Vaginal brachytherapy: Low-cost uterine cancer treatment in India

Vaginal Brachytherapy for Uterine Cancer​

Vaginal Brachytherapy is one of the internal radiation therapies that may be used to treat endometrial cancer especially after surgery. This has to do with the use of an implanting a radiation source in the vagina to confine cancer cells that may still be in the area without affecting the bladder and rectum.

Who Needs Vaginal Brachytherapy?

• Post-surgical management of early-stage endometrial cancer for the purpose of minimizing chances of recurrence.
• Patients with high-risk features (e.g., deep myometrial invasion, aggressive tumor type).
• Patients with recurrent endometrial cancer in the vaginal area.

High-dose-rate Brachytherapy in India​

HDR brachytherapy is a type of internal radiotherapy that used a high intensity and short residence time for irradiating tumor cells. This technique ensures that cancer cells can be selectively destroyed leaving the rest of the cells intact hence being effective and eventually alleviating incidences of cancer. HDR brachytherapy is commonly utilized in India and could be accessed at several dedicated cancer treatment institutions.​

Brachytherapy Side Effects​

This complication depends on the type of cancer, the dosage of radiation and the location of the brachytherapy. The side effects are common and depend on the HDR and LDR; some of which include the following:

Short-Term (During or Soon After Treatment)

• Fatigue – Common after multiple sessions but usually mild.Tenderness, swelling or redness either at the local level of the area where the treatment was administered or in the major joints.
• Urinary – Trace – increased frequency, painful or mild incontinence (which is expected where treating prostate cancer).
• Bowel – Diarrhea, discomfort, or constipation (depending upon whether radiation is for rectum).
• Vaginal discomfort –  Dryness, discharge, or irritation especially if the woman has gynecologic cancer like uterine or cervical cancer.

Long-Term (Weeks to Months after Treatment)

• Fibrosis & Scarring – May cause tissue rigidity at the site that has been targeted.
• Vaginal Narrowing (Stenosis) – intercourse may be painful; treated by the use of vaginal cones that come in various sizes and lubricants.
• Bladder & Bowel Changes – Chronic mild urgency or occasional bleeding.
• Erectile Dysfunction (For Prostate Cancer Patients) – Due to nerve damage from radiation exposure.
• Lymphedema – based on the affected lymph nodes, swelling may become apparent in the neighbouring areas.

Uterine Cancer Radiation Therapy​

The radiation therapy may be possibly utilised individually or may be used in combination with other treatments like surgery for the treatment of uterine (endometrial) cancer. It also assists in the elimination of any residual tumors and the chances of the illness coming back.

Types of Radiation Therapy for Uterine Cancer

External Beam Radiation Therapy (EBRT)

• How it works – High-energy X-rays are given from a machine located outside the human body.
• Treatment duration – Typically 5 sessions per week for 4–6 weeks.
• When – The cancer has extended to the nearest regions or there are probabilities of it recurring again.
• Common side effects – Fatigue, skin irritation, diarrhea, bladder irritation, pelvic discomfort.

Vaginal Brachytherapy (Internal Radiation)

• How it works – A radiation source is applied using an applicator that is inserted into the vagina.
• High-dose-rate – 3-5 short treatments, Low-dose rate – 1 session that takes few hours and the patient needs to stay at the hospital.
• Indications for use – after a hysterectomy by which it is used to treat the remaining cancerous cells in the vagina region.
• Common side effects – discomfort in the vagina, vaginal constriction, mild inflammation, and lethargy.

Combined Radiation (EBRT + Brachytherapy)

• Used when – Higher risk of recurrence or cancer spread to nearby lymph nodes.
• Objective – Enhances the survival rate and decreases the rate of relapse.

Endometrial Cancer Treatment Options​

Endometrial cancer can be treated according to the stage, grade and the general condition of the patient. These include surgery, radiation, hormonal, chemotherapy, and immuno-assists.

Surgery (Primary Treatment)

• Hysterectomy – Removal of the uterus (with or without ovaries and fallopian tubes).
• Lymph Node Dissection – Checks for cancer spread.
• Ovarian Removal (Oophorectomy): In case cancer is high risk.
• It is suitable for – Stage I or Stage II or cancers that have not spread beyond the uterus.

Radiation Therapy

• External Beam Radiation Therapy (EBRT) – Targets cancer cells from outside the body.
• Vaginal Brachytherapy (Internal Radiation) – Targets the vaginal cuff after surgery.
• Suitable for – Patient with high-risk profile necessary to prevent reoccurrence or in cases of non-surgical treatable ailments.

Hormone Therapy

• Progestins (e.g., Megestrol acetate) – Slows cancer growth.
• Aromatase Inhibitors (e.g., Letrozole, Anastrozole) – Blocks estrogen.
• Best for – Advanced/metastatic cases or hormone receptor-positive tumors.

Chemotherapy

• Drugs Used – Paclitaxel, Carboplatin, Doxorubicin, Cisplatin.
• Administered intravenous in cycles.
• Best for – Advanced-stage, recurrent, or aggressive endometrial cancer.

