ACR-ARS Practice Parameter for Communication: Radiation Oncology

BACKGROUND

This practice parameter was revised collaboratively by the American College of Radiology (ACR), and the American Radium Society (ARS). Timely, accurate, and effective communications are critical to quality and safety in contemporary medical practices. Radiation oncology incorporates the science and technology of complex, integrated treatment delivery and the art of providing care to individual patients. Through written physical and/or electronic reports and direct communication, radiation oncologists convey their knowledge and evaluation regarding patient care, clinical workup, and treatment provided to others in the management of the patient. Applicable practice parameters need to be revised periodically regarding medical record documentation for professional and technical components of services delivered.

METHODS

This practice parameter was developed and revised according to the process described under the heading "The Process for Developing ACR Practice Parameters and Technical Standards" on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS. Both societies have reviewed and approved the document.

RESULTS

This practice parameter addresses radiation oncology communications in general, including (a) medical record, (b) electronic, and (c) doctor-patient communications, as well as specific documentation for radiation oncology reports such as (a) consultation, (b) clinical treatment management notes (including inpatient communication), (c) treatment (completion) summary, and (d) follow-up visits.

CONCLUSIONS

The radiation oncologist's participation in the multidisciplinary management of patients is reflected in timely, medically appropriate, and informative communication with patients, caregivers, referring physician, and other members of the health care team. The ACR-ARS Practice Parameter for Communication: Radiation Oncology is an educational tool designed to assist practitioners in providing appropriate communication regarding radiation oncology care for patients.

International Expert-Based Consensus Definition, Staging Criteria, and Minimum Data Elements for Osteoradionecrosis of the Jaw: An Inter-Disciplinary Modified Delphi Study

Purpose

Osteoradionecrosis of the jaw (ORNJ) is a severe iatrogenic disease characterized by bone death after radiation therapy (RT) to the head and neck. With over 9 published definitions and at least 16 diagnostic/staging systems, the true incidence and severity of ORNJ are obscured by lack of a standard for disease definition and severity assessment, leading to inaccurate estimation of incidence, reporting ambiguity, and likely under-diagnosis worldwide. This study aimed to achieve consensus on an explicit definition and phenotype of ORNJ and related precursor states through data standardization to facilitate effective diagnosis, monitoring, and multidisciplinary management of ORNJ.

Methods

The ORAL Consortium comprised 69 international experts, including representatives from medical, surgical, radiation oncology, and oral/dental disciplines. Using a web-based modified Delphi technique, panelists classified descriptive cases using existing staging systems, reviewed systems for feature extraction and specification, and iteratively classified cases based on clinical/imaging feature combinations.

Results

The Consortium ORNJ definition was developed in alignment with SNOMED-CT terminology and recent ISOO-MASCC-ASCO guideline recommendations. Case review using existing ORNJ staging systems showed high rates of inability to classify (up to 76%). Ten consensus statements and nine minimum data elements (MDEs) were outlined for prospective collection and classification of precursor/ORNJ stages.

Conclusion

This study provides an international, consensus-based definition and MDE foundation for standardized ORNJ reporting in cancer survivors treated with RT. Head and neck surgeons, radiation, surgical, medical oncologists, and dental specialists should adopt MDEs to enable scalable health information exchange and analytics. Work is underway to develop both a human- and machine-readable knowledge representation for ORNJ (i.e., ontology) and multidisciplinary resources for dissemination to improve ORNJ reporting in academic and community practice settings.

Effects of Wildfire Events on California Radiation Oncology Clinics and Patients

Purpose

The effect of climate-driven events, such as wildfires, on health care delivery and cancer care is a growing concern. Patients with cancer undergoing radiation therapy are particularly vulnerable to treatment interruptions, which have a direct effect on survival. We report the results of a study characterizing the effect of wildfires on radiation oncology clinics and their patients.

Methods and Materials

A survey of California radiation oncologists was used to evaluate emergency preparedness and the effect of wildfires on the delivery of radiation therapy services between 2017 and 2022. Descriptive statistics and Pearson's χ2 tests were performed to investigate potential relationships between provider characteristics, practice settings, and perceptions of the effect of wildfire events. California Department of Forestry and Fire Protection data were employed to map the geographic distribution of wildfires to clinic locations.

Results

Response rate was 12.3% (51/415 radiation oncologists), representing 25% of clinics (43/176) in 41% (24/58) of California counties. Sixty-one percent (31/51) of respondents reported being affected by a wildfire, 2 of which are rural clinics (100%, 2/2) and 29 are (59%, 29/49) metropolitan practices. Of these, 18% (9/51) reported a clinic closure, and 29% (15/51) reported staffing shortages. Respondents reported effects on patients, including having to evacuate (55%, 28/51), cancel/reschedule treatments (53%, 27/51), and experiencing physical, mental, or financial hardship due to wildfires (45%, 23/51). Respondents described effects on clinical operations, including being forced to transfer patients (24%, 12/51), transportation interruptions (37%, 19/51), regional/community evacuations (35%, 18/51), and physical/mental health effects (27%, 14/51) on clinic personnel. Less than half of the respondents (47%, 24/51) reported their workplace had a wildfire emergency preparedness plan. Additionally, geographic analysis revealed that 100% (176/176) of clinics were located within 25 miles of a wildfire.

Conclusions

This study highlights the effects of wildfires on radiation oncology clinics and patients and underscores the need for emergency preparedness planning to minimize the consequences of such disasters.

Integration of Radiation Oncology Into the Preclinical Curriculum Through Problem-Based Learning

PURPOSE

Early exposure to oncology care during the preclinical years of medical school may translate to increased student interest in oncology-related fields and improved understanding of oncologic treatment modalities, including radiation oncology. Many schools incorporate problem-based learning (PBL) into the medical school curriculum; this is an opportunity to immerse students in oncologic case management. We describe the effective incorporation of one course into the medical school curriculum that may be replicated at other institutions.

METHODS AND MATERIALS

A PBL case regarding pancreatic cancer was created by a radiation oncology resident and faculty member in collaboration with the gastrointestinal course director for first-year medical students at a single institution. Pancreatic cancer was chosen based on curricular needs. Learning objectives were discussed to guide the creation of the case.

RESULTS

All 140 first-year medical students participated in the 1-hour small group case focused on oncologic work up, multidisciplinary care, and radiation therapy concepts. Students were provided with a case prompt and resources to review prior to the PBL session. Volunteer radiation oncology facilitators attended a 30-minute educational meeting and were provided a detailed case guide 1 week before the PBL session. During the PBL case, facilitators guided students to achieve desired learning objectives. Among the 76 (54%) medical students who completed an optional post-PBL survey, the majority reported that the case motivated them to learn more about oncology (89%) and radiation oncology (82%). There was an increase in the number of subscribers to the Oncology Interest Group (43% increase from previous year) and preclinical students shadowing in the radiation oncology department. The PBL case was continued in future years for all first-year students and extended to 2 hours to promote additional discussion in response to student and facilitator feedback.

