Completion Of Primary Treatment Research Articles

Early Recurrence of Breast Cancer after the Primary Treatment: Analysis of Clinicopathological and Radiological Predictive Factors

목적유방암 일차치료 후 조기 재발 예측에 도움이 되는 임상병리학적 인자 및 원발암의 영상 의학적 특징을 알아보고자 하였다.대상과 방법본원에서 2010년 1월부터 2014년 12월까지 유방 보존 수술 및 보조요법 치료 후 추적관찰을 받은 480명을 대상으로 하였다. 일차치료 완결 후 3년 이내 재발한 경우를 조기 재발으로 정의하고, 이와 관련된 임상병리학적 및 영상의학적 예측인자를 알아보기 위해 단변량 및 다변량 로지스틱 회귀분석을 시행하였다.결과단변량 분석에서 임상병리학적 인자 중 높은 종양 병기(p=0.021), 고등급 조직학적 분화도(p < 0.001), estrogen receptor 수용체 음성(p=0.002), Ki-67 과발현(p=0.017), 삼중음성유방 아형(p=0.019)과, 영상 소견 중 유방암의 다초점성(p < 0.001), 도플러 검사에서 테두리 혈류(p=0.012), 자기공명영상에서 테두리 조영증강(p < 0.001)이 조기 재발과 유의한 연관성을 보였다. 다변량 분석에서 원발암의 높은 종양 병기[odds ratio (이하 OR) = 3.47, 95% confidence interval (이하 CI) 1.12~10.73, p=0.031]와 도플러 검사에서 테두리 혈류 (OR = 3.32, 95% CI 1.38~8.02,p=0.008)가 조기 재발과 관련된 독립적인 예측인자였다.결론유방암 치료 전 도플러 검사에서 원발암의 테두리 혈류 소견은 유방암의 일차치료 후 조기 재발의 독립적인 영상의학적 예측인자이다.

Disruptive Technology Enabled Healthcare 4.0 Model for Lesion Identification with Reduced Latency

Advancement and innovations in technology have resulted in ease of accessibility and availability of resources, resulting in an increased liability on health-care services. However, the application of healthcare services in rural and undeveloped areas remains a foremost challenge, despite the investments made, largely due to unreliable communication infrastructures. Machine learning (ML) has witnessed a terrific amount of attention over the last few years in the field of medical imaging research for the lesion detection through a biomedical application such as Magnetic Resonance Images (MRI), CT scan, X-rays and Ultrasound etc. Normally, an MRI or CT scan are used by the experts to produce images of the soft tissue of the human body. Early detection of the lesion is a crucial part of follow-up care after completion of primary treatment. The goal is to reduce the mortality rate by early detection and treating the disease while it is still curable assuming a more effective salvage surgery and treatment. This paper presents a comprehensive review of the automated classification learning algorithms to identify lesion; indicates how learning algorithms have been applied to biomedical applications from data acquisition to image retrieval and from segmentation to disease prediction. This paper provides a brief overview of recent innovations and challenges associated with learning algorithms applied to medical image processing and analysis. Lastly, the paper concludes with a concise discussion and tries to predict direction for upcoming trends on more advanced research studies on lesion detection.

