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Cury FL, Viani GA, Gouveia AG, Moraes FY. In reply to Niu et al: Meta-analysis of 5-day preoperative radiotherapy for soft tissue sarcoma (5D-PREORTS). Radiother Oncol 2024; 195:110255. [PMID: 38522598 DOI: 10.1016/j.radonc.2024.110255] [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] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/21/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Fabio L Cury
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, McGill University, Montreal, Canada.
| | - Gustavo A Viani
- Ribeirao Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Andre G Gouveia
- Department of Oncology - Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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Gouveia AG, Viani GA, Bratti VF, Marta GN, Hanna SA, Jacinto AA, Silva MS, Hamamura AC, Rosa AA, Castilho MS, Carson L, Hopman WM, Sullivan R, Booth CM, Aggarwal A, Hanna TP, Moraes FY. Challenges in building radiotherapy capacity: A longitudinal study evaluating eight years of the Brazilian radiotherapy expansion plan. J Cancer Policy 2024; 39:100459. [PMID: 38029960 DOI: 10.1016/j.jcpo.2023.100459] [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: 04/05/2023] [Revised: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND In 2012, the Brazilian government launched a radiotherapy (RT) expansion plan (PER-SUS) to install 100 linear accelerators. This study assesses the development of this program after eight years. METHODS Official reports from the Ministry of Health (MoH) were reviewed. RT centres projects status, timeframes, and cost data (all converted to US dollars) were extracted. The time analysis was divided into seven phases, and for cost evaluation, there were five stages. The initial predicted project time (IPPT) and costs (estimated by the MoH) for each phase were compared between the 18 operational RT centres (able to treat patients) and 30 non-operational RT centres using t-tests, ANOVA, and the Mann-Whitney U. A p-value < 0.05 indicates statistical significance. RESULTS A significant delay was observed when comparing the IPPT with the overall time to conclude each 48 RT centres project (p < 0.001), with considerable delays in the first five phases (p < 0.001 for all). Moreover, the median time to conclude the first 18 operational RT centres (77.4 months) was shorter compared with the 30 non-operational RT centres (94.0 months), p < 0.001. The total cost of 48 RT services was USD 82,84 millions (mi) with a significant difference in the per project median total cost between 18 operational RT centres, USD1,34 mi and 30 non-operational RT centres USD2,11 mi, p < 0.001. All phases had a higher cost when comparing 30 non-operational RT centres to 18 operational RT centres, p < 0.001. The median total cost for expanding existing RT centres was USD1,30 mi versus USD2,18 mi for new RT services, p < 0.0001. CONCLUSION After eight years, the PER-SUS programs showed a substantial delay in most projects and their phases, with increased costs over time. POLICY SUMMARY Our findings indicate a need to act to increase the success of this plan. This study may provide a benchmark for other developing countries trying to expand RT capacity.
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Affiliation(s)
- Andre G Gouveia
- Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Gustavo A Viani
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Vanessa F Bratti
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Gustavo N Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology, Division of Radiation Oncology, Sírio Libanes Hospital, São Paulo, Brazil
| | - Samir A Hanna
- Department of Oncology, Division of Radiation Oncology, Sírio Libanes Hospital, São Paulo, Brazil
| | - Alexandre A Jacinto
- Radiation Oncology Department, Barretos Cancer Hospital, Barretos, SP, Brazil
| | - Mauricio S Silva
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Unit, Santa Maria Federal University, Santa Maria; and Clínica de Radioterapia de Santa Maria, Brazil
| | - Ana C Hamamura
- Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Arthur A Rosa
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiotherapy Department Oncoclinicas Salvador and Hospital Santa Izabel, Salvador, BA, Brazil
| | - Marcus S Castilho
- Radiotherapy Department of the Felicio Rocho Hospital, Belo Horizonte, MG, Brazil; President, Brazilian Radiotherapy Society - SBRT, Brazil
| | - Laura Carson
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Wilma M Hopman
- Kingston General Health Research Institute; Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Richard Sullivan
- Institute of Cancer Policy, Global Oncology Group, King's College London, London, UK
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Ajay Aggarwal
- Department of Oncology, Queen's University, Kingston, ON, Canada; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Timothy P Hanna
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada; Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Fabio Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
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Cury FL, Viani GA, Gouveia AG, Freire CVS, Grisi GDA, Moraes FY. Meta-analysis of 5-day preoperative radiotherapy for soft tissue sarcoma (5D-PREORTS). Radiother Oncol 2024; 190:109935. [PMID: 37884194 DOI: 10.1016/j.radonc.2023.109935] [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: 03/28/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND PURPOSE Although the role of conventionally fractionated radiotherapy (RT) in combination with surgery in the limb-sparing treatment of soft tissue sarcoma (STS) patients is well established, the effectiveness and safety of 5-day preoperative radiotherapy (RT) remain controversial. We performed a meta-analysis to evaluate the treatment outcomes of 5-day preoperative RT using ≥ 5 Gy per fraction with contemporary radiotherapy techniques. MATERIALS AND METHODS Medline, Embase, the Cochrane Library, and the proceedings of annual meetings through March 2022 were used to identify eligible studies. Following the PRISMA and MOOSE guidelines, a meta-regression analysis was performed to assess possible correlations between variables and outcomes. A p-value < 0.05 was considered significant. RESULTS Nine prospective studies with 786 patients (median follow-up 35 months, 20-60 months) treated with preoperative RT delivered a median total of 30 Gy (25-40 Gy) in 5 fractions. The local control (LC), R0 margins, overall survival (OS), and distant relapse (DR) rates were 92.3% (95% CI: 87---97%), 84.5% (95% CI: 78---90%), 78% (95% CI: 70---86%), and 36% (95% CI: 70---86%). The meta-regression analysis identified a significant relationship between biological equivalent dose (BED) and larger tumor size for LC and R0 margins (p < 0.05). The subgroup analysis reveals that patients receiving BED ≥ 90 (equivalent to 30 Gy in 5 fractions) had a higher LC control rate than BED < 90 (p < 0.0001). The complete pathologic response and amputation rates were 19% (95% CI: 13-26%) and 8.3% (95% CI: 0.5-15%). Amputation rates were higher in studies using the lowest and highest doses and were related to salvage surgery after recurrence and complications, respectively. The rate of wound complication and fibrosis grade 2 or worse was 30% (95% CI 23-38%) and 6.4% (95% CI 1.9-11%). CONCLUSION A 5-day course of preoperative RT results in high LC and favorable R0 margins, with acceptable complication rates in most studies. Better local control and R0 margins were associated with regimens using higher BED, i.e., doses equal to or higher than 30 Gy when using 5 fractions.
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Affiliation(s)
- Fabio L Cury
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, McGill University, Montreal, Canada.
| | - Gustavo A Viani
- Ribeirao Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil.
| | - Andre G Gouveia
- Department of Oncology - Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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Mamatjan Y, Voisin MR, Nassiri F, Moraes FY, Bunda S, So J, Salih M, Shirahata M, Ono T, Shimizu H, Schrimpf D, von Deimling A, Aldape KD, Zadeh G. Integrated molecular analysis reveals hypermethylation and overexpression of HOX genes to be poor prognosticators in isocitrate dehydrogenase mutant glioma. Neuro Oncol 2023; 25:2028-2041. [PMID: 37474126 PMCID: PMC10628942 DOI: 10.1093/neuonc/noad126] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Diffuse gliomas represent over 80% of malignant brain tumors ranging from low-grade to aggressive high-grade lesions. Within isocitrate dehydrogenase (IDH)-mutant gliomas, there is a high variability in survival and a need to more accurately predict outcome. METHODS To identify and characterize a predictive signature of outcome in gliomas, we utilized an integrative molecular analysis (using methylation, mRNA, copy number variation (CNV), and mutation data), analyzing a total of 729 IDH-mutant samples including a test set of 99 from University Health Network (UHN) and 2 validation cohorts including the German Cancer Research Center (DKFZ) and The Cancer Genome Atlas (TCGA). RESULTS Cox regression analysis of methylation data from the UHN cohort identified CpG-based signatures that split the glioma cohort into 2 prognostic groups strongly predicting survival that were validated using 2 independent cohorts from TCGA and DKFZ (all P-values < .0001). The methylation signatures that predicted poor outcomes also exhibited high CNV instability and hypermethylation of HOX gene probes. Integrated multi-platform analyses using mRNA and methylation (iRM) showed that parallel HOX gene overexpression and simultaneous hypermethylation were significantly associated with increased mutational load, high aneuploidy, and worse survival (P-value < .0001). A 7-HOX gene signature was developed and validated using the most significantly associated HOX genes with patient outcome in both 1p/19q codeleted and non-codeleted IDHmut gliomas. CONCLUSIONS HOX gene methylation and expression provide important prognostic information in IDH-mutant gliomas that are not captured by current molecular diagnostics. A 7-HOX gene signature of outcome shows significant survival differences in both 1p/19q codeleted and non-codeleted IDH-mutant gliomas.
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Affiliation(s)
- Yasin Mamatjan
- Princess Margaret Cancer Center and MacFeeters-Hamilton Center for Neuro-Oncology Research, University Health Network, Toronto, Ontario, Canada
- Faculty of Science, Thompson Rivers University, Kamloops, British Columbia, Canada
| | - Mathew R Voisin
- Princess Margaret Cancer Center and MacFeeters-Hamilton Center for Neuro-Oncology Research, University Health Network, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Princess Margaret Cancer Center and MacFeeters-Hamilton Center for Neuro-Oncology Research, University Health Network, Toronto, Ontario, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queens University, Kingston, Ontario, Canada
| | - Severa Bunda
- Princess Margaret Cancer Center and MacFeeters-Hamilton Center for Neuro-Oncology Research, University Health Network, Toronto, Ontario, Canada
| | - Jonathan So
- Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mira Salih
- Mount Sinai Hospital, New York, New York, USA
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Mitsuaki Shirahata
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Takahiro Ono
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Daniel Schrimpf
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kenneth D Aldape
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Gelareh Zadeh
- Princess Margaret Cancer Center and MacFeeters-Hamilton Center for Neuro-Oncology Research, University Health Network, Toronto, Ontario, Canada
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Yan M, Cerri GG, Moraes FY. ChatGPT and medicine: how AI language models are shaping the future and health related careers. Nat Biotechnol 2023; 41:1657-1658. [PMID: 37950005 DOI: 10.1038/s41587-023-02011-3] [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] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Affiliation(s)
- Michael Yan
- Radiation Medicine Program, Princess Margaret Cancer Centre-University Health Network, Toronto, Ontario, Canada
| | - Giovanni G Cerri
- Department of Radiology and Oncology, University of São Paulo Medical School, São Paulo, Brazil
| | - Fabio Y Moraes
- Department of Radiology and Oncology, University of São Paulo Medical School, São Paulo, Brazil.
- Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada.
- Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada.
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de Sousa CFPM, Pereira AAL, Gouveia AG, Hanna SA, Moraes FY, Arruda GV, Marta GN. Does Endocrine Therapy for DCIS Patients Treated with Breast-Conserving Surgery Followed by Postoperative Radiation Therapy is Needed? A Brazilian Retrospective Cohort Study. Int J Radiat Oncol Biol Phys 2023; 117:e173. [PMID: 37784785 DOI: 10.1016/j.ijrobp.2023.06.1016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) International previous clinical trials have demonstrated increased local control. Adjuvant endocrine therapy (ET) is a component of hormone receptor-positive breast ductal carcinoma in situ (DCIS) treatment. Previous trials have shown local control benefits. However, there are still questions regarding the reproducibility of those results in real-life scenarios and for different populations, especially in patients who received breast-conserving surgery followed by postoperative radiation therapy. Therefore, we retrospectively evaluated the impact of adjuvant ET for CDIS from a large State database in Brazil. MATERIALS/METHODS We retrospectively evaluated the Fundação Oncocentro de São Paulo (FOSP) database, which collects information on hospitals and oncology departments in the State of São Paulo, Brazil. The endpoints were local control (LC), disease-specific survival (DSS), and overall survival (OS). Moreover, we investigated the influence of medical practice (public health care system, insurance, private) and educational level (illiterate and incomplete middle school were grouped as low; complete middle school, high school, and undergraduate were grouped as medium/high). RESULTS Data from 2,192 patients who underwent breast-conserving surgery and postoperative radiotherapy and were treated between 2000 and 2020 were analyzed. The median follow-up time was 48.99 months (IQR 29.93 - 88.67). In the cohort, 53.33% (n = 1169) of patients received adjuvant ET, and 46.67% did not (n = 1023). Overall, patients not receiving adjuvant ET tend to be older (p = 0.021) and have a lower educational level (p < 0.001). Median OS and DSS were not reached. The 10-year OS and DSS for patients receiving adjuvant ET versus those not receiving it was 89.36% vs. 91.47% and 97.54% vs. 98.48%, respectively. The HR for OS for adjuvant ET vs. no ET was 0.96 (95% CI 0.63 - 1.4; p = 0.83). The HR for DSS for adjuvant ET vs. no ET was 0.79 (95% CI 0.29 - 2.12; p = 0.63). The only variable associated with survival was educational level. The 10-year OS was significantly higher for patients with medium/high educational levels (93.25% vs. 87.31%). The HR for death for medium/high versus low educational level was 0.51 (95% CI 0.32 - 0.83; p = 0.007). Recurrence rates were low in the cohort. Only 1.5% of patients had local recurrence, and 0.2% had a regional recurrence. There was no significant difference between recurrence rates for adjuvant ET (p = 0.19 and p = 0.78, respectively). CONCLUSION The benefits of adjuvant ET in DCIS patients found in international clinical trials could not be demonstrated in a Brazilian cohort. Educational level significantly impacted survival and ET usage, reflecting the influence of socioeconomic factors. Identifying these more vulnerable populations can allow for more precise interventions.
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Affiliation(s)
- C F P M de Sousa
- Department of Radiation Oncology, Hospital Sírio Libanês, Sao Paulo, Brazil
| | | | - A G Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - S A Hanna
- Hospital Sírio-Libanês, São Paulo, Sao Paulo, Brazil
| | - F Y Moraes
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - G V Arruda
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP, Ribeirão Preto, Brazil
| | - G N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
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Starling MTM, Pereira AAL, de Sousa CFPM, Restini F, Hanna SA, Gouveia AG, Moraes FY, Arruda GV, Marta GN. Brazilian Pediatric Patients with Gliomas: Treatment Characteristics and Survival Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:e531-e532. [PMID: 37785649 DOI: 10.1016/j.ijrobp.2023.06.1814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Despite being the second most frequent tumors in children, pediatric central nervous system (CNS) tumors are rare, and there are limited epidemiological data. The current study aimed to determine the survival rates of patients diagnosed with pediatric gliomas in Brazil, accounting for the influence of age, treatment modalities, and tumor site using population-based national database. MATERIALS/METHODS Patients diagnosed with pediatric gliomas of CNS from 1999-2020 were identified from The Fundação Oncocentro de São Paulo database. The Kaplan-Meier and the log-rank test were used for survival analysis. RESULTS A total of 1296 patients were included. The most common histologic tumor type were glioblastomas (38.27%; n = 496), pilocytic astrocytoma (32.87%; n = 426) and astrocytoma grade II (20.76%; n = 269) A total of 379 (29.24%) had brainstem tumor. The 1-year, 3-year 5-year OS for pilocytic astrocytoma were 93.72%, 89.98%, and 88.97%; for grade II 80,36%, 71,89%, 68,60%; for grade III 53,72%; 31,87%, 28,33%; and for glioblastoma 52,90%, 28,76%, 25,20%, respectively. Brainstem tumors had the worse OS compared to no brainstem tumors (p = 0.001). For high-grade glioma (grade III and IV) excluding brainstem tumors (n = 570), young patients had greater median OS (0 to 3 years: 22 months; 4 to 18 years: 13 months - p = 0.005). Regarding the treatment modalities, combined treatments were associated with higher median survival compared to less intensive therapy (surgery: 11 months; surgery and chemotherapy: 16 months; surgery, radiotherapy, and chemotherapy: 20 months; p = 0.005) CONCLUSION: In our cohort, low-grade gliomas had favorable prognoses and outcomes. Patients diagnosed with glioblastomas and brainstem gliomas had the worst OS. For high-grade gliomas, undergoing treatment de-intensification in the Brazilian pediatric population is associated with worse survival.
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Affiliation(s)
| | | | - C F P M de Sousa
- Department of Radiation Oncology, Hospital Sírio Libanês, Sao Paulo, Brazil
| | - F Restini
- Hospital Sirio Libanes, Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - S A Hanna
- Hospital Sírio-Libanês, São Paulo, Sao Paulo, Brazil
| | - A G Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - F Y Moraes
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - G V Arruda
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP, Ribeirão Preto, Brazil
| | - G N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
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de Sousa CFPM, Moraes FY, Gouveia AG, Hanna SA, Arruda GV, Marta GN. Timely Access to Oncological Treatment in Brazil: Analysis of the 60-Law Compliance in a State Database. Int J Radiat Oncol Biol Phys 2023; 117:S79-S80. [PMID: 37784577 DOI: 10.1016/j.ijrobp.2023.06.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) In oncology, time from diagnosis to treatment has already been shown to impact outcomes. In 2012, the Brazilian Government issued the 60-day Law, which stated that cancer treatment should start no longer than 60 days after histopathological diagnosis. However, there is scarce information on the effectiveness of the Law in improving timely access to treatment. MATERIALS/METHODS We retrospectively evaluate the Fundação Oncocentro de São Paulo (FOSP) database, which collects information on hospitals and oncology departments in the State of São Paulo, Brazil. The primary endpoint was time from diagnosis to first treatment (TDT), and we investigated the influence of medical practice (public health care system - SUS, insurance, private) and year of diagnosis (before and after 2012) on TDT. A sensitivity analysis was performed to evaluate information bias. RESULTS The database included 943,660 cancer patients diagnosed between 2000 and 2020. The median age was 62 years (range 0 - 113). The mean TDT was 65.95 days (SD 149.36), and the median time was 32 days (range 0 - 6891). Data was extremely skewed to the left, reflecting the fact that for 30.76% of patients (n = 290,262), the TDT was equal to 0 days. After excluding those patients, the mean TDT was 99.03 days (SD 173.85). Mean TDT was higher after the institution of the Law (63.1 versus 70.2 days, p < 0.001). On univariable analysis, there was a significant difference between mean times between medical practice (p < 0.001), and patients in the public health care system consistently showed longer intervals (82.1 days versus 58.3 and 39.3 for SUS, insurance, and private, respectively). This pattern remained in the sensitivity analysis. Overall, 59.9% of patients began treatment up to 60 days after diagnosis. However, 30.76% of these patients had TDT equal to zero. The proportion of patients with a TDT > 60 days was higher for SUS patients (39.52%). After the Law, the proportion of patients with a TDT > 60 days increased from 28.8% to 37.95%. CONCLUSION The approved and instituted 60-day Law did not improve timely access to treatment. Patients in the Public Healthcare System have experienced longer TDT, which could reflect barriers to access to care. The significant proportion of patients with a TDT of 0 days suggests information bias, which means that the actual scenario might be worse. There is an urgent need for public policies to ensure compliance with the Law.
