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Laughlin BS, Corbin KS, Toesca DAS, Thorpe CS, Golafshar MA, Pockaj B, Cronin P, McGee LA, Halyard MY, Mutter RW, Keole SR, Park SS, Shumway DA, Vern-Gross TZ, Vallow L, Wong WW, DeWees TA, Vargas CE. Physician- and Patient-Reported Outcomes of the MC1635 Phase 3 Trial of Ultrahypofractionated Versus Moderately Hypofractionated Adjuvant Radiation Therapy After Breast-Conserving Surgery. Int J Radiat Oncol Biol Phys 2024; 118:1049-1059. [PMID: 37914139 DOI: 10.1016/j.ijrobp.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/21/2023] [Accepted: 10/14/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE Our aim was to report physician- and patient-reported outcomes of patients with localized breast cancer treated with moderate versus ultrahypofractionated whole breast irradiation (WBI) after breast-conserving surgery (BCS). METHODS AND MATERIALS Between February 2018 and February 2020, patients with localized breast cancer (pT0-3 pN0-1 M0) were offered participation in a phase 3 randomized clinical trial assessing adjuvant moderate hypofractionation (MHF) to 40 Gy in 15 fractions versus ultrahypofractionation (UHF) to 25 Gy in 5 fractions after BCS, with an optional simultaneously integrated boost. Toxicities, cosmesis, and quality of life were assessed at baseline, end of treatment (EOT), and 3 months, 1 year, 2 years, and 3 years from irradiation using validated metric tools. RESULTS One hundred seven patients were randomized to MHF (n = 54) or UHF (n = 53) adjuvant WBI. The median follow-up was 42.8 months. Grade 2 radiation dermatitis was experienced by 4 patients (7.4%) in the MHF arm and 2 patients (3.7%) in the UHF arm at EOT (P = .726). No grade 3 or higher toxicities were observed. Deterioration of cosmesis by physician assessment was observed in 2 (6.7%) patients treated in the UHF arm and 1 (1.9%) patient treated in the MHF arm at EOT (P = .534), whereas at 3 months, only 1 (1.8%) patient treated in the MHF arm demonstrated deterioration of cosmesis (P = .315). At EOT, 91% and 94% of patients reported excellent/good cosmesis among those treated with MHF and UHF regimens, respectively (P = .550). At 3 months, more patients within the MHF arm reported excellent/good cosmesis compared with those in the UHF arm (100% vs 91%; P = .030). However, the difference in patient-reported cosmesis disappeared at the 1-, 2-, and 3-year time points. CONCLUSIONS UHF WBI showed similar treatment-related late toxicities and similar provider-scored cosmesis compared with MHF radiation in patients treated adjuvantly after BCS.
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Affiliation(s)
| | | | | | - Cameron S Thorpe
- Department of Radiation Oncology, Sanford Health, Fargo, North Dakota
| | - Michael A Golafshar
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Barbara Pockaj
- Department of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Patricia Cronin
- Department of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Laura Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Todd A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
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Kang Y, Bues M, Halyard MY, McGee LA, Vern-Gross TZ, Wong WW, Keole SR, Vargas C, James SE, Ahmed SK, Archuleta JP, Ridgway AK, Lara PR, Fatyga M. Dose delivery reproducibility for PBS proton treatment of breast cancer patients with and without mask immobilization. Radiat Oncol 2023; 18:157. [PMID: 37736727 PMCID: PMC10515054 DOI: 10.1186/s13014-023-02323-3] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Setup reproducibility of the tissue in the proton beam path is critical in maintaining the planned clinical target volume (CTV) dose coverage and sparing the organs at risk (OAR). In this study, we retrospectively evaluated radiation therapy dose reproducibility for proton pencil beam scanning (PBS) treatment of breast cancer patients with and without mask immobilization. METHODS Ninety-four patients treated between January 2019 and September 2022 with at least one verification CT scan (V-CT) in treatment position were included for this study. All patients were set up with arms up using the Orfit AIO patient positioning system, with (69 patients) or without (25 patients) mask immobilization in chin, neck, shoulder, upper arm, and chest areas. Two to three enface or near enface single field uniform dose PBS beams were optimized using a commercial treatment planning system. Prescription doses were 25 to 60 GyRBE in 5 to 45 fractions. Treatment plan doses re-calculated on V-CTs were compared to the corresponding planned doses. Cumulative doses were also calculated for patients with at least 3 V-CTs by deform and weighted sum doses from V-CTs to corresponding P-CTs. CTV D95%, ipsilateral-lung V40%, esophagus D0.01cc, and heart mean dose were evaluated and reported as percentages of prescription doses. Differences were large dose deteriorations (LDD) if: (1) CTV (V-CT/cumulative D95%) - (Planned D95%) < - 5%; or (2) Ipsilateral-lung (V-CT/cumulative V40%) - (Planned V40%) > 5%; or (3) Esophagus (V-CT/cumulative D0.01cc) - (Planned D0.01cc) > 10%; or (4) Heart (V-CT/cumulative mean) - (Planned mean) > 1.5%. RESULTS On average, V-CT/cumulative and planned CTV/OAR dose parameter differences were less than 2.2%/1.7% and 3.4%/3.7% for masked and maskless patients, respectively. The percentages of patients with at least one CTV or OAR V-CT/cumulative dose LDD were 20.3%/25.0% and 72.0%/54.0% for masked and maskless patients, respectively. CONCLUSIONS On average, masked/maskless setups achieved delivered and planned CTV/OAR dose parameters agreed within 2.2%/3.7% for PBS treatment of breast cancer patients in this study. Maskless patients had higher rate of CTV/OAR LDDs compared to masked patients. Dosimetric differences large enough to raise clinical concerns in either group were able to be addressed with replannings.
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Affiliation(s)
- Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Tamara Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sarah E James
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - James P Archuleta
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Ana K Ridgway
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Pedro R Lara
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
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3
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Thorpe CS, DeWees TA, Laughlin BS, Vallow LA, Seneviratne D, Pockaj BA, Cronin PA, Halyard MY, Vern-Gross TZ, McGee LA, McLaughlin SA, Voss MM, Golafshar MA, Bulman GF, Vargas CE. Pilot/Phase II Trial of Hypofractionated Radiation Therapy to the Whole Breast Alone Before Breast Conserving Surgery. Adv Radiat Oncol 2023; 8:101111. [PMID: 36483068 PMCID: PMC9723298 DOI: 10.1016/j.adro.2022.101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose Our purpose was to report the results of a phase II trial of patients with breast cancer treated with hypofractionated whole breast radiation therapy (RT) before breast-conserving surgery (BCS). Methods and materials Between 2019 and 2020, patients with cT0-T2, N0, M0 breast cancer were enrolled. Patients were treated with hypofractionated whole breast RT, 25 Gy in 5 fractions, 4 to 8 weeks before BCS. Pathologic assessment was performed using the residual cancer burden (RCB). Toxicities were assessed according to Common Terminology Criteria for Adverse Events (version 4). Quality of life was assessed with Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, The Breast Cancer Treatment Outcome Scale, Linear Analogue Self-Assessment, and Patient-Reported Outcomes Measurement Information System. Results Twenty-two patients were enrolled. Median follow-up was 7.6 months (range, 0.2-16.8). Seven (32%) and 2 (9%) patients experienced grade 2+ or 3 toxicities, respectively. Overall quality of life Linear Analogue Self-Assessment and Patient-Reported Outcomes Measurement Information System did not change significantly from baseline (P = .21 and P = .72, respectively). There was no clinically significant change (≥1 point) in any of The Breast Cancer Treatment Outcome Scale domains. Only 1 (5%) patient experienced a clinical deterioration that corresponded to a "fair" outcome on the Harvard Cosmesis Scale. At pathologic evaluation, 14 (64%) patients had RCB-0 or RCB-I, including 3 (14%) patients with a pathologic complete response (RCB-0). Eight patients (36%) had RCB-II. No local or distant recurrences have been observed. Conclusions Extremely hypofractionated whole breast RT before BCS is a feasible approach. There were low rates of toxicities and good cosmesis. Further investigation into this approach with RT before BCS is warranted.
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Affiliation(s)
| | - Todd A. DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
| | | | - Laura A. Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Dee Seneviratne
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | | | | | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Molly M. Voss
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Talbott JMV, Ghaith S, Reed DA, Sadosty AT, Sandefur BJ, Hayes SN, Halyard MY, Mi L, Lim ES, Lindor RA. Gender differences in academic productivity, educational positions, and leadership appointments of physicians in the U.S. Work 2023; 75:1031-1039. [PMID: 36683482 DOI: 10.3233/wor-220193] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Promotions in academic medicine are frequently based on number of publications and leadership positions held. While prior study has established women publish less than men, many evaluations are limited to individual specialties and do not evaluate involvement with educational activities. OBJECTIVE To compare gender differences in academic output, intramural leadership positions, and educational leadership positions of academic physicians. METHODS The curriculum vitae and de-identified demographic data of all permanent physicians employed at a multi-site academic medical center were reviewed from April to May 2020. Multivariable logistic and Poisson regressions evaluated leadership positions and number of publications. RESULTS Of 3,359 physicians in the demographic database, 32.3% (n = 1,087) were women and 72.5% were white (n = 2,510). Of the 3,015 physicians in the curriculum vitae database, 32% (n = 962) were women. Women were more likely (p < 0.001) to be assistant professor (54% vs. 42.7%) and less likely to be associate (18.1% vs. 20.3%) or full professor (14.6% vs. 29.1%). Women assistant professors published 22% fewer articles (ratio estimate = 0.78, p < 0.001), associate professors 18% less (coefficient = 0.82, p < 0.001), and full professors 23% less (coefficient = 0.77, p < 0.001). Fewer women were program directors for residencies (1.6% vs. 2.9%, p = 0.02) or fellowships (5.4% vs. 7.4%, p = 0.04), and held fewer division or department leadership positions (OR 0.8, 95% CI as [0.6, 1.0], p = 0.03). CONCLUSION Women physicians do not outperform men across any education, leadership, or publication category. A cultural shift is needed to redefine traditional metrics for leadership appointments if academic medicine hopes to achieve equity.
