswanathan A.N.
        • Thomadsen B.
        American Brachytherapy Society Cervical Cancer Recommendations C, American Brachytherapy S. American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part I: general principles.
        Brachytherapy. 2012; 11: 33-46
        • Gill B.S.
        • Lin J.F.
        • Krivak T.C.
        • Sukumvanich P.
        • Laskey R.A.
        • Ross M.S.
        • et al.
        National Cancer Data Base analysis of radiation therapy consolidation modality for cervical cancer: the impact of new technological advancements.
        Int. J. Radiat. Oncol. Biol. Phys. 2014; 90: 1083-1090
      1. Oncology (Williston Park). 1999; 13: 382
        • Keys H.M.
        • Bundy B.N.
        • Stehman F.B.
        • Muderspach L.I.
        • Chafe W.E.
        • Suggs 3rd, C.L.
        • et al.
        Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma.
        N. Engl. J. Med. 1999; 340: 1154-1161
        • Morris M.
        • Eifel P.J.
        • Lu J.
        • Grigsby P.W.
        • Levenback C.
        • Stevens R.E.
        • et al.
        Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer.
        N. Engl. J. Med. 1999; 340: 1137-1143
        • Peters 3rd, W.A.
        • Liu P.Y.
        • Barrett 2nd, R.J.
        • Stock R.J.
        • Monk B.J.
        • Berek J.S.
        • et al.
        Concurrent chemotherapy and pelvic radiation therapy compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early-stage cancer of the cervix.
        J. Clin. Oncol. 2000; 18: 1606-1613
        • Rose P.G.
        • Bundy B.N.
        • Watkins E.B.
        • Thigpen J.T.
        • Deppe G.
        • Maiman M.A.
        • et al.
        Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer.
        N. Engl. J. Med. 1999; 340: 1144-1153
        • Whitney C.W.
        • Sause W.
        • Bundy B.N.
        • Malfetano J.H.
        • Hannigan E.V.
        • Fowler Jr., W.C.
        • et al.
        Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: a Gynecologic Oncology Group and Southwest Oncology Group study.
        J. Clin. Oncol. 1999; 17: 1339-1348
        • Wright J.D.
        • Huang Y.
        • Ananth C.V.
        • Tergas A.I.
        • Duffy C.
        • Deutsch I.
        • et al.
        Influence of treatment center and hospital volume on survival for locally advanced cervical cancer.
        Gynecol. Oncol. 2015; 139: 506-512
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J. Chronic Dis. 1987; 40: 373-383
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J. Clin. Epidemiol. 1992; 45: 613-619
        • Carlson J.A.
        • Rusthoven C.
        • DeWitt P.E.
        • Davidson S.A.
        • Schefter T.E.
        • Fisher C.M.
        Are we appropriately selecting therapy for patients with cervical cancer? Longitudinal patterns-of-care analysis for stage IB-IIB cervical cancer.
        Int. J. Radiat. Oncol. Biol. Phys. 2014; 90: 786-793
        • Clegg L.X.
        • Li F.P.
        • Hankey B.F.
        • Chu K.
        • Edwards B.K.
        Cancer survival among US whites and minorities: a SEER (Surveillance, Epidemiology, and End Results) Program population-based study.
        Arch. Intern. Med. 2002; 162: 1985-1993
        • Margolis B.
        • Tergas A.I.
        • Chen L.
        • Hou J.Y.
        • Burke W.M.
        • Hu J.C.
        • et al.
        Natural history and outcome of neuroendocrine carcinoma of the cervix.
        Gynecol. Oncol. 2016; 141: 247-254
        • Saeed A.M.
        • Toonkel R.
        • Glassberg M.K.
        • Nguyen D.
        • Hu J.J.
        • Zimmers T.A.
        • et al.
        The influence of Hispanic ethnicity on nonsmall cell lung cancer histology and patient survival.
        Cancer-Am. Cancer Soc. 2012; 118: 4495-4501
        • Monk B.J.
        • Tian C.
        • Rose P.G.
        • Lanciano R.
        Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials.
        Gynecol. Oncol. 2007; 105: 427-433
        • Walker G.V.
        • Grant S.R.
        • Guadagnolo B.A.
        • Hoffman K.E.
        • Smith B.D.
        • Koshy M.
        • et al.
        Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status.
        J. Clin. Oncol. 2014; 32: 3118-3125