Outcomes of Moderately Dose Escalated Hypofractionated Chemoradiation for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

A modestly hypofractionated course of chemoradiation (CRT) consisting of 36 Gy/15 fractions (F) concurrent with gemcitabine used in PREOPANC and phase II trials has become increasingly common for the treatment of borderline resectable (BR) and locally advanced (LA) pancreatic cancer (PC). Achieving an R0 resection remains a key prognostic factor in PC. We tested whether escalating dose beyond standard dosing (SD) of 36-39 Gy/15 F (or 50-54 Gy/25-30 F) would improve R0 resection rates and outcomes while respecting nearby organs at risk.

MATERIALS/METHODS

This was a retrospective analysis of consecutive patients at our institution from 2012-2022 with BR/LA PC treated with moderate dose escalated (MDE) (45 Gy/15 F, N = 45) or SD (36-39 Gy/15 F, N = 68 or 50-54 Gy/25-30 F, N = 25) CRT. For MDE, a 5 mm expansion from the duodenum, small bowel, and stomach was created (GI_PRV); PTV was cropped from this structure and prescribed 45 Gy/15 F. The primary endpoint was R0 resection rate with secondary endpoints of cumulative incidence of local progression (LP, recurrence after surgery/imaging progression if no surgery) with death as a competing risk (LP after occurrence of distant metastasis [DM] were still captured), cumulative incidence of DM, and overall survival (OS). Univariable and multivariable competing risks regression analyses were performed to determine the association between baseline covariates and LP.

RESULTS

We identified 45 patients treated with MDE and 93 treated with SD. Most patients presented with BR disease (55.6% MDE; 54.8% SD) and received neoadjuvant chemotherapy with FOLFIRINOX (98% MDE; 99% SD). All patients in the MDE group and 99% in the SD group received concurrent chemotherapy with gemcitabine used most often (96% MDE; 77% SD). Median follow-up was 17 m (IQR 13-27 m). Surgical resection rates were similar between groups (33.3% MDE vs. 39.8% SD, p = 0.46). Amongst patients that had surgery, R0 resection rates were non-significantly higher in the MDE group (73.3% vs. 47.4%, p = 0.09). Cumulative incidence of LP at 18 m was significantly lower in the MDE group (9.0% vs. 24.8%, p = 0.04). No difference in rates of DM (51.2% MDE vs. 59.6% SD, p = 0.92) or OS at 18 m (53.9% vs. 53.6%, p = 0.89) were observed. On multivariable analysis, MDE (HR = 0.39, p = 0.03) and pancreatic head location (HR = 0.51, p = 0.04) were the only factors independently associated with LP. Rates of grade 2+ gastrointestinal toxicity during CRT (20% MDE vs. 20.9% SD, p = 0.91) and ≤90 days of completing CRT (11.6% MDE vs. 14.8%, p = 0.62) were similar between groups, as were rates of grade 3+ hematologic toxicity (52.3% MDE vs. 41.3% SD, p = 0.23).

CONCLUSION

In this single institutional study, we found MDE is a simple, safe, and effective strategy associated with improved local control, higher R0 resection rates, and similar toxicity to SD CRT for patients with BR/LA PC. Further prospective data is needed to clarify the role of dose-escalated RT in the management of this lethal malignancy.

Impact of the COVID-19 Pandemic on Financial Burden in Those with a Recent History of Cancer

PURPOSE/OBJECTIVE(S)

Cancer is well known to create significant financial burden on patients. The pandemic posed novel financial challenges, potentially worsening financial burden. We hypothesized that the financial burden experienced by participants with a recent history of cancer (HC) during the pandemic would be increased compared to participants without history of cancer (NC).

MATERIALS/METHODS

From June-November 2020, individuals who participated in past Ohio State University (OSU) studies, cancer patients, their caregivers and individuals on OSU community partner listservs were asked to participate in a survey to assess the pandemic's impact on employment and financial concerns (FC). Responses were compiled in a FC score. We wanted to evaluate the impact of a recent cancer diagnosis and treatment, so HC was defined as being diagnosed with cancer within 3 years prior to the survey date. Participants who worked prior to COVID, were matched by propensity score using a 1:2 algorithm to best compare financial burden across HC and NC. Negative binomial multivariable analysis (MVA) was used to compare FC scores of HC to NC, with adjustment for demographic and socioeconomic characteristics. The interaction between HC vs NC and race was examined in MVA.

