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Alvarez CM, Aliru M, Gannavarapu BS, Song T, Gilmore LA, Olaechea S, Gomez DR, Ahn C, Infante RE, Iyengar P. Impact of Pretreatment Weight Loss on Radiotherapy Utilization and Clinical Outcomes in Non-Small Cell Lung Cancer. Am J Clin Oncol 2024; 47:49-55. [PMID: 38011024 DOI: 10.1097/coc.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Cancer cachexia is a syndrome of unintentional weight loss resulting in progressive functional impairment. Knowledge of radiation therapy utilization in patients with cancer cachexia is limited. We evaluated the use of curative and palliative-intent radiation for the management of patients with non-small cell lung cancer (NSCLC) with cachexia to determine whether tumor-directed therapy affected cachexia-associated outcomes. METHODS Using an Institutional Tumor Registry, we evaluated all patients with stages of NSCLC treated at a tertiary care system from 2006 to 2013. We adopted the international consensus definition for cachexia, with staging designated by the registry and positron emission tomography. Radiotherapy delivery and intent were retrospectively assessed. RESULTS In total, 1330 patients with NSCLC were analyzed. Curative-intent radiotherapy was utilized equally between patients with cachexia and non-cachexia with stages I to III NSCLC. Conversely, significantly more patients with stage IV disease and cachexia received palliative radiotherapy versus those without (74% vs 63%, P = 0.006). Cachexia-associated survival was unchanged irrespective of tumor-directed radiation therapy with curative or palliative intent. In fact, pretreatment cachexia was associated with reduced survival for patients with stage III NSCLC receiving curative-intent radiotherapy (median survival = 23.9 vs 15.0 mo, P = 0.009). Finally, multivariate analysis identified pretreatment cachexia as an independent variable associated with worsened survival (hazard ratio = 1.31, CI: 1.14,1.52). CONCLUSION Patients with advanced NSCLC with cachexia received more palliative-intent radiation than those without weight loss. Tumor-directed therapy in either a curative or palliative approach failed to alter cachexia patient survival across all stages of the disease. These findings offer critical information on the appropriate utilization of radiation in the management of patients with NSCLC with cachexia.
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Affiliation(s)
| | | | | | - Tidie Song
- UT Southwestern Medical Center, Center for Human Nutrition, Dallas, TX
| | | | - Santiago Olaechea
- UT Southwestern Medical Center, Center for Human Nutrition, Dallas, TX
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center
| | - Chul Ahn
- UT Southwestern Medical Center, Center for Human Nutrition, Dallas, TX
| | - Rodney E Infante
- UT Southwestern Medical Center, Center for Human Nutrition, Dallas, TX
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Puneeth Iyengar
- UT Southwestern Medical Center, Center for Human Nutrition, Dallas, TX
- Department of Radiation Oncology
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Gilmore LA, Olaechea S, Gilmore BW, Gannavarapu BS, Alvarez CM, Ahn C, Iyengar P, Infante RE. A preponderance of gastrointestinal cancer patients transition into cachexia syndrome. J Cachexia Sarcopenia Muscle 2022; 13:2920-2931. [PMID: 36165100 PMCID: PMC9745477 DOI: 10.1002/jcsm.13086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/29/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cancer cachexia is frequently documented by self-reported, single time-point weight histories. This approach lacks the granularity needed to fully elucidate the progression of cachexia syndrome. This study aimed to longitudinally assess body weight changes pre- and post-cancer diagnosis in gastrointestinal (GI) cancer patients. METHODS Body weights and relevant clinical data recorded in the electronic health record 12 months pre- and post-GI cancer (colorectal, gastroesophageal, hepatobiliary and pancreatic) diagnosis were extracted. Weight loss was categorized by the International Consensus Definition for cachexia. RESULTS A total of 879 patients were included in the final cohort including patients diagnosed with colorectal (n = 317), hepatocellular (n = 185), biliary (n = 72), pancreatic (n = 186) or gastroesophageal (n = 119) cancer. Stage of disease was equally distributed. Patients without cachexia at diagnosis (n = 608) remained weight stable during the 12 months pre-diagnosis (+0.5 ± 0.5% body