402P - Work-related outcomes among cancer survivors in Singapore

BackgroundCancer survivors have been reported to face challenges as they return to work after completing antineoplastic treatment. In order to understand the burden of return-to-work challenges among cancer survivors in Singapore, we aim to describe the work-related outcomes, including employment rates, absenteeism and presenteeism, among local cancer survivors. MethodsThis was a cross-sectional study conducted at the National Cancer Centre Singapore in 2018. Breast cancer, colorectal cancer and lymphoma survivors who were in disease remission and have completed treatment for at least 6 months were recruited. Employment history and absenteeism data in the past 6 months were collected using self-administered questionnaires. Presenteeism was self-reported using the Work Limitations Questionnaire. ResultsA total of 501 patients were recruited. Most participants were Chinese (79.6%), followed by Malay (11.8%), Indian (4.6%) and other ethnicities (4.0%). Over half were breast cancer survivors (69.5%), followed by colorectal cancer (15.5%) and lymphoma (15.0%) survivors. The median age of the participants was 55.7 years (IQR: 50.1 to 60.5 years) while the median time after primary treatment completion was 3.7 years (IQR: 1.9 to 6.1 years). The majority of cancer survivors were employed with most participants reporting working full-time (47.5%), followed by part-time workers (10.2%) and self-employed individuals (5.8%). Out of the survivors who did not have paid employment, a substantial proportion (24.3%) were unemployed due to health-related reasons. Among employed participants, 56.9% reported taking time off work due to ill health or to see a physician in the past 6 months. The median absenteeism rate reported among working survivors was 0.8% of working time (range: 0 to 73.1%) while the median presenteeism or productivity loss at work due to health-related problems was reported to be 1.2% (range: 0 to 20.3%). ConclusionsA significant proportion of cancer survivors in Singapore require time off from work or leave employment due to health-related issues. Further studies should be conducted to identify survivors who are at high risk for return-to-work challenges and should be offered occupational rehabilitation. Legal entity responsible for the studyThe authors. FundingSingapore Cancer Society. DisclosureAll authors have declared no conflicts of interest.

Patients' and physicians' expectations differ significantly during the follow-up period after completion of primary treatment of gynecological or breast cancer

Patients' and physicians' expectations differ significantly during the follow-up period after completion of primary treatment of gynecological or breast cancer

Physical Symptoms, Unmet Needs, and Quality of Life in Thai Cancer Survivors after the Completion of Primary Treatment

Objectives:This study investigated physical symptoms, unmet supportive care needs, and quality of life (QoL) perception among different types of Thai cancer survivors who had completed first-line treatment.Methods:A cross-sectional study recruited breast, gynecological, colorectal, lung, and head and neck cancer survivors (n = 236) who were attending follow-up visits at a regional cancer hospital in central Thailand. Data were collected by the Physical Symptom Concerns Survey, the Cancer Survivors’ Unmet Needs Scale, and a single item measuring global QoL. Descriptive statistics, one-way analysis of variance (ANOVA), and Welch's ANOVA were used for data analysis.Results:Cancer survivors generally perceived good QoL, with significantly low QoL for lung cancer survivors (P < 0.001). There were no differences in symptom experiences among the five cancer groups, except for pain, which was significantly higher in lung cancer survivors than in the other four groups. The most frequently reported symptoms across all groups were numbness in the hands/feet, sleep disturbances, fatigue, and pain. The top unmet supportive care need among all participants was related to concerns of cancer recurrence (44.5%). Head and neck cancer survivors reported the highest number of unmet needs among the five cancer groups.Conclusions:This study mapped the unmet supportive care needs in Thai cancer patients and showed that patients with head and neck cancer and lung cancer were strongly affected. A survivorship care plan focusing on managing physical symptoms and providing supportive and psychosocial care should be developed to meet the needs of each cancer survivor group and to enhance QoL after the completion of treatment.

Multicentre, randomised controlled trial of adjuvant chemotherapy in cervical cancer with residual human papilloma virus DNA following primary radiotherapy or chemoradiotherapy: a study protocol

IntroductionThe role of adjuvant chemotherapy after radical radiotherapy (RT) or chemoradiotherapy (CRT) in cervical cancer awaits further confirmation. Evidences have shown that persistent human papilloma virus (HPV) DNA in exfoliated...

