Prophylaxis for Treatment-Induced Gynecomastia in Prostate Cancer Patients: A Network Meta-Analysis

PURPOSE/OBJECTIVE(S)

Treatment-induced gynecomastia is a side-effect that can severely limit quality of life in prostate cancer patients. We performed a network meta-analysis (NMA) to comparing the effectiveness of multiple non-surgical prophylactic treatment for gynecomastia.

MATERIALS/METHODS

A systematic review was performed through MEDLINE, Cochrane Central Register of Controlled Trials and meeting abstracts to identify randomized controlled trials comparing treatments for treatment-induced gynecomastia. Treatments included radiotherapy (RT), Anastrozole (ANZ), daily Tamoxifen (TMQD), and weekly Tamoxifen (TMQW), compared to no treatment/placebo (NoTx). The primary endpoint was events of gynecomastia development. Odds Ratio (OR) was the effect size of choice. An NMA was used to compare treatments with random-effects model was used. All tests were 2-sided with an alpha of 0.05.

RESULTS

A total of 9 studies involving 1319 patients were identified with 5 distinct arms: RT (n = 358), ANZ (n = 90), TMQD (n = 321), TMQW (n = 39) and NoTx (n = 511). Gynecomastia occurred in 79.2% (405/511) of patients with NoTx, 65.5% (59/90) with ANZ, 37.7% (135/358) with RT, 19.6% (63/321) with TMQD and 74.4% (29/39) with TMQW. TMQD was significantly better than RT (OR 4.73 [1.53, 14.61]), ANZ (OR 7.21 [2.25,23.06]), TMQW (OR 6.25 [1.07, 36.43]) and NoTx (OR 26.30 [10.42,66.40]). RT were significantly better than NoTx (OR 5.56 [2.58,11.95]), but did not reach significance compared to ANZ (OR 1.52 [0.36, 6.43]) or TMQW (OR 1.32 [0.16, 10.70]). ANZ was significantly better than NoTx (OR 3.65 [1.03,12.93]). TMQW was not significantly better than NoTx. RT, TMQW and ANZ were significantly worse compared to TMQD in terms of preventing gynecomastia development.

CONCLUSION

Daily Tamoxifen was the best prophylactic treatment choice, significantly better than RT, weekly Tamoxifen and Anastrozole. RT, weekly Tamoxifen and Anastrozole were significantly better than No Treatment/Placebo, but not daily Tamoxifen, in terms of prevention of treatment-induced gynecomastia in patients with prostate cancer.

Multidisciplinary Institutional Guidelines for Workflow Efficiency in Optimizing Patient Start Time

PURPOSE/OBJECTIVE(S)

Radiation Oncology is a field which is reliant on the intradisciplinary team and efficient completion of respected tasks. The purpose of this study was to analyze institutional workflow efficiency by comparing current practices to team-member expectations.

MATERIALS/METHODS

To measure workflow efficiency, the Aria database was queried to find sessions for treatment plans with a CT Sim image and a first treatment date between 2/23/2021 and 12/15/2022. The course, plan, prescription, image series, the associated "Provider Contouring" task, and the most recent consult appointment prior to the sim date were used to determine various workflow times using business days: (1) Consult to Sim, (2) Sim to Contour, (3) Contour to Plan, (4) Plan to Physics QA, (5) Physics QA to First Treatment. For these items, except for (3) Contour to Plan, the time points used to determine when a task was completed was based on timestamps of the actual work done rather than the associated task completion timestamp. For contouring, the completion timestamp was used. Additionally, for each treatment plan, a workflow category was assigned based on the prescription site and technique, the course and plan intents and IDs, and the activity code for the treatment associated with the session assigned to the plan. Regarding the objective analysis from the various personnel within the intradisciplinary team, an internal survey was conducted analyzing what each member of the intradisciplinary team deems as appropriate timing for task completion.

RESULTS

The mean time from simulation to treatment start for palliative treatment was 3.67 days (306 treatment plans). For definitive 3D and IMRT plans, the mean simulation to treatment time were 7.85 and 9.71 days, respectively (200 3D and 261 IMRT treatment plans). Mean time for lung SBRT plans were 11.98 days (65 plans). Survey analysis within the intradisciplinary team for appropriate timing of palliative treatments were as follows: Physicians: 5.88 days, Dosimetrists: 1.25 days, Radiation Therapists: 1.31 days, Nursing: 3.25 days. Survey analysis of definitive 3D and IMRT plans were as follows: Physicians: 10 and 10.5 days, Dosimetrists: 3 and 6 days, Radiation Therapists: 3.75 and 5.75 days, Nursing: 8.5 and 8.5 days, respectively. Survey analysis of lung SBRT simulation to treatment demonstrated: Physicians: 12.5 days, Dosimetrists: 6 days, Radiation Therapists: 6.75 days, Nursing: 9.25 days.

CONCLUSION

Analysis of our internal workflow demonstrates efficiency in total time from simulation to treatment across various modalities when compared to published data. Interestingly, when comparing our current workflow efficiency to team member expectations, there are discrepancies in the analysis of the definitive 3D and IMRT as well as lung SBRT. These variations may be due to the interdisciplinary team not having a complete understanding of the various workflow responsibilities of other team members.

Negative Predictive Value of NI-RADS Category 2 in the First Posttreatment FDG-PET/CT in Head and Neck Squamous Cell Carcinoma

BACKGROUND AND PURPOSE

FDG PET/CT has a high negative predictive value in patients with head and neck squamous cell carcinoma who responds completely to non-operative therapy. However, the treatment failure rate in patients with a partial but incomplete response is unclear. Our aim was to investigate the negative predictive value of the first posttreatment FDG-PET/CT in patients with head and neck squamous cell carcinoma with incomplete response interpreted as Neck Imaging Reporting and Data System (NI-RADS) category 2.