weight; P = 0.99). Patients with cachexia at diagnosis (n = 271) remained weight stable 6 to 12 months prior to diagnosis (+0.4 ± 0.8%; P > 0.9999) and lost 8.7 ± 0.6% (P < 0.0001) within the 6 months pre-diagnosis. Patients without cachexia at diagnosis lost more weight post-diagnosis (6.3 ± 0.6%) than patients with cachexia at diagnosis (4.7 ± 1.0%; P = 0.01). Pre-diagnosis weight trajectories did not differ between primary malignancies or stage of disease in patients without or with cachexia at diagnosis (all P ≥ 0.05). Post-diagnosis weight trajectories did differ by primary malignancy (P ≤ 0.0002) and stage (P < 0.0001). In both patients without and with cachexia at diagnosis, colorectal patients lost the least amount of weight post-diagnosis and gastroesophageal patients lost the most amount of weight post-diagnosis. Stage 4 patients without or with cachexia at diagnosis lost the most weight post-diagnosis (P ≤ 0.0003). Regardless of cachexia status at diagnosis, patients lost more weight when treated with systemic therapy (7.1 ± 0.7%; P < 0.0001; n = 419) or radiation therapy (8.4 ± 1.4%; P = 0.02; n = 116) compared to those who did not. Patients who did not have surgery lost more weight post-diagnosis (7.6 ± 1.1%; P < 0.0001; n = 355) compared to those who did have surgery. By 12 months post-diagnosis, 83% of the surviving GI cancer patients in this cohort had transitioned into cachexia syndrome. CONCLUSIONS Significant weight loss in patients with GI cancer cachexia at diagnosis initiates at least 6 months prior to diagnosis, and most patients will transition into cachexia syndrome post-diagnosis, regardless of pre-diagnosis weight change and stage of disease. These findings punctuate the importance of weight surveillance in cancer detection and earlier palliative interventions post-diagnosis in the GI cancer patient population.
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Affiliation(s)
- Linda Anne Gilmore
- Department of Clinical Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA.,Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
| | - Santiago Olaechea
- Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
| | - Brian W Gilmore
- Department of Computer Science and Engineering, University of North Texas, Denton, TX, USA
| | - Bhavani S Gannavarapu
- Department of Radiation Oncology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
| | - Christian M Alvarez
- Department of Clinical Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
| | - Chul Ahn
- Harold C. Simmons Comprehensive Cancer Center, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
| | - Puneeth Iyengar
- Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA.,Department of Radiation Oncology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
| | - Rodney E Infante
- Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA.,Department of Internal Medicine, University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
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Olaechea S, Gannavarapu BS, Alvarez C, Gilmore A, Sarver B, Xie D, Infante R, Iyengar P. Primary Tumor Fluorine‐18 Fluorodeoxydglucose (18F‐FDG) Is Associated With Cancer-Associated Weight Loss in Non-Small Cell Lung Cancer (NSCLC) and Portends Worse Survival. Front Oncol 2022; 12:900712. [PMID: 35814438 PMCID: PMC9263563 DOI: 10.3389/fonc.2022.900712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/23/2022] [Indexed: 12/02/2022] Open
Abstract
Aim To investigate the diagnostic potential of and associations between tumor 18F‐FDG uptake on PET imaging and cancer-associated weight loss. Methods 774 non-small cell lung cancer (NSCLC) patients with pre-treatment PET evaluated between 2006 and 2014 were identified. Using the international validated definition of cachexia, the presence of clinically significant pretreatment cancer-associated weight loss (WL) was retrospectively determined. Maximum Standardized Uptake Value (SUVMax) of 18F‐FDG was recorded and dichotomized based on 3 experimental cutpoints for survival analyses. Each SUVMax cutpoint prioritized either survival differences, total cohort comparison sample sizes, or sample size by stage. Patient outcomes and associations between SUVMax and cancer-associated weight loss were assessed by multivariate, categorical, and survival analyses. Results Patients were found to have an increased likelihood of having WL at diagnosis associated with increasing primary tumor SUVMax after controlling for potentially confounding patient and tumor characteristics