Second and third look laparoscopy in pT4 colon cancer patients for early detection of peritoneal metastases; the COLOPEC 2 randomized multicentre trial

BackgroundApproximately 20–30% of patients with pT4 colon cancer develop metachronous peritoneal metastases (PM). Due to restricted accuracy of imaging modalities and absence of early symptoms, PM are often detected at a stage in which only a quarter of patients are eligible for curative intent treatment. Preliminary findings of the COLOPEC trial (NCT02231086) revealed that PM were already detected during surgical re-exploration within two months after primary resection in 9% of patients with pT4 colon cancer. Therefore, second look diagnostic laparoscopy (DLS) to detect PM at a subclinical stage may be considered an essential component of early follow-up in these patients, although this needs confirmation in a larger patient cohort. Furthermore, a third look DLS after a negative second look DLS might be beneficial for detection of PM occurring at a later stage.MethodsThe aim of this study is to determine the yield of second look DLS and added value of third look DLS after negative second look DLS in detecting occult PM in pT4N0-2 M0 colon cancer patients after completion of primary treatment. Patients will undergo an abdominal CT at 6 months postoperative, followed by a second look DLS within 1 month if no PM or other metastases not amenable for local treatment are detected. Patients without PM will subsequently be randomized between routine follow-up including 18 months abdominal CT, or an experimental arm with a third look DLS provided that PM or incurable metastases are absent at the 18 months abdominal CT. Primary endpoint is the proportion of PM detected after a negative second look DLS and will be determined at 20 months postoperative.DiscussionSecond look DLS is supposed to result in 10% occult PM, and third look DLS after negative second look DLS is expected to detect an additional 10% of PM compared to routine follow-up alone in patients with pT4 colon cancer. Detection of PM at an early stage will likely increase the proportion of patients eligible for curative intent treatment and subsequently improve survival, given the uniformly reported direct association between the extent of peritoneal disease and survival.Trial registrationClinicalTrials.gov: NCT03413254, January 2018.

Long-Term Lung Function and Exercise Capacity in Postinfectious chILD.

Background: Severe postinfectious diffuse pulmonary disease may clinically mimic other entities of children's interstitial lung disease and is clinically challenging comprising various disease severities despite treatment. Long-term lung function trend and physical capacity in children with postinfectious diffuse pulmonary disease are rarely reported. We investigated trends in pulmonary function by long-term follow-up and assessed physical capacity in such patients.Methods: We performed a descriptive, single-center follow-up study in children with biopsy-verified postinfectious diffuse pulmonary disease. Patients with completed primary treatment course were eligible for follow-up, including pulmonary function and exercise (VO2peak) testing.Results: Thirty patients with postinfectious diffuse pulmonary disease were identified and included. Median (range) age at diagnose was 27.5 (2–172) months after a mean lag time of 23 months. H. influenzae and rhinovirus were the most frequent pathogens. Fifteen patients were available for follow-up after mean (range) 7.6 (2–15) years of treatment completion. Lung clearance index (LCI2.5), forced expiratory volume in 1 second (FEV1), and bronchodilator responsiveness were abnormal in 80%, 53%, and 44%, respectively. Diffusion capacity for monoxide was abnormal in 7% and total lung capacity in 33%. Only 8% demonstrated low VO2peak, while 40% reported difficulties during physical exertion. Longitudinal data on spirometry (n = 14) remained unchanged from end of treatment throughout follow-up. A significant association was found between zLCI2.5 and zFEV1 (multiple linear regression; r2 = 0.61; P = 0.0003).Conclusion: Postinfectious diffuse pulmonary disease in children carries a varying degree of chronic pulmonary impairment with onset of symptoms in the first months of life and a typical considerable lag time before diagnosis. Follow-up several years after the initial injury demonstrated moderate-to-severe peripheral airway impairment although no further lung function decline was found years after completion of treatment. Despite acceptable VO2peak, a considerable proportion struggled during heavy exercise.

