An Integrative Medicine Educational Program for Radiation Oncology Patients: Patient-Reported Outcomes

Purpose

Complementary health approaches (CHAs) equip patients to self-manage radiation therapy (RT)-related symptoms and fulfill unmet needs, but few disclose CHA use to their radiation oncologist. An integrative medicine educational program (IMEP) was developed to assess its ability to improve patient self-efficacy for symptom management and CHA use disclosure.

Methods and Materials

The IMEP included 4 1-hour sessions covering topics of (1) meditation, (2) yoga, (3) massage therapy, and (4) nutrition. Individuals over age 18 years and actively receiving RT were administered presession and postsession surveys. The primary outcomes were intention to disclose CHA use and self-efficacy. Qualitative data were assessed with a thematic approach.

Results

Overall, 23 patients attended 1 or more sessions, yielding 43 completed surveys. Compared with 35.9% of participants who had disclosed CHA use before the session, 67.4% intended to disclose after the session. Of the 5 self-efficacy statements, there were significant improvements in "I have ownership over my health" (increase of 0.42; 95% CI, 0.07-0.77; P = .01), "I have tools to manage my disease on my own" (1.14; 95% CI, 0.42-1.87; P = .001), and "I have control over my cancer" (0.96; 95% CI, 0.39-1.53; P < .001). Barriers to involvement included transportation, timing relative to RT appointment, and poor performance status.

Conclusions

A radiation-specific IMEP resulted in a high rate of intention to disclose CHA use and improvements in patients' reported self-efficacy to manage radiation-related symptoms. However, substantial resources were needed to deliver the IMEP. Future work must focus on increasing accessibility through telehealth and flexible timing.

Long-term Outcomes after Salvage Stereotactic Radiosurgery (SRS) following In-Field Failure of Initial SRS for Brain Metastases

Purpose

The optimal treatment strategy following local recurrence after stereotactic radiosurgery (SRS) remains unclear. While upfront SRS has been extensively studied, few reports focus on outcomes after retreatment. Here, we report the results following a second course of SRS for local recurrence of brain metastases previously treated with SRS.

Methods

Using institutional database, patients who received salvage SRS (SRS2) following in-field failure of initial SRS (SRS1) for brain metastases were identified. Radionecrosis and local failure were defined radiographically by MRI following SRS2. The primary endpoint was defined as the time from SRS2 to the date of all-cause death or last follow-up [overall survival (OS)]. The secondary endpoints included local failure-free survival (LFFS) and radionecrosis-free survival, defined as the time from SRS2 to the date of local failure or radionecrosis, or last follow-up, respectively.

Results

Twenty-eight patients with 32 brain metastases were evaluated between years 2004 and 2015. The median interval between SRS1 and SRS2 was 9.7 months. Median OS was 22.0 months. Median LFFS time after SRS2 was 13.6 months. The overall local control rate following SRS2 was 84.4%. The 1- and 2-year local control rates are 88.3% (95% CI, 76.7–100%) and 80.3% (95% CI, 63.5–100%), respectively. The overall rate of radionecrosis following SRS2 was 18.8%. On univariate analysis, higher prescribed isodose line (p = 0.033) and higher gross tumor volume (p = 0.015) at SRS1 were associated with radionecrosis. Although not statistically significant, there was a trend toward lower risk of radionecrosis with interval surgical resection, fractionated SRS, lower total EQD2 (<50 Gy), and lack of concurrent systemic therapy at SRS2.

Conclusion

In select patients, repeat LINAC-based SRS following recurrence remains a reasonable option leading to long-term survival and local control. Radionecrosis approaches 20% for high risk individuals and parallels historic values.

Prediction of new brain metastases after radiosurgery: validation and analysis of performance of a multi-institutional nomogram

Stereotactic radiosurgery (SRS) without whole brain radiotherapy (WBRT) for brain metastases can avoid WBRT toxicities, but with risk of subsequent distant brain failure (DBF). Sole use of number of metastases to triage patients may be an unrefined method. Data on 1354 patients treated with SRS monotherapy from 2000 to 2013 for new brain metastases was collected across eight academic centers. The cohort was divided into training and validation datasets and a prognostic model was developed for time to DBF. We then evaluated the discrimination and calibration of the model within the validation dataset, and confirmed its performance with an independent contemporary cohort. Number of metastases (≥8, HR 3.53 p = 0.0001), minimum margin dose (HR 1.07 p = 0.0033), and melanoma histology (HR 1.45, p = 0.0187) were associated with DBF. A prognostic index derived from the training dataset exhibited ability to discriminate patients' DBF risk within the validation dataset (c-index = 0.631) and Heller's explained relative risk (HERR) = 0.173 (SE = 0.048). Absolute number of metastases was evaluated for its ability to predict DBF in the derivation and validation datasets, and was inferior to the nomogram. A nomogram high-risk threshold yielding a 2.1-fold increased need for early WBRT was identified. Nomogram values also correlated to number of brain metastases at time of failure (r = 0.38, p < 0.0001). We present a multi-institutionally validated prognostic model and nomogram to predict risk of DBF and guide risk-stratification of patients who are appropriate candidates for radiosurgery versus upfront WBRT.

