cervical cancer is the fourth most common cancer affecting women worldwide ( ferlay et al . , 2010 ) .
over 85% of cases and 87% of deaths occur in low - resource countries ( siegel et al . , 2015 ) .
central and south america are among the regions with the highest incidence ( ferlay et al . ,
2010 ) , and access to internationally accepted standards of care is often inadequate . in honduras ,
cervical cancer represents 36.4% of female cancers nationally , and is the principal cause of cancer death in women . in honduras , cervical cancer
most commonly affects women aged 3069  years and patients are frequently diagnosed with locally advanced disease ( registro hospitalario de cancer 1998 - 2003 , 2004 ) . in 2009 , 23% of all cancer cases treated at the department of oncology at the hospital general san felipe ( hgsf ) were cervical cancer .
both surgery and radiotherapy ( rt ) may be offered as primary treatment in stage i - iia disease as both treatment options demonstrated similar cure rates in this patient population ( landoni et al . , 1997 ) .
standard treatment for patients with more advanced disease is concurrent chemotherapy and external beam rt ( ebrt ) followed by brachytherapy ( eifel et al . , 2004 ,
brachytherapy , a fundamental pillar of treatment for locally advanced cervical cancer , is not available at the national cancer center at the hospital of general san felipe in honduras .
for this reason , these patients are recommended for ebrt with or without concurrent chemotherapy are utilized .
following treatment , those patients with a complete clinical response ( ccr ) undergo extrafascial hysterectomy in lieu of brachytherapy 46  weeks after completion of treatment .
our goal was to evaluate clinical response rates among patients treated in the department of oncology at the hospital general san felipe ( hgsf ) , who received either ebrt alone or concurrent chemoradiation ( ccrt ) for locally advanced cervical cancer .
after approval from the internal review board , a retrospective chart review was performed for 165 patients who received primary treatment with either ebrt or ccrt for a histologically confirmed diagnosis of cervical cancer at the hgsf from january 2008 to june 2011 .
patients older than the age of 20 and younger than the age of 70 were included .
seventy gray ( gy ) of ebrt with or without chemotherapy were given to all the patients .
patients were deemed to have a clinical complete response ( ccr ) to rt   chemotherapy if there was no residual tumor on clinical physical examinations .
these patients who had ccr underwent extrafascial hysterectomy 6  weeks after completion of radiation therapy .
data analysis included age , clinical stage , histologic types , size of tumor , date of diagnosis , duration and methods of treatment , and clinical response .
the primary endpoint of this study was complete clinical response ( ccr ) upon completion of ebrt and ccrt .
comparisons of variables not normally distributed were made by the mann - whitney u test .
p values are the result of 2-sided tests and p  <  0.05 was considered to indicate a statistically significant difference .
statistical analysis was performed with software ( spss , version 19.0 ; ibm corp , armonk , ny ) .
patients were collected from january 2008 through june 2011 , and 165 women were included in the study .
ninety patients ( 54.5% ) received ebrt alone and 75 ( 45.5% ) patients received ccrt . the median age , stage , tumor size , and histology were similar in both groups .
the treatment duration was significantly longer in the patients who received non - platinum based chemotherapy ( table 1 ) .
complete clinical response ( ccr ) rates decreased with advanced stage ( table 2 ) .
stage iib was the most common stage at diagnosis in both groups with 44/90 ( 49% ) patients in the ebrt group and 38/75 ( 51% ) patients in the ccrt group respectively .
the ccr was significantly lower among stage iib and iiib patients treated with ccrt when compared with ebrt . patients with ib2 cervical cancer did equally well and all achieved ccr .
tumor size was >  4  cm in 142 ( 86.1% ) of 165 patients .
all patients with tumors <  4  cm experienced ccr , compared to 72 ( 68.6% ) in 142 patients with tumor size >  4  cm .
histologic subtype did not appear to be a prognostic indicator : 135 ( 81.8% ) of tumors were squamous cell carcinomas , 30 ( 18.2% ) were adenocarcinomas .
of the 30 cases with adenocarcinoma , 25 ( 83.3% ) underwent treatment with ebrt and 5 ( 16.7% ) received ccrt ; of the 135 squamous cell carcinoma ( scc ) cases , 73 ( 54.1% ) received ebrt and 62 ( 45.9% ) received ccrt .
overall 76/135 patients with scc demonstrated 56.3% ccr rate , which was comparable to the ccr of 18/30 ( 60% ) among adenocarcinoma cases .
the ccr of 33.3% were significantly lower in both scc and adenocarcinoma patients who received ccrt comparing to the ccr of 76.7% for those who received ebrt ( table 2 ) .
overall , ccr was seen in 95 patients ( 57.6% ) in both groups combined .
of the patients who were treated with ccrt , 23 patients ( 33.3% ) were treated with cisplatin ( 40  mg / m weekly for 5  cycles ) chemotherapy and the remaining 52 patients ( 66.7% ) received 5-fluourouracil ( 700  mg / m  day 14 every 3  weeks ) , capecitabine ( 1000  mg / m twice daily on days 1 to 14 , every 3  weeks for 2  cycles ) or gemcitabine ( 1000  mg / m on days 1 and 8 , every 3  weeks for 2  cycles ) . of the 90 patients who received ebrt alone , 70 patients had a ccr of 77.8% and underwent adjuvant hysterectomy . in the ccrt group , 25 patients ( 33% ) had a ccr ( fig .
the 25 patients that received cisplatin based therapy demonstrated an 80% ccr rate ( fig .
residual tumors were found in 50% of the patients who underwent hysterectomy in both groups .