RESULTS

Of 32,989 contacted individuals, 9,423 (26.8%) completed the survey. Those with a cancer diagnosis >3 years ago, and/or no full-time employment prior to the pandemic were excluded, leaving a sample of 2,703 participants (449 HC and 2,254 NC). The median age was 54 years for HC and 50 years for NC, 83.7% of HC and 80.0% NC had private insurance, and 4.5% of HC and 6.1% of NC had public insurance, 61.7% of HC and 60.2% of NC had income of $75k+ and 6.0% of HC and 7.2% of NC had income of <35k, 5.8% of HC and 5.2% of NC were Black (p<0.01 for all). Given significant differences in baseline characteristics of both groups, a matched pair-analysis of 1218 participants (421 HC and 797 NC) was performed and utilized for remaining analyses. There were no differences between HC and NC in being paid for a full or part-time job (p = 0.15) or job loss (p = 0.47), due to the pandemic. On MVA, HC were less likely to have financial concerns than NC. Black participants had a 1.55 times higher FC score than white participants, and those with an annual household income < $35K and $35K-50K had 1.8 and 1.5 times higher FC score compared to those with income of $75K or higher (p<0.01 for all). When Black HC were compared to Black NC, HC had 1.6 times higher odds of financial concerns (p = 0.02).

CONCLUSION

In this selected population, HC were less likely to have financial concerns than NC, potentially due to difference in baseline characteristics that could not be accounted for in MVA. However, those with total income <$50k and Black participants, particularly Black HC, were the groups most likely to have FC during the pandemic. Further analysis should investigate long-term ramifications of increased FC in these vulnerable groups, particularly when pandemic and cancer-related financial burdens are compounded.

Accessibility and Impact of Telehealth in Rural Populations with a History of Cancer

PURPOSE/OBJECTIVE(S)

After the COVID-19 pandemic, telehealth (TH) has been increasingly utilized in healthcare delivery. We aim to analyze the preference and availability of TH for participants with a history of cancer (HC) and hypothesize HC in rural areas will have lower access to TH compared to metropolitan residents (metro).

MATERIALS/METHODS

From June-November 2020, individuals who had participated in past OSU studies, cancer patients, their nominated caregivers and those on OSU community partner listservs were asked to participate in a survey to understand the pandemic's impacts on healthcare access. A follow-up survey was distributed from March-July 2021. Survey data were merged with information from the OSU James Cancer Registry to confirm history of cancer. Only participants with HC were included in this analysis. Participants were asked demographic questions and questions to assess preferences and accessibility regarding TH. Chi-square tests as well as Wilcoxon Rank Sum Test were used to review the bivariate associations between demographic and TH variables with rural/metro residence.

RESULTS

Of 9,280 who completed the first survey, 7,224 (77.8%) also completed the second survey, and 3,536 were HC (891 rural, 2,645 metro). The median age was 63 years, 63.3% of the participants were women, 89.0% were non-Hispanic white, 15.0% had public health insurance, 53.3% had a college degree or higher, 46.8% of the patients had an income >$75K. In metro areas, more participants were black, had an education of at least a college degree and had higher incomes compared to those in rural areas (p<0.001 for all). Otherwise, there were no differences in patient characteristics between rural and metro HC. When asked TH specific variables, patients in rural areas were less likely to have a smart phone (48.8% vs. 54%), less likely to have internet access (57.8% vs. 62.23%), more likely to be concerned about the cost of internet at home (18% vs. 14.8%), less likely to have participated in video TH visit since the pandemic (27.1% vs. 36.1%) (p<.01 for all). There was no difference in participation in TH by phone, satisfaction with the TH visit, or perception that TH made seeing a provider easier (p>0.05 for all) between rural and metro participants.

CONCLUSION

Participants in rural areas were less likely to have internet access, which may have a role in their decreased engagement with video TH since the pandemic, compared to metro participants. However, there was no difference in use of telephone visits. Video visits are known to allow a more comprehensive evaluation including visual assessments. Although TH options are desirable for those residing further from medical centers, barriers to completion of successful virtual visits have limited more widespread adoption of TH among this patient population. Future efforts to improve care for rural populations should focus on improving disparities in access to quality telecommunication services and expanded connections with rural providers to provide comprehensive care.