A novel integrative medicine educational program for radiation oncology patients: Feasibility and patient-reported outcomes

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Background: Integrative medicine uses complementary health approaches (CHAs) to improve wellness. Many patients use CHAs to manage acute and late toxicities of radiotherapy (RT). However, few patients disclose CHA use to their radiation oncologist. Patients acknowledge a need for improved education on CHAs and have shown interest in attending a hospital-based educational program. Here we assess the feasibility of implementing such a program and the associated patient-reported outcomes, including intention to disclose CHA use and patient satisfaction. Methods: A structured curriculum was designed as a collaboration between an academic institution’s integrative medicine center and radiation oncology department. Four one-hour lectures covered topics of meditation, yoga, massage therapy, and nutrition, each led by a topic expert. Lectures included didactic and interactive components. Individuals over age 18 and actively receiving RT were recruited by nurses, radiation therapists, and a designated study team member in the waiting room. Pre- and post-lecture surveys were used to assess patient characteristics, CHA use disclosure, satisfaction, and qualitative feedback. Results: 43 surveys were completed. The patient sample was 47% female, median age 63. The majority had breast or prostate cancer (60%). Of about 100 patients receiving RT each day, 5 to 7 attended each lecture. 36% of participants had disclosed their use of CHAs before the lecture; 67% intended to disclose their use after the lecture. 98% felt the lecture enhanced their patient experience with a median agreement of 8 on a 9-point Likert scale. Conclusions: This program is the first to increase satisfaction and CHA use disclosure. Patients expressed interest in learning simple, convenient, and effective tools to abate acute toxicities, rather than focus on chronic symptoms of remission and recovery. However, patient recruitment could not be effectively integrated into the clinical workflow. Attendance was limited by timing, transportation, and performance status. To increase reach and minimize cost, we suggest investigating a program that is integrated into the clinic visit or available in an online format.

The role of radiation therapy in palliative care of children with advanced cancer: Clinical outcomes and patterns of care

BACKGROUND

There are few published data to guide the use and timing of palliative radiation therapy (RT) in children. We aimed to determine the clinical outcomes of palliative RT in children and the relationship with palliative care and hospice referrals.

PROCEDURE

A retrospective chart review was performed on all patients younger than 18 years who received palliative RT in our clinic from January 2005 to January 2015.

RESULTS

In the specified time period, 50 children underwent 83 courses of palliative RT. Median survival after treatment was 124 days (range, 1-1141 days). Fifteen courses were delivered to children in the last 30 days of life (dol). Palliative RT was successful in 89% of courses delivered before the last 30 dol versus 28% of courses delivered in the last 30 dol (p < 0.0001, Fisher's exact test). At the time of data collection, 43 children were deceased. Altogether, 88% of children who received palliative RT were also referred to our institution's pediatric palliative care team or to hospice at some time in their course. Of the children who died, 74% were referred to hospice and 34% were on hospice while receiving palliative RT. For children not already on hospice, the median time to hospice referral was 96 days after the last fraction (range, 0-924 days).

CONCLUSIONS

Palliative RT is effective in children with advanced cancer, although less so in the last 30 dol. With careful care coordination and multidisciplinary collaboration, RT can be successfully integrated into supportive and end-of-life care for children with advanced cancer.

A comparative analysis between sequential boost and integrated boost intensity-modulated radiation therapy with concurrent chemotherapy for locally-advanced head and neck cancer

BACKGROUND

Planning and delivery of IMRT for locally advanced head and neck cancer (LAHNC) can be performed using sequential boost or simultaneous integrated boost (SIB). Whether these techniques differ in treatment-related outcomes including survival and acute and late toxicities remain largely unexplored.

METHODS

We performed a single institutional retrospective matched cohort analysis on patients with LAHNC treated with definitive chemoradiotherapy to 69.3 Gy in 33 fractions. Treatment was delivered via sequential boost (n = 68) or SIB (n = 141). Contours, plan evaluation, and toxicity assessment were performed by a single experienced physician. Toxicities were graded weekly during treatment and at 3-month follow up intervals. Recurrence-free survival, disease-free survival, and overall survival were estimated via Kaplan-Meier statistical method.

