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Sheikh S, Bruno DS, Sun Y, Deng V, McClelland S, Obi E, Vinson V, Firstencel A, Lanese B, Lausin L, Dorth JA, Zaorsky NG, Hoy K, Krishnamurthi S. Impact of Clinical Trial Design on Recruitment of Racial and Ethnic Minorities. J Cancer Educ 2024:10.1007/s13187-024-02440-x. [PMID: 38637443 DOI: 10.1007/s13187-024-02440-x] [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] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
Knowledge related to how oncology treatment trial design influences enrollment of racial and ethnic minorities is limited. Rigorous identification of clinical trial design parameters that associate favorably with minority accrual provides educational opportunities for individuals interested in designing more representative treatment trials. We identified oncology trials with a minimum of 10 patients at an NCI-Designated Comprehensive Cancer Center from 2010 to 2021. We defined a study endpoint of racial and ethnic minority accrual greater than zero. Multivariable logistic regression was used to determine whether co-variables predicted our study endpoint. P-values of less than 0.05 were considered significant. A total of 352 cancer trials met eligibility criteria. These studies enrolled a total of 7981 patients with a total of 926 racial and ethnic minorities leading to a median enrollment of 10%. Trials open in community sites (yes versus no) were more likely to have a minority patient (OR, 2.21; 95% CI, 1.02-4.96) as well as pilot/phase I studies compared to phase II/III (OR, 3.19; 95% CI, 1.34-8.26). Trials incorporating immunotherapy (yes versus no) were less likely to have a minority patient (OR, 0.47; 95% CI, 0.23-0.94). Trials open in community sites as well as early phase treatment studies were more likely to accrue minority patients. However, studies including immunotherapy were less likely to accrue racial and ethnic minorities. Knowledge gained from our analysis may help individuals design oncology treatment trials that are representative of more diverse populations.
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Affiliation(s)
- Saad Sheikh
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh PA, 15232, USA.
| | - Debora S Bruno
- Department of Hematology and Medical Oncology, Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Cleveland, OH, 44106, USA
| | - Yilun Sun
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Victoria Deng
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Shearwood McClelland
- Department of Radiation Oncology, Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Cleveland, OH, 44106, USA
| | - Elizabeth Obi
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Valerie Vinson
- Department of Radiation Oncology, Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Cleveland, OH, 44106, USA
| | - April Firstencel
- Clinical Research Office, Case Comprehensive Cancer Center, Cleveland, OH, 44106, USA
| | - Bob Lanese
- Clinical Research Office, Case Comprehensive Cancer Center, Cleveland, OH, 44106, USA
| | - Loretta Lausin
- Clinical Research Office, Case Comprehensive Cancer Center, Cleveland, OH, 44106, USA
| | - Jennifer A Dorth
- Department of Radiation Oncology, Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Cleveland, OH, 44106, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center, Cleveland, OH, 44106, USA
| | - Kevin Hoy
- Clinical Research Office, Case Comprehensive Cancer Center, Cleveland, OH, 44106, USA
| | - Smitha Krishnamurthi
- Department of Hematology and Medical Oncology, Case Comprehensive Cancer Center, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, 44195, USA
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Carpenter DJ, Patel P, Niedzwiecki D, Dillon M, Diaz AK, Kumar A, Mowery YM, Crowell KA, D'Anna R, Wu Q, Rodrigues A, Wisdom AJ, Dorth JA, Patel PR, Shortell CK, Brizel DM. Long-term risk of carotid stenosis and cerebrovascular disease after radiation therapy for head and neck cancer. Cancer 2023. [PMID: 37897711 DOI: 10.1002/cncr.35089] [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] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Recipients of radiation therapy (RT) for head and neck cancer (HNC) are at significantly increased risk for carotid artery stenosis (CAS) and cerebrovascular disease (CVD). We sought to determine (1) cumulative incidences of CAS and CVD among HNC survivors after RT and (2) whether CAS is associated with a RT dose response effect. METHODS This single-institution retrospective cohort study examined patients with nonmetastatic HNC who completed (chemo)RT from January 2000 through October 2020 and subsequently received carotid imaging surveillance ≤2 years following RT completion and, in the absence of CAS, every 3 years thereafter. Exclusion criteria included history of known CAS/CVD. Asymptomatic CAS was defined as ≥50% reduction of luminal diameter, symptomatic CAS as stroke or transient ischemic attack, and composite CAS as asymptomatic or symptomatic CAS. RESULTS Of 628 patients undergoing curative intent RT for HNC, median follow-up was 4.8 years (interquartile range, 2.6-8.3), with 97 patients followed ≥10 years. Median age was 61 years and 69% of patients received concurrent chemotherapy and 28% were treated postoperatively. Actuarial 10-year incidences of asymptomatic, symptomatic, and composite CAS were 29.6% (95% CI, 23.9-35.5), 10.1% (95% CI, 7.0-13.9), and 27.2% (95% CI, 22.5-32.1), respectively. Multivariable Cox models significant association between asymptomatic CAS and absolute carotid artery volume receiving ≥10 Gy (per mL: hazard ratio, 1.09; 95% CI, 1.02-1.16). CONCLUSIONS HNC survivors are at high risk for post-RT CAS. A dose response effect was observed for asymptomatic CAS at doses as low as 10 Gy. PLAIN LANGUAGE SUMMARY Recipients of radiation therapy for head and neck cancer are at significantly increased risk for carotid artery stenosis and cerebrovascular disease. However, carotid artery screening is not routinely performed among head and neck survivors following radiation therapy. In this single-institution retrospective cohort study, patients with head and neck cancer were initially screened for carotid artery stenosis ≤2 years following radiation therapy completion, then every 3 years thereafter. The 10-year actuarial incidence of carotid artery stenosis was >25% and stroke/transient ischemic attack >10%. Multivariable analysis demonstrated significant associations between asymptomatic carotid artery stenosis and artery volumes receiving ≥10 Gy.
