Quality of Life in Prostate Cancer Patients Undergoing Daily Adaptive Versus Non-Adaptive Radiation Therapy Utilizing A 1.5 Tesla MR-Linac

PURPOSE/OBJECTIVE(S)

Using adaptive radiation therapy (ART) physicians can re-contour normal organs (such as bladder and rectum) before each fraction. While ART may result in more reliable dosimetry to regional organs at risk, the process is time consuming and more expensive than non-ART. We evaluated differences in patient reported quality of life (PR-QOL) between daily ART and non- ART.

MATERIALS/METHODS

Patients with prostate cancer from 3 centers in the Netherlands and United States were treated using a 1.5 Tesla MR Linear accelerator. Patients consented to the Multiple Outcome Evaluation of Radiation Therapy Using the MR-Linac Study (MOMENTUM, NCT04075305) between 2019 and 2022. PR-QOL was prospectively collected using the EORTC QLQ-C30 and PR-25 at baseline (before RT), and at 3 and 6 months after RT. Patients without complete QOL data were excluded. QOL differences were compared between patients undergoing daily ART vs. non-ART. A linear mixed effect model was performed to account for repeated measurements. Analyses were performed using R Studio.

RESULTS

One hundred thirty-six patients underwent RT with QOL were analyzed. Median follow up was 13 months (6-26 months). Patients were treated without daily ART (n = 94) or with daily ART (n = 42). The median age was 70 (range 53-83) years and 65.4% had intermediate risk disease, 35% of patients received hormonal therapy. Fractionation schedules included 36 Gy/6 (n = 16), 36.25 Gy/5 (n = 103), 60 Gy/20 (n = 6), 62 Gy/20 (n = 8), and 70 Gy/28 (n = 3). Compared to baseline scores, EORTC QLQ C30 diarrhea scores at 6 months post-treatment were significantly worse for patients treated without daily ART compared to those treated with daily ART (p < 0.05). Other QLQ PR25 bowel scores were not significantly different at 3 or 6 months. Both PR25 urinary and treatment-related symptoms were improved with daily ART compared to non-ART at the 3 (p < 0.001 and p < 0.01, respectively) and 6 (p < 0.01 and p < 0.001, respectively) month time points. Magnitude of improvements can be found in Table 1.

CONCLUSION

Among prostate cancer patients treated using 1.5 Tesla MRI-guided RT, daily ART was associated with improved PR-QOL in urinary and bowel domains compared to non-ART. These hypotheses generating preliminary results provide the first indications (to our knowledge) that adapting contours to daily anatomy may improve short-term urinary and bowel PR-QOL. Updated results will be presented at ASTRO 2023.

Patient-Reported Outcomes of Rectal Cancer Patients Treated on a 1.5T MR-Linac within the MOMENTUM Study

PURPOSE/OBJECTIVE(S)

With the 1.5 MR-Linac, planning target volume (PTV) margins for the treatment of rectal cancer can be reduced by 1/3 compared to conventional radiotherapy techniques. This allows better sparing of surrounding tissues, potentially resulting in less toxicity and greater patient comfort. Patient-reported outcomes (PROs) after rectal cancer treatment on a 1.5T MR-Linac have not yet been reported. Through international collaboration, the 'Multi-OutcoMe EvaluatioN of radiation Therapy Using the MR-Linac (MOMENTUM)' registry provides the unique opportunity to study these outcomes in a relatively large patient cohort. The aim of this study is to assess PROs of rectal cancer patients treated on a 1.5T MR-Linac within MOMENTUM.

MATERIALS/METHODS

An international, prospective, observational cohort study was performed, including all patients with rectal cancer who were treated with 25 Gy in five fractions on an MR-Linac in three institutions located in the Netherlands (2019-2022). Patient-reported outcomes were measured using the general EORTC QLQ-C30 and colorectal cancer-specific EORTC QLQ-CR29 questionnaires. Scores were calculated according to the EORTC QLQ-C30 scoring manual. A high score for a functional scale represents a high functioning level, while a high score for a symptom scale represents a high symptomatology level. Outcomes were measured at regular time points (i.e., at baseline and after three, 6 and 12 months follow-up). Patients who underwent tumor resection were censored at the date of surgery.