on multivariate logistic regression (OR 1.038; 95% CI: 1.012, 1.064; P=0.0037). After stratifying the cohort by WL and dichotomized SUVMax, both factors were found to be relevant in predicting survival outcomes when the alternative variable was constant. Of note, the most striking survival differences contributed by WL status occurred in high SUVMax groups, where the presence of WL predicted a median survival time detriment of up to 10 months, significant regardless of cutpoint determination method applied to categorize high SUVMax patients. SUVMax classification was found to be most consistently relevant in both WL and no WL groups. Conclusions The significant positive association between significant pretreatment cancer-associated weight loss and primary tumor SUVMax underscores increased glucose uptake as a component of catabolic tumor phenotypes. This substantiates 18F‐FDG PET analysis as a prospective tool for assessment of cancer-associated weight loss and corresponding survival outcomes. Furthermore, the survival differences observed between WL groups across multiple SUVMax classifications supports the importance of weight loss monitoring in oncologic workups. Weight loss in the setting of NSCLCs with higher metabolic activity as determined by 18F‐FDG PET signal should encourage more aggressive and earlier palliative care interventions.
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Affiliation(s)
- Santiago Olaechea
- Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bhavani S. Gannavarapu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Christian Alvarez
- Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Anne Gilmore
- Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Brandon Sarver
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - Donglu Xie
- Academic Information Systems, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Rodney Infante
- Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, United States
- *Correspondence: Rodney Infante, ; Puneeth Iyengar,
| | - Puneeth Iyengar
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- *Correspondence: Rodney Infante, ; Puneeth Iyengar,
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Olaechea S, Gilmore A, Alvarez C, Gannavarapu BS, Infante R, Iyengar P. Associations of Prior Chronic Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Glucocorticoids With Cachexia Incidence and Survival. Front Oncol 2022; 12:922418. [PMID: 35747801 PMCID: PMC9210667 DOI: 10.3389/fonc.2022.922418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/17/2022] [Indexed: 01/06/2023] Open
Abstract
Background Cachexia is an inflammatory and metabolic syndrome of unintentional weight loss through depletion of muscle and adipose tissue. There is limited knowledge of how chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids affect cachexia development. The purpose of this study was to investigate associations between prior long-term use of NSAIDs or glucocorticoids with cachexia incidence and post-diagnosis weight loss progression in a retrospective cancer patient cohort. Methods Of 3,802 lung or gastrointestinal cancer patient records, 3,180 comprised our final cohort. Patient demographic information, tumor qualities, medication histories, and comorbidities were assessed. Cachexia was defined as having developed prior to oncologic treatment. Statistical evaluations included categorical, multivariate logistic regression, and log-rank survival analyses. Development of substantial post-diagnosis weight loss was calculated and interpreted for patients without cachexia at diagnosis. Results Chronic prior use of any NSAID or glucocorticoid medication was associated with approximate absolute and relative reductions in cachexia incidence at diagnosis of 10 and 25 percent (P<0.0001). In multivariate analyses, NSAID medications demonstrated a 23 percent reduction in cachexia incidence likelihood (OR=0.770; 95% CI=0.594, 0.998; P=0.0481). Patients without cachexia at diagnosis were significantly more likely to develop substantial post-diagnosis weight loss from pre-diagnosis use groups of glucocorticoids (OR= 1.452; 95% CI=1.065, 1.979; P=0.0183) or NSAIDs (OR=1.411; 95% CI=1.082, 1.840; P=0.011). Conclusions Our findings suggest a protective effect of prior anti-inflammatory medications, primarily NSAIDs, against manifestations of the cachexia phenotype at cancer diagnosis. These observations support further exploration of potential therapeutic benefits from anti-inflammatory medications early in cancer management.