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Affiliation(s)
- C F P M de Sousa
- Department of Radiation Oncology, Hospital Sírio Libanês, Sao Paulo, Brazil
| | - F Y Moraes
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - A G Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - S A Hanna
- Hospital Sírio-Libanês, São Paulo, Sao Paulo, Brazil
| | - G V Arruda
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP, Ribeirão Preto, Brazil
| | - G N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
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Wright K, Digby GC, Gyawali B, Jad R, Menard A, Moraes FY, Wijeratne DT. Malignant Superior Vena Cava Syndrome: A Scoping Review. J Thorac Oncol 2023; 18:1268-1276. [PMID: 37146753 DOI: 10.1016/j.jtho.2023.04.019] [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: 11/09/2022] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 05/07/2023]
Abstract
Malignant superior vena cava syndrome (SVCS) is a clinical problem that results from the obstruction of blood flow in the superior vena cava by an underlying malignancy. This may occur due to external compression, neoplastic invasion of the vessel wall, or internal obstruction with bland or tumor thrombus. Although symptoms are typically mild, SVCS can cause neurologic, hemodynamic, and respiratory compromise. Classic management options include supportive measures, chemotherapy, radiation therapy, surgery, and endovascular stenting. New targeted therapeutics and techniques have also recently been developed, which may have a role in management. Nevertheless, few evidence-based guidelines exist to guide treatment of malignant SVCS, and these recommendations are typically restricted to individual disease sites. Furthermore, there are no recent systematic literature reviews that address this question. Here, we present a theoretical case to frame this clinical problem and synthesize updated evidence published in the past decade relating to the management of malignant SVCS through a comprehensive literature review.
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Affiliation(s)
- Kristin Wright
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Geneviève C Digby
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Division of Respirology, Queen's University, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Reem Jad
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alexandre Menard
- Department of Diagnostic Imaging, Queen's University, Kingston, Ontario, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Don Thiwanka Wijeratne
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health, Queen's University, Kingston, Ontario, Canada; Division of General Internal Medicine, Queen's University, Kingston, Ontario, Canada
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Viani GA, Gouveia AG, Pavoni JF, Louie AV, Detsky J, Spratt DE, Moraes FY. A Meta-analysis of the Efficacy and Safety of Stereotactic Arrhythmia Radioablation (STAR) in Patients with Refractory Ventricular Tachycardia. Clin Oncol (R Coll Radiol) 2023; 35:611-620. [PMID: 37365062 DOI: 10.1016/j.clon.2023.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/06/2022] [Revised: 03/24/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
AIMS Reports of stereotactic arrhythmia radioablation (STAR) in patients with refractory ventricular tachycardia after catheter ablation are limited to small series. Here, we carried out a systematic review and meta-analysis of studies to better determine the efficacy and toxicity of STAR for ventricular tachycardia. MATERIALS AND METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines, eligible studies were identified on Medline, Embase, Cochrane Library and the proceedings of annual meetings to 10 February 2023. Efficacy was defined as a ventricular tachycardia burden reduction >70% at 6 months; safety was defined as <10% of any grade ≥3 toxicity. RESULTS Seven observational studies with a total of 61 patients treated were included. At 6 months, the ventricular tachycardia burden reduction was 92% (95% confidence interval 85-100%) and use of fewer than two anti-arrhythmic drugs was seen in 85% (95% confidence interval 50-100). Six months after STAR, an 86% reduction (95% confidence interval 80-93) in the number of implantable cardioverter-defibrillator shocks was observed. The rates for improved, unchanged and decreased cardiac ejection fraction were 10%, 84% and 6%, respectively. Overall survival at 6 and 12 months was 89% (95% confidence interval 81-97) and 82% (95% confidence interval 65-98). The cardiac-specific survival at 6 months was 87%. Late grade 3 toxicity occurred in 2% (95% confidence interval 0-5%) with no grade 4-5 toxicity. CONCLUSION STAR demonstrated both satisfactory efficacy and safety for the management of refractory ventricular tachycardia and was also associated with a significant decline in anti-arrhythmic drugs consumption. These findings support the continued development of STAR as a treatment option.
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Affiliation(s)
- G A Viani
- Ribeirão Preto Medical School, Department of Medical Imaging, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - A G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department - Americas Oncologia, Rio de Janeiro, Brazil
| | - J F Pavoni
- Faculdade de Filosofia, Letras e Ciências Naturais, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - A V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - J Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - D E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - F Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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11
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Booth CM, Sengar M, Goodman A, Wilson B, Aggarwal A, Berry S, Collingridge D, Denburg A, Eisenhauer EA, Ginsburg O, Goldstein D, Gunasekera S, Hammad N, Honda K, Jackson C, Karikios D, Knopf K, Koven R, Marini BL, Maskens D, Moraes FY, Mohyuddin GR, Poudyal BS, Pramesh CS, Roitberg F, Rubagumya F, Schott S, Sirohi B, Soto-Perez-de-Celis E, Sullivan R, Tannock IF, Trapani D, Tregear M, van der Graaf W, Vanderpuye V, Gyawali B. Common Sense Oncology: outcomes that matter. Lancet Oncol 2023; 24:833-835. [PMID: 37467768 DOI: 10.1016/s1470-2045(23)00319-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/21/2023]
Affiliation(s)
| | | | - Aaron Goodman
- University of California San Diego, San Diego, CA, USA
| | | | | | - Scott Berry
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | | | | | | | - Nazik Hammad
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | - Kevin Knopf
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ian F Tannock
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | | | - Verna Vanderpuye
- National Center for Radiotherapy, Oncology, and Nuclear Medicine, Accra, Ghana
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12
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Marta GN, Moraes FY, de Oliveira Franco RC, de Andrade Carvalho H, Gouveia AG, de Lima Gössling GC, de Jesus RG, Ferraris G, Schuffenegger PM, Bardales GS, Chacón MAP, Murillo R, Sánchez LEM, Gamarra-Cabezas E, Rosa AA, da Silva MF, de Mattos MD, Morais DCR, de Castro DG, Dal Pra A, Amêndola BE, Barros JM, Lara TM, Isa N, de la Mata Moya D, Hidalgo I, Velilla DG, Loayza LEA, Montenegro FG, Sanchez Chacin NO, Werutsky G, Viani GA. Moderately hypofractionated post-operative radiation therapy for breast cancer: preferences amongst radiation oncologists from countries in Latin America and the Caribbean. Rep Pract Oncol Radiother 2023; 28:340-351. [PMID: 37795395 PMCID: PMC10547413 DOI: 10.5603/rpor.a2023.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/27/2023] [Indexed: 10/06/2023] Open
Abstract
Background The safety and effectiveness of moderately hypofractionated post-operative radiation therapy for breast cancer were demonstrated by several trials. This study aimed to evaluate the current patterns of practice and prescription preference about moderately hypofractionated post-operative radiation therapy to assess possible aspects that affect the decision-making process regarding the use of fractionation in breast cancer patients in Latin America and the Caribbean (LAC). We also aimed to identify factors that can restrain the utilization of moderately hypofractionated post-operative radiation therapy for breast cancer. Materials an methods Radiation oncologists from LAC were invited to contribute to this study. A 38-question survey was used to evaluate their opinions. Results A total of 173 radiation oncologists from 13 countries answered the questionnaire. The majority of respondents (84.9%) preferred moderately hypofractionated post-operative radiation therapy as their first choice in cases of whole breast irradiation. Whole breast plus regional nodal irradiation, post-mastectomy (chest wall and regional nodal irradiation) without reconstruction, and post-mastectomy (chest wall and regional node irradiation) with reconstruction hypofractionated post-operative radiation therapy was preferred by 72.2% 71.1%, and 53.7% of respondents, respectively. Breast cancer stage, and flap-based breast reconstruction were the factors associated with absolute contraindications for the use of hypofractionated schedules. Conclusion Even though moderately hypofractionated post-operative radiation therapy for breast cancer is considered a new standard to the vast majority of the patients, its unrestricted application in clinical practice across LAC still faces reluctance.
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Affiliation(s)
- Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
- Latin American Cooperative Oncology Group (LACOG), Brazil
| | - Fabio Y. Moraes
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Oncology, Division of Radiation Oncology, Queen’s University — Kingston Health Science Centre, Kingston, ON, Canada
| | | | - Heloísa de Andrade Carvalho
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Radiology and Oncology — Radiotherapy Division — Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - André Guimaraes Gouveia
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Juravinski Cancer Centre, Department of Oncology, Division of Radiation Oncology, Hamilton, ON, Canada
| | | | | | | | - Pablo Munoz Schuffenegger
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Radiation Oncology Unit, Department of Hematology — Oncology, Pontificia Universidad Catolica de Chile, Chile
| | | | | | - Raúl Murillo
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogota, Colombia
- Facultad de Medicina, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Luis Ernesto Moreno Sánchez
- Instituto Nacional del Cáncer Rosa De Tavares (INCART), Savia Care Centro Avanzado de Radioterapia, Centro Gamma Knife Dominicano, Dominican Republic
| | - Elizabeth Gamarra-Cabezas
- Departamento de Radio-Oncología, Instituto Oncológico Nacional “Dr. Juan Tanca Marengo”
- Sociedad de Lucha Contra el Cáncer (SOLCA), Guayaquil, Ecuador
| | - Arthur Accioly Rosa
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Oncoclinicas Salvador — Hospital Santa Izabel
| | - Maurício Fraga da Silva
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Santa Maria Federal University, Santa Maria, RS, Brazil
- Clínica de Radioterapia de Santa Maria, RS, Brazil
| | | | - Diego Chaves Rezende Morais
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Oncoclinicas Recife and Hospital Santa Águeda, Brazil
| | - Douglas Guedes de Castro
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Radiation Oncology, A.C. Camargo Cancer Center, Brazil
| | - Alan Dal Pra
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Radiation Oncology, University of Miami Miller School of Medicine, United States
| | | | - José Máximo Barros
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Departamento de Radio-Oncología, Instituto Oncológico Nacional “Dr. Juan Tanca Marengo”
- Centro de Radioterapia del Hospital Universitario Austral, Argentina
| | - Tomas Merino Lara
- Department of Hematology Oncology, school of Medicine, Pontificia Universidad Catolica de Chile, Chile
| | | | - Dolores de la Mata Moya
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Cancer Center — ABC Medical Center, Mexico
| | - Iván Hidalgo
- Centro Javeriano de Oncología — Hospital Universitario San Ignacio, Colombia
| | | | | | | | | | | | - Gustavo Arruda Viani
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Brazil
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13
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Moraes FY, Gouveia AG, Marta GN, Viani GA. Radiotherapy combined or not with chemotherapy in adult or pediatric patients with brainstem glioma: a population-based study. Rep Pract Oncol Radiother 2023; 28:181-188. [PMID: 37456697 PMCID: PMC10348337 DOI: 10.5603/rpor.a2023.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/29/2023] [Indexed: 07/18/2023] Open
Abstract
Background The purpose of this study was to assess the treatment outcomes and prognostic factors of brainstem glioma (BCG) patients treated by radiotherapy (RT) or chemoradiation (CHRT) in the last 20 years in a population cohort. Materials and methods Patients diagnosed with BSG from 2000-2020 treated by RT or CHRT were identified from The Fundação Oncocentro de São Paulo database. Data on age, gender, practice setting, period of treatment, and treatment modality were extracted. The overall survival (OS) was estimated, and the subgroups were compared with the log-rank test. Cox proportional test was used in multivariate analysis. Results A total of 253 patients with a median follow-up of 12 months were included. There were 197 pediatric and 56 adult patients. For the entire cohort, the 1 and 3-year OS was 46%, and 23%, with a median OS of 11 months. In the subgroup analysis, adults had a median survival of 33 months versus 10 months in pediatric patients (p = 0.002). No significant difference in OS between RT and CHRT was observed in pediatric or adult subgroups (p > 0.05). The use of CHRT has significantly increased over the years. In the multivariate analysis, adult patients were the only independent prognostic factor associated with a better OS (p < 0.001). Conclusions BSG had poor survival with no significant improvement in the treatment outcomes over the last 20 years, despite the addition of chemotherapy. Adult patients were independently associated with better survival.
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Affiliation(s)
- Fabio Y Moraes
- Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Andre G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Radiation Oncology Department, Americas Centro de Oncologia Integrado, Rio de Janeiro, RJ, Brazil
| | - Gustavo N Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Radiation Oncology Department, Hospital Sirio Libanês, São Paulo, Brazil
| | - Gustavo A Viani
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
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14
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Sabbagh A, Weiss J, Tawk B, Mohammed MA, Abdulbaki H, Moraes FY, Grover S, Yap ML, Zubizarreta E, Lievens Y, Rodin D, Mohamad O. Hypofractionation Adoption in Prostate Cancer Radiotherapy: Results of an International Survey. JCO Glob Oncol 2023; 9:e2300046. [PMID: 37319396 PMCID: PMC10497301 DOI: 10.1200/go.23.00046] [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: 02/22/2023] [Revised: 03/22/2023] [Accepted: 04/14/2023] [Indexed: 06/17/2023] Open
Abstract
PURPOSE Hypofractionation is noninferior to conventional fractionation in the treatment of localized prostate cancer. Using results from the European Society of Radiation Oncology's (ESTRO) Global Impact of Radiotherapy in Oncology (GIRO) initiative survey on hypofractionation, this study identifies rates of adoption, facilitating factors, and barriers to adoption of hypofractionation in prostate cancer across World Bank income groups. MATERIALS AND METHODS The ESTRO-GIRO initiative administered an international, anonymous, electronic survey to radiation oncologists from 2018 to 2019. Physician demographics, clinical practice characteristics, and hypofractionation regimen use (if any) for several prostate cancer scenarios were collected. Responders were asked about specific justifications and barriers to adopting hypofractionation, and responses were stratified by World Bank income group. Multivariate logistic regression models were used to analyze variables associated with hypofractionation preference. RESULTS A total of 1,157 physician responses were included. Most respondents (60%) were from high-income countries (HICs). In the curative setting, hypofractionation was most often preferred in low- and intermediate-risk prostate cancers, with 52% and 47% of respondents reporting hypofractionation use in ≥50% of patients, respectively. These rates drop to 35% and 20% in high-risk prostate cancer and where pelvic irradiation is indicated. Most respondents (89%) preferred hypofractionation in the palliative setting. Overall, respondents from upper-middle-income countries and lower-middle- and low-income countries were significantly less likely to prefer hypofractionation than those from HICs (P < .001). The most frequently cited justification and barrier were availability of published evidence and fear of worse late toxicity, respectively. CONCLUSION Hypofractionation preference varies by indication and World Bank income group, with greater acceptance among providers in HICs for all indications. These results provide a basis for targeted interventions to increase provider acceptance of this treatment modality.
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Affiliation(s)
- Ali Sabbagh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Bouchra Tawk
- Clinical Cooperation Unit—Translational Radiation Oncology, National Center for Tumoral Diseases NCT Heidelberg, German Cancer Research Center (DKFZ), Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammed A. Mohammed
- American University of Beirut Medical Center, Beirut, Lebanon
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Hasan Abdulbaki
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Fabio Y. Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, ON, Canada
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, NSW, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, NSW, Australia
- The George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
| | | | - Yolande Lievens
- Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, ON, Canada
| | - Osama Mohamad
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
- Department of Urology, University of California San Francisco, San Francisco, CA
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15
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Viani GA, Gouveia AG, Silva INSB, Fernandes GS, Moraes FY. Tumor, patient, and social determinants of health affecting survival in patients with anal cancer treated by chemoradiation. Int J Radiat Oncol Biol Phys 2023; 116:413-420. [PMID: 36828170 DOI: 10.1016/j.ijrobp.2023.02.029] [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: 08/04/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Anal cancer (AC) is a rare disease with scarce evidence from developing countries. We performed a population-based cohort study to investigate the relationship between tumor, patient, and social determinants of health with treatment outcomes of AC treated by chemoradiation (CRT). METHODS Patients diagnosed with AC from 1999 to 2020 were identified from The Fundação Oncocentro de São Paulo database. Only patients with AC staged I-III treated by CRT were included. Age, gender, Tumor category (T), Nodal category (N), education level, practice setting, time to radiotherapy, histology, and treatment local data were extracted. With Cox proportional hazard model, the hazard ratio and 95% CI was used to test the relationship between tumor, patient, and social factors with overall survival (OS) and cancer-specific survival (CSS). RESULTS With 1,462 patients assessed, the median follow-up was 72 months, and the OS and CSS at 5/10 years were 61%/46% and 67%/60%, respectively. In the univariate analysis, T category, N category, gender, practice setting, and educational level were associated with OS and CSS, p<0.05. In the multivariate analysis, female, T1/2 category, N0 category, and private service were independently associated with OS, p<0.05. For CSS, female, T1/2 category, private service, and N0 category, remained significant, p<0.05. CONCLUSION CRT produced satisfactory rates of OS and CSS in patients with AC with tumor, patient, and social determinants of health influencing the outcomes. These data could help mitigate the effects of social distortions on the survival of AC.