CONCLUSIONS

A cancer-specific PBL case facilitated by radiation oncology educators is an effective avenue to integrate radiation oncology into the preclinical curriculum and stimulate interest in oncology among first-year medical students.

Critical review of the current and future prospects of VEGF-TKIs in the management of squamous cell carcinoma of head and neck

As the prognosis for squamous cell carcinoma of the head and neck remains unsatisfactory when compared to other malignancies, novel therapies targeting specific biomarkers are a critical emerging area of great promise. One particular class of drugs that has been developed to impede tumor angiogenesis is vascular endothelial growth factor-tyrosine kinase inhibitors. As current data is primarily limited to preclinical and phase I/II trials, this review summarizes the current and future prospects of these agents in squamous cell carcinoma of the head and neck. In particular, the combination of these agents with immunotherapy is an exciting area that may be a promising option for patients with recurrent or metastatic disease, evidenced in recent trials such as the combination immune checkpoint inhibitors with lenvatinib and cabozantinib. In addition, the use of such combination therapy preoperatively in locally advanced disease is another area of interest.

The evolving landscape of salivary gland tumors

Salivary gland cancers are a rare, histologically diverse group of tumors. They range from indolent to aggressive and can cause significant morbidity and mortality. Surgical resection remains the mainstay of treatment, but radiation and systemic therapy are also critical parts of the care paradigm. Given the rarity and heterogeneity of these cancers, they are best managed in a multidisciplinary program. In this review, the authors highlight standards of care as well as exciting new research for salivary gland cancers that will strive for better patient outcomes.

Photon vs. Proton Radiotherapy in the Definitive Treatment of Nasopharyngeal Cancer: Single Institution Experience

PURPOSE/OBJECTIVE(S)

Definitive therapy for nasopharyngeal cancer includes chemotherapy and radiation (RT). Common toxicities such as xerostomia, mucositis, and hearing loss are correlated with the RT dose delivered to associated organs at risk. We hypothesized that compared to our historical experience with IMRT, the implementation of proton therapy (PT) would reduce radiation dose to organs at risks without compromising oncologic outcomes.

MATERIALS/METHODS

A retrospective review of all non-metastatic stage II-IV nasopharyngeal carcinoma (SCC, lymphoepithelioma, undifferentiated carcinomas) treated with definitive therapy at our institution from 2012-2022. Disease parameters and the mean dose to organs at risk were evaluated. Statistical comparison was made with the chi square test for categorical and Wilcoxon rank sum test for continuous variables. The Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS), using a log-rank test to compare IMRT and PT. PFS was defined as the time from the start of treatment to the first of either disease progression, relapse or death from any cause. PT was delivered with pencil-beam scanning in all patients. IMRT included multi-field treatment and volumetric-modulated arc therapy.

RESULTS

A total of 80 patients were included in analyses: 48 treated with IMRT and 32 with PT. Comparing IMRT to PT cohorts, there was no difference in the median age of patients (51 vs 55 years, p = 0.73), nor the distribution by T stage (p = 0.57) or N stage (p = 0.34) or in the percentage of patients with ECOG 2/3 performance status at presentation (p = 0.11). All but one patient received concurrent systemic therapy and there was no difference in the use of concurrent cisplatin between cohorts (83% vs 78%, p = 0.57). The most common non-cisplatin concurrent regimen was weekly carboplatin and paclitaxel. Induction chemotherapy was more commonly used in patients treated with PT (10.4% vs 25%, p = 0.04) while there was no difference in the use of adjuvant chemotherapy (10.4% vs 9.4%, p = 0.88). Among 42 cases initiating treatment since the opening of our proton center, 32 (76%) have received PT. Comparing IMRT and PT dosimetry, patients treated with PT received significantly lower mean dose to the better spared parotid gland (32.8 vs 25.7 Gy, p = 0.001), lesser spared parotid gland (35.5 vs 31.1 Gy, p = 0.047), better spared cochlea (31.5 vs 25.5 Gy, p = 0.004), lesser spared cochlea (41.8 vs 33.2 Gy, p = 0.004), larynx (44.5 vs 21.7 Gy, p<0.001), and oral cavity (42.6 vs 17.0 Gy, p<0.001). After a median follow-up time of 30 months (45 mos IMRT, 23 mos PT) the estimated 2-year PFS was 63.9% with IMRT and 90.3% with PT (p = 0.047). The estimate of 2-year overall survival was 86.8% with IMRT and 96.8% with PT (p = 0.17).

CONCLUSION

Comparing patients by radiation treatment modality, PT was associated with a statistically significant reduction in mean radiation dose to the parotid glands, cochlea, larynx, and oral cavity with excellent initial oncologic outcomes.

The Use of Problem-Based Learning Curriculum to Increase Medical Student Exposure to Radiation Oncology

PURPOSE/OBJECTIVE(S)

In recent years, there has been a decline in the number of radiation oncology residency applicants. New techniques to recruit students to the field are necessary. Early exposure to oncology care in pre-clinical years may translate to increased student interest in oncology-related fields and improved understanding of oncologic treatment modalities. We propose that a cancer-specific problem-based learning (PBL) case will increase exposure to oncology during pre-clinical years.

MATERIALS/METHODS

A PBL case regarding pancreatic cancer was created by a radiation oncology resident/faculty member and the gastrointestinal course director for first-year medical students (n = 140) at a single institution. The one-hour small group case focused on oncologic work up, multi-disciplinary care and radiotherapy concepts. Students were provided with a case prompt and resources to review prior to the PBL session. Volunteer radiation oncology facilitators then guided students through the case to achieve desired learning objectives. Following the PBL, students completed an optional nine-question survey regarding their experience.

RESULTS

A total of 76 (54%) medical students completed the post-PBL survey. The majority (89%) of students reported that the case motivated them to learn more about oncology, and almost all (99%) noted improved understanding of the multidisciplinary nature of cancer care. 75 (99%) students reported increased understanding of how radiotherapy is delivered. 62 (82%) students reported increased motivation to learn about radiation oncology. 38 (50%) students reported that they plan to participate in an elective in oncology. 36 (47%) reported that they are considering pursuing an oncologic field. There was an increase in the number of subscribers to the Oncology Interest Group (43% increase from previous year) and positive feedback was noted from free-text responses from participants.