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Affiliation(s)
- Santiago Olaechea
- Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - Anne Gilmore
- Department of Clinical Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - Christian Alvarez
- Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - Bhavani S. Gannavarapu
- Department of Radiation Oncology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - Rodney Infante
- Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
- *Correspondence: Rodney Infante, ; Puneeth Iyengar,
| | - Puneeth Iyengar
- Center for Human Nutrition, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
- Department of Radiation Oncology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
- *Correspondence: Rodney Infante, ; Puneeth Iyengar,
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5
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Chen L, Gannavarapu BS, Desai NB, Folkert MR, Dohopolski M, Gao A, Ahn C, Cadeddu J, Bagrodia A, Woldu S, Raj GV, Roehrborn C, Lotan Y, Timmerman RD, Garant A, Hannan R. Dose-Intensified Stereotactic Ablative Radiation for Localized Prostate Cancer. Front Oncol 2022; 12:779182. [PMID: 35265519 PMCID: PMC8899031 DOI: 10.3389/fonc.2022.779182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Stereotactic ablative radiation (SAbR) has been increasingly used in prostate cancer (PCa) given its convenience and cost efficacy. Optimal doses remain poorly defined with limited prospective comparative trials and long-term safety/efficacy data at higher dose levels. We analyzed toxicity and outcomes for SAbR in men with localized PCa at escalated 45 Gy in 5 fractions. Methods and Materials This study retrospectively analyzed men from 2015 to 2019 with PCa who received linear-accelerator-based SAbR to 45 Gy in 5 fractions, along with perirectal hydrogel spacer, fiducial placement, and MRI-based planning. Disease control outcomes were calculated from end of treatment. Minimally important difference (MID) assessing patient-reported quality of life was defined as greater than a one-half standard deviation increase in American Urological Association (AUA) symptom score after SAbR. Results Two-hundred and forty-nine (249) low-, intermediate-, and high-risk PCa patients with median follow-up of 14.9 months for clinical toxicity were included. Acute urinary grade II toxicity occurred in 20.4% of patients. Acute grade II GI toxicity occurred in 7.3% of patients. For follow-up > 2 years (n = 69), late GU and GI grade ≥III toxicity occurred in 5.8% and 1.5% of patients, respectively. MID was evident in 31.8%, 23.4%, 35.8%, 37.0%, 33.3%, and 26.7% of patients at 3, 6, 12, 24, 36, and 48 months, respectively. The median follow-up for biochemical recurrence was 22.6 months with biochemical failure-free survival of 100% at 1 year (n = 226) and 98.7% for years 2 (n = 113) and 3 (n = 54). Conclusions SAbR for PCa at 45 Gy in 5 fractions shows an encouraging safety profile. Prospective studies with longer follow-up are warranted to establish this dose regimen as standard of care for PCa.