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Affiliation(s)
| | - Summer Ghaith
- Mayo Clinic Alix School of Medicine, Phoenix, AZ, USA
| | - Darcy A Reed
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Annie T Sadosty
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Lanyu Mi
- Department of EmergencyMedicine, Mayo Clinic, Phoenix, AZ, USA
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Laughlin BS, Bhangoo RS, Thorpe CS, Golafshar MA, DeWees TA, Anderson JD, Vern-Gross TZ, McGee LA, Wong WW, Halyard MY, Keole SR, Vargas CE. Patient-reported outcomes for patients with breast cancer undergoing radiotherapy: A single-center registry experience. Front Oncol 2022; 12:920739. [PMID: 36091145 PMCID: PMC9458857 DOI: 10.3389/fonc.2022.920739] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background We present Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) for patients undergoing adjuvant radiotherapy for breast cancer with curative intent. We describe the frequency and severity of PRO-CTCAE and analyze them with respect to dose fractionation. Methods Patients were included in this study if they were treated with curative intent for breast cancer and enrolled on a prospective registry. Patients must have completed at least one baseline and one post-radiation survey that addressed PRO-CTCAE. For univariate and multivariate analysis, categorical variables were analyzed by Fisher’s exact test and continuous variables by Wilcoxon rank sum test. PRO-CTCAE items graded ≥2 and ≥3 were analyzed between patients who received hypofractionation (HF) versus standard conventional fractionation (CF) therapy by the Chi-square test. Results Three hundred thirty-one patients met inclusion criteria. Pathologic tumor stage was T1–T2 in 309 (94%) patients. Eighty-seven (29%) patients were node positive. Two hundred forty-seven patients (75%) experienced any PRO-CTCAE grade ≥2, and 92 (28%) patients experienced any PRO-CTCAE grade ≥3. CF was found to be associated with an increased risk of grade ≥3 skin toxicity, swallowing, and nausea (all p < 0.01). HF (OR 0.48, p < 0.01) was significant in the multivariate model for decreased risk of any occurrence of PRO-CTCAE ≥3. Conclusions Our study reports one of the first clinical experiences utilizing multiple PRO-CTCAE items for patients with breast cancer undergoing radiation therapy with curative intent. Compared with CF, HF was associated with a significant decrease in any PRO-CTCAE ≥3 after multivariate analysis.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Ronik S. Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Cameron S. Thorpe
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Michael A. Golafshar
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Todd A. DeWees
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Justin D. Anderson
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | | | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Michele Y. Halyard
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
- *Correspondence: Carlos E. Vargas,
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Yang Y, Patel SH, Bridhikitti J, Wong WW, Halyard MY, McGee LA, Rwigema JCM, Schild SE, Vora SA, Liu T, Bues M, Fatyga M, Foote RL, Liu W. Exploratory study of seed spots analysis to characterize dose and linear energy transfer effect in adverse event initialization of pencil beam scanning proton therapy. Med Phys 2022; 49:6237-6252. [PMID: 35820062 DOI: 10.1002/mp.15859] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 03/07/2022] [Revised: 06/20/2022] [Accepted: 07/06/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Both dose and linear-energy-transfer (LET) could play a substantial role in adverse event (AE) initialization of cancer patients treated with pencil-beam-scanning proton therapy (PBS). However, not all the voxels within the AE regions are directly induced from the dose and LET effect. It is important to study the synergistic effect of dose and LET in AE initialization by only including a subset of voxels that are dosimetrically important. PURPOSE To perform exploratory investigation of the dose and LET effects upon AE initialization in PBS using seed spots analysis. METHODS 113 head and neck (H&N) cancer patients receiving curative PBS were included. Among them, 20 patients experienced unanticipated CTCAEv4.0 grade≥3 AEs (AE group) and 93 patients did not (control group). Within the AE group, 13 AE patients were included in the seed spot analysis to derive the descriptive features of AE initialization and the remaining 7 mandible osteoradionecrosis patients and 93 control patients were used to derive the feature-based volume constraint of mandible osteoradionecrosis. The AE regions were contoured and the corresponding dose-LET volume histograms (DLVHs) of AE regions were generated for all patients in the AE group. We selected high LET voxels (the highest 5% of each dose bin) with a range of moderate to high dose (≥∼40 Gy[RBE]) as critical voxels. Critical voxels which were contiguous with each other were grouped into clusters. Each cluster was considered as a potential independent seed spot for AE initialization. Seed spots were displayed in a 2D dose-LET plane based on their mean dose and LET to derive the descriptive features of AE initialization. A volume constraint of mandible osteoradionecrosis was then established based on the extracted features using a receiver operating characteristic curve. RESULTS The product of dose and LET (xBD) was found to be a descriptive feature of seed spots leading to AE initialization in this preliminary study. The derived xBD volume constraint for mandible osteoradionecrosis showed good performance with an area-under-curve of 0.87 (sensitivity of 0.714 and specificity of 0.807 in the leave-one-out cross validation) for the very limited patient data included in this study. CONCLUSION Our exploratory study showed that both dose and LET were observed to be important in AE initializations. The derived xBD volume constraint could predict mandible osteoradionecrosis reasonably well in the very limited H&N cancer patient data treated with PBS included in this study. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yunze Yang
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jidapa Bridhikitti
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Tianming Liu
- Department of Computer Science, the University of Georgia, Athens, Georgia, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Bhangoo RS, Cheng TW, Petersen MM, Thorpe CS, DeWees TA, Anderson JD, Vargas CE, Patel SH, Halyard MY, Schild SE, Wong WW. Radiation recall dermatitis: A review of the literature. Semin Oncol 2022; 49:152-159. [DOI: 10.1053/j.seminoncol.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/20/2021] [Accepted: 04/01/2022] [Indexed: 12/28/2022]
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8
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Thorpe CS, DeWees TA, Golafshar MA, Bhangoo RS, Vern-Gross TZ, McGee LA, Wong WW, Halyard MY, Keole SR, Vargas CE. Patient-reported outcomes version of the common terminology criteria for adverse events and quality-of-life linear analogue self-assessment in breast cancer patients receiving radiation therapy: single-institution prospective registry. J Patient Rep Outcomes 2022; 6:3. [PMID: 35006393 PMCID: PMC8748600 DOI: 10.1186/s41687-021-00408-9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/23/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose/objectives We sought to investigate the impact of patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE) on overall quality-of-life (QOL) employing linear analogue self-assessment (LASA) in breast cancer (BC) patients undergoing radiation therapy (RT). Materials/methods All patients treated with RT for BC with curative intent from 2015 to 2019 at our institution were included. Breast specific PRO-CTCAE and overall QOL LASA questionnaires were administered at baseline, end-of-treatment, 3, 6, 12 months, and then annually. Minimal clinically important difference in overall QOL was a 10-point change in LASA. Hypofractionation was any treatment > 2 Gy per fraction. Mixed models for repeated measures were used to determine the association of PRO-CTCAE and overall QOL LASA. Results Three hundred thirty-one (331) patients with a median follow-up of 3.1 years (range 0.4–4.9) were included. Average overall QOL LASA scores were 78.5 at baseline, 79.8 at end-of-treatment, 79.8 at 3 months, 77.1 at 6 months, 79.4 at 12 months, and 79.7 at 24 months. On univariate analysis, patients reporting a grade ≥ 3 PRO-CTCAE had, on average, a 10.4-point reduction in overall LASA QOL (p < 0.0001). On multivariate analysis, not being treated with hypofractionation and higher BMI were predictive for worse overall LASA QOL with a 10-point reduction in LASA for patients reporting a grade ≥ 3 PRO-CTCAE (p < 0.0001). Conclusions Patients reporting a grade ≥ 3 PRO-CTCAE experienced statistically significant and clinically meaningful deterioration in overall QOL LASA. Hypofractionation improved QOL while higher BMI predicted for worse QOL. PRO-CTCAE should be integrated into future clinical trials.
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Affiliation(s)
- C S Thorpe
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - T A DeWees
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA.,Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | - M A Golafshar
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - R S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - T Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - L A McGee
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - W W Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - M Y Halyard
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - S R Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - C E Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA.
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9
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Anderson JD, Hammond JB, Kosiorek HE, Thorpe CS, Bhangoo RS, Pockaj BA, Gray RJ, Cronin PA, Rebecca AM, Casey WJ, Wong WW, Keole SR, Vern-Gross TZ, McGee LA, Halyard MY, DeWees TA, Vargas CE. Unplanned implant removal in locally advanced breast cancer. Breast J 2021; 27:466-471. [PMID: 33715231 DOI: 10.1111/tbj.14224] [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: 12/09/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 11/28/2022]
Abstract
Study conducted to determine frequency and timing of unplanned breast implant removal after mastectomy, reconstruction, and postmastectomy radiation (PMRT). From 2010-2017, 52 patients underwent mastectomy, reconstruction, and PMRT. With median follow-up of 3.1 years, 23 patients (44%) experienced implant removal. Implant removal occurred in 9 (17%) patients before starting PMRT and 14 (27%) patients after starting PMRT. Implant removal rates were similar for hypofractionated PMRT compared with standard fractionation and for proton compared with photon PMRT. Implant removal is common for women undergoing mastectomy and reconstruction followed by PMRT. The risk is clinically significant even before starting radiation.
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Affiliation(s)
| | - Jacob B Hammond
- Department of General Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Heidi E Kosiorek
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Richard J Gray
- Department of General Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - William J Casey
- Department of Plastic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Todd A DeWees
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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10
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Vargas CE, Thorpe CS, Dueck AC, Tenner KS, Davidson NE, Martino S, Pisansky TM, Hwang ES, Halyard MY, Pockaj BA, Perez EA. Impact of adjuvant trastuzumab on locoregional failure rates in a randomized clinical trial: North Central Cancer Treatment Group N9831 (alliance) study. Cancer 2020; 126:5239-5246. [PMID: 32931029 DOI: 10.1002/cncr.33154] [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: 06/10/2020] [Revised: 07/06/2020] [Accepted: 07/17/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND The goal of this study was to assess the impact of trastuzumab on locoregional failure. METHODS The analysis included 2763 patients with HER2-positive (HER2+) breast cancer who were randomly assigned to adjuvant doxorubicin (A), cyclophosphamide (C), paclitaxel (T) and trastuzumab (H) (arm A, AC→T [n = 922]; arm B, AC→T→H [n = 988]; arm C, AC→T+H→H [n = 853]). Radiotherapy was given after AC→T concurrently with H. Radiotherapy was given after lumpectomy (L) or after mastectomy (M) with ≥4 positive lymph nodes but was optional for 1 to 3 positive lymph nodes. Locoregional failures at 10 years (LFR10) as first events were compared using competing risk analysis. RESULTS The median follow-up was 13.0 years. The first site of failure was local-only in 96 cases, locoregional in 16 cases, regional in 32 cases, and not specified in 2 cases; LFR10 was 4.8% (95% CI 4.1%-5.7%). LFR10 was 5.5% (95% CI 4.3%-7.2%), 4.9% (95% CI 3.7%-6.4%), and 2.8% (95% CI 1.9%-4.1%) in arms A, B, and C (B vs A: hazard ratio [HR] 0.91, P = .62; C vs A: HR 0.72, P = .12). For estrogen receptor-positive patients, LFR10 was 3.7% (95% CI 2.8%-4.8%) and for estrogen receptor-negative patients, it was 6.1% (95% CI 5.0%-7.4%; HR 0.61, P = .004). Local treatment included L+RT (n = 1044 [38%]), M+RT (n = 1025 [37%]), and M (n = 694 [25%]). LFR10 was 6.% (95% CI 5.0%-7.8%), 3.0% (95% CI 2.1%-4.3%), and 5.5% (95% CI 4.0%-7.4%) for L+RT, M+RT, and M, respectively (M+RT vs L+RT: HR 0.43, P < .001; M vs L+RT: HR 0.88, P = .57). For 1 to 3 positive lymph nodes, LFR10 was 6.5% (95% CI 4.8%-8.9%), 4.1% (95% CI 2.4%-7.0%), and 4.3% (95% CI 2.9%-6.5%) in L+RT, M+RT, and M, respectively (M vs L+RT: HR 0.68, P = .14; M vs M+RT: HR 1.2, P = .6). CONCLUSION Low 10-year LFRs were seen regardless of trastuzumab use. Differences in local therapy in patients with 1 to 3 positive lymph nodes did not appear to improve local control. Local therapy studies for HER2+ and other tumor characteristics are important as the role of local therapies continues to evolve.