CONCLUSION

Integrating a cancer-specific PBL case facilitated by radiation oncology educators into the pre-clinical curriculum is an effective avenue to introduce oncology concepts and stimulate interest in oncology amongst first-year medical students.

Impacts of Wildfire Events on California Radiation Oncology Clinics and Patients

PURPOSE/OBJECTIVE(S)

The impact of climate-related disasters such as wildfires on healthcare delivery and cancer care is a growing concern. Patients undergoing radiotherapy are particularly vulnerable to treatment interruptions which are known to have a direct impact on survival outcomes. We report results of the first pilot study characterizing the impact of wildfires on radiation oncology clinics and their patients.

MATERIALS/METHODS

A survey was sent to 415 California radiation oncologists representing 144 clinics identified using the ASTRO member directory to gather information about clinic and radiation oncologist demographics, wildfires' impacts on the clinic (physical/operational), physicians, staff, and patients between 2017 and 2022, as well as clinics' disaster preparedness efforts.

RESULTS

A total of 51 radiation oncologists completed the survey, representing 43 clinics (30% of clinics) in 24 (41%) of California counties. 35 (69%) of respondents self-identified as male, 27 (53%) worked at hospital-affiliated centers, 19 (37%) worked in academic centers, with 49 (96%) practicing in metropolitan areas. A total of 31 clinics were impacted by a wildfire between 2017 and 2020. The two rural clinics (100%) and 29 (59%) of metro practices reported being impacted by wildfires in the last 5 years, with 9 (18%) reporting a clinic closure and 15 (29%) reporting staffing shortages. 28 (55%) of respondents reported impacts on patients including having to evacuate, 27 (53%) having to cancel or reschedule treatments, and 23 (45%) experiencing physical, mental, or financial hardship due to the wildfires. Among the 25 clinics impacted by wildfires, 12 (24%) reported physical/operational impacts including being forced to evacuate patients to another treatment center, transportation interruptions (19, 37%), community and regional evacuations (18, 35%), school closures (18, 35%), and physical/mental health impacts (14, 27%) on staff due to the wildfires. Small clinics (25 staff or less) that experienced a wildfire were twice as likely to experience closures (6 of 16 clinics, 38%) but equally likely to experience staffing shortages (8 of 16, 50 %) as compared to larger practices (7 of 15, 47%). Nearly half of respondents 25 (47%) reported their workplace had a wildfire emergency preparedness plan.

CONCLUSION

The results of this study demonstrate the significant impact wildfires have on patient care in both rural and metropolitan areas. The findings emphasize the importance of emergency preparedness planning to minimize the consequences of such disasters and underscores the need for further research to explore risk factors associated with patient and community vulnerability to climate-related crises. Such research will be essential to informing and developing future emergency preparedness plans.

Cardiac Substructure Radiation Dose and Risk of Late Cardiac Disease in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

PURPOSE

Radiation-associated cardiac disease is a major cause of morbidity/mortality among childhood cancer survivors. Radiation dose-response relationships for cardiac substructures and cardiac diseases remain unestablished.

METHODS

Using the 25,481 5-year survivors of childhood cancer treated from 1970 to 1999 in the Childhood Cancer Survivor Study, we evaluated coronary artery disease (CAD), heart failure (HF), valvular disease (VD), and arrhythmia. We reconstructed radiation doses for each survivor to the coronary arteries, chambers, valves, and whole heart. Excess relative rate (ERR) models and piecewise exponential models evaluated dose-response relationships.

RESULTS

The cumulative incidence 35 years from diagnosis was 3.9% (95% CI, 3.4 to 4.3) for CAD, 3.8% (95% CI, 3.4 to 4.2) for HF, 1.2% (95% CI, 1.0 to 1.5) for VD, and 1.4% (95% CI, 1.1 to 1.6) for arrhythmia. A total of 12,288 survivors (48.2%) were exposed to radiotherapy. Quadratic ERR models improved fit compared with linear ERR models for the dose-response relationship between mean whole heart and CAD, HF, and arrhythmia, suggesting a potential threshold dose; however, such departure from linearity was not observed for most cardiac substructure end point dose-response relationships. Mean doses of 5-9.9 Gy to the whole heart did not increase the risk of any cardiac diseases. Mean doses of 5-9.9 Gy to the right coronary artery (rate ratio [RR], 2.6 [95% CI, 1.6 to 4.1]) and left ventricle (RR, 2.2 [95% CI, 1.3 to 3.7]) increased risk of CAD, and to the tricuspid valve (RR, 5.5 [95% CI, 2.0 to 15.1]) and right ventricle (RR, 8.4 [95% CI, 3.7 to 19.0]) increased risk of VD.

CONCLUSION

Among children with cancer, there may be no threshold dose below which radiation to the cardiac substructures does not increase the risk of cardiac diseases. This emphasizes their importance in modern treatment planning.

Insurance Authorization and Access to Proton Therapy for Patients With Head and Neck Cancers

PURPOSE

We evaluated our institutional experience to assess potential racial inequities in insurance coverage for proton therapy in patients with head and neck (HN) cancer.

METHODS AND MATERIALS

We examined the demographics of 1519 patients with HN cancer seen in consultation at our HN multidisciplinary clinic (HN MDC) and 805 patients for whom a proton insurance authorization was sought (PAS) from January 2020 to June 2022. The prospects for proton therapy insurance authorization were prospectively noted based on each patient's ICD-10 (International Classification of Diseases, 10th Revision) diagnosis code and their specific insurance plan. Proton-unfavorable (PU) insurance were those plans whose policy describes proton beam therapy as "experimental" or "not medically necessary" for the given diagnosis.

RESULTS

For patients seen in our HN MDC, Black, Indigenous, and people of color (BIPOC) were significantly more likely to have PU insurance than non-Hispanic White (NHW) patients (24.9% vs 18.4%, P = .005). In multivariable analysis including race, average income of residence ZIP code, and Medicare eligibility age, BIPOC patients had an odds ratio of 1.25 for PU insurance (P = .041). In the PAS cohort, while there was no difference in the percentage of patients receiving insurance approval for proton therapy between NHW and BIPOC populations (88% vs 88.2%, P = .80), for patients with PU insurance, the median time to determination was significantly longer (median, 15.5 days), and the median time to start any radiation of any modality was longer (46 vs 35 days, P = .08). Compared with NHW patients, the median time from consultation to start of radiation therapy was longer for BIPOC patients (37 vs 43 days, P = .01).

CONCLUSIONS

BIPOC patients were significantly more likely to have insurance plans unfavorable to proton therapy coverage. These PU insurance plans were associated with a longer median time to determination, a lower approval rate for proton therapy, and a longer time to start radiation of any modality.