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Affiliation(s)
- Lily Chen
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, TX, United States
| | - Bhavani S Gannavarapu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Michael Dohopolski
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ang Gao
- Department of Population and Data Sciences, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - Chul Ahn
- Department of Population and Data Sciences, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - Jeffrey Cadeddu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Solomon Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ganesh V Raj
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Claus Roehrborn
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Robert D Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Aurelie Garant
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Olaechea S, Gannavarapu BS, Gilmore A, Alvarez C, Iyengar P, Infante R. The influence of tumour fluorodeoxyglucose avidity and cachexia development on patient survival in oesophageal or gastroesophageal junction cancer. JCSM Clinical Reports 2021; 6:128-136. [DOI: 10.1002/crt2.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Santiago Olaechea
- Center for Human Nutrition UT Southwestern Medical Center Dallas TX 75390 USA
| | | | - Anne Gilmore
- Center for Human Nutrition UT Southwestern Medical Center Dallas TX 75390 USA
| | - Christian Alvarez
- Center for Human Nutrition UT Southwestern Medical Center Dallas TX 75390 USA
| | - Puneeth Iyengar
- Center for Human Nutrition UT Southwestern Medical Center Dallas TX 75390 USA
- Department of Radiation Oncology UT Southwestern Medical Center Dallas TX USA
| | - Rodney Infante
- Center for Human Nutrition UT Southwestern Medical Center Dallas TX 75390 USA
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Chen L, Gao A, Gannavarapu BS, Garant A, Desai NB, Folkert MR, Ahn C, Roehrborn CG, Lotan Y, Timmerman RD, Hannan R. Safety and outcome of stereotactic body radiation therapy (SBRT) with rectal hydrogel spacer for prostate cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.76] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
76 Background: Ultra-hypofractionated radiotherapy delivered using stereotactic body radiotherapy (SBRT) is a cost-effective treatment for localized prostate cancer. Optimal dosing remains unclear, as commonly used 30-40Gy/5fx regimens appear to overestimate hypofractionation’s control benefits. Here, we report the largest experience of 45Gy/5Fx of SBRT for prostate cancer patients treated with hydrogel peri-rectal spacer (‘hydrogel’). Methods: An IRB-approved retrospective protocol was used to conduct a registry search identifying all patients with prostate cancer who received 45Gy/5Fx between 2015-2019 with hydrogel. Genitourinary (GU) and gastrointestinal (GI) toxicities were defined using the NCI Common Toxicity Criteria for Adverse Events (CTCAE) v.5.0. The ASTRO-Phoenix failure definition of Nadir+2 ng/mL was used for biochemical failure. Results: We analyzed 250 low (9.2%), intermediate (85.2%), and high-risk (5.6%) prostate cancer patients with a median follow-up of 9.9 months (range: 0-45.7 months). Acute GU and GI grade ≥ II toxicities were noted in 15.2% and 7.2% of patients, respectively. Late GU grade II and III toxicities occurred in 24.0% and 1.2% of patients, respectively, while late GI grade II and III toxicities occurred in 4.0% and 0.4% of patients, respectively. In patients (N=44) with follow-up >2 years, late GU and GI grade III toxicities occurred in 4.55% and 2.27% of patients, respectively. A significant correlation was noted for acute GI and GU toxicity predicting the respective late GI and GU toxicity (p-value < 0.001 for both). Physician-reported Grade ≥ II new onset erectile dysfunction was 17.2%. A gradual decline in prostate-specific antigen with a mean nadir of 0.04 (95% CI: [0.018, 0.067]) at 36 months was noted. The actuarial freedom from biochemical failure was 96.33% at 3 years. Overall survival was 94.09% at 3 years with no deaths attributed to prostate cancer. Conclusions: SBRT treatment of 45Gy/5Fx with hydrogel is well tolerated with GU/GI toxicities comparable to those reported for conventional fractionation. Although short, the 3-year biochemical control rate is encouraging. Longer follow-up and prospective evaluation are warranted.
