Survival outcomes of cervical cancer patients treated with external beam radiotherapy boost in Rwanda

This study aimed to describe overall survival outcomes by treatment modality among women with International Federation of Gynecology and Obstetrics stage I to IVA cervical cancer treated with external beam radiotherapy using a boost technique in Rwanda, where brachytherapy is unavailable.

We conducted a retrospective cohort study of women with International Federation of Gynecology and Obstetrics stage I to IVA cervical cancer treated at the Rwanda Cancer Centre/Rwanda Military Teaching Hospital between July 2018 and April 2023. All patients were planned for pelvic external beam radiotherapy with a simultaneous integrated boost (45 Gy to the whole pelvis with a boost to 70 Gy to the primary tumor and involved nodes in 30 fractions) delivered using intensity-modulated radiotherapy. Overall survival was defined as the time from the date of pathologic diagnosis to death or last contact, and was censored at 3 years. Overall survival was estimated using Kaplan-Meier methods and compared using log-rank tests. Multi-variable Cox regression with multiple imputation for missing covariates was used to assess associations between treatment modality and overall survival.

Of 591 women seen, 577 met the eligibility criteria. Most (42.7%) presented with stage III disease. Treatment allocation was as follows: no treatment (12.7%), radiotherapy alone (3.9%), concurrent chemoradiotherapy (67.5%), and induction chemotherapy followed by concurrent chemoradiotherapy (15.9%). Two-year overall survival was 13.9% for no treatment, 44.1% for radiotherapy alone, 62.2% for concurrent chemoradiotherapy, and 76.4% for induction chemotherapy plus concurrent chemoradiotherapy. In adjusted models, all active treatment modalities were associated with lower hazards of death compared with no treatment.

In this cohort in which brachytherapy was unavailable, survival among women with cervical cancer was strongly determined by treatment modality. Timely delivery of concurrent chemoradiotherapy, with or without induction chemotherapy, achieved 2-year overall survival comparable to regional reports, whereas absence of treatment was associated with dismal outcomes. These findings reinforce the urgent need to invest in brachytherapy capacity in Rwanda and similar resource-constrained settings.