Does lymphovascular invasion predict survival in oral cancer? A population-based analysis

OBJECTIVE

To evaluate lymphovascular invasion as an independent predictor for overall survival in patients with oral cavity squamous cell carcinoma.

STUDY DESIGN

Retrospective cohort study.

SETTING

Multi-center, population-based facilities reporting to the National Cancer Database registry.

METHODS

The database was accessed to collect data on patients with oral cavity squamous cell carcinoma. A multivariate cox proportional hazards model was used to analyze the association between presence of lymphovascular invasion and overall survival.

RESULTS

16,992 patients met inclusion criteria. 3,457 patients had lymphovascular invasion. The mean follow-up was 32 ± 19 months. Lymphovascular invasion predicted reduced 2-year overall survival (relative hazard 1.29, 95% CI: 1.20, 1.38, p < 0.001) and 5-year overall survival (relative hazard 1.30, 95% CI: 1.23, 1.39, p < 0.001). LVI reduced overall survival in patients with squamous cell carcinoma of the oral tongue (HR: 1.27, 95% CI: 1.17, 1.39, p < 0.001), floor of mouth (HR: 1.33, 95% CI: 1.17, 1.52, p < 0.001) and buccal mucosa (HR: 1.44, 95% CI: 1.15, 1.81, p = 0.001). Patients with lymphovascular invasion treated with surgery plus post-operative radiotherapy had significantly improved survival compared to those who underwent surgery alone (relative hazard 1.79, 95% CI: 1.58, 2.03, p < 0.001), and patients treated with surgery + post-operative chemoradiotherapy had improved survival compared to those treated with surgery alone (relative hazard 2.0, 95% CI: 2.26, 1.79, p < 0.001).

CONCLUSION

Lymphovascular invasion is an important independent risk factor for decreased overall survival in oral cavity squamous cell carcinoma involving the oral tongue, floor of mouth and buccal mucosa subsites.

Cardiac Disease in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review

PURPOSE

Radiation therapy (RT) is an essential component in the treatment of many pediatric malignancies. Thoracic RT may expose the heart to radiation dose and thereby increase the risk of late cardiac disease. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on late cardiac disease in survivors of childhood cancer treated with RT.

METHODS AND MATERIALS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We identified 1496 articles; 4 were included for dose-response modeling between mean cardiac radiation dose and risk of late coronary artery disease, heart failure (HF), valvular disease, and any cardiac disease.

RESULTS

For each 10-Gy increase in corrected mean cardiac radiation dose in 1.8- to 2.0-Gy fractions, we estimated a hazard ratio of 2.01 (95% confidence interval [CI], 1.79-2.25) for coronary artery disease, of 1.87 (95% CI, 1.70-2.06) for HF, of 1.87 (95% CI, 1.78-1.96) for valvular disease, and of 1.88 (95% CI, 1.75-2.03) for any cardiac disease. From the same model, for each 100-mg/m² increase in cumulative anthracycline dose, the hazard ratio for the development of HF was 1.93 (95% CI, 1.58-2.36), equivalent to an increase in mean heart dose of approximately 10.5 Gy. Other nontreatment factors were inconsistently reported in the analyzed articles.

CONCLUSIONS

Radiation dose to the heart increases the risk of late cardiac disease, but survivors of childhood cancer who receive a mean dose <10 Gy at standard fractionation are at low absolute risk (<∼2% approximately 30 years after exposure) of late cardiac disease in the absence of anthracycline exposure. Minimizing cardiac radiation dose is especially relevant in children receiving anthracyclines. When cardiac sparing is not possible, we recommend prioritizing target coverage. It is likely that individual cardiac substructure doses will be a better predictor of specific cardiac diseases than mean dose, and we urge the pediatric oncology community to further study these relationships.

Pembrolizumab and cabozantinib in recurrent metastatic head and neck squamous cell carcinoma: a phase 2 trial

Anti-programmed cell death protein 1 (PD-1) therapy is a standard of care in recurrent metastatic head and neck squamous cell carcinoma (RMHNSCC). Vascular endothelial growth factor inhibitors, including tyrosine kinase inhibitors, have immunomodulatory properties and have offered promising results when combined with anti-PD-1 agents. We conducted a phase 2, multicenter, single-arm trial of pembrolizumab and cabozantinib in patients with RMHNSCC who had Response Evaluation Criteria in Solid Tumors v.1.1 measurable disease and no contraindications to either agent. We assessed the primary end points of tolerability and overall response rate to the combination with secondary end points of progression-free survival and overall survival and performed correlative studies with PDL-1 and combined positive score, CD8+ T cell infiltration and tumor mutational burden. A total of 50 patients were screened and 36 were enrolled with 33 evaluable for response. The primary end point was met, with 17 out of 33 patients having a partial response (52%) and 13 (39%) stable disease with an overall clinical benefit rate of 91%. Median and 1-year overall survival were 22.3 months (95% confidence interval (CI) = 11.7-32.9) and 68.4% (95% CI = 45.1%-83.5%), respectively. Median and 1-year progression-free survival were 14.6 months (95% CI = 8.2-19.6) and 54% (95% CI = 31.5%-72%), respectively. Grade 3 or higher treatment-related adverse events included increased aspartate aminotransferase (n = 2, 5.6%). In 16 patients (44.4%), the dose of cabozantinib was reduced to 20 mg daily. The overall response rate correlated positively with baseline CD8+ T cell infiltration. There was no observed correlation between tumor mutational burden and clinical outcome. Pembrolizumab and cabozantinib were well tolerated and showed promising clinical activity in patients with RMHNSCC. Further investigation of similar combinations are needed in RMHNSCC. The trial is registered at ClinicalTrials.gov under registration no. NCT03468218 .

Corrigendum to "Challenges in the transition to independent radiation oncology practice and targeted interventions for improvement" [Tech. Innov. Patient Support Radiat. Oncol. 24 (2022) 113-117]

[This corrects the article DOI: 10.1016/j.tipsro.2022.09.002.].

Ninety-day mortality following transoral robotic surgery or radiation at Commission on Cancer-accredited facilities

BACKGROUND

Postoperative mortality for oropharynx squamous cell carcinoma (OPSCC) with transoral robotic surgery (TORS) varies from 0.2% to 6.5% on trials; the real-world rate is unknown.

METHODS

NCDB study from 2010 to 2017 for patients with cT1-2N0-2M0 OPSCC with Charleson-Deyo score 0-1. Ninety-day mortality assessed from start and end of treatment at Commission on Cancer-accredited facilities.

