Carcinoma of the cervix in Zimbabwe- a review of patients' characteristics and outcome of treatment

Abstract

Carcinoma of the cervix accounts for over 30% of female malignancies in Zimbabwe. Aetiological factors include early age at first coitus, multiple sexual partners, poor hygiene and the human papilloma virus. Radiotherapy (RT) is the definitive treatment for most patients with this disease and involves both external beam therapy (EBT) and intracavitary treatment (ICT). A retrospective study was undertaken of all patients who presented to the Parirenyatwa Radiotherapy Centre (RTC) between November 1990 and December 1991 with a diagnosis of cervical carcinoma. This was an important developmental phase at the centre including the re-introduction of intra-cavitary treatment. The aim of the study was to document patient characteristics and outcomes of therapy and identify prognostic factors. Two hundred and seventy-three patients presented in this period. Of these, 52 were excluded leaving 221 patients who could be evaluated. Of the patients whose age was known (n = 190), 60% of these were in the age group 35-54 years with a range for the whole group of 21-80 years. Patients were divided into two groups according to whether they received radical RT including I.C.T. (group 1, 93 patients) or received EBT only (group 2, 128 patients). Fifty-one percent of the 221 patients presented with Stage III disease. In group 1, 77.4% were Stages I and II and 22.6% Stage III, whereas in group 2 the percentages were 12.5 and 72 respectively. The proportion of Stage III patients treated with ICT increased during the study period. Thirty-one percent of the whole group had no biopsy. Of those biopsied 95.4% had squamous cell carcinoma and 4.6% adenocarcinoma. Group 1 patient details were more reliable and so were analysed in more depth. Fifty nine percent of group I patients gave a history of 3-8 months ofsymptoms and 21.5% symptom duration longer than 1 year. The mean length follow-up time was 13.4 months for group 1 and 7.1 months for group 2. Complete remission (CR) rates at last follow-up were 49% for group 1 and 19% for group 2. Ninety-seven percent of group 1 patients achieving a CR had received 70Gy or more total dose to Point A. The CR rate was clearly inversely related to stage in group 2. In group 1 this trend was also seen though less clearly defined. Patients with both pelvic wall and lowerone third vaginal III patients. Treatment was in patients had no involvement did more poorly than other Stage general well tolerated: 78.5% of group 1 or only mild acute complications (mainly gastrointestinal) and only 2.1% had severe acute complications. The acute complication rate was higher in those who completed treatment in under 7 weeks. Follow-up was insufficient in the majority of the patients to assess late effects. Most local recurrences and metastases which occurred were seen within 1 year of completion of treatment. Health measures which could improve treatment results include: public education regarding early symptoms, medical education in early diagnosis and referral, accurate staging, more frequent use of a combination of EBT and ICT, avoiding prolonged treatment times, improved follow-up, better co-operation between gynaecologists and radiotherapists and more widespread cervical visualisation procedures in rural and district health centres areas to be reinforced in future by cytological screening