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Affiliation(s)
- Gustavo A Viani
- Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Andre G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department - Americas Centro de Oncologia Integrado, Rio de Janeiro, RJ, Brazil
| | - Ianara N S B Silva
- Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | | | - Fabio Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
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16
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Pati S, Baid U, Edwards B, Sheller M, Wang SH, Reina GA, Foley P, Gruzdev A, Karkada D, Davatzikos C, Sako C, Ghodasara S, Bilello M, Mohan S, Vollmuth P, Brugnara G, Preetha CJ, Sahm F, Maier-Hein K, Zenk M, Bendszus M, Wick W, Calabrese E, Rudie J, Villanueva-Meyer J, Cha S, Ingalhalikar M, Jadhav M, Pandey U, Saini J, Garrett J, Larson M, Jeraj R, Currie S, Frood R, Fatania K, Huang RY, Chang K, Balaña C, Capellades J, Puig J, Trenkler J, Pichler J, Necker G, Haunschmidt A, Meckel S, Shukla G, Liem S, Alexander GS, Lombardo J, Palmer JD, Flanders AE, Dicker AP, Sair HI, Jones CK, Venkataraman A, Jiang M, So TY, Chen C, Heng PA, Dou Q, Kozubek M, Lux F, Michálek J, Matula P, Keřkovský M, Kopřivová T, Dostál M, Vybíhal V, Vogelbaum MA, Mitchell JR, Farinhas J, Maldjian JA, Yogananda CGB, Pinho MC, Reddy D, Holcomb J, Wagner BC, Ellingson BM, Cloughesy TF, Raymond C, Oughourlian T, Hagiwara A, Wang C, To MS, Bhardwaj S, Chong C, Agzarian M, Falcão AX, Martins SB, Teixeira BCA, Sprenger F, Menotti D, Lucio DR, LaMontagne P, Marcus D, Wiestler B, Kofler F, Ezhov I, Metz M, Jain R, Lee M, Lui YW, McKinley R, Slotboom J, Radojewski P, Meier R, Wiest R, Murcia D, Fu E, Haas R, Thompson J, Ormond DR, Badve C, Sloan AE, Vadmal V, Waite K, Colen RR, Pei L, Ak M, Srinivasan A, Bapuraj JR, Rao A, Wang N, Yoshiaki O, Moritani T, Turk S, Lee J, Prabhudesai S, Morón F, Mandel J, Kamnitsas K, Glocker B, Dixon LVM, Williams M, Zampakis P, Panagiotopoulos V, Tsiganos P, Alexiou S, Haliassos I, Zacharaki EI, Moustakas K, Kalogeropoulou C, Kardamakis DM, Choi YS, Lee SK, Chang JH, Ahn SS, Luo B, Poisson L, Wen N, Tiwari P, Verma R, Bareja R, Yadav I, Chen J, Kumar N, Smits M, van der Voort SR, Alafandi A, Incekara F, Wijnenga MMJ, Kapsas G, Gahrmann R, Schouten JW, Dubbink HJ, Vincent AJPE, van den Bent MJ, French PJ, Klein S, Yuan Y, Sharma S, Tseng TC, Adabi S, Niclou SP, Keunen O, Hau AC, Vallières M, Fortin D, Lepage M, Landman B, Ramadass K, Xu K, Chotai S, Chambless LB, Mistry A, Thompson RC, Gusev Y, Bhuvaneshwar K, Sayah A, Bencheqroun C, Belouali A, Madhavan S, Booth TC, Chelliah A, Modat M, Shuaib H, Dragos C, Abayazeed A, Kolodziej K, Hill M, Abbassy A, Gamal S, Mekhaimar M, Qayati M, Reyes M, Park JE, Yun J, Kim HS, Mahajan A, Muzi M, Benson S, Beets-Tan RGH, Teuwen J, Herrera-Trujillo A, Trujillo M, Escobar W, Abello A, Bernal J, Gómez J, Choi J, Baek S, Kim Y, Ismael H, Allen B, Buatti JM, Kotrotsou A, Li H, Weiss T, Weller M, Bink A, Pouymayou B, Shaykh HF, Saltz J, Prasanna P, Shrestha S, Mani KM, Payne D, Kurc T, Pelaez E, Franco-Maldonado H, Loayza F, Quevedo S, Guevara P, Torche E, Mendoza C, Vera F, Ríos E, López E, Velastin SA, Ogbole G, Soneye M, Oyekunle D, Odafe-Oyibotha O, Osobu B, Shu'aibu M, Dorcas A, Dako F, Simpson AL, Hamghalam M, Peoples JJ, Hu R, Tran A, Cutler D, Moraes FY, Boss MA, Gimpel J, Veettil DK, Schmidt K, Bialecki B, Marella S, Price C, Cimino L, Apgar C, Shah P, Menze B, Barnholtz-Sloan JS, Martin J, Bakas S. Author Correction: Federated learning enables big data for rare cancer boundary detection. Nat Commun 2023; 14:436. [PMID: 36702828 PMCID: PMC9879935 DOI: 10.1038/s41467-023-36188-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Sarthak Pati
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Informatics, Technical University of Munich, Munich, Bavaria, Germany
| | - Ujjwal Baid
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | | | - Christos Davatzikos
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chiharu Sako
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Satyam Ghodasara
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michel Bilello
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Suyash Mohan
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gianluca Brugnara
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Felix Sahm
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK) within the German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center, Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Maximilian Zenk
- Division of Medical Image Computing, German Cancer Research Center, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK) within the German Cancer Research Center (DKFZ), Heidelberg, Germany
- Neurology Clinic, Heidelberg University Hospital, Heidelberg, Germany
| | - Evan Calabrese
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey Rudie
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Javier Villanueva-Meyer
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Soonmee Cha
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Madhura Ingalhalikar
- Symbiosis Center for Medical Image Analysis, Symbiosis International University, Pune, Maharashtra, India
| | - Manali Jadhav
- Symbiosis Center for Medical Image Analysis, Symbiosis International University, Pune, Maharashtra, India
| | - Umang Pandey
- Symbiosis Center for Medical Image Analysis, Symbiosis International University, Pune, Maharashtra, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - John Garrett
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Matthew Larson
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Robert Jeraj
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Stuart Currie
- Leeds Teaching Hospitals Trust, Department of Radiology, Leeds, UK
| | - Russell Frood
- Leeds Teaching Hospitals Trust, Department of Radiology, Leeds, UK
| | - Kavi Fatania
- Leeds Teaching Hospitals Trust, Department of Radiology, Leeds, UK
| | - Raymond Y Huang
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ken Chang
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | | | | | - Josep Puig
- Department of Radiology (IDI), Girona Biomedical Research Institute (IdIBGi), Josep Trueta University Hospital, Girona, Spain
| | - Johannes Trenkler
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Josef Pichler
- Department of Neurooncology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Georg Necker
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Andreas Haunschmidt
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Stephan Meckel
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
- Institute of Diagnostic and Interventional Neuroradiology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Gaurav Shukla
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, Christiana Care Health System, Philadelphia, PA, USA
| | - Spencer Liem
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory S Alexander
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
| | - Joseph Lombardo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Adam E Flanders
- Department of Radiology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Haris I Sair
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Malone Center for Engineering in Healthcare, The Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Craig K Jones
- The Malone Center for Engineering in Healthcare, The Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Archana Venkataraman
- Department of Electrical and Computer Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Meirui Jiang
- The Chinese University of Hong Kong, Hong Kong, China
| | - Tiffany Y So
- The Chinese University of Hong Kong, Hong Kong, China
| | - Cheng Chen
- The Chinese University of Hong Kong, Hong Kong, China
| | | | - Qi Dou
- The Chinese University of Hong Kong, Hong Kong, China
| | - Michal Kozubek
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Filip Lux
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Jan Michálek
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Petr Matula
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Miloš Keřkovský
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University, Brno and University Hospital Brno, Brno, Czech Republic
| | - Tereza Kopřivová
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University, Brno and University Hospital Brno, Brno, Czech Republic
| | - Marek Dostál
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University, Brno and University Hospital Brno, Brno, Czech Republic
- Department of Biophysics, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Václav Vybíhal
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, and University Hospital and Czech Republic, Brno, Czech Republic
| | - Michael A Vogelbaum
- Department of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J Ross Mitchell
- University of Alberta, Edmonton, AB, Canada
- Alberta Machine Intelligence Institute, Edmonton, AB, Canada
| | - Joaquim Farinhas
- Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | - Marco C Pinho
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Divya Reddy
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Holcomb
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neuro-Oncology Program, Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CaA, USA
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program, Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CaA, USA
| | - Catalina Raymond
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Talia Oughourlian
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Akifumi Hagiwara
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Chencai Wang
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Minh-Son To
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Sargam Bhardwaj
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Chee Chong
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Marc Agzarian
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, SA, Australia
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Bernardo C A Teixeira
- Instituto de Neurologia de Curitiba, Curitiba, Paraná, Brazil
- Department of Radiology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Flávia Sprenger
- Department of Radiology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - David Menotti
- Department of Informatics, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Diego R Lucio
- Department of Informatics, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Pamela LaMontagne
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Daniel Marcus
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Klinikum rechts der Isar, Munich, Germany
| | - Florian Kofler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Klinikum rechts der Isar, Munich, Germany
- Image-Based Biomedical Modeling, Department of Informatics, Technical University of Munich, Munich, Germany
| | - Ivan Ezhov
- Department of Informatics, Technical University of Munich, Munich, Bavaria, Germany
- TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Klinikum rechts der Isar, Munich, Germany
- Image-Based Biomedical Modeling, Department of Informatics, Technical University of Munich, Munich, Germany
| | - Marie Metz
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rajan Jain
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Matthew Lee
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Yvonne W Lui
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Richard McKinley
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes Slotboom
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Piotr Radojewski
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Raphael Meier
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Roland Wiest
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Derrick Murcia
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Eric Fu
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Rourke Haas
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - John Thompson
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - David Ryan Ormond
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Chaitra Badve
- Department of Radiology, University Hospitals Cleveland, Cleveland, OH, USA
| | - Andrew E Sloan
- Department of Neurological Surgery, University Hospitals-Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vachan Vadmal
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kristin Waite
- National Cancer Institute, National Institute of Health, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Rivka R Colen
- Department of Radiology, Neuroradiology Division, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Linmin Pei
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Murat Ak
- Department of Radiology, Neuroradiology Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ashok Srinivasan
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - J Rajiv Bapuraj
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Arvind Rao
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas Wang
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Ota Yoshiaki
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Toshio Moritani
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Sevcan Turk
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Joonsang Lee
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Snehal Prabhudesai
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Fanny Morón
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Jacob Mandel
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Konstantinos Kamnitsas
- Department of Computing, Imperial College London, London, UK
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Ben Glocker
- Department of Computing, Imperial College London, London, UK
| | - Luke V M Dixon
- Department of Radiology, Imperial College NHS Healthcare Trust, London, UK
| | - Matthew Williams
- Computational Oncology Group, Institute for Global Health Innovation, Imperial College London, London, UK
| | - Peter Zampakis
- Department of NeuroRadiology, University of Patras, Patras, Greece
| | | | - Panagiotis Tsiganos
- Clinical Radiology Laboratory, Department of Medicine, University of Patras, Patras, Greece
| | - Sotiris Alexiou
- Department of Electrical and Computer Engineering, University of Patras, Patras, Greece
| | - Ilias Haliassos
- Department of Neuro-Oncology, University of Patras, Patras, Greece
| | - Evangelia I Zacharaki
- Department of Electrical and Computer Engineering, University of Patras, Patras, Greece
| | | | | | | | | | | | | | - Sung Soo Ahn
- Yonsei University College of Medicine, Seoul, Korea
| | - Bing Luo
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Laila Poisson
- Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Ning Wen
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
- SJTU-Ruijin-UIH Institute for Medical Imaging Technology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | | | - Ruchika Verma
- Alberta Machine Intelligence Institute, Edmonton, AB, Canada
- Case Western Reserve University, Cleveland, OH, USA
| | - Rohan Bareja
- Case Western Reserve University, Cleveland, OH, USA
| | - Ipsa Yadav
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Neeraj Kumar
- University of Alberta, Edmonton, AB, Canada
- Alberta Machine Intelligence Institute, Edmonton, AB, Canada
| | - Marion Smits
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Sebastian R van der Voort
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Ahmed Alafandi
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Fatih Incekara
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Brain Tumor Center, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Maarten M J Wijnenga
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Georgios Kapsas
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Renske Gahrmann
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Joost W Schouten
- Department of Neurosurgery, Brain Tumor Center, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Hendrikus J Dubbink
- Department of Pathology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Arnaud J P E Vincent
- Department of Neurosurgery, Brain Tumor Center, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Martin J van den Bent
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Pim J French
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Stefan Klein
- Biomedical Imaging Group Rotterdam, Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Yading Yuan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tzu-Chi Tseng
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Saba Adabi
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Simone P Niclou
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - Olivier Keunen
- Translation Radiomics, Department of Cancer Research, Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - Ann-Christin Hau
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health, Luxembourg, Luxembourg
- Luxembourg Center of Neuropathology, Laboratoire National De Santé, Luxembourg, Luxembourg
| | - Martin Vallières
- Department of Computer Science, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalière Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - David Fortin
- Centre de Recherche du Centre Hospitalière Universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Division of Neurosurgery and Neuro-Oncology, Faculty of Medicine and Health Science, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Martin Lepage
- Centre de Recherche du Centre Hospitalière Universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Department of Nuclear Medicine and Radiobiology, Sherbrooke Molecular Imaging Centre, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Bennett Landman
- Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, USA
| | - Karthik Ramadass
- Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, USA
| | - Kaiwen Xu
- Department of Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Silky Chotai
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Akshitkumar Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Reid C Thompson
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yuriy Gusev
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Krithika Bhuvaneshwar
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Anousheh Sayah
- Division of Neuroradiology & Neurointerventional Radiology, Department of Radiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Camelia Bencheqroun
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Anas Belouali
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Subha Madhavan
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Thomas C Booth
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Department of Neuroradiology, Ruskin Wing, King's College Hospital NHS Foundation Trust, London, UK
| | - Alysha Chelliah
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Haris Shuaib
- Stoke Mandeville Hospital, Mandeville Road, Aylesbury, UK
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Carmen Dragos
- Stoke Mandeville Hospital, Mandeville Road, Aylesbury, UK
| | | | | | | | | | - Shady Gamal
- University of Cairo School of Medicine, Giza, Egypt
| | | | | | | | - Ji Eun Park
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Jihye Yun
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Ho Sung Kim
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Abhishek Mahajan
- The Clatterbridge Cancer Centre NHS Foundation Trust Pembroke Place, Liverpool, UK
| | - Mark Muzi
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Sean Benson
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands
- GROW School of Oncology and Developmental Biology, Maastricht, Netherlands
| | - Jonas Teuwen
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - William Escobar
- Clínica Imbanaco Grupo Quirón Salud, Cali, Colombia
- Universidad del Valle, Cali, Colombia
| | | | - Jose Bernal
- Universidad del Valle, Cali, Colombia
- The University of Edinburgh, Edinburgh, UK
| | | | - Joseph Choi
- Department of Industrial and Systems Engineering, University of Iowa, Iowa, USA
| | - Stephen Baek
- Department of Industrial and Systems Engineering, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Yusung Kim
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Heba Ismael
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Bryan Allen
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - John M Buatti
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | | | - Hongwei Li
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Tobias Weiss
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Andrea Bink
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Bertrand Pouymayou
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | | | - Joel Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Prateek Prasanna
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Sampurna Shrestha
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Kartik M Mani
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
- Department of Radiation Oncology, Stony Brook University, Stony Brook, NY, USA
| | - David Payne
- Department of Radiology, Stony Brook University, Stony Brook, NY, USA
| | - Tahsin Kurc
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
- Scientific Data Group, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Enrique Pelaez
- Escuela Superior Politecnica del Litoral, Guayaquil, Guayas, Ecuador
| | | | - Francis Loayza
- Escuela Superior Politecnica del Litoral, Guayaquil, Guayas, Ecuador
| | | | | | | | | | - Franco Vera
- Universidad de Concepción, Concepción, Biobío, Chile
| | - Elvis Ríos
- Universidad de Concepción, Concepción, Biobío, Chile
| | - Eduardo López
- Universidad de Concepción, Concepción, Biobío, Chile
| | - Sergio A Velastin
- School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK
| | - Godwin Ogbole
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | - Mayowa Soneye
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | - Dotun Oyekunle
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | | | - Babatunde Osobu
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | - Mustapha Shu'aibu
- Department of Radiology, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
| | - Adeleye Dorcas
- Department of Radiology, Obafemi Awolowo University Ile-Ife, Ile-Ife, Osun, Nigeria
| | - Farouk Dako
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amber L Simpson
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Mohammad Hamghalam
- School of Computing, Queen's University, Kingston, ON, Canada
- Department of Electrical Engineering, Qazvin Branch, Islamic Azad University, Qazvin, Iran
| | - Jacob J Peoples
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Ricky Hu
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Anh Tran
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Danielle Cutler
- The Faculty of Arts & Sciences, Queen's University, Kingston, ON, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Michael A Boss
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - James Gimpel
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Deepak Kattil Veettil
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Kendall Schmidt
- Data Science Institute, American College of Radiology, Reston, VA, USA
| | - Brian Bialecki
- Data Science Institute, American College of Radiology, Reston, VA, USA
| | - Sailaja Marella
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Cynthia Price
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Lisa Cimino
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Charles Apgar
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | | | - Bjoern Menze
- Department of Informatics, Technical University of Munich, Munich, Bavaria, Germany
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Jill S Barnholtz-Sloan
- National Cancer Institute, National Institute of Health, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
- Center for Biomedical Informatics and Information Technology, National Cancer Institute (NCI), National Institute of Health, Bethesda, MD, USA
| | | | - Spyridon Bakas
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA.