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Affiliation(s)
- Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Amylou C Dueck
- Alliance Statistics and Data Center, Mayo Clinic, Scottsdale, Arizona
| | - Kathleen S Tenner
- Alliance Statistics and Data Center, Mayo Clinic, Scottsdale, Arizona
| | - Nancy E Davidson
- Division of Medical Oncology, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Division of Medical Oncology, University of Washington, Seattle, Washington
| | - Silvana Martino
- The Angeles Clinic and Research Institute, Santa Monica, California
| | | | - E Shelley Hwang
- Department of Surgery, Duke University, Durham, North Carolina
| | | | | | - Edith A Perez
- Department of Hematology & Oncology, Mayo Clinic, Jacksonville, Florida
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11
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Reed DA, Harrison ME, Wolanskyj-Spinner AP, Dixon DA, Halyard MY, Colon-Otero G, Andresen-Reid ML, Meyer FB. Mayo Clinic Alix School of Medicine. Acad Med 2020; 95:S262-S265. [PMID: 33626696 DOI: 10.1097/acm.0000000000003454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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12
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Halyard MY. #MeToo in Health Care: A Multidimensional Problem With Widespread Effects and Incomplete Answers. Mayo Clin Proc 2020; 95:639-641. [PMID: 32247336 DOI: 10.1016/j.mayocp.2020.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/18/2020] [Indexed: 11/24/2022]
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13
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Manzar GS, Lester SC, Routman DM, Harmsen WS, Petersen MM, Sloan JA, Mundy DW, Hunzeker AE, Amundson AC, Anderson JL, Patel SH, Garces YI, Halyard MY, McGee LA, Neben-Wittich MA, Ma DJ, Frank SJ, Whitaker TJ, Foote RL. Comparative analysis of acute toxicities and patient reported outcomes between intensity-modulated proton therapy (IMPT) and volumetric modulated arc therapy (VMAT) for the treatment of oropharyngeal cancer. Radiother Oncol 2020; 147:64-74. [PMID: 32234612 DOI: 10.1016/j.radonc.2020.03.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [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: 10/18/2019] [Revised: 02/12/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE IMPT improves normal tissue sparing compared to VMAT in treating oropharyngeal cancer (OPC). Our aim was to assess if this translates into clinical benefits. MATERIALS AND METHODS OPC patients treated with definitive or adjuvant IMPT or VMAT from 2013 to 2018 were included. All underwent prospective assessment using patient-reported-outcomes (PROs) (EORTC-QLQ-H&N35) and provider-assessed toxicities (CTCAEv4.03). End-of-treatment and pretreatment scores were compared. PEG-tube use, hospitalization, and narcotic use were retrospectively collected. Statistical analysis used the Wilcoxon Rank-Sum Test with propensity matching for PROs/provider-assessed toxicities, and t-tests for other clinical outcomes. RESULTS 46 IMPT and 259 VMAT patients were included; median follow-up was 12 months (IMPT) and 30 months (VMAT). Baseline characteristics were balanced except for age (p = 0.04, IMPT were older) and smoking (p < 0.01, 10.9% IMPT >20PYs, 29.3% VMAT). IMPT was associated with lower PEG placement (OR = 0.27; 95% CI: 0.12-0.59; p = 0.001) and less hospitalization ≤60 days post-RT (OR = 0.21; 95% CI:0.07-0.6, p < 0.001), with subgroup analysis revealing strongest benefits in patients treated definitively or with concomitant chemoradiotherapy (CRT). IMPT was associated with a relative risk reduction of 22.3% for end-of-treatment narcotic use. Patients reported reduced cough and dysgeusia with IMPT (p < 0.05); patients treated definitively or with CRT also reported feeling less ill, reduced feeding tube use, and better swallow. Provider-assessed toxicities demonstrated less pain and mucositis with IMPT, but more mucosal infection. CONCLUSION IMPT is associated with improved PROs, reduced PEG-tube placement, hospitalization, and narcotic requirements. Mucositis, dysphagia, and pain were decreased with IMPT. Benefits were predominantly seen in patients treated definitively or with CRT.
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Affiliation(s)
- Gohar S Manzar
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - William S Harmsen
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - Molly M Petersen
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - Jeff A Sloan
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - Daniel W Mundy
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Adam C Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, USA
| | | | | | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, USA
| | | | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA.
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Valencia-Sanchez C, Gorelkin VC, Mrugala MM, Sharma A, Vora SA, Ashman JB, Daniels TB, Halyard MY, Rule WG, Zhang N, Butterfield RJ, Schild SE, Porter AB. Clinical evaluation of fitness to drive in patients with brain metastases. Neurooncol Pract 2019; 6:484-489. [PMID: 31832219 DOI: 10.1093/nop/npz027] [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] [Indexed: 11/12/2022] Open
Abstract
Background Guidelines to provide recommendations about driving restrictions for patients with brain metastases are lacking. We aim to determine whether clinical neurologic examination is sufficient to predict suitability to drive in these patients by comparison with an occupational therapy driving assessment (OTDA). Methods We prospectively evaluated the concordance between neurology assessment of suitability to drive (pass/fail) and OTDA in 41 individuals with brain metastases. Neuro-oncology evaluation included an interview and neurological examination. Participants subsequently underwent OTDA during which a battery of objective measures of visual, cognitive, and motor skills related to driving was administered. Results The mean age of patients who failed OTDA was age 68.9 years vs 59.3 years in the group members who passed (P = .0046). The sensitivity of the neurology assessment to predict driving fitness compared with OTDA was 16.1% and the specificity 90%. The 31 patients who failed OTDA were more likely to fail Vision Coach, Montreal Cognitive Assessment, and Trail Making B tests. Conclusions There was poor association between the assessment of suitability to drive by neurologists and the outcome of the OTDA in patients with brain metastases. Subtle deficits that may impair the ability to drive safely may not be evident on neurologic examination. The positive predictive value was high to predict OTDA failure. Age could be a factor affecting OTDA performance. The results raise questions about the choice of assessments in making recommendations about driving fitness in people with brain metastases. OTDA should be strongly considered in patients with brain metastases who wish to continue driving.
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Affiliation(s)
| | | | | | | | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | | | | | | | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - Nan Zhang
- Health Science Research, Mayo Clinic, Scottsdale, AZ
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15
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Sio TT, Blanchard MJ, Novotny PJ, Patel SH, Rwigema JCM, Pederson LD, McGee LA, Gamez ME, Seeger GR, Martenson JA, Grover Y, Neben Wittich MA, Garces YI, Foote RL, Miller RC, Halyard MY. N-Acetylcysteine Rinse for Thick Secretion and Mucositis of Head and Neck Chemoradiotherapy (Alliance MC13C2): A Double-Blind Randomized Clinical Trial. Mayo Clin Proc 2019; 94:1814-1824. [PMID: 31405750 PMCID: PMC6742495 DOI: 10.1016/j.mayocp.2019.03.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/26/2019] [Accepted: 03/18/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether N-acetylcysteine rinse was safe and could improve thickened secretions and dry mouth during and after radiotherapy. PATIENTS AND METHODS We designed a prospective pilot double-blind, placebo-controlled randomized clinical trial (Alliance MC13C2). Adult patients (age ≥18 years) were enrolled if they underwent chemoradiotherapy (≥60 Gy). Patients initiated testing rinse within 3 days of starting radiotherapy. With swish-and-spit, they received 10% N-acetylcysteine (2500 mg daily) or placebo rinse solution 5 times daily during radiotherapy and 2 weeks postradiotherapy. The primary aim was to evaluate N-acetylcysteine in improvement of saliva viscosity with the Groningen Radiotherapy-Induced Xerostomia questionnaire. Secondary aims included evaluating xerostomia improvement by the same questionnaire and with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck-35 Questions survey and adverse-event profiles. The type I error rate was 20%. RESULTS Thirty-two patients undergoing chemoradiotherapy were enrolled. Baseline characteristics were balanced for placebo (n=17) and N-acetylcysteine (n=15). N-acetylcysteine was better for improving sticky saliva (area under curve, P=.12). Scores of multiple secondary end points favored N-acetylcysteine, including sticky saliva daytime (P=.04), daytime and total xerostomia (both P=.02), pain (P=.18), and trouble with social eating (P=.15). Repeated measures models confirmed the findings. Taste was a major dissatisifer for N-acetylcysteine rinse; however, both testing rinses were safe and well tolerated overall. CONCLUSION Our pilot data showed that N-acetylcysteine rinse was safe and provided strong evidence of potential efficacy for improving thickened saliva and xerostomia by patient-reported outcome. A confirmatory phase 3 trial is required. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02123511.
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Affiliation(s)
- Terence T Sio
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, AZ
| | - Miran J Blanchard
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN; Sanford Roger Maris Cancer Center, Fargo, ND
| | - Paul J Novotny
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, AZ
| | | | - Levi D Pederson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, AZ
| | - Mauricio E Gamez
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, AZ
| | - Grant R Seeger
- Department of Radiation Oncology, Altru Cancer Center, Grand Forks, ND
| | | | - Yvonne Grover
- Department of Pharmacy, Mayo Clinic Hospital, Phoenix, AZ
| | - Michelle A Neben Wittich
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Robert C Miller
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, AZ.