RESULTS

3639 patients were treated with TORS and 1937 with radiotherapy. TORS cohort had more women and higher income, was younger, more often treated at academic centers, and more likely to have private insurance (all p < 0.05). Ninety-day mortality was 1.3% with TORS and 0.7% or 1.4% from start or end of radiotherapy, respectively. From end of therapy, there was no significant difference on MVA between treatment modality.

CONCLUSIONS

There is minimal difference between 90-day mortality in patients treated with TORS or radiotherapy for early-stage OPSCC. While overall rates are low, for patients with expectation of cure, work is needed to identify optimal treatment.

Systematic review for deep inspiration breath hold in proton therapy for mediastinal lymphoma: A PTCOG Lymphoma Subcommittee report and recommendations

PURPOSE

To systematically review all dosimetric studies investigating the impact of deep inspiration breath hold (DIBH) compared with free breathing (FB) in mediastinal lymphoma patients treated with proton therapy as compared to IMRT (intensity-modulated radiation therapy)-DIBH.

MATERIALS AND METHODS

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the PubMed database to identify studies of mediastinal lymphoma patients with dosimetric comparisons of proton-FB and/or proton-DIBH with IMRT-DIBH. Parameters included mean heart (MHD), lung (MLD), and breast (MBD) doses, among other parameters. Case reports were excluded. Absolute differences in mean doses > 1 Gy between comparators were considered to be clinically meaningful.

RESULTS

As of April 2021, eight studies fit these criteria (n = 8), with the following comparisons: proton-FB vs IMRT-DIBH (n = 5), proton-DIBH vs proton-FB (n = 5), and proton-DIBH vs IMRT-DIBH (n = 8). When comparing proton-FB with IMRT-DIBH in 5 studies, MHD was reduced with proton-FB in 2 studies, was similar (<1 Gy difference) in 2 studies, and increased in 1 study. On the other hand, MLD and MBD were reduced with proton-FB in 3 and 4 studies, respectively. When comparing proton-DIBH with proton-FB, MHD and MLD were reduced with proton DIBH in 4 and 3 studies, respectively, while MBD remained similar. Compared with IMRT-DIBH in 8 studies, proton-DIBH reduced the MHD in 7 studies and was similar in 1 study. Furthermore, MLD and MBD were reduced with proton-DIBH in 8 and 6 studies respectively. Integral dose was similar between proton-FB and proton-DIBH, and both were substantially lower than IMRT-DIBH.

CONCLUSION

Accounting for heart, lung, breast, and integral dose, proton therapy (FB or DIBH) was superior to IMRT-DIBH. Proton-DIBH can lower dose to the lungs and heart even further compared with proton-FB, depending on disease location in the mediastinum, and organ-sparing and target coverage priorities.

Challenges in the transition to independent radiation oncology practice and targeted interventions for improvement

Numerous radiation oncology residents and junior attendings have identified common weaknesses in residency training that hinder the transition from training to independent practice. Recurrent themes include not only general autonomy but also proficiency in technical skills, such as treatment plan review and image verification, and nontechnical skills, such as leadership, mentorship, and education. While multiple strategies to address these deficiencies have been investigated, many are not widely available or may be difficult to implement. We aim to summarize the frequently cited challenges in the transition to independent radiation oncology practice as well as the pertinent interventions that have been explored.

Impact of Type of Treatment Center and Access to Care on Mortality and Survival for Skull Base Chordoma and Chondrosarcoma

Introduction In adults with skull base chordoma or chondrosarcoma, the impact of treatment center and access to care have not been well described in regard to perioperative mortality and survival.

Methods A query of the National Cancer Database (NCDB) and review of 1,102 adults—488 with chordomas and 614 with chondrosarcomas—was performed. The Kaplan–Meier's product limit method and chi-square analysis, respectively, assessed overall survival and 30-day (30D) and 90-day (90D) mortalities.

Results For 925 patients who had surgery and available mortality data, the 30D and 90D mortality rates were 0.9 and 1.5%. Lower education level (p = 0.0185) and treatment at a nonacademic facility (p = 0.016) were associated with increased risk of 90-day mortality. Median follow-up was 52 months and analysis was dichotomized by histology. For those with skull base chordoma, patients from a larger metro size (p = 0.002), age below the median 52 years (p ≤ 0.001), and private insurance (<0.001) were associated with prolonged survival, whereas for skull base chondrosarcoma, the factors were treatment at an academic medical center (p = 0.001), high-volume center (p = 0.007), age below the median 52 years (p ≤ 0.001), higher income (p = 0.043), higher education (p = 0.017), and private insurance (p ≤ 0.001). Comparing high-, medium-, and low-volume centers, high-volume centers were most likely to be academic, deliver radiotherapy, escalate doses >70 Gy, and utilize proton radiotherapy consistent across both disease subsets.

Conclusion Higher educational attainment and treatment at an academic facility were associated with decreased 90D mortality for patients with skull base chordoma and chondrosarcoma. For those with skull base chordoma, larger metro size, younger age, and private insurance were associated with prolonged survival; for those with chondrosarcoma, it was treatment at a high-volume or academic medical center, younger age, higher income or education, and private insurance.

HPV as a Carcinomic Driver in Head and Neck Cancer: a De-escalated Future?

OPINION STATEMENT

Patients with HPV-associated oropharyngeal squamous cell carcinoma have improved prognosis relatively to those with tumors not driven by HPV. Both definitive radiotherapy (typically with concurrent chemotherapy) and transoral robotic surgery (with adjuvant therapies based on pathologic risk factors) are both acceptable treatment options for patients. The decision on which treatment is optimal depends on individual patient factors and should be made in a multi-disciplinary setting with input from a radiation oncologist, head and neck surgeon, and medical oncologist. Where appropriate, patients in this setting should be considered for enrollment on clinical studies evaluating de-escalation of treatment intensity given the very favorable outcomes and high toxicity profile associated with conventional therapies. However, caution is needed given negative data for de-escalation in the definitive chemotherapy and radiation setting. It remains unclear what the prognostic significance of HPV status is in patients with squamous cell carcinomas of the head and neck outside of the oropharynx.

Demographics of ASTRO Student Members and Potential Implications for Future U.S. Radiation Oncology Workforce Diversity

Purpose

The radiation oncology workforce in the United States is comparatively less diverse than the U.S. population and U.S. medical school graduates. Workforce diversity correlates with higher quality care and outcomes. The purpose of this study was to determine whether student members of the American Society for Radiation Oncology (ASTRO) are any more diverse than resident members-in-training using the recently established medical student membership category.

Methods and Materials

Self-reported sex, race and Hispanic ethnicity, medical school, and degree(s) earned for all medical students (n = 268) and members-in-training (n = 713) were collected from the ASTRO membership database. International members were excluded. The χ² test was used to assess for differences between subgroups.