one hundred and fifteen ( 69.5% ) of patients completed their treatments within 60  days .
the treatment duration was significantly longer in the patients who received non - platinum based chemotherapy ( table 1 ) .
of the 23 patients who received ccrt with cisplatin , only 5 patients had their treatments extended beyond 60  days . the majority of the ccrt patients that had treatment longer than 60  days received other agents ( 5-fluorouracil , capecitabine and gemcitabine ) .
there were no differences between the two groups in the incidence of grade 3 and 4 toxicities : 13% in the ebrt group and 19% in the ccrt groups ( ns ) .
the burden of cervical cancer continues to fall most heavily on low- and middle - income countries largely due to lack of screening and treatment modalities . in a high - resource setting , the standard of care for locally advanced cervical cancer is ccrt with cisplatin based chemotherapy followed by brachytherapy ( eifel et al . , 2004 , morris et al . , 1999 , souhami et al . , 1991 , tattersall et al . ,
1995 , rose et al . , 1999 ) . although it has previously been demonstrated that non - platinum based chemotherapy regimens are less effective ( eifel et al .
, 1999 , whitney et al . , 1999 ) , platinum - based chemotherapy may not be readily available in low - resource settings .
this was the case in the patient population at hgsf in honduras , and as would be expected , patients who received non - platinum based therapy had lower response rates .
approximately two - thirds of the patients in this cohort received non - platinum based ccrt with only a 31% response rate . among the patients in this study who received platinum based therapy , the response rates were comparable to those cited in the literature .
this emphasizes the importance of platinum based regimens in the treatment of locally advanced cervical cancer .
brachytherapy following concurrent chemotherapy and ebrt is considered standard of care , but brachytherapy is not available at the hgsf and we therefore substituted adjuvant extrafascial hysterectomy for this modality . the role of adjuvant extrafascial hysterectomy has been explored by the gynecologic oncology group ( gog ) in patients with bulky figo stage ib invasive carcinoma of the cervix .
they reported on a cohort of patients with tumors measuring >  4  cm who were randomized to extrafascial hysterectomy or observation following ebrt and brachytherapy ( chemotherapy was not administered in either arm ) . in this cohort
there was a lower rate of local relapse ( 14% vs. 27% at 5  years ) in the hysterectomy group
. however , overall survival outcomes were not statistically different between the two groups ( keys et al . , 2003 ) .
although our patients did not have brachytherapy available to them , we felt that this gog data supports the use of adjuvant extrafascial hysterectomy in these patients .
our study was not designed to assess survival , but this will be the subject of future analysis .
factors associated with treatment failure in patients with cervical cancer include large volume of disease and treatment prolongation .
the best response was seen among smaller tumors at less advanced stages in our patient population .
all patients with tumors measuring 4  cm or less had a favorable response . in comparison ,
only 50.7% of patients with tumors measuring >  4  cm had a clinical complete response . with regards to treatment time
, it has been shown that a protracted treatment course can be deleterious to overall outcomes ( fyles et al .
, 1992 , petereit et al . , 1995 , perez et al . , 1995 ) .
one group demonstrated that survival and pelvic control at 5  years decreased 0.6% and 0.7% , respectively , for each additional day of treatment beyond 55  days ( petereit et al . , 1995 ) .
in our patients treatment can be delayed for reasons including lack of financial resources , difficulty with transportation and various socioeconomic stressors .
these treatment delays likely contribute to a reduction in the ccr and once radiotherapy is initiated every effort should be made not to delay treatment .
cervical cancer is the most commonly diagnosed cancer among women in honduras . to this end , these women deserve the opportunity to receive a therapy with the goal of achieving cure .
efforts should be made to treat women with locally advanced cervical cancer with cisplatin - based ccrt .
treatment should not be delayed once it has been initiated and if cisplatin is not available , radiotherapy should be offered rather than delay treatment while awaiting availability of chemotherapy agents .
 our goal was to determine the clinical treatment response following radiation administered with or without chemotherapy for locally advanced cervical cancers in honduras . 
 this is a retrospective study of patients treated with either concurrent chemoradiation ( ccrt ) or external beam radiation therapy ( ebrt ) alone at a hospital in tegucigalpa , honduras . 
 70  gy of ebrt to the pelvis was given in all cases . 
 brachytherapy was not available . 
 chemotherapy was given when available . 
 extrafascial hysterectomy was performed 6  weeks after completion of treatment in patients with a complete clinical response ( ccr ) . 
 records for 165 women with locally advanced cervical cancer were reviewed ; 25 ( 15.2% ) stage ib2 , 15 ( 9.1% ) stage iia , 90 ( 54.5% ) stage iib , and 35 ( 21.2% ) stage iiib . 
 ninety ( 54.5% ) patients received ebrt alone ; 75 ( 45.5% ) received ccrt . 
 twenty - three ( 33.3% ) of ccrt patients received weekly cisplatin , the remainder receiving other agents . 
 seventy ( 77.8% ) of the 90 patients who received ebrt had a ccr ; 25 out of 75 ( 33.3% ) patients in the ccrt group achieved a ccr . 
 the ccrt group treated with weekly cisplatin achieved an 80% ccr ; while the ccrt group given alternative agents had only a 31% ccr . 
 patients unable to receive platinum - based ccrt had the worst outcome , and their responses were inferior to patients who received ebrt . 
 the challenges of treating women with locally advanced cervical cancer in a low - resource setting are multifactorial and include treatment delays , the lack of brachytherapy and the unpredictable availability of chemotherapy . 