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16
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Radecki Breitkopf C, Williams KP, Ridgeway JL, Parker MW, Strong-Simmons A, Hayes SN, Halyard MY. Linking Education to Action: A Program to Increase Research Participation Among African American Women. J Womens Health (Larchmt) 2018; 27:1242-1249. [PMID: 29975586 DOI: 10.1089/jwh.2017.6791] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 02/05/2023] Open
Abstract
BACKGROUND Underrepresentation of African American women as research participants contributes to health disparities. Contemporary studies have focused on clinical trial (CT) participation; epidemiologic and genetic studies utilizing medical records and/or biological samples have received less attention. In partnership with The Links, Incorporated (The Links), a national service organization of professional African American women, this study sought to examine attitudes regarding chart review (CR) studies, genetic studies/biobanking (GEN), and CTs; develop; and evaluate an online education-to-action program. METHODS In phase 1, focus groups were convened with members of The Links to inform the content and format of the program. Phases 2 and 3 involved designing and evaluating the program, respectively. RESULTS Thirty-four women across three focus groups shared attitudes and perceptions regarding research and provided guidance for program development. Subsequently, 244 women completed the program (77% response rate), including pre- and post-assessments. Participants indicating that they "definitely" or "probably" (responses combined) intend to participate in research increased from 36.5% to 69.3% (pre/post-program). Agreement with the statement "research in the U.S. is ethical" increased (52.9% to 74.4%) as did factual knowledge regarding each of the study types. There was a decrease in reporting "little or no understanding" of study types (Pre/Post: GEN: 66%/24.9%, CR: 62.9%/18.4%, CTs: 40.7%/15.5%). Pre-program, few were "very positive" about the study types (14.3% GEN, 15.0% CR, 28.6% CTs); post-program ratings increased and equalized (42.8% GEN, 43.0% CR, 42.5% CTs). CONCLUSIONS An online education-to-action program targeting professional African American women improved knowledge, perceptions of ethics, and intent to participate in biomedical research.
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Affiliation(s)
| | - Karen Patricia Williams
- 2 College of Nursing, The Ohio State University , Columbus, Ohio.,3 The Links, Incorporated, Washington, Distict of Columbia
| | - Jennifer L Ridgeway
- 4 Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota
| | - Monica W Parker
- 3 The Links, Incorporated, Washington, Distict of Columbia.,5 Department of Neurology, Emory University , Atlanta, Georgia
| | | | - Sharonne N Hayes
- 6 Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic , Rochester, Minnesota
| | - Michele Y Halyard
- 3 The Links, Incorporated, Washington, Distict of Columbia.,7 Department of Radiation Oncology, Mayo Clinic , Scottsdale, Arizona
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17
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Niska JR, Keole SR, Pockaj BA, Halyard MY, Patel SH, Northfelt DW, Gray RJ, Wasif N, Vargas CE, Wong WW. Choosing wisely after publication of level I evidence in breast cancer radiotherapy. Breast Cancer (Dove Med Press) 2018; 10:31-37. [PMID: 29445299 PMCID: PMC5810527 DOI: 10.2147/bctt.s153117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Recent trials in early-stage breast cancer support hypofractionated whole-breast radiotherapy (WBRT) as part of breast-conserving therapy (BCT). Evidence also suggests that radiotherapy (RT) omission may be reasonable for some patients over 70 years. Among radiation-delivery techniques, intensity-modulated RT (IMRT) is more expensive than 3-dimensional conformal RT (3DCRT). Based on this evidence, in 2013, the American Society for Radiation Oncology (ASTRO) recommended hypofractionated schedules for women aged ≥50 years with early-stage breast cancer and avoiding routine use of IMRT for WBRT. To assess response to level I evidence and adherence to ASTRO recommendations, we evaluated the pattern of RT use for early-stage breast cancer at our National Comprehensive Cancer Network institution from 2006 to 2008 and 2011 to 2013 and compared the results with national trends. Methods Data from a prospective database were extracted to include patients treated with BCT, aged ≥50 years, with histologic findings of invasive ductal carcinoma, stage T1-T2N0M0, estrogen receptor-positive, and HER2 normal. We retrospectively reviewed the medical records and estimated costs based on 2016 Hospital Outpatient Prospective Payment System (technical fees) and Medicare Physician Fee Schedule (professional fees). Results Among 55 cases from 2006 to 2008, treatment regimens were 11% hypofractionated, 69% traditional schedule, and 20% RT omission (29% of patients were aged >70 years). Among 83 cases from 2011 to 2013, treatment regimens were 54% hypofractionated, 19% traditional schedule, and 27% RT omission (48% of patients were aged >70 years). 3DCRT was used for all WBRT treatments. Direct medical cost estimates were as follows: 15 fractions 3DCRT, $7,197.87; 15 fractions IMRT, $11,232.33; 25 fractions 3DCRT, $9,731.39; and 25 fractions IMRT, $16,877.45. Conclusion Despite apparent resistance to shorter radiation schedules in the United States, we demonstrate that rapid practice change in response to level I evidence is feasible. Wider adoption of evidence-based guidelines in early-stage breast cancer may substantially lower health care costs and improve convenience for patients without sacrificing oncologic outcomes.
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Affiliation(s)
| | | | | | | | | | - Donald W Northfelt
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, AZ, USA
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Breitkopf CR, Williams KP, Ridgeway JL, Simmons ALS, Parker MW, Halyard MY, Hayes SN. Abstract 4233: Linking education to action: A program to increase research participation among African American women. Cancer Res 2017. [DOI: 10.1158/1538-7445.am2017-4233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Addressing underrepresentation of minorities and women as research participants has largely focused on clinical trials, while little is known about attitudes and knowledge regarding other types of biomedical research, e.g., epidemiologic and genetic studies. These types of studies are essential for advances in cancer research, including development of targeted therapies for women and minorities. As part of an academic/community partnership between Mayo Clinic and The Links, Incorporated, a national volunteer service organization of professional African American women, this study sought to: (1) examine attitudes regarding participation in research involving access to the medical record, genetic studies/biobanking, and clinical trials; and (2) develop and evaluate a novel, targeted online educational program addressing these 3 types of biomedical research. Initial qualitative inquiry via 3 focus groups (n=34) found that most women associated health-related research with clinical trials; few women were familiar with other study types. Women expressed more concerns about how information is collected, used, and shared by investigators than with personal mistreatment in research regardless of study type (genetic research (GEN), chart review (CR), clinical trial (CT)) or the kind of information (social, health, genetic) collected. The importance of investigator transparency regarding the significance of the disease in African Americans, research funding source, the investigator’s agenda, and commitment to the population being studied was emphasized. Qualitative results informed development of the educational program. A total of 244 Links members completed the program (77% response rate) and answered pre- and post-assessments of intentions, attitudes and knowledge. The percent of women indicating that they “definitely” or “probably” intend to participate in research increased from 9.4% to 19.5% and 27.1% to 49.8%, respectively, after program completion. Agreement with the statement “research in the U.S. is ethical” increased from 52.9% to 74.4%. Factual knowledge related to each of the 3 study types also increased. Prior to completing the program many women reported “little or no understanding” of the 3 types of studies (66% GEN, 62.9% CR, 40.7% CT) whereas after program completion, these numbers decreased to 24.9%, 18.4%, and 15.5%, respectively. While few women rated their opinion of the study types as “very positive” prior to beginning the program (14.3% GEN, 15.0% CR, 28.6% CT), upon completion these proportions increased and equalized (42.8% GEN, 43.0% CR, 42.5% CT). Two-month follow-up will evaluate longer-term impact including knowledge dissemination, visiting clinicaltrials.gov, and enrolling in ResearchMatch. An online education-to-action program targeting professional African American women improved knowledge, perceptions of research ethics, and intent to participate in biomedical research.
Citation Format: Carmen Radecki Breitkopf, Karen P. Williams, Jennifer L. Ridgeway, Alice L. Strong Simmons, Monica W. Parker, Michele Y. Halyard, Sharonne N. Hayes. Linking education to action: A program to increase research participation among African American women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4233. doi:10.1158/1538-7445.AM2017-4233
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Niska JR, Halyard MY, Tan AD, Atherton PJ, Patel SH, Sloan JA. Electronic patient-reported outcomes and toxicities during radiotherapy for head-and-neck cancer. Qual Life Res 2017; 26:1721-1731. [PMID: 28247313 PMCID: PMC6301021 DOI: 10.1007/s11136-017-1528-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE To characterize quality of life (QOL) using real-time, electronic patient-reported outcomes (ePROs) and to evaluate adverse events (AEs) and supportive care during head-and-neck radiotherapy (RT) and concurrent chemoradiotherapy (CCRT). METHODS Sixty-five patients undergoing head-and-neck RT completed electronic, real-time, 12-item linear analog self-assessments (LASA) at baseline, before biweekly appointments, and at the last week of RT. Changes in QOL domains between time points were calculated. Clinical data were collected from the institutional medical record. AEs were recorded at the same time points as the LASA and graded. RESULTS During head-and-neck RT, most patients had clinically meaningful decreases in all QOL domains except level of support, financial concerns, and legal concerns. QOL domains with the most prevalent, clinically meaningful decreases were fatigue (75.4% of patients; 95% CI, 62.9-84.9%), social activity (70.8%; 95% CI, 58.0-81.1%), and overall QOL (70.8%; 95% CI, 58.0-81.1%). All patients had grade 2 AEs; 35.4% had grade 3 (50.0%, CCRT; 12.0%, RT; P = .002). Weight loss averaged 5.5 kg (6.9 kg, CCRT; 2.8 kg, RT; P < .001). Intravenous hydration was needed in 52.3% (77.5%, CCRT; 12.0%, RT; P < .001); feeding tube placement 40.0% (57.5%, CCRT; 12.0%, RT; P = .001); emergency department visits without hospitalization, 10.8%; and emergent hospitalization, 27.7% (37.5%, CCRT; 12.0%, RT; P = .04). CONCLUSIONS Head-and-neck RT, particularly CCRT, negatively impacts patients' overall QOL, social activity, and fatigue, with frequent grade 3 AEs, weight loss, intravenous hydration, feeding tube placement, ED visits, and hospitalization. Real-time ePROs allow providers to monitor QOL at multiple time points during RT, potentially allowing early intervention to improve QOL and mitigate AEs.
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Affiliation(s)
- Joshua R Niska
- Department of Radiation Oncology, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Angelina D Tan
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Pamela J Atherton
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Jeff A Sloan
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
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Gamez ME, Lal D, Halyard MY, Wong WW, Vargas C, Ma D, Ko SJ, Foote RL, Patel SH. Outcomes and patterns of failure for sinonasal undifferentiated carcinoma (SNUC): The Mayo Clinic Experience. Head Neck 2017; 39:1819-1824. [PMID: 28561906 DOI: 10.1002/hed.24834] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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: 11/28/2016] [Revised: 03/02/2017] [Accepted: 04/18/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Sinonasal undifferentiated carcinoma (SNUC) is a rare aggressive disease arising in the nasal cavity and paranasal sinuses with poor prognosis and unclear optimal management. METHODS Forty patients were analyzed. Nasal cavity was the most common primary site. Most patients presented with T4 disease, received trimodality therapy, and were treated with intensity-modulated radiotherapy (IMRT). RESULTS Median follow-up was 6.9 years. Sixteen patients (40%) experienced recurrent disease, 5 local (12.5%), 1 regional (2.5%), and 10 distant (25%). The 5-year overall survival (OS), recurrence-free survival (RFS), and locoreginal control (LRC) were 44%, 39%, and 71%, respectively. Patients treated with trimodality therapy had better outcomes compared to single modality therapy. Improved OS was noted with IMRT and with doses ≥60 Gy. The most common cause of death was distant metastasis. CONCLUSION SNUC is an aggressive malignancy with a high tendency to metastasize. Better outcomes were obtained with a trimodality approach. Modern radiotherapy (RT) techniques and doses ≥ 60 Gy were associated with improved OS.