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Affiliation(s)
- David J Carpenter
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Pranalee Patel
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, North Carolina, USA
| | - Mairead Dillon
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, North Carolina, USA
| | - Alexander K Diaz
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Abhishek Kumar
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Yvonne M Mowery
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Kerri-Anne Crowell
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, North Carolina, USA
| | - Rachel D'Anna
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Qiuwen Wu
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Anna Rodrigues
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Amy J Wisdom
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer A Dorth
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Cynthia K Shortell
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - David M Brizel
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Hall WA, Li J, You YN, Gollub MJ, Grajo JR, Rosen M, dePrisco G, Yothers G, Dorth JA, Rahma OE, Russell MM, Gross HM, Jacobs SA, Faller BA, George S, Al baghdadi T, Haddock MG, Valicenti R, Hong TS, George TJ. Prospective Correlation of Magnetic Resonance Tumor Regression Grade With Pathologic Outcomes in Total Neoadjuvant Therapy for Rectal Adenocarcinoma. J Clin Oncol 2023; 41:4643-4651. [PMID: 37478389 PMCID: PMC10564288 DOI: 10.1200/jco.22.02525] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/01/2023] [Accepted: 05/09/2023] [Indexed: 07/23/2023] Open
Abstract
PURPOSE Total neoadjuvant therapy (TNT) is a newly established standard treatment for rectal adenocarcinoma. Current methods to communicate magnitudes of regression during TNT are subjective and imprecise. Magnetic resonance tumor regression grade (MR-TRG) is an existing, but rarely used, regression grading system. Prospective validation of MR-TRG correlation with pathologic response in patients undergoing TNT is lacking. Utility of adding diffusion-weighted imaging to MR-TRG is also unknown. METHODS We conducted a multi-institutional prospective imaging substudy within NRG-GI002 (ClinicalTrials.gov identifier: NCT02921256) examining the ability of MR-based imaging to predict pathologic complete response (pCR) and correlate MR-TRG with the pathologic neoadjuvant response score (NAR). Serial MRIs were needed from 110 patients. Three radiologists independently, then collectively, reviewed each MRI for complete response (mriCR), which was tested for positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity with pCR. MR-TRG was examined for association with the pathologic NAR score. All team members were blinded to pathologic data. RESULTS A total of 121 patients from 71 institutions met criteria: 28% were female (n = 34), 84% White (n = 101), and median age was 55 (24-78 years). Kappa scores for T- and N-stage after TNT were 0.38 and 0.88, reflecting fair agreement and near-perfect agreement, respectively. Calling an mriCR resulted in a kappa score of 0.82 after chemotherapy and 0.56 after TNT reflected near-perfect agreement and moderate agreement, respectively. MR-TRG scores were associated with pCR (P < .01) and NAR (P < .0001), PPV for pCR was 40% (95% CI, 26 to 53), and NPV was 84% (95% CI, 75 to 94). CONCLUSION MRI alone is a poor tool to distinguish pCR in rectal adenocarcinoma undergoing TNT. However, the MR-TRG score presents a now validated method, correlated with pathologic NAR, which can objectively measure regression magnitude during TNT.
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Affiliation(s)
- William A. Hall
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
| | - Jiahe Li
- The University of Pittsburgh, Pittsburgh, PA
| | - Y. Nancy You
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Joseph R. Grajo
- University of Florida, Gainesville, FL
- University of Florida Health Cancer Center, Gainesville, FL
| | - Mark Rosen
- Imaging and Radiation Oncology Core (IROC) Group, and the University of Pennsylvania, Philadelphia, PA
| | - Greg dePrisco
- Baylor Scott and White Health Baylor University Medical Center at Dallas, Dallas, TX
| | | | - Jennifer A. Dorth
- University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH
| | | | - Marcia M. Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | | | | | - Bryan A. Faller
- Missouri Baptist Medical Center/Heartland NCORP, St Louis, MO
| | - Sagila George
- Stephenson Cancer Center University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Tareq Al baghdadi
- Trinity Health Ann Arbor Hospital, Michigan Cancer Research Consortium (NCORP), Ann Arbor, MI
| | | | - Richard Valicenti
- University of California Davis Comprehensive Cancer Center/UC Davis School of Med/UC Davis Health, Sacramento, CA
| | - Theodore S. Hong
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Thomas J. George
- University of Florida, Gainesville, FL
- University of Florida Health Cancer Center, Gainesville, FL
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Weidhaas JB, Harris J, Gillison M, Blakaj DM, Krempl GA, Higgins KA, Phan J, Dunlap NE, Mahmood S, Dorth JA, Caudell JJ, Desai AB, Galloway TJ, Pennington JDD, Zhou Z, Lathrop J, Torres-Saavedra P, Hayes DN, Yom SS, Le QT. The KRAS-Variant and Cetuximab in HPV-Positive Oropharyngeal Cancer in NRG/RTOG 1016. Int J Radiat Oncol Biol Phys 2023; 117:S151. [PMID: 37784383 DOI: 10.1016/j.ijrobp.2023.06.571] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) NRG/RTOG 1016 was a non-inferiority phase III trial comparing radiation with cisplatin versus cetuximab monotherapy for patients with HPV-positive oropharyngeal squamous cell carcinoma (SCC). The trial did not meet the non-inferiority criteria for overall survival (OS) and had significantly worse progression-free survival (PFS) and locoregional failure (LRF) in patients treated with cetuximab. Based on prior evidence that HNSCC patients with a germ-line mutation in KRAS (the KRAS-variant) had a positive response to radiation with cisplatin plus cetuximab without increased toxicity, samples from RTOG 1016 were used to test the protocol-specified hypothesis that KRAS-variant patients will have better outcomes when receiving IMRT + cetuximab monotherapy compared to IMRT + cisplatin. MATERIALS/METHODS The KRAS-variant was tested in 562 samples at MiraDx, a CLIA-certified laboratory. OS, PFS, LRF, and distant metastases (DM) were as defined per the RTOG 1016 protocol, and hazard ratios (HRs) were estimated by (cause-specific) Cox models. Negative binomial regression was used to model the number of treatment-related acute and late (≤ and > 180 days from end of treatment, respectively) grade 3-5 adverse events. To assess the predictive role of the KRAS-variant, all models included KRAS, assigned treatment, and their interaction, with the interaction tested at two-sided 0.05. HRs and toxicity ratios are expressed as IMRT + cetuximab / IMRT + cisplatin. RESULTS The prevalence of the KRAS-variant was 16% with similar patient and tumor characteristics and well-balanced treatment arms for variant and non-variant patients. Median follow-up was 8.6 years. There was no significant interaction between KRAS and treatment for OS (p = 0.99), PFS (p = 0.56), LRF (p = 0.09), or DM (p = 0.19) (Table 1). In KRAS-variant patients the mean acute and late toxicity ratios were 0.53 (95% CI 0.36, 0.80) and 1.62 (95% CI 0.57, 4.62). In non-variant patients, the mean acute and late toxicity ratios were 0.80 (95% CI 0.67, 0.95) and 0.55 (95% CI 0.35, 0.87), respectively. The interaction of KRAS and treatment was not significant for acute (p = 0.07) or late toxicity (p = 0.07). CONCLUSION While this study does not directly refute prior evidence that KRAS-variant patients benefit from radiation + cisplatin and cetuximab, this study does not support the hypothesis that the KRAS-variant is a predictive biomarker of improved outcome in HPV+ oropharyngeal SCC patients treated with IMRT + cetuximab alone, and suggests that for KRAS-variant patients, potential benefits in LRF and acute toxicity with cetuximab may be offset by worse DM and worse late toxicity.
