Cervical Cancer in the Commonwealth: Collective Action

Background and context: Fifty-three countries are members of the Commonwealth. These countries span Africa, Asia, the Americas, Europe and the Pacific and are diverse - they are among the world's largest, smallest, richest and poorest countries. Thirty-one of these members are classified as small states - countries with a population size of 1.5 million people or less and larger member states that share similar characteristics with them. The Commonwealth Secretariat is planning to tackle the problem of cervical cancer in their low and middle member states (LMIC) through the project “Cervical Cancer in the Commonwealth: Collective Action”. There are 209,100 cervical cancer cases diagnosed per year in the Commonwealth, and in 167,300 cases radiotherapy treatment is indicated. Aim: To analyze the problem of cervical cancer in low and middle-income countries of the Commonwealth and to propose the first step for a collective action. Strategy/Tactics: The treatment of locally advanced cervical cancer includes radiotherapy (teletherapy and brachytherapy) plus concomitant chemotherapy. Cervical cancer has a high rate of curability if brachytherapy is added to teletherapy. We identified radiotherapy departments in Commonwealth LMIC with teletherapy but no brachytherapy and proposed the upgrade of these services to include brachytherapy as a first step. Program/Policy process: The evidence-based treatment of locally advanced cervical cancer is a combination of external beam radiotherapy with chemotherapy and brachytherapy. Brachytherapy has played a major role during many decades in the treatment of gynecologic cancer with good clinical results. EBRT combined with BT leads to superior survival for patients with cervix cancer as compared with EBRT alone, and additionally, MR image-guided BT further improves local control and survival. Countries with no access to BT may only offer palliative treatment to women diagnosed with locally advanced cervical cancer. Any curative attempt for these patients should include brachytherapy. The addition of brachytherapy to external beam radiotherapy in the treatment of cervical cancer is associated with a 12% increase in the 4-y overall survival rates and 13% increase in cause-specify survival. Brachytherapy can save at least 12% more cervical cancer lives than radiotherapy alone. These differences would be much bigger in LMIC because of the limited technology used for external beam radiotherapy. Outcomes: Each high dose rate (HDR) brachytherapy afterloader can treat up to 666 patients per year, of which 466 (70%) could be potentially cured. The capital costs for installing an HDR afterloader is around US$ 1 million, including equipment and building, the annual operating costs are US$ 473,000, and the costs of brachytherapy are US$ 710 per patient. In the lifetime of an HDR afterloader (10 years), 4660 patients could be cured per afterloader installed. What was learned: Brachytherapy saves lives!