Dissertations & Theses (Open Access)

Date of Award

Summer 5-2019

Degree Name

Master of Public Health (MPH)


Linda Piller, Md Mph

Second Advisor

Michelle Ludwig, Md Mph Phd


Uterine cancer is the most common gynecologic malignancy in the United States with almost 62,000 cases expected in 2019. In general, treatment consists of primary surgery possibly followed by adjuvant radiation and/or chemotherapy. However, in cases with cervical involvement or when the patient is a non-surgical candidate, neoadjuvant treatment can be employed; specifically, neoadjuvant radiation with or without brachytherapy and/or chemotherapy. There have not been any large-scale studies looking at the addition of brachytherapy to external beam radiation in the neoadjuvant setting and whether or not its addition improves outcomes. In order to analyze this, the National Cancer Database was used to study women diagnosed with uterine cancer who were treated with neoadjuvant radiation with or without brachytherapy followed by hysterectomy. Univariate and multivariate cox regression survival analysis was done to look at overall survival (OS) between the group that received brachytherapy and the group that did not. Logistic regression was performed to analyze the association between the use of brachytherapy and negative margins upon surgical resection. Both cox regression analysis and logistic regression analysis were done for the entire cohort and for each histological subtype. There were 1009 women treated with neoadjuvant radiation followed by external beam, the majority of whom did not receive brachytherapy (n=640, 63.4%). Women who did receive brachytherapy were more likely to be stage II (p<0.001), and were less likely to have been treated at a community cancer center (p=0.045). They were also less likely to have received a radical hysterectomy (p=0.009). The addition of brachytherapy was not associated with improved OS on univariate or multivariate analysis (HR=0.831, p=0.073; HR=0.868, p=0.179, respectively). This relationship remained across all histologies (all p>0.05). In addition, the use of brachytherapy was not associated with margin status on surgical resection in univariate or multivariate analysis (both p>0.05). The addition of brachytherapy to external beam radiation in the neoadjuvant setting did not affect survival in this cohort of uterine cancer patients. However, its use was associated with decreased utilization of radical hysterectomies, which is an important clinical finding as radical hysterectomies can be much more morbid than total hysterectomies.