PUMCH, using new techniques as IMRT and 3D brachytherapy, established a set of standardized precision radiotherapies for cervical cancer. In 12 years, the hospital treated 2,313 cases of locally advanced cervical cancer. Retrospective study showed a five-year survival rate of 77.8% and a local control rate of 86.9%, higher than international reports. The project won first prize of the hospital’s 2017 Medical Achievement Award.
Cervical cancer is one of the common tumors of female reproduction system. In China the annual occurrence is around 100,000, 40-50 years being the peak age. For early stage cases, surgery is mostly applied. For middle and late stage cases, which take half, radiotherapy and concurrent chemotherapy are mostly used. "A decade ago, external irradiation in radiotherapy was already developing very fast, but lacked standardized application on cervical cancer. Brachytherapy was particularly lagging behind internationally advanced practice. Our Department, supported by Obstetrics and Gynecology, has long been probing into the standardization and application of radiotherapy (both external and internal irradiation) on cervical cancer, and established its own mode of precision radiotherapy, "said Zhang Fuquan, director of Department of Radiotherapy, PUMCH.
Radiotherapy developed rapidly in the recent two decades. Compared with conventional external irradiation, the newly emerged IMRT is more precise. Its high dose area is highly consistent with the target and at the same time dose for surrounding normal areas can be significantly reduced. Therefore it is highly effective with minimized toxicity. The uterus, cervix and tumor of a patient will move with the filling of bladder and rectum, and the tumor will also move as it shrinks with treatment. In IMRT, such movement will bring the tumor out of target area and expose normal area to high dose. This made IMRT a challenge in definitive radiotherapy of cervical cancer. In 2006, PUMCH Radiotherapy was the first among Chinese hospitals to use IMRT in definitive radiotherapy of cervical cancer. To reduce risks, a series of image-led operation standards were established, including the mapping out of target area and dose, location verification before radiation and relocation during radiation. Improvements have been continuously made and solutions are found for precise location, verification of organ location, repetition of therapy and accuracy of dose. Meanwhile, new technologies and equipment in the recent decade have been introduced, including VMAT, HT, and complete equipment quality control procedures were designed to ensure therapy stability.
Internal irradiation is another indispensable means, in which the radiation source can be placed inside the body, close to the tumor so as to raise the dose and create better effects. Traditional internal irradiation used 2D technology, had insufficient control of the target area, had seen more local recurrence and complications. From 2005, PUMCH Radiotherapy was leading Chinese hospitals in carrying out clinical research of 3D brachytherapy and its gradual application. As the operations are complicated, the department probed into the implanting procedures, mapping out of the target area, protection of affected organs and the evaluation of dose, and established a set of standards. One invention patent and seven utility model patents came out of this. Based on traditional 2D therapy, the procedure was improved through increased image lead and more individualized design, so as to boost efficacy and reduce complications from location errors. Expert consensus for treating locally advanced cervical cancer was established, which was more suitable for most Chinese hospitals which were incapable of 3D therapy.
The combination of external and internal irradiation can maximize dose for the tumor, protect normal tissues, increase local control rate and significantly reduce complications. Concurrent chemotherapy would boost the overall efficacy. The team had a retrospective analysis of 1,433cases between 2006 and 2015, and reported a median follow-up time of 32.2 months, five-year overall survival rate of 77.8%, local control rate 86.9%. Of them, three-year disease-free survival rates for 2B and 3B stages were 77.3% and 60.1%. With concurrent chemoradiation, the rates could reach 81.6% and 65.4%, both higher than foreign literature reports (55.1%~73.8%), while toxicity above III was only 3.4%. The results were published in the US-based Journal of Gynecologic Cancer.
Apart from image-led precision radiation and overall procedure quality control, the hospital also provided all patients with individualized solutions. For the clinical difficulty of retroperitoneal lymph node metastasis, the hospital set up a mode of screening high-risk patients for prevention and treatment, and organized multi-center prospective study across the country. The standardized system, apart from radiotherapy, also includes assessment and indication before treatment, assessment after treatment, and especially a follow-up system, with a databank of more than 5,000 cases.
For more than a decade, Radiotherapy not only carried out advanced clinical practice but trained a batch of master and doctoral students and led many national multi-center studies. It published a dozen SCI essays and more than 30 core journal essays. It also held seven training classes and served as a training base for brachytherapy, thus serving as a leader in gynecologic cancer radiotherapy among Chinese hospitals.