Salvage High-Dose Rate (HDR) Brachytherapy as a Treatment for Locally Recurrent Prostate Cancer after Primary Radiation Therapy

Salvage brachytherapy is a treatment option for patients with locally recurrent prostate cancer following definitive radiotherapy. We report the tumor control and toxicity outcomes from using high-dose rate (HDR) brachytherapy (BT) alone for local salvage. Between 2013 and 2017, thirty-two patients with biopsy-proven (n = 23) or radiologically-evident (n = 9) locally recurrent prostate cancer were treated with salvage HDR brachytherapy. Dose-fractionation schedules included: 19Gy single fraction (n = 24), 15Gy single fraction (n = 5), 26Gy in two fractions (n = 2) and 31.5Gy in three fractions (n = 1). Three patients received treatment to the whole gland; the remaining 29 received focal therapy mapped according to combined pelvic magnetic resonance (MR) imaging and template biopsy findings (n = 21) or MR imaging alone (n = 8). The median time from completion of primary treatment to salvage HDR BT was 57 months. Seventeen patients received androgen deprivation therapy (ADT) as part of their primary treatment. In all cases, ADT had been discontinued prior to salvage HDR BT and was not re-commenced following the procedure. Biochemical progression-free survival (bPFS) using the Kaplan-Meier method was defined according to the Phoenix standard of nadir prostate-specific antigen (PSA) plus ≥2mg/ml. Acute and late genitourinary (GU) and gastrointestinal (GI) toxicities were evaluated using the Common Terminology Criteria for Adverse Events, version 4.0. Late toxicity was defined as that occurring ≥90 days after completion of salvage brachytherapy. Median follow-up after salvage HDR brachytherapy was 24 months. Median PSA nadir value was 0.8 reached at a median of 5 months from day of implant. The 2-year biochemical progression-free survival rate was 60.0%. The 2-year local relapse rate was 9.3% with 8 out of the 11 recurrences occurring at distant sites. Acute and late GU and GI toxicities are shown in Table 1. Two patients developed late grade 3 urinary toxicity, both urethral strictures requiring surgical correction. No late GI complications of grade 2 or higher were encountered with no reports of rectal fistulae or requirement for defunctioning colostomy.Abstract SU_28_2277; Table 1Number of patients presenting with acute (<90 days) and late (≥90 days) genitourinary and gastrointestinal toxicities following salvage high-dose rate brachytherapyToxicityACUTELATEGenitourinarynnGrade 1/22219Grade 302Grade 400GastrointestinalGrade 1/241Grade 300Grade 400 Open table in a new tab High-dose rate brachytherapy is an effective modality for the salvage treatment of locally recurrent prostate cancer with very good local control rates and an acceptable long-term toxicity profile. The high rate of distant relapse underscores the current challenge of accurate staging of systemic disease and appropriate patient selection in the salvage setting. The use of more sensitive imaging modalities such as PSMA-PET may improve this in the future.

Surveillance MRI for the detection of locally recurrent Ewing sarcoma seems futile.

To determine the frequency of locally recurrent Ewing sarcoma on surveillance MRI and the outcome of these patients. This retrospective single-center study included all patients with newly diagnosed Ewing sarcoma who underwent surveillance MRI of the primary tumor location after primary treatment between 1997 and 2016. Thirty-two patients underwent a total of 176 local surveillance MRI scans, yielding an average of 5.5 ± 4.4 MRI scans per patient. Follow-up time of surveillance MRI after completion of primary treatment ranged between 1 and 111months. Surveillance MRI detected five (15.6%) locally recurrent Ewing sarcomas, at 2, 4, 6, 6, and 7months after completion of primary treatment, of whom three also had simultaneous recurrent (metastatic) disease elsewhere. Two patients had recurrent metastatic disease without any signs of locally recurrent disease on surveillance MRI. All five patients with locally recurrent disease on surveillance MRI died, at 2, 4, 5, 8, and 9months after local recurrence detection. Patients with locally recurrent disease had a significantly worse overall survival than patients without locally recurrent disease (log-rank test, P < 0.0001). A limited number of patients have locally recurrent Ewing sarcoma on surveillance MRI. These patients often have simultaneous recurrent (metastatic) disease elsewhere, and their outcome is poor. Moreover, some patients present without locally recurrent disease on MRI but disease recurrence elsewhere. Therefore, surveillance MRI currently seems to have little value and should be reconsidered, also given the costs and the repeated exposure of surviving patients to gadolinium-based contrast agents.