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Affiliation(s)
| | - Devyani Lal
- Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona
| | | | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Daniel Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Stephen J Ko
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Liu W, Patel SH, Harrington DP, Hu Y, Ding X, Shen J, Halyard MY, Schild SE, Wong WW, Ezzell GE, Bues M. Exploratory study of the association of volumetric modulated arc therapy (VMAT) plan robustness with local failure in head and neck cancer. J Appl Clin Med Phys 2017; 18:76-83. [PMID: 28503916 PMCID: PMC5500391 DOI: 10.1002/acm2.12099] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 12/06/2016] [Revised: 03/02/2016] [Accepted: 03/30/2017] [Indexed: 12/25/2022] Open
Abstract
This work is to show which is more relevant to cause local failures (LFs) due to patient setup uncertainty between the planning target volume (PTV) underdosage and the potential target underdosage subject to patient setup uncertainties in head and neck (H&N) cancer treated with volumetric‐modulated arc therapy (VMAT). Thirteen LFs in 10 H&N patients treated by VMAT were analyzed. Measures have been taken to minimize the chances of insufficient target delineation for these patients and the patients were clinically determined to have LF based on the PET/CT scan results by an experienced radiologist and then reviewed by a second experienced radiation oncologist. Two methods were used to identify the possible locations of LF due to underdosage: (a) examining the standard VMAT plan, in which the underdosed volume in the nominal dose distribution (UVN) was generated by subtracting the volumes receiving the prescription doses from PTVs, and (b) plan robustness analysis, in which in addition to the nominal dose distribution, six perturbed dose distributions were created by translating the CT iso‐center in three cardinal directions by the PTV margin. The coldest dose distribution was represented by the minimum of the seven doses in each voxel. The underdosed volume in the coldest dose distribution (UVC) was generated by subtracting the volumes receiving the prescription doses in the coldest dose distribution from the volumes receiving the prescription doses in the nominal dose distribution. UVN and UVC were subsequently examined for spatial association with the locations of LF. The association was tested using the binominal distribution and the Fisher's exact test of independence. We found that of 13 LFs, 11 were associated with UVCs (P = 0.011), while three were associated with UVNs (P = 0.99). We concluded that the possible target underdosage due to patient setup uncertainties appeared to be a more relevant factor associated with LF in VMAT for H&N cancer than the compromised PTV coverage at least for the patients included in this study.
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Affiliation(s)
- Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | | | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - Xiaoning Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - Gary E Ezzell
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, 85054, USA
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Habboush Y, Shannon RP, Niazi SK, Hollant L, Single M, Gaines K, Smart B, Chimato NT, Heckman MG, Buskirk SJ, Vallow LA, Tzou KS, Ko SJ, Peterson JL, Biers HA, Day AB, Nelson KA, Sloan JA, Halyard MY, Miller RC. Patient-reported distress and survival among patients receiving definitive radiation therapy. Adv Radiat Oncol 2017; 2:211-219. [PMID: 28740934 PMCID: PMC5514245 DOI: 10.1016/j.adro.2017.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Patient-reported distress (PRD) has not been well assessed in association with survival after radiation therapy (RT). The aims of this study were to evaluate the association between PRD level and survival after definitive RT and to identify the main causes of distress in definitive RT patients. METHODS AND MATERIALS A total of 678 consecutive patients receiving definitive RT at our institution from April 2012 through May 2015 were included. All patients answered a PRD questionnaire that contained 30 items related to possible causes of distress, which could be rated from 1 (no distress) to 5 (high distress). Additionally, patients were asked to rate their overall distress level from 0 (no distress) to 10 (extreme distress). This overall distress level was our primary patient-reported distress measure and was examined as a continuous variable and as a categorical variable with 3 PRD levels (low, 0-3 [n = 295]; moderate, 4-6 [n = 222]; and high, 7-10 [n = 161]). RESULTS As a continuous variable in multivariable Cox regression analysis, a higher overall PRD level was associated with poorer survival after RT (hazard ratio [HR], 1.39; P = .004). As a categorical variable, compared with patients with low distress, survival was poorer for patients with moderate distress (HR, 1.62; P = .038) or high distress (HR, 1.49; P = .12), but the latter difference was not significant. When the moderate and high distress levels were combined, survival was significantly poorer compared with the low distress level (HR, 1.57; P = .034). The top 5 specific causes of distress that patients mentioned were "How I feel during treatment," "Fatigue," "Out-of-pocket medical costs," "Pain that affects my daily functioning," and "Sleep difficulties." CONCLUSIONS PRD before or during RT is a prognostic factor associated with decreased survival. Distress screening guidelines and interventions should be implemented for patients receiving definitive RT.
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Affiliation(s)
- Yacob Habboush
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Laeticia Hollant
- Visiting students, Mayo School of Health Sciences, Mayo Clinic College of Medicine, Jacksonville, Florida
| | - Megan Single
- Visiting students, Mayo School of Health Sciences, Mayo Clinic College of Medicine, Jacksonville, Florida
| | - Katherine Gaines
- Visiting students, Mayo School of Health Sciences, Mayo Clinic College of Medicine, Jacksonville, Florida
| | - Bridget Smart
- Visiting students, Mayo School of Health Sciences, Mayo Clinic College of Medicine, Jacksonville, Florida
| | | | | | - Steven J. Buskirk
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Laura A. Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Katherine S. Tzou
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Stephen J. Ko
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Heather A. Biers
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Atiya B. Day
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Kimberly A. Nelson
- Division of Hematology/Oncology/Cancer Center/Breast Clinic, Mayo Clinic, Jacksonville, Florida
| | - Jeff A. Sloan
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Michele Y. Halyard
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Robert C. Miller
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
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Gamez ME, Halyard MY, Hinni ML, Hayden RE, Nagel TH, Vargas CE, Wong WW, Curtis KK, Zarka MA, Ma D, Patel SH. Mucosal Sparing Radiation Therapy in Resected Oropharyngeal Cancer. Ann Otol Rhinol Laryngol 2017; 126:185-191. [PMID: 28056518 DOI: 10.1177/0003489416681580] [Citation(s) in RCA: 8] [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: 11/16/2022]
Abstract
PURPOSE To report the outcomes of patients with favorable risk oropharyngeal cancer that underwent adjuvant radiation therapy with omission of the primary site from the clinical target volume (CTV). MATERIAL/METHODS A retrospective study of 40 patients treated with transoral surgery (TOS) followed by neck only radiation using intensity modulated radiation therapy (IMRT) with exclusion of the primary site. For all patients, a CTV of the primary surgical bed was contoured to obtain the estimated incidental dose to the primary site. RESULTS Median follow-up was 51 months (range, 13-155 months). The median radiation therapy (RT) dose to the neck was 6000 cGy (range, 5400-6400 cGy). The mean incidental dose to the primary tonsillar site was 4320 cGy (SD ± 480 cGy) and to the primary base of tongue site was 4060 cGy (SD ± 420 cGy). There were no local failures and only 1 regional failure, resulting in 97.5% locoregional control rate at 4 years. Two patients developed distant metastases, without evidence of locoregional recurrence, for a 4-year overall survival rate of 97%. CONCLUSIONS Our analysis suggests that mucosal sparing RT after TOS in favorable risk oropharyngeal cancer patients may provide comparable oncologic and improved functional outcomes compared to conventional treatment in selected patients.
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Affiliation(s)
- Mauricio E Gamez
- 1 Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Michael L Hinni
- 2 Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona
| | | | - Thomas H Nagel
- 2 Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona
| | - Carlos E Vargas
- 1 Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - William W Wong
- 1 Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Kelly K Curtis
- 3 Division of Hematology/Medical Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Matthew A Zarka
- 4 Department of Medicine-Pathology, Mayo Clinic, Scottsdale, Arizona
| | - Daniel Ma
- 5 Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Samir H Patel
- 1 Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Chang JM, Kosiorek HE, Dueck AC, Casey WJ, Rebecca AM, Mahabir R, Patel SH, Keole SR, Wong WW, Vargas CE, Halyard MY, Gray RJ, Wasif N, Stucky CCH, Pockaj BA. Trends in mastectomy and reconstruction for breast cancer; a twelve year experience from a tertiary care center. Am J Surg 2016; 212:1201-1210. [DOI: 10.1016/j.amjsurg.2016.08.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 08/23/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
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25
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Liu W, Patel SH, Shen JJ, Hu Y, Harrington DP, Ding X, Halyard MY, Schild SE, Wong WW, Ezzell GA, Bues M. Robustness quantification methods comparison in volumetric modulated arc therapy to treat head and neck cancer. Pract Radiat Oncol 2016; 6:e269-e275. [PMID: 27025166 DOI: 10.1016/j.prro.2016.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/13/2016] [Accepted: 02/10/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND To compare plan robustness of volumetric modulated arc therapy (VMAT) with intensity modulated radiation therapy (IMRT) and to compare the effectiveness of 3 plan robustness quantification methods. METHODS AND MATERIALS The VMAT and IMRT plans were created for 9 head and neck cancer patients. For each plan, 6 new perturbed dose distributions were computed using ±3 mm setup deviations along each of the 3 orientations. Worst-case analysis (WCA), dose-volume histogram (DVH) band (DVHB), and root-mean-square dose-volume histogram (RVH) were used to quantify plan robustness. In WCA, a shaded area in the DVH plot bounded by the DVHs from the lowest and highest dose per voxel was displayed. In DVHB, we displayed the envelope of all DVHs in band graphs of all the 7 dose distributions. The RVH represents the relative volume on the vertical axis and the root-mean-square-dose on the horizontal axis. The width from the first 2 methods at different target DVH indices (such as D95% and D5%) and the area under the RVH curve for the target were used to indicate plan robustness. Results were compared using Wilcoxon signed-rank test. RESULTS The DVHB showed that the width at D95% of IMRT was larger than that of VMAT (unit Gy) (1.59 vs 1.18) and the width at D5% of IMRT was comparable to that of VMAT (0.59 vs 0.54). The WCA showed similar results between IMRT and VMAT plans (D95%: 3.28 vs 3.00; D5%: 1.68 vs 1.95). The RVH showed the area under the RVH curve of IMRT was comparable to that of VMAT (1.13 vs 1.15). No statistical significance was found in plan robustness between IMRT and VMAT. CONCLUSIONS The VMAT is comparable to IMRT in terms of plan robustness. For the 3 quantification methods, WCA and DVHB are DVH parameter-dependent, whereas RVH captures the overall effect of uncertainties.