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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17
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Mushonga M, Weiss J, Liu ZA, Nyakabau AM, Mohamad O, Tawk B, Moraes FY, Grover S, Yap ML, Zubizarreta E, Lievens Y, Rodin D. Hypofractionation in Breast Cancer Radiotherapy Across World Bank Income Groups: Results of an International Survey. JCO Glob Oncol 2023; 9:e2200127. [PMID: 36706350 PMCID: PMC10166450 DOI: 10.1200/go.22.00127] [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: 01/28/2023] Open
Abstract
PURPOSE Hypofractionated breast radiotherapy has been found to be equivalent to conventional fractionation in many clinical trials. Using data from the European Society for Radiotherapy and Oncology Global Impact of Radiotherapy in Oncology survey, we identified preferences for hypofractionation in breast cancer across World Bank income groups and the perceived facilitators and barriers to its use. MATERIALS AND METHODS An international, electronic survey was administered to radiation oncologists from 2018 to 2019. Demographics, practice characteristics, preferred hypofractionation regimen for specific breast cancer scenarios, and facilitators and barriers to hypofractionation were reported and stratified by World Bank income groups. Variables associated with hypofractionation were assessed using multivariate logistic regression models. RESULTS One thousand four hundred thirty-four physicians responded: 890 (62%) from high-income countries (HICs), 361 (25%) from upper-middle-income countries (UMICs), 183 (13%) from low- and lower-middle-income countries (LLMICs). Hypofractionation was preferred most frequently in node-negative disease after breast-conserving surgery, with the strongest preference reported in HICs (78% from HICs, 54% from UMICs, and 51% from LLMICs, P < .001). Hypofractionation for node-positive disease postmastectomy was more frequently preferred in LLMICs (28% from HICs, 15% from UMICs, and 35% from LLMICs, P < .001). Curative doses of 2.1 to < 2.5 Gy in 15-16 fractions were most frequently reported, with limited preference for ultra-hypofractionation, but significant variability in palliative dosing. In adjusted analyses, UMICs were significantly less likely than LLMICs to prefer hypofractionation across all curative clinical scenarios, whereas respondents with > 1 million population catchments and with intensity-modulated radiotherapy were more likely to prefer hypofractionation. The most frequently cited facilitators and barriers were published evidence and fear of late toxicity, respectively. CONCLUSION Preference for hypofractionation varied for curative indications, with greater acceptance in earlier-stage disease in HICs and in later-stage disease in LLMICs. Targeted educational interventions and greater inclusivity in radiation oncology clinical trials may support greater uptake.
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Affiliation(s)
- Melinda Mushonga
- Sally Mugabe Central Hospital, Harare, Zimbabwe.,Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Anna-Mary Nyakabau
- Department of Oncology, Faculty of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Osama Mohamad
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Bouchra Tawk
- German Cancer Research Consortium, Core Site Heidelberg, German Cancer Research Center, Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine and Heidelberg University Hospital, Heidelberg, Germany
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, Ontario, Canada
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, Campbelltown, Australia
| | | | - Yolande Lievens
- Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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18
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Pati S, Baid U, Edwards B, Sheller M, Wang SH, Reina GA, Foley P, Gruzdev A, Karkada D, Davatzikos C, Sako C, Ghodasara S, Bilello M, Mohan S, Vollmuth P, Brugnara G, Preetha CJ, Sahm F, Maier-Hein K, Zenk M, Bendszus M, Wick W, Calabrese E, Rudie J, Villanueva-Meyer J, Cha S, Ingalhalikar M, Jadhav M, Pandey U, Saini J, Garrett J, Larson M, Jeraj R, Currie S, Frood R, Fatania K, Huang RY, Chang K, Balaña C, Capellades J, Puig J, Trenkler J, Pichler J, Necker G, Haunschmidt A, Meckel S, Shukla G, Liem S, Alexander GS, Lombardo J, Palmer JD, Flanders AE, Dicker AP, Sair HI, Jones CK, Venkataraman A, Jiang M, So TY, Chen C, Heng PA, Dou Q, Kozubek M, Lux F, Michálek J, Matula P, Keřkovský M, Kopřivová T, Dostál M, Vybíhal V, Vogelbaum MA, Mitchell JR, Farinhas J, Maldjian JA, Yogananda CGB, Pinho MC, Reddy D, Holcomb J, Wagner BC, Ellingson BM, Cloughesy TF, Raymond C, Oughourlian T, Hagiwara A, Wang C, To MS, Bhardwaj S, Chong C, Agzarian M, Falcão AX, Martins SB, Teixeira BCA, Sprenger F, Menotti D, Lucio DR, LaMontagne P, Marcus D, Wiestler B, Kofler F, Ezhov I, Metz M, Jain R, Lee M, Lui YW, McKinley R, Slotboom J, Radojewski P, Meier R, Wiest R, Murcia D, Fu E, Haas R, Thompson J, Ormond DR, Badve C, Sloan AE, Vadmal V, Waite K, Colen RR, Pei L, Ak M, Srinivasan A, Bapuraj JR, Rao A, Wang N, Yoshiaki O, Moritani T, Turk S, Lee J, Prabhudesai S, Morón F, Mandel J, Kamnitsas K, Glocker B, Dixon LVM, Williams M, Zampakis P, Panagiotopoulos V, Tsiganos P, Alexiou S, Haliassos I, Zacharaki EI, Moustakas K, Kalogeropoulou C, Kardamakis DM, Choi YS, Lee SK, Chang JH, Ahn SS, Luo B, Poisson L, Wen N, Tiwari P, Verma R, Bareja R, Yadav I, Chen J, Kumar N, Smits M, van der Voort SR, Alafandi A, Incekara F, Wijnenga MMJ, Kapsas G, Gahrmann R, Schouten JW, Dubbink HJ, Vincent AJPE, van den Bent MJ, French PJ, Klein S, Yuan Y, Sharma S, Tseng TC, Adabi S, Niclou SP, Keunen O, Hau AC, Vallières M, Fortin D, Lepage M, Landman B, Ramadass K, Xu K, Chotai S, Chambless LB, Mistry A, Thompson RC, Gusev Y, Bhuvaneshwar K, Sayah A, Bencheqroun C, Belouali A, Madhavan S, Booth TC, Chelliah A, Modat M, Shuaib H, Dragos C, Abayazeed A, Kolodziej K, Hill M, Abbassy A, Gamal S, Mekhaimar M, Qayati M, Reyes M, Park JE, Yun J, Kim HS, Mahajan A, Muzi M, Benson S, Beets-Tan RGH, Teuwen J, Herrera-Trujillo A, Trujillo M, Escobar W, Abello A, Bernal J, Gómez J, Choi J, Baek S, Kim Y, Ismael H, Allen B, Buatti JM, Kotrotsou A, Li H, Weiss T, Weller M, Bink A, Pouymayou B, Shaykh HF, Saltz J, Prasanna P, Shrestha S, Mani KM, Payne D, Kurc T, Pelaez E, Franco-Maldonado H, Loayza F, Quevedo S, Guevara P, Torche E, Mendoza C, Vera F, Ríos E, López E, Velastin SA, Ogbole G, Soneye M, Oyekunle D, Odafe-Oyibotha O, Osobu B, Shu'aibu M, Dorcas A, Dako F, Simpson AL, Hamghalam M, Peoples JJ, Hu R, Tran A, Cutler D, Moraes FY, Boss MA, Gimpel J, Veettil DK, Schmidt K, Bialecki B, Marella S, Price C, Cimino L, Apgar C, Shah P, Menze B, Barnholtz-Sloan JS, Martin J, Bakas S. Federated learning enables big data for rare cancer boundary detection. Nat Commun 2022; 13:7346. [PMID: 36470898 PMCID: PMC9722782 DOI: 10.1038/s41467-022-33407-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/16/2022] [Indexed: 12/12/2022] Open
Abstract
Although machine learning (ML) has shown promise across disciplines, out-of-sample generalizability is concerning. This is currently addressed by sharing multi-site data, but such centralization is challenging/infeasible to scale due to various limitations. Federated ML (FL) provides an alternative paradigm for accurate and generalizable ML, by only sharing numerical model updates. Here we present the largest FL study to-date, involving data from 71 sites across 6 continents, to generate an automatic tumor boundary detector for the rare disease of glioblastoma, reporting the largest such dataset in the literature (n = 6, 314). We demonstrate a 33% delineation improvement for the surgically targetable tumor, and 23% for the complete tumor extent, over a publicly trained model. We anticipate our study to: 1) enable more healthcare studies informed by large diverse data, ensuring meaningful results for rare diseases and underrepresented populations, 2) facilitate further analyses for glioblastoma by releasing our consensus model, and 3) demonstrate the FL effectiveness at such scale and task-complexity as a paradigm shift for multi-site collaborations, alleviating the need for data-sharing.
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Affiliation(s)
- Sarthak Pati
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Informatics, Technical University of Munich, Munich, Bavaria, Germany
| | - Ujjwal Baid
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | | | - Christos Davatzikos
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chiharu Sako
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Satyam Ghodasara
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michel Bilello
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Suyash Mohan
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gianluca Brugnara
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Felix Sahm
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK) within the German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center, Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Maximilian Zenk
- Division of Medical Image Computing, German Cancer Research Center, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK) within the German Cancer Research Center (DKFZ), Heidelberg, Germany
- Neurology Clinic, Heidelberg University Hospital, Heidelberg, Germany
| | - Evan Calabrese
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey Rudie
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Javier Villanueva-Meyer
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Soonmee Cha
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Madhura Ingalhalikar
- Symbiosis Center for Medical Image Analysis, Symbiosis International University, Pune, Maharashtra, India
| | - Manali Jadhav
- Symbiosis Center for Medical Image Analysis, Symbiosis International University, Pune, Maharashtra, India
| | - Umang Pandey
- Symbiosis Center for Medical Image Analysis, Symbiosis International University, Pune, Maharashtra, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - John Garrett
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Matthew Larson
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Robert Jeraj
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Stuart Currie
- Leeds Teaching Hospitals Trust, Department of Radiology, Leeds, UK
| | - Russell Frood
- Leeds Teaching Hospitals Trust, Department of Radiology, Leeds, UK
| | - Kavi Fatania
- Leeds Teaching Hospitals Trust, Department of Radiology, Leeds, UK
| | - Raymond Y Huang
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ken Chang
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | | | | | - Josep Puig
- Department of Radiology (IDI), Girona Biomedical Research Institute (IdIBGi), Josep Trueta University Hospital, Girona, Spain
| | - Johannes Trenkler
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Josef Pichler
- Department of Neurooncology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Georg Necker
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Andreas Haunschmidt
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
| | - Stephan Meckel
- Institute of Neuroradiology, Neuromed Campus (NMC), Kepler University Hospital Linz, Linz, Austria
- Institute of Diagnostic and Interventional Neuroradiology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Gaurav Shukla
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, Christiana Care Health System, Philadelphia, PA, USA
| | - Spencer Liem
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory S Alexander
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
| | - Joseph Lombardo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Adam E Flanders
- Department of Radiology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Haris I Sair
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Malone Center for Engineering in Healthcare, The Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Craig K Jones
- The Malone Center for Engineering in Healthcare, The Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Archana Venkataraman
- Department of Electrical and Computer Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Meirui Jiang
- The Chinese University of Hong Kong, Hong Kong, China
| | - Tiffany Y So
- The Chinese University of Hong Kong, Hong Kong, China
| | - Cheng Chen
- The Chinese University of Hong Kong, Hong Kong, China
| | | | - Qi Dou
- The Chinese University of Hong Kong, Hong Kong, China
| | - Michal Kozubek
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Filip Lux
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Jan Michálek
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Petr Matula
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czech Republic
| | - Miloš Keřkovský
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University, Brno and University Hospital Brno, Brno, Czech Republic
| | - Tereza Kopřivová
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University, Brno and University Hospital Brno, Brno, Czech Republic
| | - Marek Dostál
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University, Brno and University Hospital Brno, Brno, Czech Republic
- Department of Biophysics, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Václav Vybíhal
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, and University Hospital and Czech Republic, Brno, Czech Republic
| | - Michael A Vogelbaum
- Department of Neuro Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J Ross Mitchell
- University of Alberta, Edmonton, AB, Canada
- Alberta Machine Intelligence Institute, Edmonton, AB, Canada
| | - Joaquim Farinhas
- Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | - Marco C Pinho
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Divya Reddy
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Holcomb
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neuro-Oncology Program, Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CaA, USA
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program, Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CaA, USA
| | - Catalina Raymond
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Talia Oughourlian
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Akifumi Hagiwara
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Chencai Wang
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Minh-Son To
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Sargam Bhardwaj
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Chee Chong
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Marc Agzarian
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, SA, Australia
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Bernardo C A Teixeira
- Instituto de Neurologia de Curitiba, Curitiba, Paraná, Brazil
- Department of Radiology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Flávia Sprenger
- Department of Radiology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - David Menotti
- Department of Informatics, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Diego R Lucio
- Department of Informatics, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Pamela LaMontagne
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Daniel Marcus
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Klinikum rechts der Isar, Munich, Germany
| | - Florian Kofler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Klinikum rechts der Isar, Munich, Germany
- Image-Based Biomedical Modeling, Department of Informatics, Technical University of Munich, Munich, Germany
| | - Ivan Ezhov
- Department of Informatics, Technical University of Munich, Munich, Bavaria, Germany
- TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Klinikum rechts der Isar, Munich, Germany
- Image-Based Biomedical Modeling, Department of Informatics, Technical University of Munich, Munich, Germany
| | - Marie Metz
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rajan Jain
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Matthew Lee
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Yvonne W Lui
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Richard McKinley
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes Slotboom
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Piotr Radojewski
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Raphael Meier
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Roland Wiest
- Support Center for Advanced Neuroimaging, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Derrick Murcia
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Eric Fu
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Rourke Haas
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - John Thompson
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - David Ryan Ormond
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Chaitra Badve
- Department of Radiology, University Hospitals Cleveland, Cleveland, OH, USA
| | - Andrew E Sloan
- Department of Neurological Surgery, University Hospitals-Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vachan Vadmal
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kristin Waite
- National Cancer Institute, National Institute of Health, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Rivka R Colen
- Department of Radiology, Neuroradiology Division, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Linmin Pei
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Murat Ak
- Department of Radiology, Neuroradiology Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ashok Srinivasan
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - J Rajiv Bapuraj
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Arvind Rao
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas Wang
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Ota Yoshiaki
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Toshio Moritani
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Sevcan Turk
- Department of Neuroradiology, University of Michigan, Ann Arbor, MI, USA
| | - Joonsang Lee
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Snehal Prabhudesai
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Fanny Morón
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Jacob Mandel
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Konstantinos Kamnitsas
- Department of Computing, Imperial College London, London, UK
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Ben Glocker
- Department of Computing, Imperial College London, London, UK
| | - Luke V M Dixon
- Department of Radiology, Imperial College NHS Healthcare Trust, London, UK
| | - Matthew Williams
- Computational Oncology Group, Institute for Global Health Innovation, Imperial College London, London, UK
| | - Peter Zampakis
- Department of NeuroRadiology, University of Patras, Patras, Greece
| | | | - Panagiotis Tsiganos
- Clinical Radiology Laboratory, Department of Medicine, University of Patras, Patras, Greece
| | - Sotiris Alexiou
- Department of Electrical and Computer Engineering, University of Patras, Patras, Greece
| | - Ilias Haliassos
- Department of Neuro-Oncology, University of Patras, Patras, Greece
| | - Evangelia I Zacharaki
- Department of Electrical and Computer Engineering, University of Patras, Patras, Greece
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- Yonsei University College of Medicine, Seoul, Korea
| | - Bing Luo
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Laila Poisson
- Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Ning Wen
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
- SJTU-Ruijin-UIH Institute for Medical Imaging Technology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | | | - Ruchika Verma
- Alberta Machine Intelligence Institute, Edmonton, AB, Canada
- Case Western Reserve University, Cleveland, OH, USA
| | - Rohan Bareja
- Case Western Reserve University, Cleveland, OH, USA
| | - Ipsa Yadav
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Neeraj Kumar
- University of Alberta, Edmonton, AB, Canada
- Alberta Machine Intelligence Institute, Edmonton, AB, Canada
| | - Marion Smits
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Sebastian R van der Voort
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Ahmed Alafandi
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Fatih Incekara
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Brain Tumor Center, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Maarten M J Wijnenga
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Georgios Kapsas
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Renske Gahrmann
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Joost W Schouten
- Department of Neurosurgery, Brain Tumor Center, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Hendrikus J Dubbink
- Department of Pathology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Arnaud J P E Vincent
- Department of Neurosurgery, Brain Tumor Center, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Martin J van den Bent
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Pim J French
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Stefan Klein
- Biomedical Imaging Group Rotterdam, Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Yading Yuan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tzu-Chi Tseng
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Saba Adabi
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Simone P Niclou
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - Olivier Keunen
- Translation Radiomics, Department of Cancer Research, Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - Ann-Christin Hau
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health, Luxembourg, Luxembourg
- Luxembourg Center of Neuropathology, Laboratoire National De Santé, Luxembourg, Luxembourg
| | - Martin Vallières
- Department of Computer Science, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalière Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - David Fortin
- Centre de Recherche du Centre Hospitalière Universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Division of Neurosurgery and Neuro-Oncology, Faculty of Medicine and Health Science, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Martin Lepage
- Centre de Recherche du Centre Hospitalière Universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Department of Nuclear Medicine and Radiobiology, Sherbrooke Molecular Imaging Centre, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Bennett Landman
- Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, USA
| | - Karthik Ramadass
- Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, USA
| | - Kaiwen Xu
- Department of Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Silky Chotai
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Akshitkumar Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Reid C Thompson
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yuriy Gusev
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Krithika Bhuvaneshwar
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Anousheh Sayah
- Division of Neuroradiology & Neurointerventional Radiology, Department of Radiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Camelia Bencheqroun
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Anas Belouali
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Subha Madhavan
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University, Washington, DC, USA
| | - Thomas C Booth
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Department of Neuroradiology, Ruskin Wing, King's College Hospital NHS Foundation Trust, London, UK
| | - Alysha Chelliah
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Haris Shuaib
- Stoke Mandeville Hospital, Mandeville Road, Aylesbury, UK
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Carmen Dragos
- Stoke Mandeville Hospital, Mandeville Road, Aylesbury, UK
| | | | | | | | | | - Shady Gamal
- University of Cairo School of Medicine, Giza, Egypt
| | | | | | | | - Ji Eun Park
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Jihye Yun
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Ho Sung Kim
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Abhishek Mahajan
- The Clatterbridge Cancer Centre NHS Foundation Trust Pembroke Place, Liverpool, UK
| | - Mark Muzi
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Sean Benson
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands
- GROW School of Oncology and Developmental Biology, Maastricht, Netherlands
| | - Jonas Teuwen
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - William Escobar
- Clínica Imbanaco Grupo Quirón Salud, Cali, Colombia
- Universidad del Valle, Cali, Colombia
| | | | - Jose Bernal
- Universidad del Valle, Cali, Colombia
- The University of Edinburgh, Edinburgh, UK
| | | | - Joseph Choi
- Department of Industrial and Systems Engineering, University of Iowa, Iowa, USA
| | - Stephen Baek
- Department of Industrial and Systems Engineering, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Yusung Kim
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Heba Ismael
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Bryan Allen
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - John M Buatti
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | | | - Hongwei Li
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Tobias Weiss
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Andrea Bink
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Bertrand Pouymayou
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | | | - Joel Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Prateek Prasanna
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Sampurna Shrestha
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Kartik M Mani
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
- Department of Radiation Oncology, Stony Brook University, Stony Brook, NY, USA
| | - David Payne
- Department of Radiology, Stony Brook University, Stony Brook, NY, USA
| | - Tahsin Kurc
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
- Scientific Data Group, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Enrique Pelaez
- Escuela Superior Politecnica del Litoral, Guayaquil, Guayas, Ecuador
| | | | - Francis Loayza
- Escuela Superior Politecnica del Litoral, Guayaquil, Guayas, Ecuador
| | | | | | | | | | - Franco Vera
- Universidad de Concepción, Concepción, Biobío, Chile
| | - Elvis Ríos
- Universidad de Concepción, Concepción, Biobío, Chile
| | - Eduardo López
- Universidad de Concepción, Concepción, Biobío, Chile
| | - Sergio A Velastin
- School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK
| | - Godwin Ogbole
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | - Mayowa Soneye
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | - Dotun Oyekunle
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | | | - Babatunde Osobu
- Department of Radiology, University College Hospital Ibadan, Oyo, Nigeria
| | - Mustapha Shu'aibu
- Department of Radiology, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
| | - Adeleye Dorcas
- Department of Radiology, Obafemi Awolowo University Ile-Ife, Ile-Ife, Osun, Nigeria
| | - Farouk Dako
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amber L Simpson
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Mohammad Hamghalam
- School of Computing, Queen's University, Kingston, ON, Canada
- Department of Electrical Engineering, Qazvin Branch, Islamic Azad University, Qazvin, Iran
| | - Jacob J Peoples
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Ricky Hu
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Anh Tran
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Danielle Cutler
- The Faculty of Arts & Sciences, Queen's University, Kingston, ON, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Michael A Boss
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - James Gimpel
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Deepak Kattil Veettil
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Kendall Schmidt
- Data Science Institute, American College of Radiology, Reston, VA, USA
| | - Brian Bialecki
- Data Science Institute, American College of Radiology, Reston, VA, USA
| | - Sailaja Marella
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Cynthia Price
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Lisa Cimino
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | - Charles Apgar
- Center for Research and Innovation, American College of Radiology, Philadelphia, PA, USA
| | | | - Bjoern Menze
- Department of Informatics, Technical University of Munich, Munich, Bavaria, Germany
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Jill S Barnholtz-Sloan
- National Cancer Institute, National Institute of Health, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
- Center for Biomedical Informatics and Information Technology, National Cancer Institute (NCI), National Institute of Health, Bethesda, MD, USA
| | | | - Spyridon Bakas
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA.