Results

Compared with members-in-training, student members were more likely to be female (40.0% vs 31.5%, P = .032), black or African American (10.7% vs 4.8%, P = .009), candidates for or holders of a DO rather than MD degree (5.2% vs 1.5%, P = .002), and from a U.S. medical school that is not affiliated with a radiation oncology residency program (30.5% vs 20.9%, P = .001). There was no significant difference in self-reported Hispanic ethnicity (7.3% vs 5.4%, P = .356). There were no indigenous members in either category assessed.

Conclusions

Medical student members of ASTRO are more diverse in terms of black race, female sex, and osteopathic training, though not in terms of Hispanic ethnicity or nonmultiracial indigenous background, than the members-in-training. Longitudinal engagement with these students and assessment of the factors leading to specialty retention versus attrition may increase diversity, equity, and inclusion in radiation oncology.

Retromolar trigone squamous cell carcinoma: A population-based analysis of survival

OBJECTIVES

To evaluate the difference in overall survival (OS) in patients with retromolar trigone squamous cell carcinoma (RMT SCC) treated with surgery alone versus surgery plus postoperative radiotherapy (PORT) versus surgery plus postoperative chemoradiotherapy (POCRT).

MATERIALS AND METHODS

Retrospective cohort study of patients from 1,500 US facilities reporting to the National Cancer Database (NCDB) registry. Participants were adult patients treated with surgery as primary treatment modality for RMT SCC (n = 2,877). Exposures were primary definitive surgery versus surgery + PORT versus surgery + POCRT. Outcomes included OS after diagnosis and treatment of RMT SCC. A multivariate Cox proportional hazards model was constructed to compare survival between the three treatment modalities. Subgroup analysis was performed by T classification and overall staging.

RESULTS

There were 1,415 (50%) patients treated with surgery alone, 870 (30%) patients treated with surgery + PORT, and 572 (20%) treated with surgery + POCRT. Treatment with surgery + PORT was associated with improved OS compared to surgery alone (relative hazard: 1.25, 95% CI: 1.01, 1.54, p = 0.042). Patients treated with surgery + POCRT also had improved OS compared with surgery alone (relative hazard: 1.89, 95% CI 1.45, 2.43, p < 0.001). Patients with T3/4 tumors had improved OS when treated with surgery + PORT (relative hazard 1.39, 95% CI: 1.05, 1.84, p = 0.022) or surgery + POCRT (relative hazard 2.27, 95% CI: 1.66, 3.15, p < 0.001). Patients with T1 or T2 disease had no significant difference in survival in both the surgery + PORT (p = 0.331) and surgery + POCRT treatment groups (p = 0.134). Therefore, there was no difference in OS for patients with stage I or II disease treated with surgery + PORT (p = 0.451), nor with surgery + POCRT (p = 0.853).

CONCLUSION

Treatment with surgery + PORT +/- chemotherapy appears to be associated with significantly improved OS compared to surgery alone for advanced RMT SCCa.

Radiation therapy related cardiac disease risk in childhood cancer survivors: Updated dosimetry analysis from the Childhood Cancer Survivor Study

BACKGROUND AND PURPOSE

We previously evaluated late cardiac disease in long-term survivors in the Childhood Cancer Survivor Study (CCSS) based on heart radiation therapy (RT) doses estimated from an age-scaled phantom with a simple atlas-based heart model (H_Atlas). We enhanced our phantom with a high-resolution CT-based anatomically realistic and validated age-scalable cardiac model (H_Hybrid). We aimed to evaluate how this update would impact our prior estimates of RT-related late cardiac disease risk in the CCSS cohort.

METHODS

We evaluated 24,214 survivors from the CCSS diagnosed from 1970 to 1999. RT fields were reconstructed on an age-scaled phantom with H_Hybrid and mean heart dose (D_m), percent volume receiving ≥ 20 Gy (V₂₀) and ≥ 5 Gy with V₂₀ = 0 ( [Formula: see text] ) were calculated. We reevaluated cumulative incidences and adjusted relative rates of grade 3-5 Common Terminology Criteria for Adverse Events outcomes for any cardiac disease, coronary artery disease (CAD), and heart failure (HF) in association with D_m, V₂₀, and [Formula: see text] (as categorical variables). Dose-response relationships were evaluated using piecewise-exponential models, adjusting for attained age, sex, cancer diagnosis age, race/ethnicity, time-dependent smoking history, diagnosis year, and chemotherapy exposure and doses. For relative rates, D_m was also considered as a continuous variable.

RESULTS

Consistent with previous findings with H_Atlas, reevaluation using H_Hybrid dosimetry found that, D_m ≥ 10 Gy, V₂₀ ≥ 0.1%, and [Formula: see text]  ≥ 50% were all associated with increased cumulative incidences and relative rates for any cardiac disease, CAD, and HF. While updated risk estimates were consistent with previous estimates overall without statistically significant changes, there were some important and significant (P < 0.05) increases in risk with updated dosimetry for D_m in the category of 20 to 29.9 Gy and V₂₀ in the category of 30% to 79.9%. When changes in the linear dose-response relationship for D_m were assessed, the slopes of the dose response were steeper (P < 0.001) with updated dosimetry. Changes were primarily observed among individuals with chest-directed RT with prescribed doses ≥ 20 Gy.

CONCLUSION

These findings present a methodological advancement in heart RT dosimetry with improved estimates of RT-related late cardiac disease risk. While results are broadly consistent with our prior study, we report that, with updated cardiac dosimetry, risks of cardiac disease are significantly higher in two dose and volume categories and slopes of the Dm-specific RT-response relationships are steeper. These data support the use of contemporary RT to achieve lower heart doses for pediatric patients, particularly those requiring chest-directed RT.

Comparative Effectiveness of Proton Therapy versus Photon Radiotherapy in Adolescents and Young Adults for Classical Hodgkin Lymphoma

Purpose

Early stage (stages I-II) classical Hodgkin lymphoma (cHL) is a highly curable disease typically diagnosed in adolescents and young adults (AYAs). Proton therapy can also reduce the late toxicity burden in this population, but data on its comparative efficacy with photon radiotherapy in this population are sparse. We assessed outcomes in AYAs with cHL in a multi-institution retrospective review.

Materials and Methods

We identified 94 patients aged 15 to 40 years with stages I and II cHL treated with radiotherapy as part of their initial treatment between 2008 and 2017. We used Kaplan-Meier analyses and log-rank testing to evaluate survival differences between groups of patients.