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Affiliation(s)
- Wei Liu
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona.
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Jiajian Jason Shen
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | | | - Xiaoning Ding
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Gary A Ezzell
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
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26
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Kaufman SA, Harris EER, Bailey L, Chadha M, Dutton SC, Freedman GM, Goyal S, Halyard MY, Horst KC, Novick KLM, Park CC, Suh WW, Toppmeyer D, Zook J, Haffty BG. ACR Appropriateness Criteria® Ductal Carcinoma in Situ. Oncology (Williston Park) 2015; 29:446-461. [PMID: 26089220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Ductal carcinoma in situ (DCIS) is a breast neoplasm with potential for progression to invasive cancer. Management commonly involves excision, radiotherapy, and hormonal therapy. Surgical assessment of regional lymph nodes is rarely indicated except in cases of microinvasion or mastectomy. Radiotherapy is employed for local control in breast conservation, although it may be omitted for select low-risk situations. Several radiotherapy techniques exist beyond standard whole-breast irradiation (ie, partial-breast irradiation [PBI], hypofractionated whole-breast radiation); evidence for these is evolving. We present an update of the American College of Radiology (ACR) Appropriateness Criteria® for the management of DCIS. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions, which are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review includes an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi technique) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Curtis KK, Ross HJ, Garrett AL, Jizba TA, Kosiorek H, Patel SH, Wong W, Halyard MY, Foote RL. Outcomes of head and neck squamous cell carcinomas (HNSCC) treated with reirradiation (RRT) at Mayo Clinic. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.6064] [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] [Indexed: 11/20/2022] Open
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Abstract
Breast cancer is a common and complex disease often necessitating multimodality care. Breast cancer may be treated with surgical resection, radiotherapy (RT), and systemic therapy, including chemotherapy, hormonal therapy, and targeted therapies, or a combination thereof. In the past 50 years, RT has played an increasingly significant role in the treatment of breast cancer, resulting in improvements in locoregional control and survival for women undergoing mastectomy who are at high risk of recurrence, and allowing for breast conservation in certain settings. Although radiation provides significant benefit to many women with breast cancer, it is also associated with risks of toxicity, including cardiac and pulmonary toxicity, lymphedema, and secondary malignancy. RT techniques have advanced and continue to evolve dramatically, offering increased precision and reproducibility of treatment delivery and flexibility of treatment schedule. This increased sophistication of RT offers promise of improved outcomes by maintaining or improving efficacy, reducing toxicity, and increasing patient access and convenience. A review of the role of radiation therapy in breast cancer, its associated toxicities and efforts in toxicity reduction is presented.
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Affiliation(s)
- Lindsay C Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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Patel SH, Hayden RE, Hinni ML, Wong WW, Foote RL, Milani S, Wu Q, Ko SJ, Halyard MY. Angiosarcoma of the Scalp and Face. JAMA Otolaryngol Head Neck Surg 2015; 141:335-40. [DOI: 10.1001/jamaoto.2014.3584] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Samir H. Patel
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Richard E. Hayden
- Department of Otolaryngology–Head and Neck Surgery/Audiology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Michael L. Hinni
- Department of Otolaryngology–Head and Neck Surgery/Audiology, Mayo Clinic Hospital, Phoenix, Arizona
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Robert L. Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Shadi Milani
- medical student at Midwestern University, Phoenix, Arizona
| | - Qing Wu
- Division of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Stephen J. Ko
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
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Patel SH, Munson ND, Grant DG, Buskirk SJ, Hinni ML, Perry WC, Foote RL, McNeil RB, Halyard MY. Relapse patterns after transoral laser microsurgery and postoperative irradiation for squamous cell carcinomas of the tonsil and tongue base. Ann Otol Rhinol Laryngol 2014; 123:32-9. [PMID: 24574421 DOI: 10.1177/0003489414521383] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES We evaluated relapse patterns after transoral laser microsurgery (TLM) in squamous cell carcinoma (SCC) of the tonsil and tongue base and evaluated the indications for adjuvant irradiation. METHODS Between December 1, 1996, and December 31, 2005, 79 patients with previously untreated SCC of the tonsil or tongue base underwent TLM with or without neck dissection. Thirty-eight patients (48%) underwent postoperative irradiation (median, 62 Gy) to the primary site and the neck. Analysis of relapse patterns was performed on the basis of adverse risk factors and the presence or absence of adjuvant irradiation. RESULTS The median follow-up for living patients was 47 months (range, 10 to 107 months), and patients were monitored for at least 2 years or until recurrence or death. Local, regional, and distant treatment failures numbered 4, 6, and 4 for surgery alone (n = 41) and 0, 2, and 6 for adjuvant irradiation (n = 38), respectively. Patients with high-risk features (extracapsular extension or at least 2 adverse factors) had locoregional control rates at 2 or more years of 66% and 94% for TLM alone and TLM plus adjuvant irradiation, respectively. CONCLUSIONS Adjuvant irradiation after TLM resection of oropharyngeal SCC with intermediate- or high-risk features improves locoregional control compared with TLM alone.
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Affiliation(s)
- Samir H Patel
- Departments of Radiation Oncology (Patel, Halyard), Mayo Clinic, Scottsdale, Arizona
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Brewer LC, Hayes SN, Parker MW, Balls-Berry JE, Halyard MY, Pinn VW, Radecki Breitkopf C. African American women's perceptions and attitudes regarding participation in medical research: the Mayo Clinic/The Links, Incorporated partnership. J Womens Health (Larchmt) 2014; 23:681-7. [PMID: 25046058 PMCID: PMC4129970 DOI: 10.1089/jwh.2014.4751] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [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] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To examine perceptions and attitudes toward health-related research participation among professional African American women. METHODS Participants were members of an African American women's service organization, The Links, Incorporated. Data were collected via self-administered questionnaires at The Links, Incorporated 2012 National Assembly. Sociodemographics, prior research experience, intention to participate (ITP), willingness to participate (WTP) in a variety of research studies and attitudes about research participation were measured. RESULTS A total of 381 surveys were analyzed. A majority of respondents were married (66%), employed (69%), and college educated (96%). Median age was 59; 38% reported prior research participation. Overall, 78% agreed with the statement, "Participation in research will mean better care," 24% agreed "Participation in research is risky" and 3% agreed "Scientists cannot be trusted." Fifty-two percent agreed with the statement, "Research conducted in the U.S. is ethical." Mean ITP in research was 4.9±1.7 on a rating scale of 1 ("definitely no") to 7 ("definitely yes"). WTP was highest for an interview study and providing a blood sample, and lowest for clinical trial and medical record review. CONCLUSION Attitudes toward research participation were generally favorable among professional African American women; many expressed WTP in a variety of research study types.
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Affiliation(s)
- LaPrincess C. Brewer
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Sharonne N. Hayes
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Monica W. Parker
- Division of Geriatrics, Emory University, Atlanta, Georgia
- The Links, Incorporated, Washington, District of Columbia
| | - Joyce E. Balls-Berry
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, Minnesota
| | - Michele Y. Halyard
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona
- The Links, Incorporated, Washington, District of Columbia
| | - Vivian W. Pinn
- The Links, Incorporated, Washington, District of Columbia
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Halyard MY. From out of the desert blooms a jewel of the southwest: a commentary on the history of Mayo Clinic in Arizona. Mayo Clin Proc 2014; 89:873-7. [PMID: 24996232 DOI: 10.1016/j.mayocp.2014.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
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33
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Dueck AC, Hillman DW, Kottschade LA, Halyard MY, Sloan JA, Flickinger LM, Wolff AC, Harris L, Gralow J, Pritchard KI, Ellard S, Le-Lindqwister N, Boyle FM, De Azambuja E, McCaskill-Stevens WJ, Zujewski JA, Piccart-Gebhart MJ, Perez EA. Quality of life (QOL) among patients (pts) with HER2+ breast cancer (bc) treated with adjuvant lapatinib and/or trastuzumab in the ALTTO study (BIG 2-06, Alliance N063D). J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Antonio C. Wolff
- The Johns Hopkins Hospital and The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | | | | | - Susan Ellard
- British Columbia Cancer Agency (Centre for the Southern Interior), Kelowna, BC, Canada
| | | | - Frances M. Boyle
- Patricial Rigchie Centre for Cancer Care and Research, North Sydney NSW, Australia
| | - Evandro De Azambuja
- Institut Jules Bordet, Brussels, Université Libre de Bruxelles, Brussels, Belgium
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Peters DE, Casale SA, Halyard MY, Frey KA, Bunkers BE, Caubet SL. The evolution of leadership: a perspective from Mayo Clinic. Physician Exec 2014; 40:24-32. [PMID: 24964546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Eton DT, Beebe TJ, Hagen PT, Halyard MY, Montori VM, Naessens JM, Sloan JA, Thompson CA, Wood DL. Harmonizing and consolidating the measurement of patient-reported information at health care institutions: a position statement of the Mayo Clinic. Patient Relat Outcome Meas 2014; 5:7-15. [PMID: 24550683 PMCID: PMC3926456 DOI: 10.2147/prom.s55069] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Patient-reported outcomes (PROs) capture how patients perceive their health and their health care; their use in clinical research is longstanding. Today, however, PROs increasingly are being used to inform the care of individual patients, and document the performance of health care entities. We recently wrote and internally distributed an institutional position statement titled “Harmonizing and Consolidating the Measurement of Patient-Reported Outcomes at Mayo Clinic: A Position Statement for the Center for the Science of Health Care Delivery”. The statement is meant to educate clinicians, clinical teams, and institutional administrators about the merits of using PROs in a systematic manner for clinical care and quality measurement throughout the institution. The present article summarizes the most important messages from the statement, describing PROs and their use, identifying practical considerations for implementing them in routine practice, elucidating potential barriers to their use, and formulating strategies to overcome these barriers. The lessons learned from our experience – including pitfalls, challenges, and successes – may inform other health care institutions that are interested in systematically using PROs in health care delivery science and practice.