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Viani GA, Gouveia AG, Moraes FY. In reply to Li et al. Letter to the editor. "Once daily (OD) versus twice-daily (BID) chemoradiation for limited stage small cell lung cancer (LS-SCLC): A meta-analysis of randomized clinical trials.". Radiother Oncol 2022; 177:245-246. [PMID: 36265684 DOI: 10.1016/j.radonc.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Gustavo A Viani
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Andre G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department - Americas Centro de Oncologia Integrado, Rio de Janeiro, RJ, Brazil
| | - Fabio Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
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Pucchio A, Rathagirishnan R, Caton N, Gariscsak PJ, Del Papa J, Nabhen JJ, Vo V, Lee W, Moraes FY. Exploration of exposure to artificial intelligence in undergraduate medical education: a Canadian cross-sectional mixed-methods study. BMC Med Educ 2022; 22:815. [PMID: 36443720 PMCID: PMC9703803 DOI: 10.1186/s12909-022-03896-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Emerging artificial intelligence (AI) technologies have diverse applications in medicine. As AI tools advance towards clinical implementation, skills in how to use and interpret AI in a healthcare setting could become integral for physicians. This study examines undergraduate medical students' perceptions of AI, educational opportunities about of AI in medicine, and the desired medium for AI curriculum delivery. METHODS A 32 question survey for undergraduate medical students was distributed from May-October 2021 to students to all 17 Canadian medical schools. The survey assessed the currently available learning opportunities about AI, the perceived need for learning opportunities about AI, and barriers to educating about AI in medicine. Interviews were conducted with participants to provide narrative context to survey responses. Likert scale survey questions were scored from 1 (disagree) to 5 (agree). Interview transcripts were analyzed using qualitative thematic analysis. RESULTS We received 486 responses from 17 of 17 medical schools (roughly 5% of Canadian undergraduate medical students). The mean age of respondents was 25.34, with 45% being in their first year of medical school, 27% in their 2nd year, 15% in their 3rd year, and 10% in their 4th year. Respondents agreed that AI applications in medicine would become common in the future (94% agree) and would improve medicine (84% agree Further, respondents agreed that they would need to use and understand AI during their medical careers (73% agree; 68% agree), and that AI should be formally taught in medical education (67% agree). In contrast, a significant number of participants indicated that they did not have any formal educational opportunities about AI (85% disagree) and that AI-related learning opportunities were inadequate (74% disagree). Interviews with 18 students were conducted. Emerging themes from the interviews were a lack of formal education opportunities and non-AI content taking priority in the curriculum. CONCLUSION A lack of educational opportunities about AI in medicine were identified across Canada in the participating students. As AI tools are currently progressing towards clinical implementation and there is currently a lack of educational opportunities about AI in medicine, AI should be considered for inclusion in formal medical curriculum.
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Affiliation(s)
- Aidan Pucchio
- School of Medicine, Queen's University, 15 Arch Street Kingston, Kingston, ON, K7L 3N6, Canada
| | - Raahulan Rathagirishnan
- School of Medicine, Queen's University, 15 Arch Street Kingston, Kingston, ON, K7L 3N6, Canada
| | - Natasha Caton
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Peter J Gariscsak
- School of Medicine, Queen's University, 15 Arch Street Kingston, Kingston, ON, K7L 3N6, Canada
| | - Joshua Del Papa
- School of Medicine, Queen's University, 15 Arch Street Kingston, Kingston, ON, K7L 3N6, Canada
| | - Jacqueline Justino Nabhen
- School of Medicine, Federal University of Paraná, Rua XV de Novembro, 1299 - Centro, Curitiba, PR, 80060-000, Brazil
| | - Vicky Vo
- Schulich School of Medicine & Dentistry, London, Ontario Canada Schulich School of Medicine & Dentistry, Western University, Clinical Skills Building, London, ON, N6A 5C1, Canada
| | - Wonjae Lee
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main Street West, Michael DeGroote Centre for Learning and Discovery - 3104, Hamilton, ON, L8S 4K1, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, 25 King St W, Kingston, ON, K7L 5P9, Canada.
- Kingston Health Sciences Centre, 25 King St W, Kingston, ON, K7L 5P9, Canada.
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Moraes FY, Gouveia AG, Lima RP, Bratti VF, Hamamura AC, Viani GA. Radiotherapy activity in the COVID 19 pandemic: Brazil's operational national-level study. J Cancer Policy 2022; 36:100367. [PMID: 36216270 PMCID: PMC9540705 DOI: 10.1016/j.jcpo.2022.100367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/26/2022] [Accepted: 10/05/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE During the COVID-19 pandemic, patients with cancer are at increased risk of not having timely diagnosis and access to cancer treatment. The present study evaluated the COVID-19 pandemic impact on radiotherapy activity in Brazil. METHODS A national-level study was performed to evaluate the RT utilization for prostate, breast, head & neck (HN), Gynecology (GYN), Gastrointestinal (GI), lung cancers, and bone/brain metastases. The data on the RT executed was extracted from the Brazilian Ministry of Health database. The NON-COVID period was considered the control group, and the comparison groups were COVID-2020 (without vaccine) and COVID-2021 (with vaccine). RESULTS We collected the data of 238,355 procedures executed on three periods. Significant difference in the RT utilization between NON-COVID and COVID-2020 were observed for prostate cancer, bone and brain metastases (-12.3 %, p = 0.02, +24 %, p = 0.02 and +14 %, p = 0.04, respectively). Comparing 2 equivalents months from NON-COVID-2019 (ref), COVID-2020, and COVID-2021, a significant increase was identified for bone and brain metastases (2020 +21 %, and 2021 +32 %), and (2020 +20 %, and 2021 +14 %). A stable drop occurred for prostate cancer (2020 -11 % and 2021 -10 %), and a variation was observed for breast (2020 +8 %, and 2021 -1 %) and lung cancer (2020 +10 %, and 2021 -3 %). For other cancers, non-significant changes were observed when comparing 2020 and 2021. CONCLUSION The RT activity was heterogeneously affected with a substantial increase for bone and brain metastases and a meaningful decline for prostate cancer. POLICY SUMMARY With a significant increase in the use of palliative radiotherapy for bone and brain metastases and a meaningful reduction in curative radiotherapy for prostate cancer, we hope these findings can help governments, RT services, medical communities, and other stakeholders develop strategies to mitigate the impact of the present and future pandemics. Finally, despite the changes imposed by the COVID pandemic, it is imperative to enhance screening, increase cancer diagnosis at an early stage, and improve access to all cancer treatments, including radiotherapy.
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Affiliation(s)
- Fabio Y Moraes
- Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Andre G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department - Americas Centro de Oncologia Integrado, Rio de Janeiro, RJ, Brazil
| | - Renato P Lima
- Radiation Oncology Department - Hospital Haroldo Juaçaba, Fortaleza, Ceará, Brazil
| | - Vanessa F Bratti
- Queen's University School of Medicine, Department of Public Health Sciences, Kingston, Canada
| | - Ana C Hamamura
- Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Gustavo A Viani
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil.
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Viani GA, Gouveia AG, Matsuura FK, Jacinto AA, Moraes FY. Once daily (OD) versus twice-daily (BID) chemoradiation for limited stage small cell lung cancer (LS-SCLC): A meta-analysis of randomized clinical trials. Radiother Oncol 2022; 173:41-48. [PMID: 35101470 DOI: 10.1016/j.radonc.2022.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 09/20/2021] [Revised: 12/27/2021] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Assess Once daily (OD) chemoradiation effectiveness for LS-SCLC compared with twice daily (BID) chemoradiation. METHODS AND MATERIALS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, eligible randomized clinical trials (RCT) comparing OD and BID were identified on electronic databases. A meta-analysis was performed to compare overall survival (OS), progression-free survival (PFS), and toxicity. A metaregression analysis was conducted to explore the influence of fractionation, biological effective dose (BED), the proportion of patients treated with prophylactic cranial irradiation (PCI), elective nodal irradiation (ENI), and the start of radiotherapy (week 1 or week 4). RESULTS Five RCTs with a total of 1941 patients (OD vs. BID) were included. The relative risk (RR) for OS and PFS was 0.97 (CI95% 0.8-1.1, p = 0.731) and 0.90 (CI95% 0.7-1.1, p = 0.20) at 3-years. In the metaregression analysis, hypofractionated radiotherapy schedules were associated with an improvement in overall survival (p = 0.03). The start of radiotherapy (W1 or W4), BED, and ENI had no significant effect on OS and PFS. The complete response rate partial response and overall response rate for BID vs OD were 40% vs. 33% (p = 0.97), 50% vs. 57% (p = 0.94), and 89% vs. 93% (p = 0.99). The rate of completed planned RT 96% vs. 94% (p = 0.66), and the % of ≥4 chemotherapy cycles received 74% vs. 74% (p = 0.99), did not differ between OD and BID. The local and distant failure rates were not significantly different between OD and BID 40% vs. 33% (p = 0.88) and 36% vs. 36% (p = 0.99). No difference in grade 2 or grade 3 pneumonitis and esophagitis was observed among the groups (p = NS). CONCLUSION For LS-SCLC, OD conventional chemoradiation results in similar outcomes to BID chemoradiation. In contrast, hypofractionated radiotherapy was associated with a better OS and PFS than BID. Additional randomized phase III trials exploring hypofractionation with systemic therapy are warranted to validate our findings.
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Affiliation(s)
- Gustavo A Viani
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Brazil.
| | - Andre G Gouveia
- Radiation Oncology Department - Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - Fernando K Matsuura
- Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Brazil
| | | | - Fabio Y Moraes
- Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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Moraes FY, Abreu CE, Siqueira GS, Haddad CK, Degrande FA, Hopman WM, Neves-Junior WF, Gadia R, Carvalho HA. Applying PET-CT for predicting the efficacy of SBRT to inoperable early-stage lung adenocarcinoma: A Brazilian case-series. Lancet Reg Health Am 2022; 11:100241. [PMID: 36778931 PMCID: PMC9903613 DOI: 10.1016/j.lana.2022.100241] [Citation(s) in RCA: 1] [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: 06/18/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is a treatment option for early-stage inoperable primary lung cancer. Here we report a thorough description of the prognostic value of pre-SBRT SUVmax for predicting the efficacy of SBRT in early-stage lung adenocarcinoma. METHODS This is a retrospective study of consecutive cases of early-stage inoperable lung adenocarcinoma, staged with PET-CT, treated with SBRT between 2007 and 17. Kaplan-Meier (KM) curves were used to assess overall survival and compare time to event between those with PET-CT SUVmax values ≤ 5.0 and those > 5. Fisher's Exact tests and the Mann-Whitney U were used to compare the patient and clinical data of those with SUVmax≤5.0 and >5.0, and those with and without any failure. FINDINGS Amongst 50 lung carcinoma lesions, from 47 patients (34 (68%)-T1a or <T1b), estimated median overall survival from the KM was 44.9 months (95% confidence interval 35.5-54.3). Five experienced a local failure, which was inadequate for detecting differences between those with PET-CT SUVmax ≤5.0 and those >5 (p = 0.112). In addition, 5 experienced a regional failure and 4 a distant failure. Higher PET-CT SUVmax values before SBRT were associated with an increased risk of any failure (36% versus 0%, p = 0.0040 on Fisher's Exact test) and faster time to event (p = 0.010, log rank test). Both acute and late toxicities profile were acceptable. INTERPRETATION Patients with early-stage inoperable lung adenocarcinoma present good clinical outcomes when treated with SBRT. We raised the hypothesis that the value of PET-CT SUVmax before SBRT may be an important predictive factor in disease control. FUNDING None.
