Stephanie Gulstene

Pain control and opioid use as a function of workflow in MRI-guided interstitial cervix brachytherapy

/Objective(s): Pain management during brachytherapy for cervix cancer is challenging. Institutional practice for brachytherapy delivery and pain management varies. Here we retrospectively assessed pain control and opioid use requirements during different MRI-guided interstitial cervix brachytherapy workflows. /Methods: In this retrospective study, data was collected on ninety-one patients receiving MR-guided interstitial brachytherapy for cervix cancer between June 2022 and June 2024. Abstracted data included: demographics, disease characteristics, pain scores, opioid use, and brachytherapy workflow. Patients were either treated as in-patients or out-patients. In-patients remained overnight to receive a second fraction the following day. Out-patients received a single fraction and were discharged the same day. Out-patients were further divided into intra-operative versus post-operative treatment. For intra-operative treatment the entire procedure was performed under general anesthesia (GA). For post-operative treatment only applicator insertion was under GA. Multivariable linear regression modelling was used for analysis of opioid dose and pain scores. Ninety-one patients were eligible for inclusion, corresponding to 201 separate insertions. Median age was 51. Majority (69 %) had cT2b disease. Mean CTV In-patient treatment was associated with worse pain control, despite increased opioid use. Within those treated as out-patients, intra-operative treatment further improved pain management.

Understanding the value of paracervical block during gynecologic brachytherapy: A systematic review of the literature

Paracervical block is a technique to provide local anesthesia with evidence supporting its use for various gynecologic procedures; however, the literature on its use for gynecologic brachytherapy is limited. This systematic review seeks to understand the efficacy and safety of paracervical block in cervical cancer brachytherapy. PubMed and EMBASE/Cochrane Library databases were searched from inception to June 2023. Articles were included if they described or mentioned the use of paracervical block in the context of HDR brachytherapy for cervix cancer. Non-English language or abstract-only articles were excluded. Citations were reviewed for relevant papers. Pain control and toxicity outcomes were abstracted along with technical details of anesthesia and brachytherapy procedure. Of the 396 articles identified, eight were included. Two gave general recommendations around the role of paracervical block. The rest described its use during brachytherapy at their respective institutions. There was heterogeneity in paracervical block technique across different publications. The majority of included articles describe use of paracervical block for procedural pain control, while only one describe its use for postprocedure pain control. Pain was well controlled with <10% of patients experiencing moderate or higher pain. However, there were no studies specifically assessing pain management with versus without use of paracervical block. The rate of grade 3+ toxicity associated with its use was <5%. Paracervical block is safe and can be part of effective pain management for patients receiving cervical brachytherapy. However, the incremental benefit of adding paracervical block is not well assessed in the current literature.