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Affiliation(s)
- David T Eton
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Timothy J Beebe
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Philip T Hagen
- Department of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Victor M Montori
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Knowledge and Evaluation Research Unit, Rochester, MN, USA
| | - James M Naessens
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Jeff A Sloan
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Rochester, MN, USA
| | | | - Douglas L Wood
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Center for Innovation, Mayo Clinic, Rochester, MN, USA
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Halyard MY, Harris EER, Bailey L, Bellon JR, Freedman GM, Goyal S, Horst KC, Moran MS, Park CC, Suh WW, Toppmeyer D, Haffty BG. ACR Appropriateness Criteria local-regional recurrence (LRR) and salvage surgery-breast cancer. Oncology (Williston Park) 2014; 28:157-C3. [PMID: 24701707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Although both breast-conserving surgery and mastectomy generally provide excellent local-regional control of breast cancer, local-regional recurrence (LRR) does occur. Predictors for LRR include patient, tumor, and treatment-related factors. Salvage after LRR includes coordination of available modalities, including surgery, radiation, chemotherapy, and hormonal therapy, depending on the clinical scenario. Management recommendations for breast cancer LRR, including patient scenarios, are reviewed, and represent evidence-based data and expert opinion of the American College of Radiology Appropriateness Criteria Expert Panel on LRR.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel.The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Tondato F, Ng DW, Srivathsan K, Altemose GT, Halyard MY, Scott LR. Radiotherapy-induced pacemaker and implantable cardioverter defibrillator malfunction. Expert Rev Med Devices 2014; 6:243-9. [DOI: 10.1586/erd.09.7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wong WW, Pockaj BA, Vora SA, Halyard MY, Gray RJ, Schild SE. Six-year outcome of a prospective study evaluating tumor bed boost with intra-operative electron irradiation followed by whole-breast irradiation for early-stage breast cancer. Breast J 2013; 20:125-30. [PMID: 24372873 DOI: 10.1111/tbj.12235] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A prospective study was performed for patients with early-stage breast cancer in which a single fraction of intraoperative electron irradiation (IOERT) was given to the tumor bed, followed by conventional fractionated whole-breast irradiation (WBRT). Patients with T1/T2N0 breast cancer underwent lumpectomy and sentinel lymph node biopsy. A tumor bed boost of 10 Gy of IOERT using 6-12 MeV electrons was administered by a dedicated mobile linear accelerator in the operating room. After adequate wound healing, 48 Gy WBRT was given to the whole breast in 24 fractions. Fifty-two patients were enrolled between February 2003 and January 2005. At a median follow-up of 79 months, there were two local relapses. The 6-year actuarial overall survival and distant control rates were 89% and 96%, respectively. At last follow-up, cosmesis was graded as excellent or good in 45 (87%), fair in five (10%), and poor in two patients (4%), respectively. Difficulty in wound healing occurred in two patients who had additional surgery later. One patient developed significant fibrosis after aspiration of a symptomatic seroma. The result of this pilot study shows the feasibility of using IOERT as the tumor bed boost in lieu of 6-8 days of standard electron beam treatment with good local control and cosmetic results. However, late surgical intervention of the lumpectomy bed may result in more pronounced tissue fibrosis and wound healing difficulty.
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Affiliation(s)
- William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
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Patel SH, Hinni ML, Hayden RE, Wong WW, Dueck AC, Zarka MA, Curtis KK, Halyard MY. Transoral laser microsurgery followed by radiation therapy for oropharyngeal tumors: the Mayo Clinic Arizona experience. Head Neck 2013; 36:220-5. [PMID: 23529906 DOI: 10.1002/hed.23279] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to report the treatment outcomes of patients with advanced oropharyngeal cancer treated with transoral laser microsurgery (TLM) followed by radiation therapy (RT) at Mayo Clinic in Arizona. METHODS A retrospective study of 80 patients treated from January 1, 2000 to November 7, 2011 was performed. All patients had stage III/IV oropharyngeal tumors and underwent TLM with neck dissection. Adjuvant RT was then given. Thirty-seven patients received concurrent adjuvant chemotherapy. The primary outcome was locoregional control. RESULTS Median follow-up was 47.3 months (range, 9.7-139.2 months). The 3-year locoregional control, recurrence-free survival, and overall survival rates were 98.6% (95% confidence interval [CI], 91% to 100%), 91.1% (95% CI, 81% to 96%), and 93.7% (95% CI, 84% to 98%), respectively. There were a total of 5 treatment failures, 1 regional and 4 distant. Twenty-six patients underwent neck only RT with exclusion of the primary site. CONCLUSION TLM followed by RT for advanced oropharyngeal cancer results in excellent locoregional control rates.
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Affiliation(s)
- Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona
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Tarantola TI, Vallow LA, Halyard MY, Weenig RH, Warschaw KE, Grotz TE, Jakub JW, Roenigk RK, Brewer JD, Weaver AL, Otley CC. Prognostic factors in Merkel cell carcinoma: analysis of 240 cases. J Am Acad Dermatol 2012. [PMID: 23200197 DOI: 10.1016/j.jaad.2012.09.036] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Knowledge regarding behavior of and prognostic factors for Merkel cell carcinoma (MCC) is limited. OBJECTIVE We sought to further understand the characteristics, behavior, prognostic factors, and optimal treatment of MCC. METHODS A multicenter, retrospective, consecutive study of patients with known primary MCC was completed. Overall survival and survival free of locoregional recurrence were calculated and statistical analysis of characteristics and outcomes was performed. RESULTS Among the 240 patients, the mean age at diagnosis was 70.1 years, 168 (70.0%) were male, and the majority was Caucasian. The most common location was head and neck (111, 46.3%). Immunosuppressed patients had significantly worse survival, with an overall 3-year survival of 43.4% compared with 68.1% in immunocompetent patients. In our study, patients with stage II disease had improved overall survival versus those with stage I disease, in a statistically significant manner. Patients with stage III disease had significantly worse survival compared with stage I and with stage II. Primary tumor size did not predict nodal involvement. CONCLUSION The data presented represent one of the largest series of primary MCC in the literature and confirm that MCC of all sizes has metastatic potential, supporting sentinel lymph node biopsy for all primary MCC. Because of the unpredictable natural history of MCC, we recommend individualization of care based on the details of each patient's tumor and clinical presentation.
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Affiliation(s)
- Tina I Tarantola
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA.
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Tarantola TI, Vallow LA, Halyard MY, Weenig RH, Warschaw KE, Weaver AL, Roenigk RK, Brewer JD, Otley CC. Unknown primary Merkel cell carcinoma: 23 new cases and a review. J Am Acad Dermatol 2012. [PMID: 23182060 DOI: 10.1016/j.jaad.2012.07.035] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Knowledge is limited regarding unknown primary Merkel cell carcinoma (UPMCC). OBJECTIVE We sought to document the characteristics and behavior of UPMCC, and determine the most appropriate treatment. METHODS A multicenter, retrospective, consecutive study reviewing patients given a diagnosis of UPMCC between 1981 and 2008 was completed. In addition, a literature review of cases of UPMCC was performed. RESULTS In all, 23 patients with UPMCC are described and 34 cases from previous reports are compiled. Among the 23 new cases of UPMCC, the average age at diagnosis was 66.0 years; the majority of patients were male (87%) and Caucasian (100% of those reported). One patient was immunosuppressed, and 39% had a history of other cancer. After the initial biopsy, 16 patients had further evaluation of the involved lymph node basin. Half of these had additional positive nodes (8 of 16). The majority of patients had lymph node basin involvement only (78%), whereas 22% had lymph node basin and distant metastasis. The most common lymph node basin involved was inguinal. The median size of the involved lymph node at diagnosis was 5.0 cm. At 2 years, the overall survival of stage IIIB UPMCC was significantly improved versus stage IIIB known primary Merkel cell carcinoma (MCC): 76.9% to 36.4%. LIMITATIONS Limited number of cases and retrospective review are limitations. CONCLUSION Our data demonstrate improved overall survival in patients with stage IIIB UPMCC versus those with stage IIIB known primary MCC. Because of the unpredictable natural history of UPMCC, we recommend individualization of care based on the details of each patient's clinical presentation.
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Affiliation(s)
- Tina I Tarantola
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA.
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Atherton PJ, Halyard MY, Sloan JA, Miller RC, Deming RL, Tai THP, Stien KJ, Martenson JA. Assessment of patient-reported measures of bowel function before and after pelvic radiotherapy: an ancillary study of the North Central Cancer Treatment Group study N00CA. Support Care Cancer 2012; 21:1193-9. [PMID: 23151649 DOI: 10.1007/s00520-012-1648-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [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: 06/22/2012] [Accepted: 10/30/2012] [Indexed: 01/08/2023]
Abstract
PURPOSE The Bowel Function Questionnaire (BFQ) has been used in clinical trials to assess symptoms during and after pelvic radiotherapy (RT). This study evaluated the importance of symptoms in the BFQ from a patient perspective. METHODS Patients reported presence or absence of symptoms and rated importance of symptoms at baseline, 4 weeks after completion of pelvic RT, and 12 and 24 months after RT. The BFQ measured overall quality of life (QOL) and symptoms of nocturnal bowel movements, incontinence, clustering, need for protective clothing, inability to differentiate stool from gas, liquid bowel movements, urgency, cramping, and bleeding. Bowel movement frequency also was recorded. A content validity questionnaire (CVQ) was used to rate symptoms as "not very important," "moderately unimportant," "neutral," "moderately important," or "very important." RESULTS Most of the 125 participating patients rated all symptoms as moderately or very important. Generally, patients gave similar ratings for symptom importance at all study points, and ratings were independent of whether the patient experienced the symptom. Measures of greatest importance (moderately or very important) at baseline were ability to control bowel movements (94 %), not having to wear protective clothing (90 %), and not having rectal bleeding (94 %). With the exception of need for protective clothing, the presence of a symptom at 4 weeks was associated with significantly worse QOL (P < .01 for all). CONCLUSIONS The BFQ has excellent content validity. Patients rated most symptoms as moderately or very important, indicating the BFQ is an appropriate tool for symptom assessment during and after pelvic RT.
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Affiliation(s)
- Pamela J Atherton
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
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Halyard MY, Tan AD, Atherton PJ, Wong W, Schild SE, Vora SA, Ashman J, Callister M, Ciafone D, Zimmerman P, Phillips P, Mortarotti J, Kruse J, Luna H, Olson J, Burris P, Young B, Dueck AC, Sloan JA. Assessing the clinical significance of real-time quality of life data in cancer patients treated with radiation therapy. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.6108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6108 Background: This pilot study evaluated whether providing clinicians with patient(pt) QOL results and symptom management pathways linked to QOL domains at the time of clinical appointment would result in improvement in QOL and treatment (tx) satisfaction. The objective was to obtain preliminary effect size estimates and logistical evidence for design of a larger, definitive trial. Methods: Oncology pts receiving 5-7 weeks of radiotherapy (RT) electronically completed QOL assessments (LASA) at baseline and biweekly prior to seeing clinicians. Was It Worth It (WIWI) and Interpersonal Patient-Provider Relationship (IPPRS) were measured at tx end. Pt endpoints (pro-rated primary endpoint LASA area under the curve (AUC), LASA changes from baseline, and WIWI responses) and clinician endpoints (IPPRS) were compared between the control group (Phase 1: no QOL feedback) and the intervention group (Phase 2: QOL feedback) via Wilcoxon, Chi-square and Fisher Exact tests. There was 80% power to detect a 10 point difference in average AUC. Results: 148 pts enrolled (79 Phase 1, 69 Phase 2) from 11/28/2008 to 09/20/2011 (sites GI (27%), Lung (22%) and Head and Neck (52%)). 68% received RT and chemo. There were consistently moderate effect sizes observed but no statistically significant differences in any AUC nor end of tx change from baseline scores. 20% fewer pts in phase 2 reported clinical deficits in overall QOL (pain). In pts receiving 7 weeks of RT, end of tx average overall QOL, mental well-being (WB), physical WB and pain severity were significantly better in Phase 2 pts. WIWI results showed 76% found participation worthwhile, 95% would participate again, and 92% would recommend the study to others. No differences between groups were found in communication between clinicians and pts (IPPRS). Conclusions: Preliminary estimates indicate potentially clinically significant improvements of moderate effect size in mental and physical WB and pain severity when clinicians received QOL real time with symptom management pathways. Further study is warranted in larger trial setting.