Results

A total of 91 patients were included in the analysis. The 2-year progression-free survival (PFS) rate was 89%. Of the 12 patients who experienced progression after radiotherapy, 4 occurred out-of-field, 2 occurred in-field, and 6 experienced both in- and out-of-field progression. There was no significant difference in 2-year PFS among AYA patients by radiotherapy dose received (≥ 30 Gy, 91%; < 30 Gy, 86%; P = .82). Likewise, there was no difference in 2-year PFS among patients who received either proton or photon radiotherapy (proton, 94%; photon, 83%; P = .07).

Conclusion

Our cohort of AYA patients had comparable outcomes regardless of radiotherapy dose or modality used. For patients with significant risk of radiation-induced late effects, proton therapy is a reasonable treatment modality.

Second tumor risk in children treated with proton therapy

BACKGROUND

Out-of-field neutron dissemination during double-scattered proton therapy has raised concerns of increased second malignancies, disproportionally affecting pediatric patients due to the proportion of body exposed to scatter dose and inherent radiosensitivity of developing tissue. We sought to provide empiric data on the incidence of early second tumors.

METHODS

Between 2006 and 2019, 1713 consecutive children underwent double-scattered proton therapy. Median age at treatment was 9.1 years; 371 were ≤3 years old. Thirty-seven patients (2.2%) had tumor predisposition syndromes. Median prescription dose was 54 Gy (range 15-75.6). Median follow-up was 3.3 years (range 0.1-12.8), including 6587 total person-years. Five hundred forty-nine patients had ≥5 years of follow-up. A second tumor was defined as any solid neoplasm throughout the body.

RESULTS

Eleven patients developed second tumors; the 5- and 10-year cumulative incidences were 0.8% (95% CI, 0.4-1.9%) and 3.1% (95% CI, 1.5-6.2%), respectively. Using age- and gender-specific data from the Surveillance, Epidemiology, and End Results (SEER) program, the standardized incidence ratio was 13.5; the absolute excess risk was 1.5/1000 person-years. All but one patient who developed second tumors were irradiated at ≤5 years old (p < .0005). There was also a statistically significant correlation between patients with tumor predisposition syndromes and second tumors (p < .0001). Excluding patients with tumor predisposition syndromes, 5- and 10-year rates were 0.6% (95% CI, 0.2-1.7%) and 1.7% (95% CI, 0.7-4.0%), respectively, with all five malignant second tumors occurring in the high-dose region.

CONCLUSION

Second tumors are rare within the decade following double-scattered proton therapy, particularly among children irradiated at >5 years old and those without tumor predisposition syndrome.

Geographic access to brachytherapy services in the United States

PURPOSE

Disparities in geographic access to medical care exist in nearly all fields of medicine including radiation oncology. We aim to update knowledge of the geographic distribution of radiation oncologists in the United States.

METHODS AND MATERIALS

We used the Physician and Other Supplier Public Use File (PUF) from the Centers for Medicare & Medicaid Services (CMS) as well as the International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centers (DIRAC) database to identify practices that either coded for or are marked as having access to brachytherapy services. Geographic analysis was performed on several levels including United States (US) Census region, Dartmouth Atlas Healthcare Referral Region, and the county level.

RESULTS

We identified 327 providers that billed for a brachytherapy code during the calendar year 2018 and 564 facilities providing brachytherapy. Within the 306 HRRs in the US, 149 have access to brachytherapy. This represents 247.5 million people based on 2018 estimates of population from the US Census Bureau. This implies that 76.7% of people within the US live in an HRR with access to brachytherapy, and, conversely, that 75.3 million people (23.3%) do not. Numerically, counties in metropolitan areas were more likely to have access to brachytherapy than those outside of a metropolitan area.

CONCLUSIONS

Geographic disparities exist in access to brachytherapy; metropolitan counties are more likely to have access than non-metropolitan counties. We support continued development of databases of brachytherapy providers and programs that may support travel and lodging costs to minimize these disparities.

Development and validation of an age-scalable cardiac model with substructures for dosimetry in late-effects studies of childhood cancer survivors

BACKGROUND AND PURPOSE

Radiation therapy is a risk factor for late cardiac disease in childhood cancer survivors. Several pediatric cohort studies have established whole heart dose and dose-volume response models. Emerging data suggest that dose to cardiac substructures may be more predictive than whole heart metrics. In order to develop substructure dose-response models, the heart model previously used for pediatric cohort dosimetry needed enhancement and substructure delineation.

METHODS

To enhance our heart model, we combined the age-scalable capability of our computational phantom with the anatomically-delineated (with substructures) heart models from an international humanoid phantom series. We examined cardiac volume similarity/overlap between registered age-scaled phantoms (1, 5, 10, and 15 years) with the enhanced heart model and the reference phantoms of the same age; dice similarity coefficient (DSC) and overlap coefficient (OC) were calculated for each matched pair. To assess the accuracy of our enhanced heart model, we compared doses from computed tomography-based planning (ground truth) with reconstructed heart doses. We also compared doses calculated with the prior and enhanced heart models for a cohort of nearly 5000 childhood cancer survivors.

RESULTS

We developed a realistic cardiac model with 14-substructures, scalable across a broad age range (1-15 years); average DSC and OC were 0.84 ± 0.05 and 0.90 ± 0.05, respectively. The average percent difference between reconstructed and ground truth mean heart doses was 4.2%. In the cohort dosimetry analysis, dose and dose-volume metrics were approximately 10% lower on average when the enhanced heart model was used for dose reconstructions.

CONCLUSION

We successfully developed and validated an anatomically realistic age-scalable cardiac model that can be used to establish substructure dose-response models for late cardiac disease in childhood cancer survivor cohorts.

Visual decline in pediatric survivors of brain tumors following radiotherapy

PURPOSE

Radiotherapy-related visual decline is a significant concern in survivors of childhood cancer; however, data establishing the dose-response relationship between dose to the optic apparatus and visual acuity decline in children are sparse. We aimed to determine this relationship in a cohort of children treated with proton therapy.

MATERIAL AND METHODS

We identified 458 children with 875 eyes at risk treated with proton therapy for intracranial malignancy between December 2006 and September 2018. Eyes were considered at risk if either the ipsilateral optic nerve or optic chiasm received ≥30 GyRBE to 0.1 cm³. Kaplan-Meier and Normal Tissue Complication Probability modeling was used to establish the relationship between radiotherapy dose and risk of visual decline.

RESULTS

Excluding children with tumor progression, no patient experienced complete vision loss. The actuarial 5-year rate of any visual acuity decline was 2.6% (95% confidence interval [CI]: 1.5%-4.6%). The dose to 0.1 cm³ of the ipsilateral optic nerve or optic chiasm resulting in a 1%, 5%, and 10% risk of acuity decline were 52.7 GyRBE, 56.6 GyRBE, and 58.3 GyRBE. Visual decline was only seen in children with primary tumors of the optic pathway or suprasellar region.