Targeted Therapy & Immunotherapy

• Targeted Therapy (e.g., Lenvatinib + Pembrolizumab) – Blocks cancer cell growth.
• Immunotherapy (e.g., Pembrolizumab, Dostarlimab) – this increases the activities of migrating cells to destroy cancerous cells.
• Best for – Advanced or recurrent cases with specific genetic mutations (e.g., MSI-H, dMMR).

Cervical Cancer Brachytherapy​

The utilization of brachytherapy in cervical cancer treatment is very widespread and considered mandatory for locally advanced cervical cancers (Stage IB2 to IVA). That is the ability to deliver radiation directly to the tumor with minimal invasion of other healthy cells or tissues.

Types of Brachytherapy for Cervical Cancer

High-Dose-Rate (HDR) Brachytherapy

• One of most frequent – Short treatment period, during which overall amount of irradiation is rather high.
• Sessions – Typically 3–5 sessions over 1–2 weeks.
• Outpatient procedure – No hospital stay required.

Low-Dose-Rate (LDR) Brachytherapy

• A single application of gamma radiation with a change in the location of the implanted radiation sources every 8–12 hours during 1–2 days.
• Requires hospital stay for monitoring.
• Also, they are not very common as they present certain practical difficulties.

Pulsed-Dose-Rate (PDR) Brachytherapy

• Similar to LDR but radiation is done in a cyclic manner or in different times.
• Less commonly available.

Gynecologic Oncology Hospitals in India​

Indraprastha Apollo Hospital, Delhi

​Indraprastha Apollo Hospital in Delhi has an outstanding Gynaecologic Oncology section aimed at diagnosis and treatment of malignant diseases of the female reproductive system organs, such as the uterus, cervix, ovaries, vagina, and vulva. It offers services that include surgeries, hormone replacement therapies, robotic and laparoscopic procedures among others.  Gynaecologic Oncology of the Indraprastha Apollo Hospital is offering highly specialized and quality treatment to the patients using equipped techniques and techniques for better patient response.

Fortis Memorial Research Institute, Gurgaon

Fortis Memorial Research Institute (FMRI) in Gurgaon has a separate department of Gynaecologic Oncology for the diagnosis, treatment and management of cancers that affect the female reproductive organs; cervical, ovarian, endometrial, vaginal and vulval cancers. The management of the department also underlines the need that calls for early diagnosis and the use of elaborated methods and technologies in diagnosis and treatment of ailments. ​

Max Hospital, Saket

Max super specialty hospital at Saket, New Delhi has a specialized Gynaecologic Oncology to manage various forms of cancer in women that include ovarian, endometrial, cervical, vulvar, and vaginal cancers. There is also minimally invasive and robotic surgeries that are employed in the diagnosis and treatment of the diseases by the department.

Factors Affecting Cost of Uterine Cancer Treatment in India​

The cost of uterine cancer treatment in India depends on some factors, such as the hospital, the type of treatment and the stage of cancer. There are the following potential factors that contribute to the total cost:

• Stage & Severity of Cancer
• Type of Treatment
• Type of Hospital & Location
• Type of Surgery
• Duration of Hospital Stay
• Radiation Therapy Type
• Chemotherapy & Targeted Therapy Costs

Survival Rates for Uterine Cancer Patients​

The survival rates of uterine cancer vary depending on the stage, grade of the cancer, general condition of the patient and response to the treatment. The 5-year relative survival is the overall survival rate of the given types of cancer in five years after the observation period has been diagnosed concerning the general population of the same sex and age.

Survival Rates by Stage

• Stage I: 90%-95%
• Stage II & III: 50%-70%
• Stage IV: 15%-20%

Latest Advancements in Uterine Cancer Therapy

Recent innovations in uterine (endometrial) cancer treatment have vastly enhanced results and increased patient choices. Of major developments are:

Immunotherapy

Immune checkpoint inhibitors have been promising, especially for tumors with mismatch repair deficiencies (dMMR) or high microsatellite instability (MSI-H). These agents enable the immune system to recognize and attack cancer cells more efficiently.

Combination Therapies

The integration of immunotherapy with conventional therapies has been successful. For example, the administration of durvalumab (an immunotherapy agent) and olaparib (a PARP inhibitor) together has enhanced progression-free survival compared to chemotherapy alone, particularly in patients with certain biomarkers. ​

Antibody-Drug Conjugates (ADCs)

ADCs are proving to be promising therapies for advanced or recurrent endometrial cancer. These medications bring powerful chemotherapy right into cancer cells, sparing normal tissue damage.

Targeted Therapies

Advances in molecular profiling have resulted in target therapies that target unique genetic mutations in tumors. This can be tailored to create personalized treatment strategies, enhancing efficacy and minimizing unnecessary side effects.

Hormonal Therapy Combinations

Novel hormonal strategies, at times in combination with other therapies, have emerged as effective, providing alternative means of controlling certain forms of endometrial cancer.

These developments point to the direction of personalized medicine in the treatment of uterine cancer, seeking to enhance patient care through customized approaches.