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Affiliation(s)
- J B Weidhaas
- Department of Radiation Oncology, UCLA, Los Angeles, CA
| | - J Harris
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | - D M Blakaj
- James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH
| | - G A Krempl
- University of Oklahoma Health Sciences Center, OKLAHOMA CITY, OK
| | - K A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - N E Dunlap
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - S Mahmood
- Allan Blair Cancer Centre, Saskatchewan, SK, Canada
| | - J A Dorth
- Department of Radiation Oncology, University Hospitals Case Medical Center, Cleveland, OH
| | | | | | - T J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | | | | | - P Torres-Saavedra
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | - S S Yom
- University of California, San Francisco, Department of Radiation Oncology, San Francisco, CA
| | - Q T Le
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
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Dorth JA, Anker CJ. Patient-Reported Outcome Measures in Anal Carcinoma: Essential, But Are We Magnifying Patient Voice With the Best Megaphone? Int J Radiat Oncol Biol Phys 2023; 115:1178-1180. [PMID: 36922082 DOI: 10.1016/j.ijrobp.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 03/18/2023]
Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont; Larner College of Medicine, University of Vermont, Burlington, Vermont.
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Gillison ML, Ferris RL, Harris J, Colevas AD, Mell LK, Kong C, Jordan RC, Moore KL, Truong MT, Kirsch C, Chakravarti A, Blakaj DM, Clump DA, Ohr JP, Deeken JF, Gensheimer MF, Saba NF, Dorth JA, Rosenthal DI, Leidner RS, Kimple RJ, Machtay M, Curran WJ, Torres-Saavedra P, Le QT. Safety of Nivolumab Added to Chemoradiation Therapy Platforms for Intermediate and High-Risk Locoregionally Advanced Head and Neck Squamous Cell Carcinoma: RTOG Foundation 3504. Int J Radiat Oncol Biol Phys 2023; 115:847-860. [PMID: 36228746 DOI: 10.1016/j.ijrobp.2022.10.008] [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] [Received: 07/12/2022] [Revised: 09/10/2022] [Accepted: 10/04/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE Programmed death-1 immune checkpoint blockade improves survival of patients with recurrent/metastatic head and neck squamous cell carcinoma (HNSCC), but the benefits of addition to (chemo)radiation for newly diagnosed patients with HNSCC remain unknown. METHODS AND MATERIALS We evaluated the safety of nivolumab concomitant with 70 Gy intensity modulated radiation therapy and weekly cisplatin (arm 1), every 3-week cisplatin (arm 2), cetuximab (arm 3), or alone for platinum-ineligible patients (arm 4) in newly diagnosed intermediate- or high-risk locoregionally advanced HNSCC. Patients received nivolumab from 2 weeks prior to radiation therapy until 3 months post-radiation therapy. The primary endpoint was dose-limiting toxicity (DLT). If ≤2 of the first 8 evaluable patients experienced a DLT, an arm was considered safe. Secondary endpoints included toxicity and feasibility of adjuvant nivolumab to 1 year, defined as all 7 additional doses received by ≥4 of the first 8 evaluable patients across arms. RESULTS Of 39 patients (10 in arms 1, 3, 4 and 9 in arm 2), 72% had T3-4 tumors, 85% had N2-3 nodal disease, and 67% had >10 pack-years of smoking. There were no DLTs in arms 1 and 2, 1 in arm 3 (mucositis), and 2 in arm 4 (lipase elevation and mucositis in 1 and fatigue in another). The most common grade ≥3 nivolumab-related adverse events were lipase increase, mucositis, diarrhea, lymphopenia, hyponatremia, leukopenia, fatigue, and serum amylase increase. Adjuvant nivolumab was feasible as defined in the protocol. CONCLUSIONS Concomitant nivolumab with the 4 tested regimens was safe for patients with intermediate- and high-risk HNSCC, and subsequent adjuvant nivolumab was feasible as defined (NCT02764593).
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Affiliation(s)
| | | | - Jonathan Harris
- RTOG Foundation Statistics and Data Management Center, American College of Radiology, Philadelphia, Pennsylvania
| | | | - Loren K Mell
- UC San Diego Moores Cancer Center, La Jolla, California
| | - Christina Kong
- Stanford Cancer Institute, Palo Alto, Stanford, California
| | | | - Kevin L Moore
- UC San Diego Moores Cancer Center, La Jolla, California
| | | | | | | | | | - David A Clump
- UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - James P Ohr
- UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | | | - Nabil F Saba
- Emory University Hospital/Winship Cancer Institute, Atlanta, Georgia
| | | | | | - Rom S Leidner
- Providence Portland Medical Center, Portland, Oregon
| | - Randall J Kimple
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Mitchell Machtay
- Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania
| | | | - Pedro Torres-Saavedra
- RTOG Foundation Statistics and Data Management Center, American College of Radiology, Philadelphia, Pennsylvania
| | - Quynh Thu Le
- Stanford Cancer Institute, Palo Alto, Stanford, California.