Biomarkers of aging associated with past treatments in breast cancer survivors

Radiation and chemotherapy are effective treatments for cancer, but are also toxic to healthy cells. Little is known about whether prior exposure to these treatments is related to markers of cellular aging years later in breast cancer survivors. We examined whether past exposure to chemotherapy and/or radiation treatment was associated with DNA damage, telomerase activity, and telomere length 3–6 years after completion of primary treatments in breast cancer survivors (stage 0–IIIA breast cancer at diagnosis). We also examined the relationship of these cellular aging markers with plasma levels of Interleukin (IL)-6, soluble TNF-receptor-II (sTNF-RII), and C-reactive protein (CRP). Ninety-four women (36.4–69.5 years; 80% white) were evaluated. Analyses adjusting for age, race, BMI, and years from last treatment found that women who had prior exposure to chemotherapy and/or radiation compared to women who had previously received surgery alone were more likely to have higher levels of DNA damage (P = .02) and lower telomerase activity (P = .02), but did not have differences in telomere length. More DNA damage and lower telomerase were each associated with higher levels of sTNF-RII (P’s < .05). We found that exposure to chemotherapy and/or radiation 3–6 years prior was associated with markers of cellular aging, including higher DNA damage and lower telomerase activity, in post-treatment breast cancer survivors. Furthermore, these measures were associated with elevated inflammatory activation, as indexed by sTNF-RII. Given that these differences were observed many years after the treatment, the findings suggest a long lasting effect of chemotherapy and/or radiation exposure.

Cortisol Awakening Response as a Prospective Risk Factor for Depressive Symptoms in Women After Treatment for Breast Cancer.

The aim of the study was to investigate hypothalamic-pituitary-adrenal axis (HPA axis) functioning as a neurobiological risk factor for depressive symptoms in an ongoing longitudinal, observational study of women undergoing treatment and recovery from breast cancer. Many women with breast cancer experience depressive symptoms that interfere with their treatment, recovery, and quality of life. Psychosocial risk factors for depression among patients with cancer and survivors have been identified, yet neurobiological risk factors in this population remain largely unexamined. Women recently diagnosed with early-stage breast cancer (N = 135) were enrolled before starting neoadjuvant/adjuvant treatment (radiation, chemotherapy, endocrine therapy). At baseline, participants collected saliva samples to measure diurnal HPA axis functioning for 3 days: at waking, 30 minutes after waking, 8 hours after waking, and bedtime. Participants also completed a standardized measure of depressive symptoms (Center for Epidemiological Studies-Depression Scale) at baseline and 6 months after completion of primary treatment. Multivariate regression was used to predict continuous depressive symptoms at 6-month posttreatment from continuous depressive symptoms at baseline, cortisol awakening response (CAR), and other measures of diurnal HPA axis functioning. The magnitude of CAR predicted changes in depressive symptoms over time, such that women with a higher CAR showed a greater increase from baseline to 6-month posttreatment (b = 5.67, p = .023). Diurnal slope and total cortisol output were not associated with concurrent depressive symptoms or their change over time. Elevated CAR may be a neurobiological risk factor for increases in depressive symptoms in the months after breast cancer treatment and warrants further investigation.