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Affiliation(s)
- Lily Chen
- University of Texas Rio Grande Valley School of Medicine, Edinburg, TX
| | - Ang Gao
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Aurelie Garant
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Chul Ahn
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Yair Lotan
- The University of Texas Southwestern Medical Center, Dallas, TX
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Gannavarapu BS, Hrycushko B, Jia X, Albuquerque K. Upfront radiotherapy with brachytherapy for medically inoperable and unresectable patients with high-risk endometrial cancer. Brachytherapy 2020; 19:139-145. [PMID: 32061534 DOI: 10.1016/j.brachy.2020.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/16/2019] [Accepted: 01/02/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Comprehensive surgery with adjuvant therapy is standard of care for high-risk endometrial cancers, whereas upfront radiotherapy with brachytherapy is indicated for inoperable/unresectable patients, irrespective of risk. We evaluated outcomes for inoperable/unresectable patients with high-risk endometrial cancer (HREC: stage III and/or grade 3) and low-risk endometrial cancer (LREC: stage I/II and grade 1/2) treated with upfront radiotherapy. METHODS Twenty-nine patients with inoperable/unresectable endometrial cancer were treated with upfront radiotherapy at an academic medical center from 2012 to 2019. Cancer-specific survival (CSS), overall survival (OS), and recurrence rates between patients with HREC and LREC were compared. RESULTS Median follow-up was 17.0 months (range 3.7-54.0). Twenty cancers were stage I + II and nine were stage III. Twenty-one cancers were grade 1 + 2 and eight were grade 3. Thirteen patients (45%) had HREC. Twenty-five patients received radiotherapy/chemoradiotherapy for primary treatment, while 4 patients received chemoradiotherapy before surgery. All patients underwent high dose rate brachytherapy (HDR) with 7 receiving HDR alone and 22 receiving external beam radiation and HDR. Two-year CSS was 100% for both HREC and LREC patients (log-rank p = 0.32). There was no OS difference between HREC and LREC patients (2-year: 73% vs. 77%; log-rank p = 0.33). Four HREC and 1 LREC patients recurred with one local recurrence in each group. There were no acute grade ≥3 and two late grade ≥3 gastrointestinal/genitourinary toxicities. CONCLUSIONS Upfront radiotherapy for inoperable/unresectable HREC patients was well tolerated with high local control and CSS rates. Upfront radiotherapy with brachytherapy remains important even for high-risk inoperable and unresectable endometrial cancer patients.
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Affiliation(s)
- Bhavani S Gannavarapu
- Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Brian Hrycushko
- Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Xun Jia
- Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Kevin Albuquerque
- Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, Dallas, TX.
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Atluri PS, Gannavarapu BS, Timmerman RD, Garant A, Hannan R, Folkert MR, Desai NB. Addition of Iodinated Contrast to Rectal Hydrogel Spacer to Facilitate MRI-Independent Target Delineation and Treatment Planning for Prostate Cancer. Pract Radiat Oncol 2019; 9:e528-e533. [DOI: 10.1016/j.prro.2019.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/28/2019] [Indexed: 11/29/2022]
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Gannavarapu BS, Hrycushko B, Jia X, Albuquerque K. Inoperable Patients with High-Risk Endometrial Cancer (HREC) - Is Brachytherapy Worth the Effort? Brachytherapy 2019. [DOI: 10.1016/j.brachy.2019.04.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lau SKM, Gannavarapu BS, Carter K, Gao A, Ahn C, Meyer JJ, Sher DJ, Jatoi A, Infante R, Iyengar P. Impact of Socioeconomic Status on Pretreatment Weight Loss and Survival in Non-Small-Cell Lung Cancer. J Oncol Pract 2018; 14:e211-e220. [PMID: 29558251 DOI: 10.1200/jop.2017.025239] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Socioeconomic status (SES) influences health care outcomes, but the influence of primary payer on cancer-associated wasting is unknown. We hypothesized that primary payer as an indicator of SES would influence pretreatment cancer-associated weight loss and treatment outcomes. MATERIALS AND METHODS Retrospective review of medical records identified 1,366 patients with non-small-cell lung cancer (NSCLC) consecutively treated at a tertiary care health system between January 1, 2006 and December 31, 2013. Insurance status was obtained from an institutional tumor registry. Cancer-associated weight loss was based on the validated international consensus definition of cachexia. Multivariable regression analyses were used to identify prognostic factors of pretreatment cancer-associated weight loss and survival. RESULTS The cohort included a representative group of patients with a median age at diagnosis of 64 years, 47% females, and 33% patients of nonwhite race. Pretreatment cancer-associated weight loss was present at the time of NSCLC diagnosis in 17%, 14%, 32%, and 38% of patients with stage I, II, III, and IV disease, respectively. Pretreatment cancer-associated weight loss was associated with increasing age at diagnosis, black race, single marital status, tobacco use, and disease stage. Compared with private insurance, Medicaid insurance (odds ratio, 2.17; 95% CI, 1.42 to 3.30) and lack of insurance (odds ratio, 2.32; 95% CI, 1.50 to 3.58) were associated with pretreatment cancer-associated weight loss. Among cachectic patients, comorbidity, histology, tumor grade, and disease stage were prognostic of survival on multivariable analysis; however, primary payer was not. CONCLUSION Pretreatment cancer-associated weight loss is common in patients with NSCLC, and its presence is significantly associated with lower SES. However, among patients with pretreatment cancer-associated weight loss, SES was not predictive of survival. Early use of cancer cachexia-directed therapies may improve outcomes, and further study on the biologic mechanisms of cancer cachexia will provide novel therapeutic avenues.
