Purpose

Brachytherapy remains integral component in curative-intent management of locally advanced cervical cancer, with overall treatment time (OTT) strongly influencing outcomes. In this study, we intended to analyze single-application two-fraction (SATF) high-dose-rate (HDR) brachytherapy feasibility, treatment outcomes, and toxicities.

Material and methods

This study included 238 patients with stage IB-IVA (FIGO 2018) cervical cancer treated with definitive external beam chemoradiation 45 Gray (Gy) in 25 fractions and concurrent weekly cisplatin, followed by SATF HDR brachytherapy (7 Gy × 4 fractions in two applications, ≥ 12 hours apart) between April 2020 and December 2022. Primary endpoint was 3-year disease-free survival (DFS), while secondary endpoints were 3-year overall survival (OS), local control (LC), and acute/late toxicities (as per RTOG criteria).

Results

Out of 238 treated patients, majority of them had squamous cell carcinoma (96.6%) and locally advanced disease (stage IIB: 47.5%, IIIC1r: 28.2%). Intracavitary brachytherapy was used in 89.5% of cases. The mean EQD₂ D₉₀ HR-CTV and point A were 88 Gy and 77.7 Gy, respectively. The mean EQD₂ of the bladder 2 cc, rectum 2 cc, and sigmoid 2 cc were 85.1 Gy, 66.0 Gy, and 69.9 Gy, respectively. At a median follow-up of 45 months, 73 DFS events and
69 deaths were recorded. The 3-year DFS and OS were 70.2 ±3% and 72.2 ±3%, respectively. On univariate analysis, stage IIB was associated with a significantly lower hazard of recurrence (HR: 0.27, 95% CI: 0.11-0.65, p = 0.003) and death (HR: 0.23, 95% CI: 0.10-0.57, p = 0.001). No acute grade ≥ 3 toxicities were reported. At 24 months, the cumulative actuarial rates for late grade ≥ 2 late gastrointestinal (GI) and genitourinary (GU) toxicities were 12.2% and 1.7%, respectively, with grade ≥ 3 GI toxicity (8.2% at 12 months) showing a declining trend over time.

Conclusions

SATF HDR brachytherapy with chemoradiation offers favorable disease control and acceptable late toxicities, with good dosimetry while optimizing OTT in cervical cancer management. This approach is feasible and especially effective in high-volume, resource-constrained LMIC settings.