Implementing Image-Guided Brachytherapy (IGBT) For Cervical Cancer in Resource-Limited Settings: An International Multicentric Cross-Sectional Study of Resource and Workflow Impact

Use of image-guided brachytherapy (IGBT) in cervical cancer improves patient outcomes. However, implementation in resource-limited settings is challenging due to limited capacity upscale, absence of workflow enhancement strategies, and financial barriers. Optimizing workflows is essential, yet the relationship between workflow efficiency and IGBT uptake remains unclear.

This cross-sectional study examined brachytherapy (BT) workflows across 14 nationally representative centers. Standardized forms collected data on infrastructure, treatment workflows ((A): Conventional two-dimensional (2D) X-Ray-Guided BT, with point-A-based fractions planned using 2D X-ray imaging, (B): Standard intracavitary (IC) three-dimensional (3D) IGBT, with fractions planned using computed tomography (CT)- or magnetic resonance (MR)-based imaging with volume-based prescriptions, (C): Advanced 3D IGBT, with fractions delivered using advanced IC or intracavitary-interstitial (IC-IS) techniques and planned using CT- or MR-based imaging with volume-based prescriptions.)), procedural times, anesthesia, imaging, and treatment planning. National BT resource data was also collected. Recommendations were developed to optimize workflows and facilitate IGBT transition.

A total of 365 workflows were analyzed, wherein workflow B was most common (51%). Median procedure times were 2 hours 08 minutes (Interquartile range (IQR) 1 hour and 7 minutes), 2 hours 35 minutes (IQR 1 hour and 51 minutes), and 4 hours 16 minutes (IQR 2 hours and 33 minutes) for workflows A, B, and C, respectively. Using sedation instead of full anesthesia shortened workflows by a median of 35 minutes. BT machine demand, based on national cervical cancer incidence, ranged from 0.2 to 9.5; four countries had low (< 0.5), two moderate (0.5 - 1.0), and eight high demand (>1.0). Resource- and context-specific recommendations for IGBT transition were provided.

BT workflows varied widely. Substantially increased procedure times and resource use were observed with advanced workflows. Findings highlight opportunities to improve efficiency through anesthesia choice, imaging strategy, and planning workflow optimization. Implementing context-specific strategies will be crucial for IGBT transition.

Funding from the XXXX, in collaboration with XXXX and participating sites.