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Affiliation(s)
- Fabio Y. Moraes
- Instituto de Ensino e Pesquisa do Hospital Sírio Libanês, R. Prof. Daher Cutait, 69 - Bela Vista, São Paulo, SP 01308-060, Brazil
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | | | | | - Cecilia K. Haddad
- Departamento de Radioterapia, Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Fabiana A.M. Degrande
- Departamento de Radioterapia, Hospital Sírio Libanês, São Paulo, SP, Brazil
- Departamento de Radioterapia, Hospital Santa Paula, São Paulo, SP, Brazil
| | - Wilma M. Hopman
- Department of Public Health Sciences, Queen's University, ON, Canada
| | | | - Rafael Gadia
- Departamento de Radioterapia, Hospital Sírio Libanês, Brasília, DF, Brazil
| | - Heloisa A. Carvalho
- Instituto de Ensino e Pesquisa do Hospital Sírio Libanês, R. Prof. Daher Cutait, 69 - Bela Vista, São Paulo, SP 01308-060, Brazil
- Departamento de Radioterapia, Hospital Sírio Libanês, São Paulo, SP, Brazil
- Departamento de Radiologia e Oncologia, Divisão de Radioterapia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Yan M, Zalay O, Kennedy T, Owen TE, Purzner J, Taslimi S, Purzner T, Alkins R, Moideen N, Fung AS, Moraes FY. Outcomes of Hypofractionated Stereotactic Radiotherapy for Small and Moderate-Sized Brain Metastases: A Single-Institution Analysis. Front Oncol 2022; 12:869572. [PMID: 35444935 PMCID: PMC9014302 DOI: 10.3389/fonc.2022.869572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/03/2022] [Indexed: 12/04/2022] Open
Abstract
Background Stereotactic radiosurgery (SRS) is the standard treatment for limited intracranial metastases. With the advent of frameless treatment delivery, fractionated stereotactic radiotherapy (FSRT) has become more commonly implemented given superior control and toxicity rates for larger lesions. We reviewed our institutional experience of FSRT to brain metastases without size restriction. Methods We performed a retrospective review of our institutional database of patients treated with FSRT for brain metastases. Clinical and dosimetric details were abstracted. All patients were treated in 3 or 5 fractions using LINAC-based FSRT, did not receive prior cranial radiotherapy, and had at least 6 months of MRI follow-up. Overall survival was estimated using the Kaplan–Meier method. Local failure and radionecrosis cumulative incidence rates were estimated using a competing risks model with death as the competing risk. Univariable and multivariable analyses using Fine and Gray’s proportional subdistribution hazards regression model were performed to determine covariates predictive of local failure and radionecrosis. Results We identified 60 patients and 133 brain metastases treated at our institution from 2016 to 2020. The most common histologies were lung (53%) and melanoma (25%). Most lesions were >1 cm in diameter (84.2%) and did not have previous surgical resection (88%). The median duration of imaging follow-up was 9.8 months. The median survival for the whole cohort was 20.5 months. The local failure at 12 months was 17.8% for all lesions, 22.1% for lesions >1 cm, and 13.7% for lesions ≤1 cm (p = 0.36). The risk of radionecrosis at 12 months was 7.1% for all lesions, 13.2% for lesions >1 cm, and 3.2% for lesions ≤1 cm (p = 0.15). Conclusions FSRT is safe and effective in the treatment of brain metastases of any size with excellent local control and toxicity outcomes. Prospective evaluation against single-fraction SRS is warranted for all lesion sizes.
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Affiliation(s)
- Michael Yan
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Osbert Zalay
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Thomas Kennedy
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Timothy E Owen
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - James Purzner
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Teresa Purzner
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Ryan Alkins
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Nikitha Moideen
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Andrea S Fung
- Department of Oncology, Division of Medical Oncology and Hematology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
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Viani GA, Gouveia AG, Moraes FY, Cury FL. "Meta-analysis of elective pelvic nodal irradiation using moderate hypofractionation for high-risk prostate cancer" (MENHYP-ENI). Int J Radiat Oncol Biol Phys 2022; 113:1044-1053. [PMID: 35430317 DOI: 10.1016/j.ijrobp.2022.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/19/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Despite several advances in planning and delivery of radiotherapy (RT) for prostate cancer, the role of elective pelvic nodal irradiation (EPNI) remains controversial for high-risk disease. We performed a meta-analysis to evaluate the outcomes of patients treated with moderate hypofractionated RT (MHF-RT) with EPNI using modern radiotherapy techniques. METHODS Eligible studies were identified on Medline, Embase, the Cochrane Library, and proceedings of annual meetings through October 2021. We followed the PRISMA and MOOSE guidelines. A meta-regression analysis was performed to assess a possible correlation between selected variables and outcomes. A p-value <0.05 was considered significant. RESULTS Eighteen studies with a total of 1745 patients, median follow-up 61 months, treated with EPNI employing MHF-RT were included. The biochemical relapse-free survival (bRFS) at 5-, 7- and 10-year was 90% (95% CI 88-94%), 83% (95%CI 78-91%) and 78% (95%CI 68-88%). The 5-year prostate cancer-specific survival, disease-free survival, distant metastases-free survival and overall survival were 98% (95%CI 97-99%), 88.7% (95%CI 85-93%), 91.2% (95%CI 88-92%), and 93% (95%CI 90-96%), respectively. The rates of local, pelvic, and distant recurrence were 0.38% (95%CI 0-2%), 0.13% (95%CI 0-1.5%), and 7.35% (95%CI 2-12%), respectively. The rate of late GI and GU toxicity grade ≥ 2 were 6.7% (95%CI 4-9%), and 11.3% (95%CI 7.6-15%), with heterogeneity, but with rare cases of toxicity grade 3-5. CONCLUSION EPNI with concomitant MHF-RT provides satisfactory bRFS in the long-term follow-up, with low rates of GU and GI severe toxicities and minimal pelvic and local failure.
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Affiliation(s)
- Gustavo A Viani
- Ribeirao Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirao Preto, Brazil.
| | - Andre G Gouveia
- Radiation Oncology Department, Americas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
| | - Fabio L Cury
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, McGill University, Montreal, Canada.
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Farina E, Nabhen JJ, Dacoregio MI, Batalini F, Moraes FY. An overview of artificial intelligence in oncology. Future Sci OA 2022; 8:FSO787. [PMID: 35369274 PMCID: PMC8965797 DOI: 10.2144/fsoa-2021-0074] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 06/11/2021] [Accepted: 01/19/2022] [Indexed: 11/23/2022] Open
Abstract
Cancer is associated with significant morbimortality globally. Advances in screening, diagnosis, management and survivorship were substantial in the last decades, however, challenges in providing personalized and data-oriented care remain. Artificial intelligence (AI), a branch of computer science used for predictions and automation, has emerged as potential solution to improve the healthcare journey and to promote precision in healthcare. AI applications in oncology include, but are not limited to, optimization of cancer research, improvement of clinical practice (eg., prediction of the association of multiple parameters and outcomes - prognosis and response) and better understanding of tumor molecular biology. In this review, we examine the current state of AI in oncology, including fundamentals, current applications, limitations and future perspectives.
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Affiliation(s)
- Eduardo Farina
- Department of Radiology, Federal University of São Paulo, SP, 04021-001, Brazil; Diagnósticos da America SA (Dasa), 05425-020, Brazil
| | - Jacqueline J Nabhen
- School of Medicine, Federal University of Paraná, Curitiba, PR, 80060-000, Brazil
| | - Maria Inez Dacoregio
- School of Medicine, State University of Centro-Oeste, Guarapuava, PR, 85040-167, Brazil
| | - Felipe Batalini
- Department of Medicine, Division of Medical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, ON, K7L 3N6, Canada
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Viani GA, Gouveia AG, Bratti VF, Pavoni JF, Sullivan R, Hopman WM, Booth CM, Aggarwal A, Hanna TP, Moraes FY. Prioritising locations for radiotherapy equipment in Brazil: a cross-sectional, population-based study and development of a LINAC shortage index. Lancet Oncol 2022; 23:531-539. [DOI: 10.1016/s1470-2045(22)00123-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 01/03/2023]
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Gyawali B, Carson LM, Berry S, Moraes FY. Challenges of globalization of cancer drug trials- recruitment in LMICs, approval in HICs. Lancet Reg Health Am 2021; 7:100157. [PMID: 36777649 PMCID: PMC9903727 DOI: 10.1016/j.lana.2021.100157] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Taslimi S, Brar K, Ellenbogen Y, Deng J, Hou W, Moraes FY, Glantz M, Zacharia BE, Tan A, Ahluwalia MS, Khasraw M, Zadeh G, Mansouri A. Comparative Efficacy of Systemic Agents for Brain Metastases From Non-Small-Cell Lung Cancer With an EGFR Mutation/ALK Rearrangement: A Systematic Review and Network Meta-Analysis. Front Oncol 2021; 11:739765. [PMID: 34950579 PMCID: PMC8691653 DOI: 10.3389/fonc.2021.739765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Brain metastases (BM) from non-small-cell lung cancer (NSCLC) are frequent and carry significant morbidity, and current management options include varying local and systemic therapies. Here, we performed a systematic review and network meta-analysis to determine the ideal treatment regimen for NSCLC BMs with targetable EGFR-mutations/ALK-rearrangements. METHODS We searched MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CENTRAL and references of key studies for randomized controlled trials (RCTs) published from inception until June 2020. Comparative RCTs including ≥10 patients were selected. We used a frequentist random-effects model for network meta-analysis (NMA) and assessed the certainty of evidence using the GRADE approach. Our primary outcome of interest was intracranial progression-free survival (iPFS). RESULTS We included 24 studies representing 19 trials with 1623 total patients. Targeted tyrosine kinase inhibitors (TKIs) significantly improved iPFS, with second-and third- generation TKIs showing the greatest benefit (HR=0.25, 95%CI 0.15-0.40). Overall PFS was also improved compared to conventional chemotherapy (HR=0.47, 95%CI 0.36-0.61). In EGFR-mutant patients, osimertinib showed the greatest benefit in iPFS (HR=0.32, 95%CI 0.15-0.69) compared to conventional chemotherapy, while gefitinib + chemotherapy showed the greatest overall PFS benefit (HR=0.26, 95%CI 0.10-0.70). All ALKi improved overall PFS compared to conventional chemotherapy, with alectinib having the greatest benefit (HR=0.13, 95%CI 0.07-0.24). CONCLUSIONS In patients with NSCLC BMs and EGFR/ALK mutations, targeted TKIs improve intracranial and overall PFS compared to conventional modalities such as chemotherapy, with greater efficacy seen using newer generations of TKIs. This data is important for treatment selection and patient counseling, and highlights areas for future RCT research. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=179060.
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Affiliation(s)
- Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yosef Ellenbogen
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Winston Hou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Fabio Y. Moraes
- Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Brad E. Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
| | - Aaron Tan
- Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Manmeet S. Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, NC, United States
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
- Penn State Cancer Institute, Hershey, PA, United States
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Ito E, Moraes FY, Ramotar M, Lunsky I, Soliman H, Catton CN, Kassam Z, Morton G, Tosoni S, Gospodarowicz M, Wong RKS, Liu FF, Chung PWM. Radiation Oncology Fellowship: a Value-Based Assessment Among Graduates of a Mature Program. J Cancer Educ 2021; 36:1295-1305. [PMID: 32683629 PMCID: PMC8605971 DOI: 10.1007/s13187-020-01767-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The University of Toronto - Department of Radiation Oncology (UTDRO) has had a well-established Fellowship Program for over 20 years. An assessment of its graduates was conducted to evaluate training experience and perceived impact on professional development. Graduates of the UTDRO Fellowship Program between 1991 and 2015 were the focus of our review. Current employment status was collected using online tools. A study-specific web-based questionnaire was distributed to 263/293 graduates for whom active e-mails were identified; questions focused on training experience, and impact on career progression and academic productivity. As a surrogate measure for the impact of UTDRO Fellowship training, a comparison of current employment and scholarly activities of individuals who obtained their Fellow of the Royal College of Physicians of Canada (FRCPC) designation in Radiation Oncology between 2000 and 2012, with (n = 57) or without (n = 230) UTDRO Fellowship training, was conducted. Almost all UTDRO Fellowship graduates were employed as staff radiation oncologists (291/293), and most of those employed were associated with additional academic (130/293), research (53/293), or leadership (68/293) appointments. Thirty-eight percent (101/263) of alumni responded to the online survey. The top two reasons for completing the Fellowship were to gain specific clinical expertise and exposure to research opportunities. Respondents were very satisfied with their training experience, and the vast majority (99%) would recommend the program to others. Most (96%) felt that completing the Fellowship was beneficial to their career development. University of Toronto, Department of Radiation Oncology Fellowship alumni were more likely to hold university, research, and leadership appointments, and author significantly more publications than those with FRCPC designation without fellowship training from UTDRO. The UTDRO Fellowship Program has been successful since its inception, with the majority of graduates reporting positive training experiences, benefits to scholarly output, and professional development for their post-fellowship careers. Key features that would optimize the fellowship experience and its long-term impact on trainees were also identified.
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Affiliation(s)
- Emma Ito
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Matthew Ramotar
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
| | - Isis Lunsky
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
| | - Hany Soliman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Charles N Catton
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Zahra Kassam
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Stronach Regional Cancer Centre, Newmarket, Ontario, Canada
| | - Gerard Morton
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sarah Tosoni
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
| | - Mary Gospodarowicz
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca K S Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Fei-Fei Liu
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Peter W M Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, M5G 2M9, Canada.
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Marta GN, de Arruda FF, Miranda FA, Silva ARNS, Neves-Junior WFP, Mancini A, Hanna SA, Abreu CECV, da Silva JLF, Nascimento JEV, Haddad CMK, Moraes FY, Gadia R. Stereotactic ablative radiation therapy for spinal metastases: experience at a single Brazilian institution. Rep Pract Oncol Radiother 2021; 26:756-763. [PMID: 34760310 DOI: 10.5603/rpor.a2021.0086] [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: 06/09/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022] Open
Abstract
Background This study aims to assess the clinical outcomes of patients with spine metastases who underwent stereotactic ablative radiation therapy (SABR) as part of their treatment. SABR has arisen as a contemporary treatment option for spinal metastasis patients with good prognoses. Materials and methods Between November 2010 and September 2018, Spinal SABR was performed in patients with metastatic disease in different settings: radical (SABR only), postoperative (after decompression and/or fixation surgery), and reirradiation. Local control (LC), pain control, overall survival (OS) and toxicities were reported. Results Eighty-five patients (corresponding to 96 treatments) with spine metastases were included. The median age was 59 years (range, 23-91). In most SA BR (82.3%, n = 79) was performed as the first local spine treatment, while in 12 settings (12.5%), fixation and/or decompression surgery was performed prior to SABR. Two-year overall survival rate was 74.1%, and median survival was 19 months. The LC rate at 2 years was 72.3%. With regard to pain control, among 67 patients presenting with pain before SA BR, 83.3% had a complete response, 12.1% had a partial response, and 4.6% had progression. Vertebral compression fractures occurred in 10 patients (11.7%), of which 5 cases occurred in the reirradiation setting. Radiculopathy and myelopathy were not observed. No grade III or IV toxicities were seen. Conclusion This is the first study presenting a Brazilian experience with spinal SA BR, and the results confirm its feasibility and safety. SABR was shown to produce good local and pain control rates with low rates of adverse events.
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Affiliation(s)
- Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | | | - Fabiana A Miranda
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - Alice R N S Silva
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | | | - Anselmo Mancini
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - Samir A Hanna
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - Carlos E C V Abreu
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | | | | | | | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University - Kingston Health Science Centre, Kingston, ON, Canada
| | - Rafael Gadia
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
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Abstract
OBJECTIVES To provide an overview of the achievements and future research with stereotactic body radiotherapy (SBRT) in prostate cancer. METHODS SBRT publications for prostate cancer were retrieved from the Web of Science and Dimension database. Bibliometric analyses were performed using VOSviewer and Prism graph. Analysis of variance test was used to compare the publication, citation, and the mean citation between specialty journals. Network maps were produced to identify authors' and countries' collaboration clusters. RESULTS Between 2006 and 2020, 574 publications fulfilling the inclusion criteria were identified, and a significant growth trend in publication (P<0.0001) and citation (P=0.001) number was recognized over the period. The United States was the most productive country with 253 (44.2%) articles. The RED Journal had the highest number of publications (14%) and citations (19%). Urology journals published (P=0.01) and cited significantly less than radiation oncology journals (P=0.01). All open access and non-open access number of publications increased over time, with a significant difference between non-open access and open access journals (P<0.0001). Two author clusters were identified, in the United States with the collaboration of Canadian and British authors, and in Italy with the participation of European authors. CONCLUSION The number of publications and citations on SBRT for prostate cancer has grown linearly in the last decades. The United States is the leading country in this research field, and the use of SBRT in oligometastatic disease, reirradiation, and salvage seems to be hot topics in this research field.
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Affiliation(s)
- Gustavo A Viani
- Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto Medical School, Ribeirão Preto
| | - Andre G Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, RJ, Brazil
| | | | - Fabio Y Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
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Brar K, Taslimi S, Ellenbogen Y, Deng J, Hou W, Moraes FY, Glantz M, Zacharia BE, Tan A, Ahluwalia MS, Khasraw M, Zadeh G, Mansouri A. Comparative Efficacy of Treatments for Brain Metastases from Non-Small Cell Lung Cancer without an EGFR-Mutation/ALK-Rearrangement: A Systematic Review and Network Meta-Analysis. World Neurosurg 2021; 158:e87-e102. [PMID: 34688937 DOI: 10.1016/j.wneu.2021.10.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/21/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION As many as 30% of patients with non-small cell lung cancer (NSCLC) will develop brain metastases (BMs) over the course of their illness. Here, we quantitatively compare the efficacy of the various emerging regimens for NSCLC BMs without a definitive targetable epidermal growth factor receptor mutation/ALK rearrangement. METHODS We searched MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CENTRAL, and references of key studies for randomized controlled trials (RCTs) published from inception until June 2020. Comparative RCTs that included ≥10 patients were included. We used a frequentist fixed or random-effects model for network meta-analysis. The outcomes of interest included intracranial progression-free survival (iPFS), overall survival (OS), and overall progression-free survival. RESULTS In total, 18 studies representing 17 trials (n = 2726 patients) were identified. Immune checkpoint inhibitor regimens showed significant improvement in OS compared with chemotherapy alone, including pembrolizumab and chemotherapy (6 studies, hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.21-0.62), atezolizumab alone (HR 0.54, 95% CI 0.33-0.89), and nivolumab and ipilimumab (HR 0.64, 95% CI 0.42-0.97). An improvement in overall PFS was seen with use of pembrolizumab and chemotherapy compared with chemotherapy alone (3 studies, HR 0.42, 95% CI 0.26-0.68). Studies evaluating checkpoint inhibitors did not report iPFS data, and we did not find improvement in iPFS or OS with the addition of any chemotherapy regimen to whole-brain radiation therapy. CONCLUSIONS In this network meta-analysis, we demonstrate the promising survival benefit with use of checkpoint inhibitor-based regimens in NSCLC BMs without a targetable epidermal growth factor receptor mutation/ALK rearrangement. Moving forward, large-scale BM-focused RCTs are necessary to establish the iPFS benefit of immune checkpoint inhibitor-based immunotherapy in this patient population.