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Eng C, Ciombor KK, Cho M, Dorth JA, Rajdev LN, Horowitz DP, Gollub MJ, Jácome AA, Lockney NA, Muldoon RL, Washington MK, O'Brian BA, Benny A, Lebeck Lee CM, Benson AB, Goodman KA, Morris VK. Anal Cancer: Emerging Standards in a Rare Rare Disease. J Clin Oncol 2022; 40:2774-2788. [PMID: 35649196 DOI: 10.1200/jco.21.02566] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The social stigma surrounding an anal cancer diagnosis has traditionally prevented open discussions about this disease. However, as recent treatment options and an increasing rate of diagnoses are made worldwide, awareness is growing. In the United States alone, 9,090 individuals were expected to be diagnosed with anal cancer in 2021. The US annual incidence of squamous cell carcinoma of the anus continues to increase by 2.7% yearly, whereas the mortality rate increases by 3.1%. The main risk factor for anal cancer is a human papillomavirus infection; those with chronic immunosuppression are also at risk. Patients with HIV are 19 times more likely to develop anal cancer compared with the general population. In this review, we have provided an overview of the carcinoma of the anal canal, the role of screening, advancements in radiation therapy, and current trials investigating acute and chronic treatment-related toxicities. This article is a comprehensive approach to presenting the existing data in an effort to encourage continuous international interest in anal cancer.
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Affiliation(s)
- Cathy Eng
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Kristen K Ciombor
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - May Cho
- Division of Hematology and Oncology, Department of Medicine, University of California- Irvine School of Medicine, Irvine, CA
| | - Jennifer A Dorth
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lakshmi N Rajdev
- Division for Hematology and Oncology, Department of Medicine, Northwell Health/Lenox Hill Hospital, New York, NY
| | - David P Horowitz
- Department of Radiation Oncology, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Alexandre A Jácome
- OncoBio Comprehensive Cancer Center, Department of Gastrointestinal Medical Oncology, Nova Lima, Brazil
| | - Natalie A Lockney
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Roberta L Muldoon
- Division of Colon and Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Mary Kay Washington
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Brittany A O'Brian
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Amala Benny
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Cody M Lebeck Lee
- VA Tennessee Valley Healthcare System, Department of Internal Medicine, Nashville, TN
| | - Al B Benson
- Division of Hematology-Oncology, Northwestern University, Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Van Karlyle Morris
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Damico NJ, Wu AK, Kharouta MZ, Eitan T, Pidikiti R, Jesseph FB, Smith M, Langmack C, Mattson DL, Dobbins D, Mansur DB, Machtay MX, Dorth JA, Choi S, Yao M, Bhatt AD. Proton Beam Therapy in the Treatment of Periorbital Malignancies. Int J Part Ther 2021; 7:42-51. [PMID: 33829072 PMCID: PMC8019573 DOI: 10.14338/ijpt-20-00025.1] [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: 04/28/2020] [Accepted: 01/05/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Periorbital tumor location presents a significant challenge with 3-dimensional conformal radiation therapy or intensity modulated radiation therapy due to high tumor dose needed in the setting of close proximity to orbital structures with lower tolerance. Proton beam therapy (PBT) is felt to be an effective modality in such cases due to its sharp dose gradient. Materials and Methods We reviewed our institutional PBT registry and identified 17 patients with tumor epicenters within 2 cm of the eye and optic apparatus treated with passive scatter PBT with comparison volumetric arc therapy plans available. Maximum and mean doses to organs at risk of interest, including optic nerves, optic chiasm, lens, eye ball, pituitary, cochlea, lacrimal gland, and surrounding brain, were compared using the paired Wilcoxon signed rank test. Overall survival was determined using the Kaplan-Meier method. Results Median age was 67. Median follow-up was 19.7 months. Fourteen patients underwent upfront resection and received postoperative radiation and 3 received definitive radiation. One patient received elective neck radiation, 2 underwent reirradiation, and 3 had concurrent chemotherapy. There was a statistically significant reduction in mean dose to the optic nerves and chiasm, brain, pituitary gland, lacrimal glands, and cochlea as well as in the maximum dose to the optic nerves and chiasm, pituitary gland, lacrimal glands, and cochlea with PBT. The 18-month cumulative incidence of local failure was 19.1% and 1-year overall survival was 80.9%. Conclusion Proton beam therapy resulted in significant dose reductions to several periorbital and optic structures compared with volumetric arc therapy. Proton beam therapy appears to be the optimal radiation modality in such cases to minimize risk of toxicity to periorbital organs at risk.
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Affiliation(s)
- Nicholas J Damico
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Anna K Wu
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Michael Z Kharouta
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Tal Eitan
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Rajesh Pidikiti
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Frederick B Jesseph
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Mark Smith
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Christian Langmack
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Diana L Mattson
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Donald Dobbins
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - David B Mansur
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Mitchell X Machtay
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Serah Choi
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Min Yao
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Aashish D Bhatt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
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9
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Howell JN, Anker CJ, Walker AJ, Dorth JA, Kharofa JR. Analysis of Patient-Reported Outcome Utilization Within National Clinical Trials Network Cooperative Group Radiation Oncology Trials Over the Past 2 Decades. Int J Radiat Oncol Biol Phys 2021; 109:1151-1160. [PMID: 33321191 DOI: 10.1016/j.ijrobp.2020.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/09/2020] [Accepted: 12/05/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE When treating cancer, both quantity and quality of life are valuable, though oncology trials have long placed greater emphasis on the former. The goal of this work was to evaluate how patient-reported outcomes (PROs) have been incorporated into radiation therapy trials within the National Clinical Trials Network over the last 2 decades to measure quality of life and to assess how PRO data have been disseminated in publications upon trial conclusion. METHODS AND MATERIALS This cross-sectional study analyzed the frequency of use of PROs in National Clinical Trials Network cooperative group radiation therapy phase 2 and 3 clinical trials over the past 2 decades. A literature review was performed to determine the publication outcomes of PRO data, including only trials that used PROs in their design and were mature enough to have published results. RESULTS Fifty-seven (56.4%) of the 101 trials included in this study included PROs in their design. Brain and head and neck trials demonstrated the largest proportional incorporation of PROs (81.8% and 76.9%, respectively), and thoracic and breast trials used the fewest (18.8% and 37.5%, respectively). The EQ-5D family of questionnaires was the most commonly used PROs, used in 22.8% of trials included. The literature review demonstrated a pattern of increased publication of PRO data alongside survival endpoints in manuscripts derived from these trials over time. CONCLUSIONS Though there is room for improvement, the field of radiation oncology has embraced the incorporation of PROs into multicenter, high-impact clinical trials over the past 2 decades and has increased its publication of this data alongside survival data from these trials.
