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Original article
peer-reviewed

Barriers to Timely Completion of Radiation Therapy in Patients with Cervical Cancer in an Urban Tertiary Care Center



Abstract

Background

In 2017, there will be an estimated 12,820 women diagnosed with cervical cancer in the United States, causing an estimation of 4,210 deaths. Among U.S. women, there is a 33% greater incidence and 71% higher cervical cancer mortality in high-poverty counties when compared to low-income counties [1]. In those dispositioned to chemoradiation, treatment time of less than eight weeks is associated with compromised pelvic control. We sought to identify patient or disease characteristics and socioeconomic or psychosocial barriers that contribute to delays in treatment completion in order to formulate new policies to address these needs.

​​​​​​Methods

Cervical cancer patients treated with primary chemoradiation through the University of Maryland from 2011-2016 were identified retrospectively. Patients were placed in one of two groups: those who completed radiation treatment within 56 days, and those who failed to complete treatment within 56 days. Time to completion of radiation therapy was evaluated in relation to patient and disease variables.

​​​​Results

Forty-three patients with sufficient information for inclusion were identified. The median age was 51 years. Ten patients were stage I at diagnosis (23.3%), 16 were stage II (37.2%), 11 were stage III (25.5%) and six were stage IV (14%). Histopathology revealed squamous cell carcinoma in 37 patients (86%), adenocarcinoma in three patients (7%), mixed histology in two patients (4.7%), and neuroendocrine histology in one patient (2.3%). Twenty patients (46.5%) completed treatment within the recommended timeframe of 56 days while 23 patients (53.5%) did not. The most common reasons for a protracted treatment, or failure to complete the prescribed treatment were non-compliance/psychosocial factors (10 patients, 43.5%). Age, race, primary language, marital status, insurance, employment status, HIV status, mental health, substance abuse, tobacco use, stage at diagnosis, performance status at diagnosis, BMI (body mass index, kg/m2) at diagnosis, and income by zip code were not significantly associated with protracted treatment. The distance to treatment center was a significant factor (p=0.07); patients who lived closest to the treatment center were least likely to complete RT in the designated time frame. This is most likely due to the location of the treatment center, which is in the heart of an urban, low socioeconomic area.

Conclusions

More than half of all cervical cancer patients presenting to an urban tertiary care center do not complete chemoradiation therapy in the recommended timeframe. Underlying psychosocial factors are prominent. The role for patient navigation in this vulnerable population must be investigated.



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Original article
peer-reviewed

Barriers to Timely Completion of Radiation Therapy in Patients with Cervical Cancer in an Urban Tertiary Care Center


Author Information

Justin Cohen

Department of Radiation Oncology, University of Maryland Medical Center

Amy Harper

Deptment of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine

Elizabeth M. Nichols

Department of Radiation Oncology, University of Maryland School of Medicine

Gautam G. Rao

Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine

Pranshu Mohindra

Department of Radiation Oncology, University of Maryland School of Medicine

Dana Marie Roque Corresponding Author

Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Human Research Protections Office issued approval HP-00061673. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Original article
peer-reviewed

Barriers to Timely Completion of Radiation Therapy in Patients with Cervical Cancer in an Urban Tertiary Care Center


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Original article
peer-reviewed

Barriers to Timely Completion of Radiation Therapy in Patients with Cervical Cancer in an Urban Tertiary Care Center

Justin Cohen">Justin Cohen, Amy Harper">Amy Harper, Elizabeth M. Nichols">Elizabeth M. Nichols, Gautam G. Rao">Gautam G. Rao, Pranshu Mohindra">Pranshu Mohindra, Dana Marie Roque">Dana Marie Roque

  • Author Information
    Justin Cohen

    Department of Radiation Oncology, University of Maryland Medical Center

    Amy Harper

    Deptment of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine

    Elizabeth M. Nichols

    Department of Radiation Oncology, University of Maryland School of Medicine

    Gautam G. Rao

    Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine

    Pranshu Mohindra

    Department of Radiation Oncology, University of Maryland School of Medicine

    Dana Marie Roque Corresponding Author

    Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Human Research Protections Office issued approval HP-00061673. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