RESULTS

At 4 years, the estimated overall survival was 69.3% in the sequential boost cohort and 76.8% in the SIB cohort (p = 0.13). Disease-free survival was 63 and 69% respectively (p = 0.27). There were no significant differences in local, regional or distant recurrence-free survival. There were no significant differences in weight loss (p = 0.291), gastrostomy tube placement (p = 0.494), or duration of gastrostomy tube dependence (p = 0.465). Rates of acute grade 3 or 4 dysphagia (82% vs 55%) and dermatitis (78% vs 58%) were significantly higher in the SIB group (p < 0.001 and p = 0.012 respectively). Moreover, a greater percentage of the SIB cohort did not receive the prescribed dose due to acute toxicity (7% versus 0, p = 0.028).

CONCLUSIONS

There were no differences in disease related outcomes between the two treatment delivery approaches. A higher rate of grade 3 and 4 radiation dermatitis and dysphagia were observed in the SIB group, however this did not translate into differences in late toxicity. Additional investigation is necessary to further evaluate the acute toxicity differences.

Initial radiographic tumor control is similar following single or multi-fractionated stereotactic radiosurgery for jugular paragangliomas

OBJECTIVE

To evaluate radiographic tumor control and treatment-related toxicity in glomus jugulare tumors treated with stereotactic radiosurgery (SRS).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic referral center.

PATIENTS

Glomus jugulare tumors treated with SRS between 1998 and 2014 were identified. The data analysis only included patients with at least 18months of post-treatment follow up (FU).

INTERVENTION

Patients were treated with either single fraction or fractionated SRS.

MAIN OUTCOME MEASURE

Patient demographics and tumor characteristics were assessed. Radiographic control was determined by comparing pre and post treatment MRI, and was categorized as no change, regression, or progression.

RESULTS

Eighteen patients were treated with SRS, and 14 met inclusion criteria. Median age at treatment was 55years (range 35-79), and 71.4% of patients were female. 5 patients (35.7%) received single fraction SRS (dose range 15-18Gy), and 9 (64.3%) fractionated therapy (dose 3-7Gy×3-15 fractions). Median tumor volume was 3.78cm(3) (range 1.15-30.6). Median FU was 28.8months (range 18.6-56.1), with a mean of 31.7months. At their last recorded MRI, 7 patients (50%) had tumor stability, 6 (42.9%) had improvement, and 1 (7.1%) had progression. Disease improvement and progression rates in the single fraction group were 40% and 0%, and in the multiple-fraction group, 44.4% and 11.1%, respectively. There was no statistically significant difference in disease improvement (p=0.88) or progression (p=0.48) rates between groups (unpaired t-test).

CONCLUSIONS

At a median follow up of 28months, both single fraction and fractionated SRS appear to have comparable radiographic tumor control outcomes and toxicity profiles.

The utilization of chemotherapy and radiation at the end of life in individuals with metastatic non-small cell lung cancer

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Background: Advancements in the diagnosis and treatment of metastatic non-small cell lung cancer (NSCLC) have contributed to improved quality of life and survival. However, these successes are matched with rising healthcare costs and a growing debate over the appropriate utilization of medical resources near the end of life. To date, the majority of utilization studies report outcomes based on single institution or Medicare models. This may lead to significant bias due to individual physician preferences, narrow age groups or single payer systems. The purpose of this study is to analyze the broader trends and variables impacting the use of chemotherapy (CHT) and radiation (XRT) in the final months of life. Methods: The Florida Cancer Data System (FCDS) was used to evaluate patients with Stage IV (M1) NCLC from 1995 to 2010. Logistic Regression was used to determine the association between insurance types, census-based socioeconomic status (SES) and demographic variables with XRT received or CHT received. Results: 48,858 patients were identified within the FCDS and eligible for this study. The median age was 69 years. The median survival was 4.8 months. The overall use of XRT decreased between 1995 and 2010 from 52% to 37%, while the use of CHT increased from 35% to 49%. The utilization of treatment during the final 60, 30 and 14 days of death was 28%, 13% and 5% respectively for XRT, and 18%, 8% and 4% for CHT. Neither insurance status (OR, 0.852; 95% CI, 0.721 -1.174) nor poverty status (OR, 1.026; 95% CI, 0.950 -1.109) was predictive for XRT received. Those classified as low SES (OR, 0.685, 95% CI, 0.633-0.741) or not insured (OR, 0.678, 95% CI, 0.572-0.804) were less likely to receive CHT. Older-unmarried-females were less likely to receive CHT and XRT compared to their younger-married-male counterparts. Conclusions: When examining a broader demographic and insurance mix, the utilization of XRT and CHT in the final 30 and 14 days of death remain low at 13% and 5% for radiation and 8% and 4% for chemotherapy consistent with previously reported studies. Younger-married-males were more likely to receive palliative treatments. Insurance and SES did not influence the delivery of XRT while they did impact the use of CHT.