MATERIALS AND METHODS

We retrospectively identified patients with head and neck squamous cell carcinoma treated with chemoradiation or radiation therapy with curative intent in our institution between 2008 and 2016. We included patients whose first posttreatment FDG-PET/CT was interpreted as showing marked improvement of disease but who had a mild residual mass or FDG avidity in either the primary tumor bed or lymph nodes (NI-RADS 2). The negative predictive value of FDG-PET/CT was calculated, including the 95% CI, using the Newcombe method. Two-year disease-free survival was the reference standard.

RESULTS

Seventeen of 110 patients (15%) experienced locoregional treatment failure within 2 years of completing treatment, yielding a negative predictive value of 85% (95% Cl, 77%-90%). The most common location of tumor recurrence was the cervical lymph nodes (59%). The median time interval between completion of therapy and treatment failure was 10 months (range, 5-24 months).

CONCLUSIONS

In patients with an incomplete response after treatment of head and neck squamous cell carcinoma, the negative predictive value of the first posttreatment FDG-PET/CT was 85%, which is lower than the 91% negative predictive value of FDG-PET/CT in patients with an initial complete response. Patients with an incomplete response (NI-RADS 2) should undergo more frequent clinical and imaging surveillance than patients with an initial complete response (NI-RADS 1).

Phase II trial of post-operative radiotherapy with concurrent cisplatin plus panitumumab in patients with high-risk, resected head and neck cancer

BACKGROUND

Treatment intensification for resected, high-risk, head and neck squamous cell carcinoma (HNSCC) is an area of active investigation with novel adjuvant regimens under study. In this trial, the epidermal growth-factor receptor (EGFR) pathway was targeted using the IgG2 monoclonal antibody panitumumab in combination with cisplatin chemoradiotherapy (CRT) in high-risk, resected HNSCC.

PATIENTS AND METHODS

Eligible patients included resected pathologic stage III or IVA squamous cell carcinoma of the oral cavity, larynx, hypopharynx, or human-papillomavirus (HPV)-negative oropharynx, without gross residual tumor, featuring high-risk factors (margins <1 mm, extracapsular extension, perineural or angiolymphatic invasion, or ≥2 positive lymph nodes). Postoperative treatment consisted of standard RT (60-66 Gy over 6-7 weeks) concurrent with weekly cisplatin 30 mg/m² and weekly panitumumab 2.5 mg/kg. The primary endpoint was progression-free survival (PFS).

RESULTS

Forty-six patients were accrued; 44 were evaluable and were analyzed. The median follow-up for patients without recurrence was 49 months (range 12-90 months). The probability of 2-year PFS was 70% (95% CI = 58%-85%), and the probability of 2-year OS was 72% (95% CI = 60%-87%). Fourteen patients developed recurrent disease, and 13 (30%) of them died. An additional five patients died from causes other than HNSCC. Severe (grade 3 or higher) toxicities occurred in 14 patients (32%).

CONCLUSIONS

Intensification of adjuvant treatment adding panitumumab to cisplatin CRT is tolerable and demonstrates improved clinical outcome for high-risk, resected, HPV-negative HNSCC patients. Further targeted monoclonal antibody combinations are warranted.

REGISTERED CLINICAL TRIAL NUMBER

NCT00798655.

Phase II randomized trial of radiation therapy, cetuximab, and pemetrexed with or without bevacizumab in patients with locally advanced head and neck cancer

BACKGROUND

We previously reported the safety of concurrent cetuximab, an antibody against epidermal growth factor receptor (EGFR), pemetrexed, and radiation therapy (RT) in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). In this non-comparative phase II randomized trial, we evaluated this non-platinum combination with or without bevacizumab, an inhibitor of vascular endothelial growth factor (VEGF).

PATIENTS AND METHODS

Patients with previously untreated stage III-IVB SCCHN were randomized to receive: conventionally fractionated radiation (70 Gy), concurrent cetuximab, and concurrent pemetrexed (arm A); or the identical regimen plus concurrent bevacizumab followed by bevacizumab maintenance for 24 weeks (arm B). The primary end point was 2-year progression-free survival (PFS), with each arm compared with historical control. Exploratory analyses included the relationship of established prognostic factors to PFS and quality of life (QoL).

RESULTS

Seventy-eight patients were randomized: 66 oropharynx (42 HPV-positive, 15 HPV-negative, 9 unknown) and 12 larynx; 38 (49%) had heavy tobacco exposure. Two-year PFS was 79% [90% confidence interval (CI) 0.69-0.92; P < 0.0001] for arm A and 75% (90% CI 0.64-0.88; P < 0.0001) for arm B, both higher than historical control. No differences in PFS were observed for stage, tobacco history, HPV status, or type of center (community versus academic). A significantly increased rate of hemorrhage occurred in arm B. SCCHN-specific QoL declined acutely, with marked improvement but residual symptom burden 1 year post-treatment.

CONCLUSIONS

RT with a concurrent non-platinum regimen of cetuximab and pemetrexed is feasible in academic and community settings, demonstrating expected toxicities and promising efficacy. Adding bevacizumab increased toxicity without apparent improvement in efficacy, countering the hypothesis that dual EGFR-VEGF targeting would overcome radiation resistance, and enhance clinical benefit. Further development of cetuximab, pemetrexed, and RT will require additional prospective study in defined, high-risk populations where treatment intensification is justified.