Vaginal Stenosis in Patients Treated With Radiotherapy for Cancer of the Cervix in Uganda

PURPOSE The occurrence of Vaginal Stenosis (VS) is likely to be underreported and never treated in resource-limited settings. This study aimed to assess the incidence, risk factors, and clinical manifestation(s) of radiation-induced VS in patients with cervical cancer in Uganda. METHODS A retrospective cohort study was conducted in April-July 2022 for patients diagnosed with cervical cancer and treated with radiotherapy in 2019 at the Uganda Cancer Institute (UCI). Data was abstracted on patient demographics, stage of disease, type/technique/modality of radiotherapy received, incidence, grade/severity of vaginal stenosis, and treatments administered. Descriptive and Logistic Regression was used for data analysis using Excel and Stata. RESULTS 363 patients enrolled in the study. Overall mean age was 50.6 years. Eight percent of patients were diagnosed at stage IB, 46.3% at stage II, 38.3% at stage III, 5.5% at stage IV and 1.9% were not staged. 101(28%) patients were excluded from the analysis due to missing radiotherapy treatment chart data. VS incidence was 5.3% (N= 14); 36% with CTCAE v4.03 Grade 1 VS, 14% with Grade 2, and 50% with Grade 3 VS. However, 94.7% had no documented assessment of the presence or absence of VS in their medical records. Apart from the total dose of radiotherapy (OR=1.0, p=0.045), other known risk factors were not statistically significant in predicting VS such as: tumor extension to the vagina (OR=2.4, p=0.190), receiving both external beam radiotherapy and brachytherapy (OR=2.6, p=0.100)), age (OR=1.0, p=0.077) and hyper-fractionation (OR=10.2, p=0.065). Sexual dysfunction was the most reported (71%) manifestation and 79% of VS occurred within one year of radiation treatment. CONCLUSION The reported radiation-induced VS incidence was low at UCI. This may be due to significant underreporting of VS in patients records as most of the identified cases were patient-reported versus physician-reported during examination. Since, there is no uniformly adopted method or grading system for VS at UCI, underreporting of VS may be related to low physician knowledge/practice to identify/diagnose VS and lack of patient education about the possible side effects associated with radiotherapy treatment. Hence, deploying a physician VS education program and a prospective study would provide a more accurate estimate of VS incidence in Uganda and other resource-limited settings.