“My Insides Feel Like Keith Richards’ Face”: A Narrative Analysis of Humor and Biographical Disruption in Young Adults’ Cancer Blogs

ABSTRACTIn this thematic narrative analysis, I examine how three young adult (YA) cancer survivors use humor and the five functions of illness-related storytelling in personal blogs maintained across the cancer trajectory to describe and counter their age-distinct biographical disruption. In 370 blog entries, YA narrators employed humor to facilitate biographical reconstruction and achieve “aligning moments” with audiences. Researchers and practitioners can use YA blogs to better understand the interpersonal health communication challenges associated with medical decision-making, altered social identities, the “void” following the completion of primary treatment, uncertainty about disclosure, and social isolation from other YA survivors.

Self‐management strategies used by head and neck cancer survivors following completion of primary treatment: A directed content analysis

Head and neck cancer (HNC) survivors encounter unique challenges following treatment. This study aimed to identify self-management strategies that HNC survivors use to overcome these posttreatment challenges. Twenty-seven individuals from 4 designated cancer centres in Ireland were interviewed about self-management strategies that helped them overcome challenges following HNC treatment. Interviews were audio-recorded, transcribed, and analysed using directed content analysis. Twenty self-management strategy types (encompassing 77 specific strategies) were identified. The most frequently used self-management strategy types were self-sustaining (used by 26 survivors), self-motivating (n=25), and proactive problem solving (n=25). The most frequently used specific strategies were adaptive approaches to ongoing physical consequences of HNC and its treatment (n=24), customising dietary practices (n=24), and maintaining a positive outlook (n=22). The study identified strategies that helped HNC survivors to self-manage posttreatment challenges. This information could inform the design/development of self-management interventions tailored towards HNC survivors.

Patterns of local-regional recurrence after conformal and intensity-modulated radiotherapy for head and neck cancer

AimTo evaluate the patterns of loco-regional recurrences in head and neck cancer patientsMethodsTwenty-six out of 112 patients treated with primary or postoperative 3D CRT or IMRT for their primary and recurrent disease between 2007 and 2013 were included. The CT images of recurrent disease were rigidly registered with the primary CT images for each patient. To assess overlaps and overlap localization, the recurrence volume overlapping with the primary target volume was identified. For relapses occurring in the regional lymph nodes, the epicenter distance in recurrences and primary volumes and dose in recurrences were also identified. The recurrences were defined as in-field, marginal or out-of-field.ResultsThe majority of the failures occurred within 1 year after completed primary treatment. The dose differences in recurrence volume were not statistically significant when patients were treated with IMRT or 3D CRT. Recurrence in 15/26 of the included patients occurred in the regional lymph nodes located fully or partly inside the primary target volume or the elective lymph node region. The majority of recurrences were recognized as in-field, independent of the primary treatment.ConclusionRecurrence in the majority of the patients occurred in the regional lymph nodes located in high dose area. The cause of recurrence may be due to inadequate total dose in the primary treatment and/or lack of optimal primary diagnosis leading to inadequate primary target delineation.

Phase 2 trial of brentuximab vedotin and gemcitabine for pediatric and young adult patients with relapsed or refractory Hodgkin lymphoma (HL): A Children’s Oncology Group (COG) report.