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Affiliation(s)
- Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Yosef Ellenbogen
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Winston Hou
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Aaron Tan
- Division of Medical Oncology, National Cancer Center Singapore, Singapore
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, North Carolina, USA
| | - Gelareh Zadeh
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA.
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Viani GA, Gouveia AG, Louie AV, Korzeniowski M, Pavoni JF, Hamamura AC, Moraes FY. Stereotactic body radiotherapy to treat breast cancer oligometastases: A systematic review with meta-analysis. Radiother Oncol 2021; 164:245-250. [PMID: 34624408 DOI: 10.1016/j.radonc.2021.09.031] [Citation(s) in RCA: 11] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Stereotactic ablative radiotherapy (SABR) has been reported to be an effective treatment for oligometastatic disease from different primary cancer sites. Here we assess the effectiveness and safety of SABR for oligometastatic breast cancer patients by performing a meta-analysis. METHODS Following PRISMA and MOOSE guidelines, a systematic review and meta-analysis was performed. Eligible studies were identified on Medline, Embase, Cochrane Library, and annual meetings proceedings from 1990 to June 2021. A meta-regression analysis was performed to assess if there was a correlation between moderator variables and outcomes, and a p-value <0.05 was considered significant. RESULTS Ten studies met criteria for inclusion, comprising 467 patients and 653 treated metastases. The 1- and 2-year local control rates were 97% (95% CI 95-99%), and 90% (95% CI 84-94%), respectively. Overall survival (OS) was 93% (95% CI 89-96%) at 1 year, 81% (95% CI 72-88%) at 2 years. The rate of any grade 2 or 3 toxicity was 4.1 % (95% CI 0.1-5%), and 0.7% (0-1%), respectively. In the meta-regression analysis, only prospective design (p = 0.001) and bone-only metastases (p = 0.01) were significantly associated with better OS. In the subgroup analysis, the OS at 2y were significantly different comparing HER2+, HR+/HER2(-) and triple negative breast cancer 100%, 86% and 32%, p = 0.001. For local control outcomes, hormone receptor status (p = 0.01) was significantly associated on meta-regression analysis. CONCLUSION SABR for oligometastatic breast cancer is safe and associated with high rates of local control. Longer follow-up of existing data and ongoing prospective trials will help further define the role of this management strategy.
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Affiliation(s)
- Gustavo A Viani
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Andre G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department - Americas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Martin Korzeniowski
- Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
| | - Juliana F Pavoni
- Faculty of Philosophy, Letters and Natural Sciences, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Carolina Hamamura
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Fabio Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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Viani GA, Gouveia AG, Louie AV, Moraes FY. Stereotactic radiosurgery for brain metastases from small cell lung cancer without prior whole-brain radiotherapy: A meta-analysis. Radiother Oncol 2021; 162:45-51. [PMID: 34171453 DOI: 10.1016/j.radonc.2021.06.026] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Assess upfront Stereotactic radiosurgery (SRS) effectiveness for small cell lung cancer (SCLC) brain metastases (BM). Where possible, a comparison with whole-brain radiotherapy (WBRT) was performed. METHODS Following PRISMA and MOOSE guidelines, eligible studies were identified on Medline, Embase, Cochrane Library, and proceedings of annual meetings between inception and July 01, 2020. RESULTS Nine observational studies with 1638 patients were included. The median overall survival (OS) was 8.3 months (95% CI 7.1-9.5 months, I2 = 0%). OS rate at 12 months was 39% (95% CI 31-44%, I2 = 0%). The relative risk between SRS and WBRT for the OS at 12 months was 1.33 (95% CI 1.13-1.51, P = 0.0001). The projected OS for 6, 12, 18- and 24-months comparing SRS with WBRT was 67% vs. 57%, 39% vs. 29%, 22% vs. 15% and 15% vs 9%, favoring SRS (P < 0.001). The LC rate at 12 months was 93% (95% CI 91-94%, I2 = 0%). The distant brain failure rate (DBFR) at 12 months was 41% (95% CI 33-48%, I2 = 52%, P = 0.08). The SRS or WBRT as salvage treatment after upfront SRS was 32% and 19%, respectively. The freedom from neurologic death at 12 months was 87% (95% CI 84-89%). CONCLUSION Based on the pooling of a large sample of retrospective studies our meta-analysis suggests that for high selected SCLC patients with limited BM upfront SRS produces favorable lesion control and survival outcomes. These findings support the design of randomized clinical trial to confirm the role of SRS in this clinical scenario.
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Affiliation(s)
- G A Viani
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Brazil.
| | - A G Gouveia
- Radiation Oncology Department - Americas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - A V Louie
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - F Y Moraes
- Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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So J, Mamatjan Y, Zadeh G, Aldape K, Moraes FY. Transcription factor networks of oligodendrogliomas treated with adjuvant radiotherapy or observation inform prognosis. Neuro Oncol 2021; 23:795-802. [PMID: 33367753 DOI: 10.1093/neuonc/noaa300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/24/2022] Open
Abstract
BACKGROUND Recent international sequencing efforts have allowed for the molecular taxonomy of lower-grade gliomas (LGG). We sought to analyze The Cancer Genome Atlas (TCGA, 2015) gene expression datasets on molecularly defined oligodendrogliomas (IDH-mutated and 1p/19q-codeleted) patients treated with adjuvant radiation or those observed to discover prognostic markers and pathways. METHODS mRNA expression and clinical information of patients with oligodendroglioma were taken from the TCGA "Brain Lower Grade Glioma" provisional dataset. Transcription factor network reconstruction and analysis were performed using the R packages "RTN" and "RTNsurvival." Elastic net regularization and survival modeling were performed using the "biospear," "plsRCox," "survival" packages. RESULTS From our cohort of 137 patients, 65 received adjuvant radiation and 72 were observed. In the cohort that received adjuvant radiotherapy, a transcription factor activity signature, that correlated with hypoxia, was associated with shorter disease-free survival (DFS) (median = 45 months vs 108 months, P < .001). This increased risk was not seen in patients who were observed (P = .2). Within the observation cohort, a transcription factor activity signature was generated that was associated with poor DFS (median = 72 months. vs 143 months., P < .01). CONCLUSIONS We identified a transcription factor activity signature associated with poor prognosis in patients with molecular oligodendroglioma treated with adjuvant radiotherapy. These patients would be potential candidates for treatment intensification. A second signature was generated for patients who were more likely to progress on observation. This potentially identifies a cohort who would benefit from upfront adjuvant radiotherapy.
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Affiliation(s)
- Jonathan So
- Radiation Medicine Program, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Yasin Mamatjan
- Department of Laboratory Medicine and Pathobiology, Princess Margaret Cancer Centre, University of Toronto and MacFeeters-Hamilton Centre for Neuro-Oncology Research, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Department of Laboratory Medicine and Pathobiology, Princess Margaret Cancer Centre, University of Toronto and MacFeeters-Hamilton Centre for Neuro-Oncology Research, Toronto, Ontario, Canada.,Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth Aldape
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Fabio Y Moraes
- Department of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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Rodin D, Tawk B, Mohamad O, Grover S, Moraes FY, Yap ML, Zubizarreta E, Lievens Y. Hypofractionated radiotherapy in the real-world setting: An international ESTRO-GIRO survey. Radiother Oncol 2021; 157:32-39. [PMID: 33453312 DOI: 10.1016/j.radonc.2021.01.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [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: 08/27/2020] [Revised: 12/21/2020] [Accepted: 01/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Multiple large trials have established the non-inferiority of hypofractionated radiotherapy compared to conventional fractionation. This study will determine real-world hypofractionation adoption across different geographic regions for breast, prostate, cervical cancer, and bone metastases, and identify barriers and facilitators to its use. MATERIALS AND METHODS An anonymous, electronic survey was distributed from January 2018 through January 2019 to radiation oncologists through the ESTRO-GIRO initiative. Predictors of hypofractionation were identified in univariable and multivariable regression analyses. RESULTS 2316 radiation oncologists responded. Hypofractionation was preferred in node-negative breast cancer following lumpectomy (82·2% vs. 46·7% for node-positive; p < 0.001), and in low- and intermediate-risk prostate cancer (57·5% and 54·5%, respectively, versus 41·2% for high-risk (p < 0.001)). Hypofractionation was used in 32·3% of cervix cases in Africa, but <10% in other regions (p < 0.001). For palliative indications, hypofractionation was preferred by the majority of respondents. Lack of long-term data and concerns about local control and toxicity were the most commonly cited barriers. In adjusted analyses, hypofractionation was least common for curative indications amongst low- and lower-middle-income countries, Asia-Pacific, female respondents, small catchment areas, and in centres without access to intensity modulated radiotherapy. CONCLUSION Significant variation was observed in hypofractionation across curative indications and between regions, with greater concordance in palliation. Using inadequate fractionation schedules may impede the delivery of affordable and accessible radiotherapy. Greater regionally-targeted and disease-specific education on evidence-based fractionation schedules is needed to improve utilization, along with best-case examples addressing practice barriers and supporting policy reform.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada.
| | - Bouchra Tawk
- German Cancer Research Consortium, Core Site Heidelberg, German Cancer Research Center, Heidelberg, Germany; Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine and Heidelberg University Hospital, Heidelberg, Germany
| | - Osama Mohamad
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, United States
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, Canada
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, Australia; Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, Australia
| | | | - Yolande Lievens
- Ghent University Hospital and Ghent University, Ghent, Belgium
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Takami H, Nassiri F, Moraes FY, Zadeh G, Bernstein M, Conrad T, Berlin A, Laperriere N, Millar BA, Shultz DB, Kongkham P. A Phase II Study of Neoadjuvant Stereotactic Radiosurgery for Large Brain Metastases: Clinical Trial Protocol. Neurosurgery 2021; 87:403-407. [PMID: 31673708 DOI: 10.1093/neuros/nyz442] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 04/22/2019] [Accepted: 08/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Brain metastases which require resection are treated with surgery followed by whole brain radiation therapy or postoperative cavity boost stereotactic radiosurgery (POCBS). Recently a novel strategy using neoadjuvant stereotactic radiosurgery (NaSRS) followed by resection was reported, demonstrating lower rates of postoperative leptomeningeal dissemination (LMD) and symptomatic radiation toxicity compared to a comparative cohort of patients treated with postoperative SRS. OBJECTIVE To determine if the rate of symptomatic radiation toxicity at 1 yr in patients who receive NaSRS differs significantly from historical rates for patients treated with POCBS. METHODS This is a multi-center, non-randomized, open phase II clinical trial. A total of 30 patients with up to 10 brain metastases, at least 1 of which is appropriate for surgical resection, will be enrolled for over 4 yr. All enrolled patients will be assigned to receive NaSRS followed by surgery. EXPECTED OUTCOME This study will clarify whether symptomatic radiation toxicity caused by NaSRS is significantly decreased compared to historical rates associated with POCBS. Secondary endpoints will include 1-yr local control (LC) of the treated lesion, 1-yr rates of LMD, median survival and 2-yr rates of progression-free and overall survival. Tertiary analyses will include correlation between LC and radiation toxicity with pretreatment clinical factors, serum markers, radiomic features, and molecular assessments of the resected tumors. DISCUSSION This prospective study will determine the toxicity associated with NaSRS and provide additional quantitative metrics of efficacy for future comparative trials.
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Affiliation(s)
- Hirokazu Takami
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Fabio Y Moraes
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Tatiana Conrad
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - David Benjamin Shultz
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Paul Kongkham
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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Yan M, Gouveia AG, Cury FL, Moideen N, Bratti VF, Patrocinio H, Berlin A, Mendez LC, Moraes FY. Practical considerations for prostate hypofractionation in the developing world. Nat Rev Urol 2021; 18:669-685. [PMID: 34389825 PMCID: PMC8361822 DOI: 10.1038/s41585-021-00498-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
External beam radiotherapy is an effective curative treatment option for localized prostate cancer, the most common cancer in men worldwide. However, conventionally fractionated courses of curative external beam radiotherapy are usually 8-9 weeks long, resulting in a substantial burden to patients and the health-care system. This problem is exacerbated in low-income and middle-income countries where health-care resources might be scarce and patient funds limited. Trials have shown a clinical equipoise between hypofractionated schedules of radiotherapy and conventionally fractionated treatments, with the advantage of drastically shortening treatment durations with the use of hypofractionation. The hypofractionated schedules are supported by modern consensus guidelines for implementation in clinical practice. Furthermore, several economic evaluations have shown improved cost effectiveness of hypofractionated therapy compared with conventional schedules. However, these techniques demand complex infrastructure and advanced personnel training. Thus, a number of practical considerations must be borne in mind when implementing hypofractionation in low-income and middle-income countries, but the potential gain in the treatment of this patient population is substantial.
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Affiliation(s)
- Michael Yan
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
| | - Andre G. Gouveia
- Department of Radiation Oncology, Americas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - Fabio L. Cury
- grid.14709.3b0000 0004 1936 8649Department of Radiation Oncology, Cedars Cancer Centre, McGill University, Montreal, Canada
| | - Nikitha Moideen
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
| | - Vanessa F. Bratti
- grid.410356.50000 0004 1936 8331Queen’s University School of Medicine, Department of Public Health Sciences, Kingston, Canada
| | - Horacio Patrocinio
- grid.14709.3b0000 0004 1936 8649Department of Medical Physics, Cedars Cancer Centre, McGill University, Montreal, Canada
| | - Alejandro Berlin
- grid.17063.330000 0001 2157 2938Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Lucas C. Mendez
- grid.39381.300000 0004 1936 8884Department of Radiation Oncology, London Regional Cancer Program, Western University, London, Canada
| | - Fabio Y. Moraes
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
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Glicksman RM, Tjong MC, Neves-Junior WFP, Spratt DE, Chua KLM, Mansouri A, Chua MLK, Berlin A, Winter JD, Dahele M, Slotman BJ, Bilsky M, Shultz DB, Maldaun M, Szerlip N, Lo SS, Yamada Y, Vera-Badillo FE, Marta GN, Moraes FY. Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases: A Review. JAMA Oncol 2020; 6:567-577. [PMID: 31895403 DOI: 10.1001/jamaoncol.2019.5351] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Rising cancer incidence combined with improvements in systemic and local therapies extending life expectancy are translating into more patients with spinal metastases. This makes the multidisciplinary management of spinal metastases and development of new therapies increasingly important. Spinal metastases may cause significant pain and reduced quality of life and lead to permanent neurological disability if compression of the spinal cord and/or nerve root occurs. Until recently, treatments for spinal metastases were not optimal and provided temporary local control and pain relief. Spinal stereotactic ablative radiotherapy (SABR) is an effective approach associated with an improved therapeutic ratio, with evolving clinical application. Objective To review the literature of spinal SABR for spinal metastases, discuss a multidisciplinary approach to appropriate patient selection and technical considerations, and summarize current efforts to combine spinal SABR with systemic therapies. Evidence Review The MEDLINE database was searched to identify articles reporting on spinal SABR to September 30, 2018. Articles including clinical trials, prospective and retrospective studies, systematic reviews, and consensus recommendations were selected for relevance to multidisciplinary management of spinal metastases. Results Fifty-nine unique publications with 5655 patients who underwent SABR for spinal metastases were included. Four comprehensive frameworks for patient selection were discussed. Spinal SABR was associated with 1-year local control rates of approximately 80% to 90% in the de novo setting, greater than 80% in the postoperative setting, and greater than 65% in the reirradiation setting. The most commonly discussed adverse effect was development of a vertebral compression fracture with variable rates, most commonly reported as approximately 10% to 15%. High-level data on the combination of SABR with modern therapies are still lacking. At present, 19 clinical trials are ongoing, mainly focusing on combined modality therapies, radiotherapy prescription dose, and oligometastic disease. Conclusions and Relevance These findings suggest that spinal SABR may be an effective treatment option for well-selected patients with spinal metastases, achieving high rates of local tumor control with moderate rates of adverse effects. Optimal management should include review by a multidisciplinary care team.
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Affiliation(s)
- Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Kevin L M Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Mark Bilsky
- Department of Neurosurgery, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcos Maldaun
- Division of Neurosurgery, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Yoshiya Yamada
- Department of Radiation Oncology, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.,Division of Radiation Oncology, Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Y Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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Tjong MC, Moraes FY, Yamada Y, Brar S, Cederquist GY, Yorke E, Schmitt AM, Shultz DB. Radiation-induced Lumbosacral Plexopathy after Spine Stereotactic Body Radiotherapy - Should the Lumbosacral Plexi be Contoured? Clin Oncol (R Coll Radiol) 2020; 32:884-886. [PMID: 33082091 DOI: 10.1016/j.clon.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022]
Affiliation(s)
- M C Tjong
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - F Y Moraes
- Department of Radiation Oncology, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Y Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Brar
- Division of Surgical Oncology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - G Y Cederquist
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - E Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - A M Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - D B Shultz
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
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Goldberg H, Glicksman R, Woon D, Hoffman A, Shaikh H, Chandrasekar T, Klaassen Z, Wallis CJD, Ahmad AE, Sanmamed-Salgado N, Qu X, Moraes FY, Diamandis EP, Berlin A, Fleshner NE. Can post-treatment free PSA ratio be used to predict adverse outcomes in recurrent prostate cancer? BJU Int 2020; 127:654-664. [PMID: 32926761 DOI: 10.1111/bju.15236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/16/2022]
Abstract
OBJECTIVES To assess whether free PSA ratio (FPSAR) at biochemical recurrence (BCR) can predict metastasis, castrate-resistant prostate cancer (CRPC), and cancer-specific survival (CSS), following therapy for localised disease. PATIENTS AND METHODS A single-centre retrospective cohort study (NCT03927287) including a discovery cohort composed of patients with an FPSAR after radical prostatectomy (RP) or radiotherapy (RT) between 2000 and 2017. For validation, an independent Biobank cohort of patients with BCR after RP was tested. Using a defined FPSAR cut-off, the metastasis-free-survival (MFS), CRPC-free survival, and CSS were compared. Multivariable Cox models determined the association between post-treatment FPSAR, metastases, and CRPC. RESULTS Overall, 822 patients (305 RP- and 363 RT-treated patients and 154 Biobank patients) were analysed. In the RP cohort, a total of 272/305 (89.1%) and 33/305 (10.9%) had a FPSAR test incidentally and reflexively, respectively. In the RT cohort, 155/363 (42.7%) and 208/263 (57.3%) had a FPSAR test incidentally and reflexively, respectively. However, in the prospective Biobank RP cohort, FPSAR testing was done on all samples of patients diagnosed with BCR. A FPSAR cut-off of 0.10 was determined using receiver operating characteristic analyses in both the RP and RT cohorts. A FPSAR of <0.10 resulted in longer median MFS (14.8 vs 9.3 years and 14.8 vs 13 years, respectively), and longer median CRPC-free survival (median not reached vs 9.9 years and 20.7 vs 13.8 years, respectively). Multivariable analyses showed that a FPSAR of ≥0.10 was associated with increased metastasis in the RP cohort (hazard ratio [HR] 1.915, 95% confidence interval [CI] 1.241-2.955) and RT cohort (HR 1.754, 95% CI 1.112-2.769), and increased CRPC in the RP cohort (HR 2.470, 95% CI 1.493-4.088). Findings were validated in the Biobank cohort. CONCLUSIONS A post-treatment FPSAR of ≥0.10 is associated with more aggressive disease, suggesting a potentially novel role for this biomarker.