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Affiliation(s)
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, University of Vermont Medical Center, Burlington, Vermont
| | - Amanda J Walker
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, Bethesda, Maryland
| | - Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Jordan R Kharofa
- Department of Radiation Oncology, University of Cincinnati Cancer Center, University of Cincinnati, Cincinnati, Ohio.
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10
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Worrell SG, Towe CW, A Dorth J, Machtay M, Perry Y, Linden PA. Higher Doses of Neoadjuvant Radiation for Esophageal Cancer Do Not Affect the Pathologic Complete Response Rate or Survival: A Propensity-Matched Analysis. Ann Surg Oncol 2019; 27:500-508. [PMID: 31571054 DOI: 10.1245/s10434-019-07849-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traditional neoadjuvant therapy for esophageal cancer has used chemoradiation doses greater than 45 Gy. This study aimed to examine the dose of preoperative radiation in relation to the pathologic complete response (pCR) rate and overall survival (OS) for patients with resectable esophageal cancer. METHODS The National Cancer Database was queried for all patients with esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiation (CRT) followed by esophagectomy between 2006 and 2015. The radiation doses were divided into four ranges based on Grays (Gy) received: less than 39.6 Gy, 39.60-44.99 Gy, 45-49.99 Gy, and 50 Gy or more. RESULTS The inclusion criteria were met by 10,293 patients. All patients received neoadjuvant CRT, with 689 patients (6.7%) receiving less than 39.6 Gy, 973 patients (9.5%) receiving 39.6-44.9 Gy, 3837 patients (37.3%) receiving 45-49.9 Gy, and 4794 patients (46.6%) receiving 50 Gy or more. The overall pCR rate was 17.2% (1769/10,293) and was significantly lower for those who received less than 39.6 Gy of radiation than for those who received 39.6 Gy or more (13.9% [96/689] vs. 17.4% [1673/9604]; p = 0.017). The median OS of 37.2 months was significantly better for those who received 39.6 Gy or more than for those who received less than 39.6 Gy (38 vs. 29.6 months (p < 0.0001). The pCR and OS did not differ between the three higher radiation doses (39.6-44.9 vs. 45-49.9 Gy vs. ≥ 50 Gy; pCR [p = 0.1] vs. OS [p = 0.097]). The patients who received 39.6-44.9 Gy were propensity matched with those who received 45 Gy or more of radiation. There remained no difference in pCR (p = 0.375) or OS (p = 0.957). CONCLUSIONS In the United States, the heterogeneity in neoadjuvant CRT dosing is significant, with 84% of patients receiving more than 45 Gy. The benefit of neoadjuvant CRT in terms of pCR and overall survival is seen with doses of 39.6 Gy or more, but not with doses higher than 45 Gy.
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Affiliation(s)
- Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jennifer A Dorth
- Division of Radiation Oncology, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mitchell Machtay
- Division of Radiation Oncology, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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11
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Chen X, Zheng Y, Tatsuoka C, Muzic RF, Okoye CC, O'Donnell JK, Zidar D, Avril N, Oliveira GH, Liu H, Bucher J, Machtay M, Yao M, Dorth JA. Chemoradiotherapy-related carotid artery inflammation in head and neck cancer patients quantified by [ 18F]FDG PET/CT. Oral Oncol 2019; 93:101-106. [PMID: 31109689 DOI: 10.1016/j.oraloncology.2019.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/02/2019] [Accepted: 04/05/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Radiotherapy (RT) is associated with an increased risk of cardiovascular disease (CVD), but little is known about the mechanism for vascular injury and methods for early detection. MATERIALS AND METHODS We conducted a prospective, pilot study of carotid artery inflammation using 18F-labeled 2-fluoro-2-deoxy-d-glucose ([18F]FDG) PET/CT imaging pre- and 3 months post-RT in head-and-neck cancer (HNC) patients. [18F]FDG uptake by the carotid arteries was measured by the maximum and mean target to background ratio (TBRMAX, TBRMEAN) and the mean partial volume corrected standardized uptake value (pvcSUVMEAN). RESULTS Of the 22 patients who completed both pre and post-RT scans, the majority (82%) had stage III or stage IV disease and received concurrent chemotherapy. TBRMAX, TBRMEAN, and pvcSUVMEAN were all significantly higher 3 months after RT versus before RT with mean difference values (95% CI; p-value) of 0.17 (0.1-0.25; 0.0001), 0.19 (0.12-0.25; 0.0001), and 0.31 g/ml (0.12-0.5; 0.002), respectively. Fifteen patients (68%) had HPV-positive tumors, which were associated with lower pre-RT [18F]FDG signal, but a greater increase in TBRMAX (19% vs 5%), TBRMEAN (21% vs 11%) and pvcSUVMEAN (20% increase vs 3% decrease), compared to HPV negativity. CONCLUSION There is a significant increase in carotid artery inflammation in HNC patients due to CRT that amounts to a degree that has previously been associated with higher risk for future CVD events. The subset of patients with HPV-positive tumors experienced the greatest increases in vascular inflammation due to CRT. Carotid [18F]FDG uptake may be an early biomarker of RT-related vascular injury.
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Affiliation(s)
- Xuguang Chen
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yiran Zheng
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Curtis Tatsuoka
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Raymond F Muzic
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Center for Imaging Research, Case Western Reserve University, Cleveland, OH, United States
| | - Christian C Okoye
- Department of Radiation Oncology, St. Bernards Medical Group, Jonesboro, AR, United States
| | - James K O'Donnell
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University Cleveland, OH, United States
| | - David Zidar
- Harrington Heart and Vascular Institute, Department of Medicine, University Hospitals, Case Western Reserve University, Cleveland, OH, United States
| | - Norbert Avril
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University Cleveland, OH, United States
| | - Guilherme H Oliveira
- Onco-Cardiology Program, and Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, Department of Medicine, University Hospitals, Case Western Reserve University, Cleveland, OH, United States
| | - Hongyan Liu
- Department of Neurology, University Hospitals Cleveland Medical Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Jessica Bucher
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Mitchell Machtay
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Min Yao
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, United States.