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Affiliation(s)
- Steven K M Lau
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Bhavani S Gannavarapu
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Kristen Carter
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Ang Gao
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Chul Ahn
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Jeffrey J Meyer
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - David J Sher
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Aminah Jatoi
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Rodney Infante
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Puneeth Iyengar
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
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Gannavarapu BS, Lau SKM, Carter K, Cannon NA, Gao A, Ahn C, Meyer JJ, Sher DJ, Jatoi A, Infante R, Iyengar P. Prevalence and Survival Impact of Pretreatment Cancer-Associated Weight Loss: A Tool for Guiding Early Palliative Care. J Oncol Pract 2018; 14:e238-e250. [PMID: 29466074 DOI: 10.1200/jop.2017.025221] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Cancer-associated weight loss is associated with poor prognosis in advanced malignancy; however, its pretreatment prevalence and survival impact are inadequately described in large cohorts. Such data, stratified by tumor type and stage, may facilitate the optimal and timely allocation of complementary care, leading to improvements in patient survival and quality of life. METHODS We performed a retrospective cohort study of 3,180 consecutively treated adult patients with lung or GI (including colorectal, liver, and pancreatic) cancer. Pretreatment cancer-associated weight loss was based on the international consensus definition of cachexia. Prevalence and survival impact of pretreatment cancer-associated weight loss were evaluated using the Kaplan-Meier method and compared using log-rank test. RESULTS Cancer-associated weight loss was observed at the time of cancer diagnosis in 34.1% of patients. Pretreatment weight loss was documented in 17.6%, 25.8%, 36.6%, and 43.3% of stage I, II, III, and IV cancers, respectively. Wasting was common regardless of tumor type, with prevalence at diagnosis ranging from 27.3% in patients with colorectal cancer to 53.4% in patients with gastroesophageal cancer. Pretreatment weight loss was associated with reduced overall survival after adjusting for stage, size, grade, comorbidity, age, sex, and tobacco history (hazard ratio, 1.26; 95% CI, 1.13 to 1.39). CONCLUSION Pretreatment cancer-associated weight loss is common, even in early-stage disease, and is independently associated with reduced survival. Minimal weight loss represents a clinically distinct entity with an associated overall survival intermediate to that of no weight loss and overt wasting. Early diagnosis and treatment of cancer-associated wasting offers a novel therapeutic avenue for reducing cancer mortality.