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Affiliation(s)
- Hanan Goldberg
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada.,Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Rachel Glicksman
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Dixon Woon
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - Ally Hoffman
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - Hina Shaikh
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - Thenappan Chandrasekar
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Zachary Klaassen
- Division of Urology, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA.,Georgia Cancer Center, Augusta, GA, USA
| | - Christopher J D Wallis
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - Ardalan E Ahmad
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - Noelia Sanmamed-Salgado
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Xuanlu Qu
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Fabio Y Moraes
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Eleftherios P Diamandis
- Department of Pathology and Laboratory Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Techna Institute, University Health Network, Toronto, ON, Canada
| | - Neil E Fleshner
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
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Warsi NM, Karmur BS, Brar K, Moraes FY, Tsang DS, Laperriere N, Kondziolka D, Mansouri A. The Role of Stereotactic Radiosurgery in the Management of Brain Metastases From a Health-Economic Perspective: A Systematic Review. Neurosurgery 2020; 87:484-497. [PMID: 32320030 DOI: 10.1093/neuros/nyaa075] [Citation(s) in RCA: 5] [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] [Received: 06/14/2019] [Accepted: 01/30/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is an effective option in the management of brain metastases, offering improved overall survival to whole-brain radiation therapy (WBRT). However, given the need for active surveillance and the possibility of repeated interventions for local/distant brain recurrences, the balance between clinical benefit and economic impact must be evaluated. OBJECTIVE To conduct a systematic review of health-economic analyses of SRS for brain metastases, compared with other existing intervention options, to determine the cost-effectiveness of this treatment across different clinical scenarios. METHODS The MEDLINE, EMBASE, Cochrane, CRD, and EconLit databases were searched for health-economic analyses, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using terms relevant to brain metastases and radiation-based therapies. Simple cost analysis studies were excluded. Quality analysis was based on BMJ Consolidated Health Economics Reporting Standards (CHEERS) checklist. RESULTS Eleven eligible studies were identified. For lesions with limited mass effect, SRS was more cost-effective than surgical resection (6 studies). In patients with Karnofsky performance scale (KPS) >70 and good predicted survival, SRS was cost-effective compared to WBRT (7 studies); WBRT became cost-effective with poor performance status or low anticipated life span. Following SRS, routine magnetic resonance imaging surveillance saved $1326/patient compared to symptomatic imaging due to reduced surgical salvage and hospital stay (1 study). CONCLUSION Based on our findings, SRS is cost-effective in the management of brain metastases, particularly in high-functioning patients with longer expected survival. However, before an optimal care pathway can be proposed, emerging factors such as tumor molecular subtype, diagnosis-specific graded prognostic assessment, neuroprognostic score, tailored surveillance imaging, and patient utilities need to be studied in greater detail.
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Affiliation(s)
- Nebras M Warsi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Brij S Karmur
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Fabio Y Moraes
- Division of Radiation Oncology, Department of Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Toronto, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Toronto, Canada
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York.,Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Alireza Mansouri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
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de Melo SM, Marta GN, Yan M, Cruz C, Moraes FY, Riera R. Management of elderly patients with glioblastoma: current status with a focus on the post-operative radiation therapy. Ann Palliat Med 2020; 9:3553-3561. [PMID: 32819127 DOI: 10.21037/apm-20-768] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/10/2020] [Indexed: 11/06/2022]
Abstract
Glioblastoma (GBM) is one of the most malignant primary intracranial neoplasms. This review aims to summarize the treatment of elderly patients with newly diagnosed GBM, with a focus on the radiation therapy (RT) approach. The available literature was reviewed, and we describe the most significant results relating to the post-operative approach of elderly GBM patients. Age limitations in randomized phase III studies have restricted the inclusion of elderly patients, and consequently, limited the generalizability of their results to this patient subset. Chronological age should not prohibit the best treatment, but instead, treatment decisions should consider patient functional status. RT showed efficacy and safety in the elderly population, without compromising quality of life. Hypofractionated RT is not inferior to standard RT. Reduction of overall RT schedule length mitigates the difficulties faced by elderly patients, improving treatment adherence. The addition of both concomitant and adjuvant temozolomide to standard RT is superior to either modality alone and should be the treatment of choice in the subset of patients with good/very good prognosis. It is reasonable to offer hypofractionated RT or temozolomide alone for poor prognosis, and best supportive care (BSC) for very poor prognosis elderly GBM patients. Although combined modality treatment is well established for the management of the good prognosis population, different RT schemes require further investigation with randomized controlled trials to determine the best regimen. A robust analysis of the molecular signatures of GBM in elderly patients might reveal opportunities for clinical protocol modifications to customize management in this group of patients.
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Affiliation(s)
- Suely Maymone de Melo
- Post-graduation Program of Evidence-based Health, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; 3 Department of Radiology and Oncology, Radiation Oncology Unit of University of São Paulo, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Michael Yan
- Department of Oncology, Division of Radiation Oncology, Queen's University - Kingston Health Science Centre, Kingston, ON, Canada
| | - Carol Cruz
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, Brazil
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University - Kingston Health Science Centre, Kingston, ON, Canada
| | - Rachel Riera
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, Brazil; Center of Health Technological Assessment - Hospital Sírio-Libanês, Sao Paulo, Brazil
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45
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Dasgupta A, Moraes FY, Rawal S, Diamandis P, Shultz DB. Focal Leptomeningeal Disease with Perivascular Invasion in EGFR-Mutant Non-Small-Cell Lung Cancer. AJNR Am J Neuroradiol 2020; 41:1430-1433. [PMID: 32616581 DOI: 10.3174/ajnr.a6640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/07/2020] [Indexed: 11/07/2022]
Abstract
We report a previously undescribed pattern of brain metastases in patients with epidermal growth factor receptor-mutated non-small-cell lung cancer treated with tyrosine kinase inhibitors and radiation therapy. These highly distinct lesions appear to spread focally within the leptomeninges, with invasion along the perivascular spaces (FLIP). The survival of patients with FLIP was significantly better compared with patients with classic leptomeningeal disease (median survival, 21 versus 3 months; P = .003). It is unclear whether this pattern of growth is unique to epidermal growth factor receptor-mutated non-small-cell lung cancer.
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Affiliation(s)
- A Dasgupta
- From the Department of Radiation Oncology (A.D., F.Y.M., D.B.S.), Division of Neuroimaging, Joint Department of Medical Imaging (S.R.), and Department of Neuropathology (P.D.), Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada
| | - F Y Moraes
- From the Department of Radiation Oncology (A.D., F.Y.M., D.B.S.), Division of Neuroimaging, Joint Department of Medical Imaging (S.R.), and Department of Neuropathology (P.D.), Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada
| | - S Rawal
- From the Department of Radiation Oncology (A.D., F.Y.M., D.B.S.), Division of Neuroimaging, Joint Department of Medical Imaging (S.R.), and Department of Neuropathology (P.D.), Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada
| | - P Diamandis
- From the Department of Radiation Oncology (A.D., F.Y.M., D.B.S.), Division of Neuroimaging, Joint Department of Medical Imaging (S.R.), and Department of Neuropathology (P.D.), Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada
| | - D B Shultz
- From the Department of Radiation Oncology (A.D., F.Y.M., D.B.S.), Division of Neuroimaging, Joint Department of Medical Imaging (S.R.), and Department of Neuropathology (P.D.), Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada.
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46
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Moraes FY, Winter J, Atenafu EG, Dasgupta A, Raziee H, Coolens C, Millar BA, Laperriere N, Patel M, Bernstein M, Kongkham P, Zadeh G, Conrad T, Chung C, Berlin A, Shultz DB. Outcomes following stereotactic radiosurgery for small to medium-sized brain metastases are exceptionally dependent upon tumor size and prescribed dose. Neuro Oncol 2020; 21:242-251. [PMID: 30265328 DOI: 10.1093/neuonc/noy159] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 12/14/2022] Open
Abstract
BACKGROUND At our institution, we have historically treated brain metastasis (BM) ≤2 cm in eloquent brain with a radiosurgery (SRS) lower prescription dose (PD) to reduce the risk of radionecrosis (RN). We sought to evaluate the impact of this practice on outcomes. METHODS We analyzed a prospective registry of BM patients treated with SRS between 2008 and 2017. Incidences of local failure (LF) and RN were determined and Cox regression was performed for univariate and multivariate analyses (MVAs). RESULTS We evaluated 1533 BM ≤2 cm. Median radiographic follow-up post SRS was 12.7 months (1.4-100). Overall, the 2-year incidence of LF was lower for BM treated with PD ≥21 Gy (9.3%) compared with PD ≤15 Gy (19.5%) (sub-hazard ratio, 2.3; 95% CI: 1.4-3.7; P = 0.0006). The 2-year incidence of RN was not significantly higher for the group treated with PD ≥21 Gy (9.5%) compared with the PD ≤15 Gy group (7.5%) (P = 0.16). MVA demonstrated that PD (≤15 Gy) and tumor size (>1 cm) were significantly correlated (P < 0.05) with higher rates of LF and RN, respectively. For tumors ≤1 cm, when comparing PD ≤15 Gy with ≥21 Gy, the risks of LF and RN are equivalent. However, for lesions >1 cm, PD ≥21 Gy is associated with a lower incidence of LF without significantly increasing the risk of RN. CONCLUSION Our results indicate that rates of LF or RN following SRS for BM are strongly correlated with size and PD. Based on our results, we now, depending upon the clinical context, consider increasing PD to 21 Gy for BM in eloquent brain, excluding the brainstem.
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Affiliation(s)
- Fabio Y Moraes
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeff Winter
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Archya Dasgupta
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Hamid Raziee
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Coolens
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Maitry Patel
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kongkham
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tatiana Conrad
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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47
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Moraes FY, Chen X, Yan M, Spratt DE, Redmond K, Jackson WC, Yamada YJ. Evolving Role of Stereotactic Body Radiation Therapy in the Management of Spine Metastases: Defining Dose and Dose Constraints. Neurosurg Clin N Am 2020; 31:167-189. [PMID: 32147009 DOI: 10.1016/j.nec.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/22/2022]
Abstract
When treating solid tumor spine metastases, stereotactic high-dose-per-fraction radiation, given in a single fraction or in a hypofractionated approach, has proved to be a highly effective and safe therapeutic option for any tumor histology, in the setting of de novo therapy, as salvage treatment of local progression after previous radiation, and in the postoperative setting. There are variations in practice based on the clinical presentation, goals of therapy, as well as institutional preferences. As a biologically potent therapy, a thoughtful and careful attention to detail with patient selection, treatment planning, and delivery is crucial for treatment success.
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Affiliation(s)
- Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Xuguang Chen
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Yan
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Kristen Redmond
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Yoshiya Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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48
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Lukovic J, Alfaraj FA, Mierzwa ML, Marta GN, Xu W, Su J, Moraes FY, Huang SH, Bratman SV, O'Sullivan B, Kim JJ, Ringash JG, Waldron J, de Almeida JR, Goldstein DP, Casper KA, Rosko AJ, Spector ME, Kowalski LP, Hope A, Hosni A. Development and validation of a clinical prediction-score model for distant metastases in major salivary gland carcinoma. Ann Oncol 2020; 31:295-301. [PMID: 31959347 DOI: 10.1016/j.annonc.2019.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 09/07/2019] [Revised: 10/15/2019] [Accepted: 10/25/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The most common pattern of failure in major salivary gland carcinoma (SGC) is development of distant metastases (DMs). The objective of this study was to develop and validate a prediction score for DM in SGC. PATIENTS AND METHODS Patients with SGC treated curatively at four tertiary cancer centers were divided into discovery (n = 619) and validation cohorts (n = 416). Multivariable analysis using competing risk regression was used to identify predictors of DM in the discovery cohort and create a prediction score of DM; the optimal score cut-off was determined using a minimal P value approach. The prediction score was subsequently evaluated in the validation cohort. The cumulative incidence and Kaplan-Meier methods were used to analyze DM and overall survival (OS), respectively. RESULTS In the discovery cohort, DM predictors (risk coefficient) were: positive margin (0.6), pT3-4 (0.7), pN+ (0.7), lymphovascular invasion (0.8), and high-risk histology (1.2). High DM-risk SGC was defined by sum of coefficients greater than two. In the discovery cohort, the 5-year incidence of DM for high- versus low-risk SGC was 50% versus 8% (P < 0.01); this was similar in the validation cohort (44% versus 4%; P < 0.01). In the pooled cohorts, this model performed similarly in predicting distant-only failure (40% versus 6%, P < 0.01) and late (>2 years post surgery) DM (22% versus 4%; P < 0.01). Patients with high-risk SGC had an increased incidence of DM in the subgroup receiving postoperative radiation therapy (46% versus 8%; P < 0.01). The 5-year OS for high- versus low-risk SGC was 48% versus 92% (P < 0.01). CONCLUSION This validated prediction-score model may be used to identify SGC patients at increased risk for DM and select those who may benefit from prospective evaluation of treatment intensification and/or surveillance strategies.
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Affiliation(s)
- J Lukovic
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - F A Alfaraj
- Department of Radiation Oncology, BC Cancer Agency Centre for the North, Prince George, Canada
| | - M L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - G N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - W Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - J Su
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - F Y Moraes
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - S H Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - S V Bratman
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - B O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - J J Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - J G Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - J Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - J R de Almeida
- Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - D P Goldstein
- Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - K A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, USA
| | - A J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, USA
| | - M E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, USA
| | - L P Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
| | - A Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada
| | - A Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Canada.
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Brierley J, O'Sullivan B, Asamura H, Byrd D, Huang SH, Lee A, Piñeros M, Mason M, Moraes FY, Rösler W, Rous B, Torode J, van Krieken JH, Gospodarowicz M. Global Consultation on Cancer Staging: promoting consistent understanding and use. Nat Rev Clin Oncol 2019; 16:763-771. [PMID: 31388125 PMCID: PMC7136160 DOI: 10.1038/s41571-019-0253-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 01/06/2023]
Abstract
Disease burden is the most important determinant of survival in patients with cancer. This domain, reflected by the cancer stage and codified using the tumour-node-metastasis (TNM) classification, is a fundamental determinant of prognosis. Accurate and consistent tumour classification is required for the development and use of treatment guidelines and to enable clinical research (including clinical trials), cancer surveillance and control. Furthermore, knowledge of the extent and stage of disease is frequently important in the context of translational studies. Attempts to include additional prognostic factors in staging classifications, in order to facilitate a more accurate determination of prognosis, are often made with a lack of knowledge and understanding and are one of the main causes of the inconsistent use of terms and definitions. This effect has resulted in uncertainty and confusion, thus limiting the utility of the TNM classification. In this Position paper, we provide a consensus on the optimal use and terminology for cancer staging that emerged from a consultation process involving representatives of several major international organizations involved in cancer classification. The consultation involved several steps: a focused literature review; a stakeholder survey; and a consultation meeting. This aim of this Position paper is to provide a consensus that should guide the use of staging terminology and secure the classification of anatomical disease extent as a distinct aspect of cancer classification.
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Affiliation(s)
- James Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | - David Byrd
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Anne Lee
- Department of Clinical Oncology, The University of Hong Kong and the University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Marion Piñeros
- Cancer Surveillance Section, International Agency for Research on Cancer, Lyon, France
| | | | - Fabio Y Moraes
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
- Department of Oncology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Wiebke Rösler
- Union for International Cancer Control (UICC), Geneva, Switzerland
| | - Brian Rous
- National Cancer Registration Service, London, UK
| | - Julie Torode
- Union for International Cancer Control (UICC), Geneva, Switzerland
| | | | - Mary Gospodarowicz
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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50
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Affiliation(s)
| | - Charles T Orjiakor
- Project PINK BLUE-Health & Psychological Trust Centre, Nigeria; Department of Psychology, University of Nigeria, Nsukka.
| | - Ian Pereira
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Canada
| | - Sampson C Ipiankama
- Project PINK BLUE-Health & Psychological Trust Centre, Nigeria; Department of Psychology, University of Nigeria, Nsukka
| | - David W Lounsbury
- Division of Community Collaboration and Implementation Science, Albert Einstein College of Medicine, USA
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Canada
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