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12
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Carpenter DJ, Mowery YM, Broadwater G, Rodrigues A, Wisdom AJ, Dorth JA, Patel PR, Shortell CK, Clough R, Brizel DM. The risk of carotid stenosis in head and neck cancer patients after radiation therapy. Oral Oncol 2018; 80:9-15. [PMID: 29706194 DOI: 10.1016/j.oraloncology.2018.02.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/27/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Head and neck radiotherapy (RT) is a risk factor for cerebrovascular disease. We performed a retrospective cohort study to evaluate carotid artery stenosis (CAS) incidence in head and neck cancer (HNC) patients undergoing RT, characterizing associated risk factors. MATERIALS AND METHODS Records were retrospectively reviewed for HNC patients undergoing carotid ultrasound screening after definitive or adjuvant RT between January 2000 and May 2016. CAS was defined as ≥50% stenosis on imaging, stroke, or transient ischemic attack. Actuarial CAS rates were calculated by Kaplan-Meier method. Univariate and multivariate analyses predicted CAS risk based on carotid dosimetric and clinical parameters. RESULTS 366 patients met inclusion criteria. Median time from RT completion to last follow-up was 4.1 yr. Actuarial risk for CAS was 29% (95% CI 22-36%) at 8 years. Univariate analysis showed that smoking (HR 1.7; 95% CI 1.1-2.7), hyperlipidemia (HR 1.6; 95% CI 1.03-2.6), diabetes (HR 2.8; 95% CI 1.6-4.8), coronary artery disease (HR 2.4; 95% CI 1.4-4.2), and peripheral artery disease (HR 3.6; 95% CI 1.1-11.6) were significantly associated with increased CAS. In multivariate analysis, diabetes was predictive of time to CAS (HR 1.9; 95% CI 1.1-3.4). Carotid dose parameters were not significantly associated with CAS. CONCLUSIONS CAS incidence is high after head and neck radiotherapy, gradually rising over time. No clear dose-response effect between carotid dose and CAS was identified for HNC patients. Carotid artery screening and preventative strategies should be employed in this high-risk patient population.
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Affiliation(s)
| | - Yvonne M Mowery
- Department of Radiation Oncology, Duke Cancer Institute, USA
| | | | - Anna Rodrigues
- Department of Radiation Oncology, Duke Cancer Institute, USA
| | - Amy J Wisdom
- Duke University School of Medicine, Durham, NC, USA
| | - Jennifer A Dorth
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH, USA
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | | | - Robert Clough
- Department of Radiation Oncology, Duke Cancer Institute, USA
| | - David M Brizel
- Department of Radiation Oncology, Duke Cancer Institute, USA; Department of Surgery, Duke University Medical Center, USA.
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13
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Dorth JA, Lee WR, Chino J, Abouassaly R, Ellis RJ, Myers ER. Cost-Effectiveness of Primary Radiation Therapy Versus Radical Prostatectomy for Intermediate- to High-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2017; 100:383-390. [PMID: 29353655 DOI: 10.1016/j.ijrobp.2017.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/05/2017] [Accepted: 10/12/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To compare, using a cost-effectiveness analysis, the quality-adjusted life expectancy (QALE) and cost between the 2 treatment options for intermediate- to high-risk prostate cancer: (1) radiation (RT) with androgen deprivation therapy (ADT) or (2) radical prostatectomy (RP) followed by adjuvant RT for patients with risk factors. METHODS AND MATERIALS Our Markov model allowed patients to transition between health states with yearly probabilities of developing cancer recurrence and/or toxicity. Probabilities were assigned according to favorable intermediate, unfavorable intermediate, or high-risk prostate cancer groups. The primary analysis examined outcomes for patients aged 65 years, whereas secondary analyses explored the effects of younger age, elevated baseline cardiovascular risk, and the use of salvage therapy. One-way and probabilistic sensitivity analyses were performed. RESULTS Across all primary and secondary analyses, and using a wide-range of assumptions, RT + ADT was the preferred treatment strategy for men with intermediate- to high-risk prostate cancer. The QALE was higher after RT + ADT by 0.5 to 1.14 quality-adjusted life years, compared with RP. Radiation plus ADT was cost-effective in all situations, falling beneath a threshold of $100,000 per quality-adjusted life year. Among all risk groups, a greater proportion of patients undergoing RP experienced single or multiple treatment toxicities. CONCLUSIONS Radiation plus ADT may result in improved QALE compared with RP for intermediate- to high-risk prostate cancer. Although biochemical failure is similar between treatment groups, there is a higher rate of developing multiple toxicities among patients treated with upfront RP.
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Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio.
| | - W Robert Lee
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Junzo Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Robert Abouassaly
- Department of Urology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Rodney J Ellis
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
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14
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Okoye CC, Bucher J, Tatsuoka C, Parikh SA, Oliveira GH, Gibson MK, Machtay M, Yao M, Zender CA, Dorth JA. Cardiovascular risk and prevention in patients with head and neck cancer treated with radiotherapy. Head Neck 2016; 39:527-532. [PMID: 28032680 DOI: 10.1002/hed.24646] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/05/2016] [Accepted: 10/21/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The underlying contributors to cardiovascular disease (CVD) in patients with head and neck squamous cell carcinoma (HNSCC) are poorly characterized. METHODS Patients with HNSCC who underwent definitive or adjuvant (chemo)radiation between 2011 and 2013 were retrospectively reviewed. The 10-year risk estimates for a CVD event were calculated according to the Framingham Risk Score (FRS). RESULTS One hundred fifteen patients with predominantly stage III/IV HNSCC had a median follow-up of 2 years. At diagnosis, 23% of patients had CVD. The FRS was higher among patients with laryngeal cancer versus other sites (20.5% vs 14.4%). Twenty-four percent of all patients had uncontrolled blood pressure at diagnosis. Among the patients with CVD, 41% were not taking antiplatelet therapy and 30% were not taking statin therapy. Thirty-four percent of patients without CVD had indications for initiating statin therapy. CONCLUSION Patients with HNSCC have a high baseline CVD risk and many do not receive optimal preventive care. © 2016 Wiley Periodicals, Inc. Head Neck 39: 527-532, 2017.