RESULTS

In total, 152patients were included, with a median follow-up of 17 (interquartile range [IQR] 11-27) months. Of these, six patients (4%) had American Joint Committee on Cancer (AJCC) stage I disease, 11 patients (7%) stage II, 85 patients (56%) stage III, and 12 patients (8%) stage IV. A total of 87 patients (57%) reached three months follow-up without surgery, 60 patients (39%) six months, and 40 patients (26%) twelve months. At six months follow-up, 25/132 patients (19%) had received additional chemotherapy. The median global health score was 83 (interquartile range [IQR] 67-83) at baseline, 75 (IQR 58-83) at three months, 75 (IQR 58-83) at six months and 83 (IQR 83-100) at twelve months. In most QLQ-C30 domains, functional and symptom scores deteriorated during the first six months after treatment, but returned to or exceeded baseline scores at 12 months. Overall, treatment resulted in improved QLQ-CR29 scores after 12 months follow-up. Most frequently reported symptoms were blood and mucus in stool, urinary frequency, stool frequency and anxiety.

CONCLUSION

This study presents patient-reported outcomes in the currently largest cohort of patients with rectal cancer who received treatment on a 1.5T MR-Linac. Overall, treatment resulted in improved symptom management, and stabilized or improved quality of life outcomes after twelve months of follow-up.

Evolution of the MOMENTUM Study for Evidence-Based Implementation of MR-Guided Radiotherapy Using the 1.5 Tesla MR-Linac

PURPOSE/OBJECTIVE(S)

The international prospective 'Multiple Outcome Evaluation of Radiation Therapy Using the MR-Linac' (MOMENTUM) study (NCT04075305) was initiated in 2019 by seven hospitals and industry partner precision radiation medicine company, with the aim to facilitate evidence-based implementation of magnetic resonance (MR) guided radiotherapy using the 1.5 Tesla (T) MR-linear accelerator (Linac). Over the last four years, MOMENTUM has expanded to other institutions and the design and organization of MOMENTUM have evolved. Herein, we give an overview of the current status of MOMENTUM and study innovations that have been implemented to accelerate development and assessment of the 1.5T MR-Linac.

MATERIALS/METHODS

We summarized operational outputs of MOMENTUM, including site participation, data aggregation, academic output, and study design elements that have been introduced since 2019.

RESULTS

As of January 2023, 17 sites have joined and 10 sites are actively enrolling patients in MOMENTUM. The MOMENTUM infrastructure, which consists of prospectively collected clinical and technical patient data and patient reported outcomes, is increasingly being used for predicate studies, technical development studies, safety and early clinical evaluation, and hypothesis testing studies according to R-IDEAL. Over 3500 patients who received treatment for 33 different tumor sites have provided informed consent for using their data for scientific research and product development. The technical database currently includes over 190.000 items, including approximately 98,000 MRI scans and 33,800 dose plans. A total of 38 data requests have been accepted (2019: n = 1; 2020: n = 5; 2021: n = 10; 2022: n = 22), including technical studies focused on algorithmic development. The MOMENTUM infrastructure is also hosting prospective clinical studies, including the randomized HERMES trial (NCT04595019) and prospective UNITED study (NCT04726397). Recently, the 'Trials within Cohorts' (TwiCs) design has been implemented, which is well suited to perform pragmatic randomized trials. MOMENTUM has partnered with Kaiku Health, an electronic patient-reported outcomes application, to facilitate collection of patient reported toxicity.

CONCLUSION

Over the past four years, the MOMENTUM study has evolved into a unique platform, whose infrastructure is increasingly being used by clinicians, researchers, physicists and industry. Continuous efforts are being made to encourage the participation of new sites and the development of innovative tools to facilitate the conduct of well-designed trials that are expected to transform daily clinical practice.

Abstract P4-09-06: Breast Cancer Prognosis Is Inherited Independently of Patient, Tumor and Treatment Characteristics

Fondation Jean Dausset, Paris, France; Karolinska Institute, Stockolm, Sweden; Geneva University Hospitals, Switzerland Introduction: Several studies have suggested that survival of breast cancer is inherited, but none has assessed if this observation is linked to shared tumor characteristics or type of treatment. We studied the association of survival among first-degree relatives (FDRs) with breast cancer, taking into account characteristics of patients, tumors and treatments. Methods: In the population-based Geneva Breast Cancer Registry, we identified 162 pairs of FDRs diagnosed with breast cancer. Based on the breast cancer specific survival status of their proband (i.e. the mother or older sister), we categorized FDRs into poor, medium and good familial survival risk groups. We compared patient, tumor and treatment characteristics between categories and calculated standardized mortality ratios (SMRs) and adjusted disease specific mortality for each group. Results: Breast cancer patients in the poor familial survival risk group were more likely to be diagnosed at later stages than those in the good familial survival risk group. Similarly, they had higher SMRs than those in the medium and good survival risk groups (18.7, 95% Confidence Interval [CI]: 9.4-33.5 versus 16.5 95% CI: 7.6-31.4 and 9.4, 95% CI: 3.4-20.3, respectively). After adjustment for prognostic factors, women in the poor familial survival risk group were almost five times more likely to die of breast cancer than those in the good survival risk group (adjusted Hazard Ratio 4.8, 95% CI: 1.4-16.4).