7527 Background: AHOD1221 (NCT01780662) tested Brentuximab vedotin (Bv) with gemcitabine (GEM) in children or young adults with HL. The primary objective was to describe the complete response (CR) rate within 4 cycles of therapy. Methods: Eligibility criteria included age ≤30 years; no prior Bv exposure; and primary refractory HL or advanced stage disease with early relapse. Each 21-day cycle consisted of Bv on day 1 at the recommended phase 2 dose (RP2D), 1.8 mg/kg and GEM 1000mg/m2 on days 1 and 8. Patients were evaluable for response if they completed 4 cycles of Bv+GEM, had a CR after 2 cycles, or progressive disease at any time. Response was assessed after even cycles, and confirmed by central review. CR was defined by FDG-PET negativity (Deauville 1-2) regardless of residual lesion size. Results: 42 patients were treated with Bv+GEM. Median age was 17.4 years (range 5.4-28.7), and 23 (55%) were female. The majority (n=35; 83%) had primary refractory disease or early relapse &lt;6 months after completion of primary treatment. Common (&gt;10%) adverse events included maculopapular rash (36% in cycle 1), neutropenia (33%) and elevated serum transaminases (21%). GCSF-stimulated peripheral blood stem cell (PBSC) collection was successful in all patients (n=23) for whom it was attempted, with median total collection of 9.4x106CD34+ cells/kg (range 3.5-36.8). 23 of 40 evaluable patients experienced a CR (58%; 95% CI 42-73%) within four cycles, and 6 had a partial response (PR), for an ORR of 73% (95% CI, 59-86%). For 4 patients with PR or stable disease, all target lesions were Deauville 3 or less after cycle 4, considered a CR by modern response criteria (Cheson et al. Blood 2016;128(21): 2489). Conclusions: Bv+GEM is a highly active combination for primary refractory or high-risk relapse of HL, with a CR rate exceeding that seen after either Bv (34%) or GEM (9%) alone. PBSCs can be collected successfully following Bv+GEM, making this an effective reinduction regimen when autologous stem cell transplantation is indicated. Compared to alternate retrieval regimens, Bv+GEM offers the advantage of avoiding agents associated with late treatment sequelae. Clinical trial information: NCT01780662.

Long-term survival of high-grade primary peritoneal papillary serous adenocarcinoma: a case report and literature review

BackgroundPrimary peritoneal papillary serous carcinoma (PPPSC) is an uncommon disease which has a high malignancy and a poor prognosis.Case presentationWe report here a long-term survival case of PPPSC with postoperative lung metastasis. A 62-year-old female patient with PPPSC was administered two cycles of neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) and six cycles of platinum-based (docetaxel + carboplatin) intraperitoneal chemotherapy postoperatively. The patient reached a complete remission at the completion of primary treatment. Malignant thoracic effusion and lung metastasis developed 5 months after the treatment. The patient underwent video-assisted thoracoscopic surgery plus hyperthermic intrapleural chemotherapy.ConclusionsUp to present, the patient has been survived with tumor for over 86 months with a good performance status, with only encapsulated effusion found at the latest follow-up. As a relatively new regime, the application of CRS + HIPEC in our patient has been proved example for MPE management, although more large-scale studies are needed to substantiate its efficiency and safety.

PP73. IS ROUTINE INTERVAL SURVEILLANCE IMAGING AFTER COMPLETION OF PRIMARY TREATMENT EFFECTIVE AT DETECTING RECURRENCE IN GBM PATIENTS?

AbstractINTRODUCTION: There is currently no evidence on the effectiveness of routine interval scanning compared to symptomatic scanning, of glioblastoma multiforme (GBM) patients, in detecting disease progression after completion of primary treatment. This issue has now been highlighted by the Neuro-Oncology Clinical Trials UK Research Network as a priority for clinical research. METHODS: We looked at all GBM patients treated at our unit from 2004 to 2012 (N=340), and analysed those who were scanned as part of the routine interval surveillance after completion of primary treatment (Stupp protocol) or those who were scanned due to symptoms, and correlated these with diagnosis of disease progression. RESULTS: Of the 340 GBM patients, 86 (25.3%) patients were commenced on adjuvant temozolomide (after surgery/biopsy and concurrent chemoradiotherapy) and only 38 (44.2%) patients completed all 6 cycles of adjuvant temozolomide. These patients then had further scans as part of the routine interval surveillance (145 scans), or if they became symptomatic (12 scans). More symptomatic scans compared to routine interval scans detected disease progression (58.3% vs 22.7%; P= 0.018). Median time to death after a progression scan was 5.7 ± 2.6 months. No patient had disease progression after a 5th stable routine interval surveillance scan. CONCLUSION: Routine interval surveillance imaging after completion of primary treatment may identify disease progression but whether this leads to better survival remains unproven. Frequent scans are costly, and “scanxiety” may affect quality of life; whether interval scanning is justified is up for debate, given that symptomatic scanning is more predictive of disease progression. The optimum frequency of interval scanning has also not been studied. More research using a larger dataset that could enable mathematical modelling is needed to clarify this important issue.