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Atherton PJ, Halyard MY, Sloan JA, Miller RC, Deming RL, Tai THP, Stien KJ, Martenson JA. Patient assessment of measures of bowel function during and after pelvic radiation therapy: An ancillary study of North Central Cancer Treatment Group study N00CA. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.e16572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16572 Background: The Bowel Function Questionnaire (BFQ) has been used in clinical trials to document patient-reported symptoms following pelvic radiation therapy (RT). This study evaluated the importance patients placed on the symptoms included in the BFQ as measured by a Content Validity Questionnaire (CVQ). Methods: Patients treated with pelvic RT assessed symptoms and importance at baseline, after completion of RT (4 weeks), and 12 and 24 months. BFQ measured quality of life (QOL) and symptoms of: nocturnal bowel movements, incontinence, greater than one bowel movement in 30 minutes, need for protective clothing, inability to differentiate stool and gas, liquid bowel movements, urgency, cramping, and bleeding. Bowel movement frequency was also assessed. Symptoms were rated via the CVQ as “not very important,” “moderately unimportant,” “neutral,” “moderately important,” or “very important." Summary statistics were compiled. Fisher Exact, Chi-Square and Wilcoxon methodology compared BFQ and CVQ results. Results: 125 patients participated. All symptoms were rated as moderately important or very important by most patients.Measures of bowel function of greatest importance (moderately or very important) at baseline were ability to control bowel movements (94%), not having to wear protective clothing (90%), and not having rectal bleeding (93%). In general, patients gave similar ratings of symptom importance at all time points in the study and ratings were independent of whether the symptom was experienced. With the exception of the need for protective clothing, the presence of a symptom at 4 weeks was associated with significantly worse QOL (p-values < 0.001 to 0.005). Conclusions: The BFQ has excellent content validity. Patients rated most symptoms measured by the BFQ as moderately important or very important, indicating the BFQ is an appropriate tool for symptom assessment during and after pelvic RT. With the exception of the need for protective clothing, the presence of every symptom measured by the BFQ was associated with worse QOL. These criteria make them appropriate targets for future research to mitigate radiation-related bowel dysfunction.
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Halyard MY. The use of real-time patient-reported outcomes and quality-of-life data in oncology clinical practice. Expert Rev Pharmacoecon Outcomes Res 2012; 11:561-70. [PMID: 21958101 DOI: 10.1586/erp.11.62] [Citation(s) in RCA: 16] [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] [Indexed: 11/08/2022]
Abstract
The collection of patient-reported outcome (PRO) data such as quality of life (QoL) has provided important information in clinical trials. Increasingly, researchers are evaluating the use of this type of data in the clinical setting. The benefits of PRO/QoL data collection, methods for collecting data and the use of the data by clinicians are increasingly being studied. This article will address the issues and benefits of QoL and other PRO data collection within oncology clinical practice.
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Affiliation(s)
- Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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Moran MS, Bai HX, Harris EER, Arthur DW, Bailey L, Bellon JR, Carey L, Goyal S, Halyard MY, Horst KC, MacDonald SM, Haffty BG. ACR appropriateness criteria(®) ductal carcinoma in situ. Breast J 2011; 18:8-15. [PMID: 22107336 DOI: 10.1111/j.1524-4741.2011.01197.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ductal carcinoma in situ (DCIS) describes a wide spectrum of non-invasive tumors which carry a significant risk of invasive relapse, thus prevention of local recurrence is vital. For appropriate patients with limited disease, management with breast conserving surgery (BCS) followed by whole-breast radiation (RT) is supported by multiple Phase III studies, but mastectomy may be appropriate in selected patients. Omission of RT may also be reasonable in some patients, though which criteria are to be utilized remain unclear, and the existing data are contradictory with limited follow-up. Various RT techniques such as boost to the tumor bed, partial breast radiation or hypofractionated, whole-breast RT are increasingly utilized but the data to support their use specifically in DCIS is limited. Tamoxifen also increases local control for ER + DCIS, adding to the complexity of the local treatment management. This article reviews the existing scientific evidence, the controversies surrounding local management, and clinical guidelines for DCIS based on the group consensus by the ACR Breast Expert Panel. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Snyder CF, Aaronson NK, Choucair AK, Elliott TE, Greenhalgh J, Halyard MY, Hess R, Miller DM, Reeve BB, Santana M. Implementing patient-reported outcomes assessment in clinical practice: a review of the options and considerations. Qual Life Res 2011; 21:1305-14. [PMID: 22048932 DOI: 10.1007/s11136-011-0054-x] [Citation(s) in RCA: 499] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2011] [Indexed: 11/27/2022]
Affiliation(s)
- Claire F Snyder
- Johns Hopkins School of Medicine, 624 N. Broadway, Room 657, Baltimore, MD 21205, USA.
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MacDonald SM, Harris EER, Arthur DW, Bailey L, Bellon JR, Carey L, Goyal S, Halyard MY, Moran MS, Horst KC, Haffty BG. ACR Appropriateness Criteria® Locally Advanced Breast Cancer. Breast J 2011; 17:579-85. [DOI: 10.1111/j.1524-4741.2011.01150.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bellon JR, Harris EER, Arthur DW, Bailey L, Carey L, Goyal S, Halyard MY, Horst KC, Moran MS, MacDonald SM, Haffty BG. ACR Appropriateness Criteria® conservative surgery and radiation--stage I and II breast carcinoma: expert panel on radiation oncology: breast. Breast J 2011; 17:448-55. [PMID: 21790842 DOI: 10.1111/j.1524-4741.2011.01132.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Breast conservation is a safe and effective alternative to mastectomy for the majority of women with early-stage breast cancer. Adjuvant radiation therapy lowers the risk of recurrence within the breast and also confers a survival benefit. Although acute side effects of radiation therapy are generally well tolerated; efforts are ongoing to minimize the long-term side effects of radiation, most prominently atherosclerotic heart disease. Efforts to minimize radiation therapy are also underway. They include omitting treatment altogether in the elderly and using accelerated, hypofractionated whole-breast irradiation, and accelerated partial-breast irradiation. Several randomized studies are ongoing to determine the efficacy, safety, and appropriate patients for these shorter treatments.
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Affiliation(s)
- Jennifer R Bellon
- Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Halyard MY, Dueck AC, Pisansky TM, McLaughlin SA, Pierce LJ, Marks LB, Solin LJ, Pockaj BA, Perez EA. Abstract P5-13-02: Impact of Adjuvant Trastuzumab on Local Regional Recurrence: Data from the NCCTG N9831 Study. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p5-13-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Trastuzumab (H) improves disease-free survival (DFS) in patients (pts) with HER2 positive breast cancer (BR Ca) when used with adjuvant chemotherapy. We herein compare the rates of local regional recurrence (LRR) in pts randomized to adjuvant chemotherapy with or without adjuvant H.
Methods: The phase 3 randomized trial NCCTG N9831 enrolled 3505 pts with high risk HER2 positive Br Ca to evaluate the effect of adjuvant H on DFS. Pts were randomized to either doxorubicin (A) and cyclophosphamide (C) followed by paclitaxel (T); or AC→TH→H. RT was given concurrently with H after ACT chemotherapy. Pts analyzed underwent lumpectomy (L) + radiotherapy (RT), mastectomy (M) alone, or M+RT. All pts underwent sentinel lymph node biopsy alone and/or axillary dissection. 2816 pts were eligible for competing risk analysis of LRR as a first event (competing risks were distant recurrence, contralateral Br Ca, second primary cancer, or death). Median follow-up is 5.3 years.
Results: Primary breast therapy included L+RT 1062 (38%), M 711 (25%), and M+RT 1043 (37%). Axillary dissection was performed in 90% of pts but less frequently with L+RT (83%) compared to M (88%) or M+RT (98%), chi-sq P<0.001. Stage at presentation was I 41%, II 51%, and III 8% with a significant greater proportion of higher stage pts undergoing M+RT, chi-sq P<0.001. Overall the 5-year LRR rate was 4.1% (95% CI 3.5-4.9%) and similar among the treatment groups: L+RT 4.7% (95% CI 3.6-6.1%), M 3.5% (95% CI 2.4-5.1%), and M+RT 2.3% (95% CI 1.6-3.4%). Among pts with a LRR, 66% were local recurrence only, 11% were local-regional, and 23% were regional only. In the L+RT patients with a LRR, the corresponding rates were 74%, 7%, and 19%, respectively. In the M patients with a LRR, the corresponding rates were 40%, 23%, and 37%, respectively. In the M+RT patients with LRR, the rates were 79%, 4%, and 17%, respectively. H is associated with a non-statistically significant reduction in the risk of LRR for pts who receive L+RT or M+RT (Table 1). No such trend was seen in the M alone group but the number of events was low.
Table 1. LRR According to Local and Adjuvant Treatment Groups
Conclusion: The LRR as the first reported site of failure was low with a median 5. 3 year follow-up. Adjuvant H was associated with a trend of lower LRR in the pts treated with L + RT or M+RT. This observation suggests an additive effect of RT and H on LRR that warrants further investigation. The small number of local-regional events in this one randomized trial supports further investigation of LRR across other adjuvant trastuzumab trials.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-13-02.
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Affiliation(s)
- MY Halyard
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - AC Dueck
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - TM Pisansky
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - SA McLaughlin
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - LJ Pierce
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - LB Marks
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - LJ Solin
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - BA Pockaj
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
| | - EA. Perez
- Mayo Clinic, Scottsdale, Az; Mayo Clinic, Rochester, Mn; Mayo Clinic, Jacksonville, FL; University of Michigan, Ann Arbor; University of North Carolina Chapel Hill; Albert Einstein, Philadelphia, PA
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