Conclusion: This study shows that breast cancer prognosis clusters within families, and suggests that the hereditary component is independent of patient, tumor characteristics and type of treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-06.

Childbirth Following Breast Cancer: An Evaluation of the 'Healthy Mothers' Excess Mortality Risk

Background: The favorable outcome of mothers giving birth after breast cancer compared to those who do not, has been attributed to a healthy mother effect. Mainly former breast cancer patients with excellent health status and outlook proceed to having children after their disease. This study evaluates the excess mortality risk among these 'healthy mothers' and factors modifying this risk.Methods: By linking the Singapore Birth Registry (319'437 individuals) and Swedish Multi-Generation Cohort (11 million women) with the respective national cancer registries we identified all 509 women who gave birth &gt;12 months after a breast cancer diagnosis. We calculated excess absolute mortality risks and Standardized Mortality Ratios (SMRs). We used Poisson regression analysis to calculate relative risks of death by country, period of follow up and interval between cancer diagnosis and subsequent birth.Results: The overall 15-year cumulative mortality was 18.2% (95% CI: 13.3 – 20.7%) which is substantially higher than that of the background population (SMR 13.3, 95%CI: 10.4-16.9). Excess mortality risks remained constant over follow up time and were comparable between Sweden and Singapore. Mortality risks decreased significantly with increasing interval between diagnosis and subsequent birth.Conclusion: Despite being 'healthy mothers', women who give birth after a diagnosis of breast cancer have a substantially higher risk of death than the background population. This information may be useful in a woman's decision whether to have a(another) child after breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3173.

Impact of Older Age on Presentation and Management of Breast Cancer in the Multi-Ethnic Population of Singapore

Background: Studies in Caucasian populations have shown that older breast cancer patients are less likely to be treated according to standard guidelines and that this under-treatment is strongly associated with impaired survival. In Asia, where population sizes and life expectancy rates are rising, the number of older women developing breast cancer is growing rapidly. This study aims to evaluate characteristics and treatment patterns of older breast cancer patients in the multi-ethnic population of Singapore, where breast cancer rates have tripled over the past three decades.Methods: This study includes all 2547 women, diagnosed with breast cancer between 1995 and 2006 at the National University Hospital in Singapore. Patients were classified into younger (&lt; 65 years, n=2220) and older (&gt;= 65 years, n=327). Differences in patient and tumor characteristics and treatment between older and younger age groups were explored using multivariate logistic regression models.Results: Even though older Singapore breast cancer patients had more favorable tumor characteristics than younger ones (better tumor differentiation, more often expressing estrogen and progesterone receptors), they presented significantly more often with stage III (adjusted Odds Ratio [ORadj] 1.57, 95%CI 1.0-2.4) and metastatic disease (ORadj 4.3, 95%CI 2.9-6.5). Elderly women were at increased risk not to receive breast surgery (ORadj 1.61, 95%CI 1.0-2.6) and axillary clearance (ORadj 1.74, 95%CI 1.2-2.6). In case of stage I disease, older women were significantly less likely than younger women to be treated with breast conserving surgery (ORadj 0.31, 95%CI 0.2-0.5).Conclusion: Similar to their Caucasian counterparts, older Asian breast cancer patients in Singapore are diagnosed at a later stage and receive less often standard treatment than younger women. Further studies are being undertaken to estimate the impact of these discrepancies on outcome.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3078.

Adjuvant therapy for patients with stage I papillary serous endometrial cancer

Uterine papillary serous carcinoma (UPSC) is an aggressive variant of endometrial cancer characterized by a high recurrence rate and poor prognosis. Several studies have demonstrated that UPSC has a tendency to manifest with extra-uterine disease, even for tumors which appear to be limited to the endometrium. The data on adjuvant chemotherapy for stage I UPSC are limited, and the available studies are generally under-powered to assess if chemotherapy improves survival. However, we believe that, patients with UPSC should receive complete surgical staging, including omentectomy and peritoneal biopsies, and then until the results of larger series or randomized controlled trials will be available, we feel that combined radiotherapy and chemotherapy is justified for all stage I UPSC.