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Affiliation(s)
- Christian C Okoye
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Jessica Bucher
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Curtis Tatsuoka
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Sahil A Parikh
- Harrington Heart and Vascular Institute, Department of Internal Medicine - Cardiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Guilherme H Oliveira
- Onco-Cardiology Program, and Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, Department of Internal Medicine, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Michael K Gibson
- Division of Hematology and Oncology, Department of Medicine, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Mitchell Machtay
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Min Yao
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Chad A Zender
- Department of Otolaryngology - Head and Neck Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
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15
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Myrehaug S, Sahgal A, Russo SM, Lo SS, Rosati LM, Mayr NA, Lock M, Small W, Dorth JA, Ellis RJ, Teh BS, Herman JM. Stereotactic body radiotherapy for pancreatic cancer: recent progress and future directions. Expert Rev Anticancer Ther 2016; 16:523-30. [PMID: 26999329 DOI: 10.1586/14737140.2016.1168698] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Despite advances in surgical, medical, and radiation therapy for pancreatic cancer, the prognosis remains poor. At this time, the only chance for long-term survival is surgical resection. More challenging is the optimal management of unresectable locally advanced pancreatic cancer, which has historically been treated with concurrent chemoradiation or chemotherapy alone. However, the survival and local control benefit of conventional radiotherapy in addition to chemotherapy was unclear. More recently, stereotactic body radiotherapy (SBRT) is emerging as a viable approach to maximizing local tumor control with a tolerable side effect profile. SBRT achieves sharp dose fall-off facilitating safe delivery of highly focused radiation to the tumor over 1-5 days. Although the optimal regimen of pancreas SBRT has not yet been established, its short treatment course limits the delay of additional. Future directions involve prospective study of pancreas SBRT and exploration of biomarkers and imaging technology in order to adopt a personalized management paradigm.
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Affiliation(s)
- Sten Myrehaug
- a Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre , University of Toronto , Toronto , ON , Canada
| | - Arjun Sahgal
- a Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre , University of Toronto , Toronto , ON , Canada
| | - Suzanne M Russo
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Simon S Lo
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Lauren M Rosati
- c Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center , Johns Hopkins University , Baltimore , MD , USA
| | - Nina A Mayr
- d Department of Radiation Oncology , University of Washington , Seattle , WA , USA
| | - Michael Lock
- e Department of Radiation Oncology, London Regional Cancer Program , University of Western Ontario , London , ON , Canada
| | - William Small
- f Department of Radiation Oncology , Loyola University Medical Center , Maywood , IL , USA
| | - Jennifer A Dorth
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Rodney J Ellis
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Bin S Teh
- g Department of Radiation Oncology , Houston Methodist Hospital, Weill Cornell Medical College , Houston , TX , USA
| | - Joseph M Herman
- c Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center , Johns Hopkins University , Baltimore , MD , USA
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16
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Klein J, Korol R, Lo SS, Chu W, Lock M, Dorth JA, Ellis RJ, Mayr NA, Huang Z, Chung HT. Stereotactic body radiotherapy: an effective local treatment modality for hepatocellular carcinoma. Future Oncol 2015; 10:2227-41. [PMID: 25471036 DOI: 10.2217/fon.14.167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Although liver-directed therapies such as surgery or ablation can cure hepatocellular carcinoma, few patients are eligible due to advanced disease or medical comorbidities. In advanced disease, systemic therapies have yielded only incremental survival benefits. Historically, radiotherapy for liver cancer was dismissed due to concerns over unacceptable toxicities from even moderate doses. Although implementation requires more resources than standard radiotherapy, stereotactic body radiotherapy can deliver reproducible, highly conformal ablative radiotherapy to tumors while minimizing doses to nearby critical structures. Trials of stereotactic body radiotherapy for hepatocellular carcinoma have demonstrated promising local control and survival results with low levels of toxicity in Child-Pugh class A patients. We review the published literature and make recommendations for the future of this emerging modality.
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Affiliation(s)
- Jonathan Klein
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, University of Toronto, Toronto, ON, M4N 3M5, Canada
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17
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Dorth JA, Pura JA, Palta M, Willett CG, Uronis HE, D'Amico TA, Czito BG. Patterns of recurrence after trimodality therapy for esophageal cancer. Cancer 2014; 120:2099-105. [PMID: 24711267 DOI: 10.1002/cncr.28703] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 02/25/2014] [Accepted: 03/10/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patterns of failure after neoadjuvant chemoradiotherapy and surgery for esophageal cancer are poorly defined. METHODS All patients in the current study were treated with trimodality therapy for nonmetastatic esophageal cancer from 1995 to 2009. Locoregional failure included lymph node failure (NF), anastomotic failure, or both. Abdominal paraaortic failure (PAF) was defined as disease recurrence at or below the superior mesenteric artery. RESULTS Among 155 patients, the primary tumor location was the upper/middle esophagus in 18%, the lower esophagus in 32%, and the gastroesophageal junction in 50% (adenocarcinoma in 79% and squamous cell carcinoma in 21%) of patients. Staging methods included endoscopic ultrasound (73%), computed tomography (46%), and positron emission tomography/computed tomography (54%). Approximately 40% of patients had American Joint Committee on Cancer stage II disease and 60% had stage III disease. The median follow-up was 1.3 years. The 2-year locoregional control, event-free survival, and overall survival rates were 86%, 36%, and 48%, respectively. The 2-year NF rate was 14%, the isolated NF rate was 3%, and the anastomotic failure rate was 6%. The 2-year PAF rate was 9% and the isolated PAF rate was 5%. PAF was found to be increased among patients with gastroesophageal junction tumors (12% vs 6%), especially for the subset with ≥ 2 clinically involved lymph nodes at the time of diagnosis (19% vs 4%). CONCLUSIONS Few patients experience isolated NF or PAF as their first disease recurrence. Therefore, it is unlikely that targeting additional regional lymph node basins with radiotherapy would significantly improve clinical outcomes.
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Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
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18
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Dorth JA, Patel PR, Broadwater G, Brizel DM. Incidence and risk factors of significant carotid artery stenosis in asymptomatic survivors of head and neck cancer after radiotherapy. Head Neck 2013; 36:215-9. [PMID: 23554082 DOI: 10.1002/hed.23280] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The incidence and risk factors of carotid artery stenosis in asymptomatic patients after head and neck radiation therapy (RT) are unknown. METHODS This retrospective study reviewed asymptomatic patients treated with RT for head and neck cancer from 2000 to 2009 who underwent screening carotid ultrasound. RESULTS Two hundred twenty-four patients were included, the majority of whom had stage III to IV disease and received cisplatin-based chemotherapy. Median time from RT completion to last carotid ultrasound was 3 years. Actuarial rate of carotid artery stenosis at 4 years was 14% (95% confidence interval [CI], 4% to 22%). Multivariate analysis revealed that carotid artery stenosis was associated with Framingham risk factors (hazard ratio [HR], 1.6 per factor; 95% CI, 1.2-2.2; p = .003). Among 135 patients treated with intensity-modulated radiation therapy (IMRT), the HR for carotid artery stenosis was 1.4 for every 10 Gy increase in mean RT dose to the carotid bulb plus 2 cm (95% CI, 0.8-2.4; p = .35). CONCLUSION Prevention and screening programs should be considered for head and neck cancer survivors given the high risk of carotid artery stenosis.
