Risk factors and clinical outcomes of radiation-induced fistula after chemoradiation and image-guided brachytherapy for locally advanced cervical cancer

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Purpose/Objectives: The standard treatment for locally advanced cervical cancer (LACC) is concurrent chemoradiation and brachytherapy (CRT-B). Fistula formation is a serious complication of pelvic radiation; however, risk factors and outcomes are not well described. We sought to identify the incidence, risk factors and prognosis of radiation-induced fistula in women who underwent CRT-B for LACC. Materials/Methods: Patients with FIGO IB2-IV cervical cancer treated with CRT-B at a single institution from 2013 to 2022 were reviewed. Patient and treatment characteristics were analyzed. The primary endpoint was fistula incidence. Logistic regression model was performed to assess factors associated with fistula. Fistula-free survival and overall survival were estimated using the Kaplan-Meier method. Results: Thirteen (9 %) of 150 reviewed patients developed fistula with median follow up of 20 months (CI: 22.8-35.4). Fistula symptoms resolved in 8/13 patients (62 %). Two-year overall survival and fistula-free survival was 72.0 % (CI: 62.6-79.5) and 91.6 % (CI: 84.9-95.4), respectively. On univariate analysis, higher BMI was associated with decreased fistula risk (OR 0.90, CI: 0.82-1.00; p = 0.048). Current smoking (OR 8.37, CI: 2.58-27.22; p < 0.001), lack of MRI guidance (OR 4.77, CI: 1.42-15.97; p = 0.011) and disease extension into bladder (OR 3.99, CI: 1.27-12.53; p = 0.018), were associated with increased fistula risk. On multivariable analysis, only current smoking (OR 5.14, CI: 1.43-18.48; p = 0.012) was associated with increased fistula risk. Conclusions: Patients treated with CRT-B for LACC have a 9% risk of fistula formation. MRI guidance may be useful in brachytherapy planning to reduce the risk of toxicity.

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