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Affiliation(s)
- Bhavani S Gannavarapu
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Steven K M Lau
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Kristen Carter
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Nathan A Cannon
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Ang Gao
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Chul Ahn
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Jeffrey J Meyer
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - David J Sher
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Aminah Jatoi
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Rodney Infante
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
| | - Puneeth Iyengar
- University of Texas Southwestern Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS; and Mayo Clinic, Rochester, MN
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Lau S, Gannavarapu BS, Carter K, Gao A, Ahn C, Meyer JJ, Sher DJ, Jatoi A, Iyengar P. Impact of socioeconomic status on pretreatment cachexia and survival in non-small cell lung cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.31_suppl.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
101 Background: Socioeconomic status (SES) influences healthcare outcomes, but the influence of SES on cancer cachexia is unknown. We identify components of SES associated with pre-treatment cachexia in patients with non-small cell lung cancer (NSCLC) and assess their prognostic significance on survival. Methods: A prospectively maintained institutional tumor registry identified 1,365 patients with NSCLC consecutively treated at a tertiary care health system from 1/1/06 to 12/31/13. Insurance status was abstracted from the registry. Educational attainment and household income were estimated from census data using location of primary residence. Cancer cachexia was defined retrospectively using the international consensus definition. Multivariable regression analysis was used to identify prognostic factors of pre-treatment cancer cachexia and survival. Results: Cachexia was present at the time of NSCLC diagnosis in 30% of all patients including 17% of patients with stage I disease. Patients with Medicaid or no insurance were more likely to have pre-treatment cachexia compared to those with private insurance (Odds Ratio [OR] 1.9, 95% Confidence Interval [CI] 1.2-3.1; OR 2.1, 95% CI 1.2-3.4, respectively). Attainment of a high school diploma was inversely associated with pre-treatment cachexia (OR: 0.1, 95% CI 0.02-0.2). On multivariable analysis, comorbidity, histology, tumor grade, and disease stage were prognostic of survival among cachectic patients; however, insurance status, educational attainment, and household income were not. Conclusions: Lower SES is associated with pre-treatment cachexia in patients with NSCLC, but pre-treatment cachexia is detrimental to survival regardless of SES. Together, these findings suggest early intervention for patients with cancer cachexia may improve outcomes.
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Affiliation(s)
- Steven Lau
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Ang Gao
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Chul Ahn
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - David J Sher
- University of Texas Southwestern Medical Center, Dallas, TX
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Abstract
133 Background: The presence of cachexia at the time of cancer diagnosis and its influence on disease management and treatment outcomes for patients receiving radiotherapy are poorly described. Here, we assess the role of baseline cachexia in patients with NSCLC on first-line treatment modality and clinical outcomes. Methods: Retrospective review of medical records identified 1,334 patients with NSCLC consecutively treated at a tertiary care health system between 1/1/06 and 12/31/13. Cachexia was defined using the well-accepted and validated international consensus definition. The delivery of radiotherapy and its treatment intent were abstracted. Results: The cohort included a representative group of patients with a median age at diagnosis of 64 years, 47% females, and 32% patients of non-White race. Stage at diagnosis was I, II, III, and IV in 291, 105, 356, and 578 (43.3%) patients, respectively. Cachexia was present at the time of diagnosis in 403 (30.2%) patients including 18%, 14%, 32%, and 39% of stage I, II, III, and IV patients, respectively. Palliative intent radiotherapy was received by significantly more stage IV patients with cachexia (74%) than without cachexia (63%) (X2, P = .01). In contrast, baseline cachexia was not associated with curative intent radiotherapy in stage I-III disease. At a median follow-up of 24 months, 857 deaths have been observed. Cachexia at the time of diagnosis was prognostic for worse survival by stage. For patients with stage IV NSCLC, median survival was 11 months for patients without cachexia but 6 months for patients with cachexia at diagnosis (P < .001). Cachexia remained significant in stage I NSCLC, with median survival of 45 and 67 months with or without cachexia at diagnosis, respectively (P = .03). Conclusions: Cancer cachexia at the time of diagnosis is common in patients with NSCLC even with early stage disease. The presence of cachexia at diagnosis is associated with utilization of radiotherapy as a palliative treatment. However, cachexia at diagnosis of NSCLC, even with early stage disease, is prognostic of worse outcomes despite curative intent radiotherapy.
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Affiliation(s)
- Steven Lau
- University of Texas Southwestern, Dallas, TX
| | | | | | - Puneeth Iyengar
- The University of Texas Southwestern Medical Center, Dallas, TX
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