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Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina
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Dorth JA, Prosnitz LR, Broadwater G, Diehl LF, Beaven AW, Coleman RE, Kelsey CR. Impact of Consolidation Radiation Therapy in Stage III-IV Diffuse Large B-cell Lymphoma With Negative Post-Chemotherapy Radiologic Imaging. Int J Radiat Oncol Biol Phys 2012; 84:762-7. [DOI: 10.1016/j.ijrobp.2011.12.067] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 12/16/2011] [Accepted: 12/20/2011] [Indexed: 10/28/2022]
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Dorth JA, Prosnitz LR, Broadwater G, Beaven AW, Kelsey CR. Radiotherapy dose-response analysis for diffuse large B-cell lymphoma with a complete response to chemotherapy. Radiat Oncol 2012; 7:100. [PMID: 22720801 PMCID: PMC3464871 DOI: 10.1186/1748-717x-7-100] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/21/2012] [Indexed: 11/12/2022] Open
Abstract
Objective To examine the efficacy of different radiation doses after achievement of a complete response to chemotherapy in diffuse large B-cell lymphoma (DLBCL). Methods Patients with stage I-IV DLBCL treated from 1995–2009 at Duke Cancer Institute who achieved a complete response to chemotherapy were reviewed. In-field control, event-free survival, and overall survival were calculated using the Kaplan-Meier method. Dose response was evaluated by grouping treated sites by delivered radiation dose. Results 105 patients were treated with RT to 214 disease sites. Chemotherapy (median 6 cycles) was R-CHOP (65%), CHOP (26%), R-CNOP (2%), or other (7%). Post-chemotherapy imaging was PET/CT (88%), gallium with CT (1%), or CT only (11%). The median RT dose was 30 Gy (range, 12–40 Gy). The median radiation dose was higher for patients with stage I-II disease compared with patients with stage III-IV disease (30 versus 24.5 Gy, p < 0.001). Five-year in-field control, event-free survival, and overall survival for all patients was 94% (95% CI: 89-99%), 84% (95% CI: 77-92%), and 91% (95% CI: 85-97%), respectively. Six patients developed an in-field recurrence at 10 sites, without a clear dose response. In-field failure was higher at sites ≥ 10 cm (14% versus 4%, p = 0.06). Conclusion In-field control was excellent with a combined modality approach when a complete response was achieved after chemotherapy without a clear radiation dose response.
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Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Chernikova SB, Razorenova OV, Higgins JP, Sishc BJ, Nicolau M, Dorth JA, Chernikova DA, Kwok S, Brooks JD, Bailey SM, Game JC, Brown JM. Deficiency in mammalian histone H2B ubiquitin ligase Bre1 (Rnf20/Rnf40) leads to replication stress and chromosomal instability. Cancer Res 2012; 72:2111-9. [PMID: 22354749 DOI: 10.1158/0008-5472.can-11-2209] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Mammalian Bre1 complexes (BRE1A/B (RNF20/40) in humans and Bre1a/b (Rnf20/40) in mice) function similarly to their yeast homolog Bre1 as ubiquitin ligases in monoubiquitination of histone H2B. This ubiquitination facilitates methylation of histone H3 at K4 and K79, and accounts for the roles of Bre1 and its homologs in transcriptional regulation. Recent studies by others suggested that Bre1 acts as a tumor suppressor, augmenting expression of select tumor suppressor genes and suppressing select oncogenes. In this study, we present an additional mechanism of tumor suppression by Bre1 through maintenance of genomic stability. We track the evolution of genomic instability in Bre1-deficient cells from replication-associated double-strand breaks (DSB) to specific genomic rearrangements that explain a rapid increase in DNA content and trigger breakage-fusion-bridge cycles. We show that aberrant RNA-DNA structures (R-loops) constitute a significant source of DSBs in Bre1-deficient cells. Combined with a previously reported defect in homologous recombination, generation of R-loops is a likely initiator of replication stress and genomic instability in Bre1-deficient cells. We propose that genomic instability triggered by Bre1 deficiency may be an important early step that precedes acquisition of an invasive phenotype, as we find decreased levels of BRE1A/B and dimethylated H3K79 in testicular seminoma and in the premalignant lesion in situ carcinoma.
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Affiliation(s)
- Sophia B Chernikova
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, USA
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Chernikova SB, Dorth JA, Razorenova OV, Game JC, Brown JM. Deficiency in Bre1 impairs homologous recombination repair and cell cycle checkpoint response to radiation damage in mammalian cells. Radiat Res 2010; 174:558-65. [PMID: 20738173 DOI: 10.1667/rr2184.1] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The pathway involving Bre1-dependent monoubiquitination of histone H2B lysine 123, which leads to Dot1-dependent methylation of histone H3 lysine 79 (H3K79me2), has been implicated in survival after exposure to ionizing radiation in Saccharomyces cerevisiae. We found that depletion of mammalian homologs of Bre1 compromises the response to ionizing radiation, leading to increased radiosensitivity and a G(2)/M checkpoint defect. The deficiency in Bre1a/b function was also associated with increased sensitivity to crosslinking drugs and defective formation of Rad51 foci in mouse cells, suggesting a defect in homologous recombinational repair analogous to that seen in Saccharomyces. In budding yeast, H3K79me2 is important for the recruitment of the checkpoint signaling protein Rad9 to sites of double-strand breaks (DSBs). However, in mammalian cells, 53BP1 (the Rad9 ortholog) in addition to H3K79me2 recognizes a different residue, H4K20me2, and some studies argue that it is H4K20me2 and not H3K79me2 that is the preferred target for 53BP1. We show here that depletion of Bre1b specifically reduced dimethylation of H3K79 without affecting dimethylation of H4K20. Thus our data suggest that the observed defects in the radiation response of Bre1a/b-deficient cells are associated with reduced H3K79me2 and not with H4K20me2.
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Affiliation(s)
- Sophia B Chernikova
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California 94305-5152, USA
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