CONCLUSIONS

Visual acuity decline following radiotherapy for intracranial malignancies in children is rare. A dose of approximately 56 GyRBE to 0.1 cm³ results in an approximately 5% risk of visual acuity decline for children with suprasellar or optic pathway tumors. A dose to 0.1 cm³ of 56 GyRBE appears to be safe for children with tumors elsewhere in the brain.

Risk of brain metastases in T1-3N0 NSCLC: a population-based analysis

Aim:

Several consensus guidelines recommend against routine brain imaging at diagnosis of T1-3N0 non-small cell lung cancer (NSCLC).

Methods:

From the Surveillance, Epidemiology and End Results registry, patients with pathologically confirmed T1-3N0 NSCLC were identified. Risks of brain metastases at time of initial diagnosis were analyzed.

Results:

Patients selected to not undergo primary NSCLC resection had approximately tenfold greater incidence of brain metastases versus those who did. Younger age, adenocarcinoma histology, higher tumor stage and higher histologic grade were all significantly (p < 0.0001) associated with greater likelihood of presenting with brain metastases.

Conclusion:

Given the morbidity and mortality of brain metastases, routine brain screening after NSCLC diagnosis (particularly adenocarcinoma) may be justifiable, though more refined cost-benefit analyses are warranted.

Immunotherapy with hypofractionated radiotherapy in metastatic non-small cell lung cancer: An analysis of the National Cancer Database

PURPOSE

Metastatic non-small cell lung cancer (NSCLC) is associated with an exceedingly poor prognosis. Recent advances in immunotherapy offer promise in enhancing overall survival (OS) in these patients. Preclinical evidence suggests that radiotherapy (RT), especially when offered in a high-dose per fraction hypofractionated RT (HRT) as in stereotactic ablative body radiotherapy (SABR), may augment the efficacy of immunotherapy. We aimed to assess the role of RT in patients with metastatic NSCLC receiving immunotherapy in a national hospital-based database.

METHODS

Using the National Cancer Database (NCDB), we identified 6,383 patients treated with immunotherapy for metastatic NSCLC and 170,479 patients treated with RT but without immunotherapy. Patients receiving fractional doses of at least 5 Gy were designated as having received HRT, doses <5 Gy/fraction, were deemed standard fractionation (SFRT). The Kaplan-Meier analysis and proportional hazards modeling were performed, and propensity scores were generated via an inverse weighting method to evaluate the impact of RT on OS in this cohort.

RESULTS

The median follow-up of the cohort is 12 months. Patients receiving HRT had numerically improved 1-year OS (59.0%) compared to those not receiving RT (55.7%), however this was not statistically significant (hazard ratio = 0.9, p = 0.22). Patients receiving non-HRT RT did substantially worse than those receiving no RT. Immunotherapy improved OS in patients receiving RT regardless of fraction size.

CONCLUSIONS

This hypothesis-generating retrospective analysis suggests that patients treated with immunotherapy with or without HRT in the upfront treatment of metastatic NSCLC experience similar survival. Further prospective evaluation of this combination should be undertaken in an attempt to maximize survival in this challenging disease.

Prognostic Significance of Sites of Visceral Metastatic Disease in Prostate Cancer: A Population-based Study of 12,180 Patients

INTRODUCTION

Metastatic prostate cancer (MPC) prognosis is variable. Few population-based studies have examined the impact of particular visceral metastatic sites on MPC survival outcomes. We investigated this using the Surveillance, Epidemiology, and End Results (SEER) database.

MATERIALS AND METHODS

We analyzed the overall survival (OS) and prostate cancer mortality (PCM) risk of 12,180 patients, from SEER 18 registries, diagnosed with MPC from 2010 to 2014. We identified those with metastatic disease in bone, brain, liver, and lung. Kaplan-Meier analyses, competing risks regression, and Cox proportional hazards models were used to assess the impact of visceral metastatic disease sites on OS and PCM.

RESULTS

Most patients were coded as having metastatic disease in the bone without disease in the brain, liver, or lung (bone group, n = 10,620; 87% of total). On Cox multivariable regression analysis, patients with lung metastases, with or without bone metastases, did not differ significantly from patients in the bone group with respect to OS (hazard ratio, 0.82; 95% confidence interval, 0.63-1.06; P = .13 and hazard ratio, 1.12; 95% confidence interval, 0.98-1.28; P = .10, respectively). These patients also did not differ from the bone group with respect to PCM incidence on competing risks regression analysis.

CONCLUSIONS

This study suggests that patients with MPC confined to bone and/or lung may have improved survival relative to those with MPC affecting other visceral sites. Although it was anticipated that patients with bone metastases would represent a favorable subgroup, the favorable outcomes in patents with lung metastases (with or without bone metastases) was unexpected. These findings may inform future therapeutic investigations to improve the prognosis of patients with MPC.

Therapy-Related Cardiac Risk in Childhood Cancer Survivors: An Analysis of the Childhood Cancer Survivor Study

PURPOSE

The impacts of radiotherapy dose and exposed cardiac volume, select chemotherapeutic agents, and age at exposure on risk for late-onset cardiac disease in survivors of childhood cancer remain unresolved.

PATIENTS AND METHODS

We determined the rates of severe to fatal cardiac disease in 24,214 5-year survivors in the Childhood Cancer Survivor Study diagnosed between 1970 and 1999 at a median age of 7.0 years (range, 0 to 20.9 years), with a median attained age of 27.5 years (range, 5.6 to 58.9 years). Using piecewise exponential models, we evaluated the association between cardiac disease rates and demographic and treatment characteristics.

RESULTS

The cumulative incidence of cardiac disease 30 years from diagnosis was 4.8% (95% CI, 4.3 to 5.2). Low to moderate radiotherapy doses (5.0 to 19.9 Gy) to large cardiac volumes (≥ 50% of heart) were associated with an increased rate of cardiac disease (relative rate, 1.6; 95% CI, 1.1 to 2.3) compared with survivors without cardiac radiotherapy exposure. Similarly, high doses (≥ 20 Gy) to small cardiac volumes (0.1% to 29.9%) were associated with an elevated rate (relative rate, 2.4; 95% CI, 1.4 to 4.2). A dose-response relationship was observed between anthracycline chemotherapy and heart failure with younger children (age ≤ 13 years) at the greatest risk for heart failure after comparable dosing.

CONCLUSION

These observations support advances in radiation field design and delivery technology to reduce cardiac dose/volume and should guide future treatment protocols. They also inform clinical practice guidelines for post-therapy surveillance and risk-reducing strategies.