The Refusal of Palliative Radiation in Metastatic Non-Small Cell Lung Cancer and Its Prognostic Implications

CONTEXT

Patients with metastatic non-small cell lung cancer (NSCLC) have limited survival. Population studies have evaluated the impact of radiation refusal in the curative setting; however, no data exist concerning the prognostic impact of radiation refusal in the palliative care setting.

OBJECTIVES

To investigate the patterns of radiation refusal in newly diagnosed patients with metastatic NSCLC.

METHODS

Patients with Stage IV NSCLC diagnosed between 1988 and 2010 were identified in the Surveillance, Epidemiology, and End Results database. Univariate and multivariate analyses were used to identify predictors for refusal of radiation and the impact of radiation and refusal on survival in the palliative setting.

RESULTS

A total of 285,641 patients were initially included in the analysis. Palliative radiation was recommended in 42% and refused by 3.1% of patients. Refusal rates remained consistent across included years of study. On multivariate analysis, older, nonblack/nonwhite, unmarried females were more likely to refuse radiation (P < 0.001 in all cases). Median survival for patients refusing radiation was three months vs. five months for those receiving radiation and two months for those whom radiation was not recommended.

CONCLUSION

Patients with metastatic NSCLC who refuse recommended palliative radiation have a poor survival. Radiation refusal or the recommendation against treatment can serve as a trigger for integrating palliative care services sooner and contributes greatly to prognostic awareness. Further investigation into this survival difference and the factors behind refusal are warranted.

Clinical and scientific impact of human papillomavirus on head and neck cancer

Head and neck cancer (HNC) arises from the skull base to the clavicles and is the fifth most common cancer in the world by incidence. Historically, in the developed world HNC was associated with tobacco use and alcohol consumption, and the combination of the two produced a synergistic increase in risk. However, beginning in 1983, investigators have found a significant and growing proportion of HNC patients with human papillomavirus-positive (HPV) tumors who neither drank nor used tobacco. Since that time, there has been increased interest in the molecular biology of HPV-positive HNC. Multiple studies now show that HPV has shifted the epidemiological landscape and prognosis of head and neck squamous cell carcinoma (HNSCC). These studies provide strong evidence for improved survival outcomes in patients with HPV-positive HNSCC compared to those with HPV-negative HNSCC. In many reports, HPV status is the strongest predictor of locoregional control, disease specific survival and overall survival. In response to these findings, there has been significant interest in the best management of HPV-positive disease. Discussions within major cooperative groups consider new trials designed to maintain the current strong survival outcomes while reducing the long-term treatment-related toxicities. This review will highlight the epidemiological, clinical and molecular discoveries surrounding HPV-related HNSCC over the recent decades and we conclude by suggesting how these findings may guide future treatment approaches.

Does radiation dose to the vestibule predict change in balance function and patient perceived dizziness following stereotactic radiotherapy for vestibular schwannoma?

OBJECTIVE

To date, the majority of the vestibular schwannoma (VS) literature has focused on tumor control rates, facial nerve function and hearing preservation. Other factors that have been shown to significantly affect quality-of-life (QOL), such as dizziness, remain understudied. The primary objective of the current study is to investigate the association between radiation dose to the vestibule and post-treatment changes in vestibular function and patient reported dizziness handicap.

MATERIALS AND METHODS

This is a prospective observational pilot study at a tertiary academic referral center including all subjects that underwent linear accelerator-based stereotactic radiotherapy (SRS) for sporadic VS and completed pre-treatment and post-treatment vestibular testing and Dizziness Handicap Inventory (DHI) questionnaires. Associations between objective vestibular test results, patient-reported DHI scores and radiation dose parameters were investigated.

RESULTS

Ten patients met inclusion criteria. Tumor control was achieved in all individuals. There were no statistically significant associations or identifiable trends between radiation dose and change in vestibular function or DHI scores. Notably, the four ears receiving the highest vestibular dose had minimal changes in vestibular function tests and DHI scores.

CONCLUSIONS

To the best of our knowledge, no previous reports have described the association between radiation dose to the vestibule and post-treatment changes in vestibular function and patient reported DHI. Based on these preliminary data, radiation dose to the vestibule does not reliably predict change in objective or subjective vestibular outcome measures.