Clinical Indications and Impact on Management: Fourth and Subsequent Posttherapy Follow-up 18F-FDG PET/CT Scans in Oncology Patients.

The Centers for Medicare and Medicaid Services coverage includes 3 posttherapy 18F-FDG PET/CT scans per patient and per tumor type. Any additional follow-up 18F-FDG PET/CT scans will be reimbursed at the discretion of a local Medicare administrator, if deemed medically necessary. This study aimed to investigate common clinical indications for performing a fourth or additional follow-up 18F-FDG PET/CT scans that could affect the management of patients. Methods: This was a retrospective institutional review of 433 oncology patients (203 men; mean age, 55 y), including a total of 1,659 fourth or subsequent follow-up PET/CT scans after completion of primary treatment. Twelve indications for performing a fourth or subsequent follow-up PET/CT scan were determined, and the impact of each of the 12 indications on patients' management was evaluated. Results: The primary tumors were breast cancer (92 patients, 426 scans), non-Hodgkin lymphoma (77 patients, 208 scans), Hodgkin disease (41 patients, 182 scans), colorectal cancer (70 patients, 286 scans), melanoma (69 patients, 271 scans), and lung cancer (84 patients, 286 scans). The indications were categorized in 4 groups: PET/CT for diagnosis of tumor recurrence (303/1,659, 18.3%), PET/CT before starting therapy for tumor recurrence (64/1,659, 3.9%), PET/CT to assess therapy response for tumor recurrence (507/1,659, 30.6%), and follow-up PET/CT after completion of treatment for tumor recurrence (785/1,659, 47.3%). Overall, fourth and subsequent follow-up 18F-FDG PET/CT scans resulted in change in management in 31.6% of the scans (356 of 1,128) when the scans were obtained for medical necessities (indications 1-11), and in 5.6% of the scans (30/531) when the scans were obtained without any medical necessity (indication 12). Conclusion: The fourth and subsequent PET/CT scans obtained after completion of primary treatment led to a change in management in 31.6% of the scans when acquired for appropriate clinical reasons. Performing follow-up PET/CT without appropriate medical reason had a low impact on patients' management and should be avoided.

Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, or epithelial ovarian cancer: a Program in Evidence-Based Care guideline adaptation.

A need for follow-up recommendations for survivors of fallopian tube, primary peritoneal, or epithelial ovarian cancer after completion of primary treatment was identified by Cancer Care Ontario's Program in Evidence-Based Care. We searched for existing guidelines, conducted a systematic review (medline, embase, and cdsr, January 2010 to March 2015), created draft recommendations, and completed a comprehensive review process. Outcomes included overall survival, quality of life, and patient preferences. The Cancer Australia guidance document Follow Up of Women with Epithelial Ovarian Cancer was adapted for the Ontario context. A key randomized controlled trial found that the overall survival rate did not differ between asymptomatic women who received early treatment based on elevated serum cancer antigen 125 (ca125) alone and women who waited for the appearance of clinical symptoms before initiating treatment (hazard ratio: 0.98; 95% confidence interval: 0.80 to 1.20; p = 0.85); in addition, patients in the delayed treatment group reported good global health scores for longer. No randomized studies were found for other types of follow-up. We recommend that survivors be made aware of the potential harms and benefits of surveillance, including a discussion of the limitations of ca125 testing. Women could be offered the option of no formal follow-up or a follow-up schedule that is agreed upon by the woman and her health care provider. Education about the most common symptoms of recurrence should be provided. Alternative models of care such as nurse-led or telephone-based follow-up (or both) could be emerging options. The recommendations provided in this guidance document have a limited evidence base. Recommendations should be updated as further information becomes available.