    Acknowledgements


    Article Information

    Published: September 12, 2017

    DOI

    10.7759/cureus.1681

    Cite this article as:

    Cohen J, Harper A, Nichols E M, et al. (September 12, 2017) Barriers to Timely Completion of Radiation Therapy in Patients with Cervical Cancer in an Urban Tertiary Care Center. Cureus 9(9): e1681. doi:10.7759/cureus.1681

    Publication history

    Received by Cureus: June 27, 2017
    Peer review began: July 06, 2017
    Peer review concluded: September 07, 2017
    Published: September 12, 2017

    Copyright

    © Copyright 2017
    Cohen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background

In 2017, there will be an estimated 12,820 women diagnosed with cervical cancer in the United States, causing an estimation of 4,210 deaths. Among U.S. women, there is a 33% greater incidence and 71% higher cervical cancer mortality in high-poverty counties when compared to low-income counties [1]. In those dispositioned to chemoradiation, treatment time of less than eight weeks is associated with compromised pelvic control. We sought to identify patient or disease characteristics and socioeconomic or psychosocial barriers that contribute to delays in treatment completion in order to formulate new policies to address these needs.

​​​​​​Methods

Cervical cancer patients treated with primary chemoradiation through the University of Maryland from 2011-2016 were identified retrospectively. Patients were placed in one of two groups: those who completed radiation treatment within 56 days, and those who failed to complete treatment within 56 days. Time to completion of radiation therapy was evaluated in relation to patient and disease variables.

​​​​Results

Forty-three patients with sufficient information for inclusion were identified. The median age was 51 years. Ten patients were stage I at diagnosis (23.3%), 16 were stage II (37.2%), 11 were stage III (25.5%) and six were stage IV (14%). Histopathology revealed squamous cell carcinoma in 37 patients (86%), adenocarcinoma in three patients (7%), mixed histology in two patients (4.7%), and neuroendocrine histology in one patient (2.3%). Twenty patients (46.5%) completed treatment within the recommended timeframe of 56 days while 23 patients (53.5%) did not. The most common reasons for a protracted treatment, or failure to complete the prescribed treatment were non-compliance/psychosocial factors (10 patients, 43.5%). Age, race, primary language, marital status, insurance, employment status, HIV status, mental health, substance abuse, tobacco use, stage at diagnosis, performance status at diagnosis, BMI (body mass index, kg/m2) at diagnosis, and income by zip code were not significantly associated with protracted treatment. The distance to treatment center was a significant factor (p=0.07); patients who lived closest to the treatment center were least likely to complete RT in the designated time frame. This is most likely due to the location of the treatment center, which is in the heart of an urban, low socioeconomic area.

Conclusions

More than half of all cervical cancer patients presenting to an urban tertiary care center do not complete chemoradiation therapy in the recommended timeframe. Underlying psychosocial factors are prominent. The role for patient navigation in this vulnerable population must be investigated.



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Justin Cohen

Department of Radiation Oncology, University of Maryland Medical Center

Amy Harper

Deptment of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine

Elizabeth M. Nichols

Department of Radiation Oncology, University of Maryland School of Medicine

Gautam G. Rao

Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine

Pranshu Mohindra

Department of Radiation Oncology, University of Maryland School of Medicine

Dana Marie Roque

Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine

For correspondence:
dana.m.roque@gmail.com

Justin Cohen

Department of Radiation Oncology, University of Maryland Medical Center

Amy Harper

Deptment of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine

Elizabeth M. Nichols

Department of Radiation Oncology, University of Maryland School of Medicine

Gautam G. Rao

Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine

Pranshu Mohindra

Department of Radiation Oncology, University of Maryland School of Medicine

Dana Marie Roque

Division of Gynecologic Oncology, Department of Ob/Gyn, University of Maryland School of Medicine

For correspondence:
dana.m.roque@gmail.com