Multivariate Variables Research Articles

Association of socioeconomic disadvantage with lower patient satisfaction at an academic radiation oncology center.

347 Background: The correlation between socioeconomic status and healthcare outcomes is well-established. Patient satisfaction serves as a crucial indicator of healthcare quality, however, it is unclear if patient satisfaction relates to patient socioeconomic status. To assess socioeconomic status, the Area Deprivation Index (ADI) is utilized, encompassing factors such as income, education, employment, and housing quality to measure the status of a neighborhood. The purpose of this study was to evaluate if there was a correlation between socioeconomic status and the likelihood a patient would recommend the facility or provider. Methods: This is a single-institution study evaluating the responses to a CMS approved patient satisfaction vendor survey of patients seen at an outpatient academic radiation oncology department from May 2021 through March 2023. ADI was collected using the Neighborhood Atlas, including both national percentiles and state deciles, with the higher values indicating greater socioeconomic disadvantage. Univariate (UVA) and multivariate (MVA) logistic regression analyses were conducted using the survey recommendation scores between 0 and 10 as the primary outcome. We used the score ≥9 to represent increased likelihood for recommendation for facility or provider and <9 represented decreased likelihood. Results: There were 5,403 survey results included in our analysis. The mean state and national ADI in our cohort were 3.9 (range 1-10) and 50.35, respectively. Patients with state and national ADI scores below the mean were more likely to recommend the provider than those above the mean, 95.6% versus 93.6% (p=0.002) and 95.8% versus 93.6% (p<0.001), respectively. There was no difference in the likelihood of recommending the facility between the groups. On univariate analysis state ADI <3.9 (OR 1.46, p=0.016) and national ADI <50.35 (OR 1.43, p=0.023) were associated with increased likelihood to recommend the facility or provider. On multivariate analysis, state ADI <3.9 (OR 1.44, p=0.018) and national ADI <50.35 (OR 1.40, p=0.033) remained significant. Conclusions: The findings of this study highlight the significance of socioeconomic status as an independent factor influencing patient satisfaction and their likelihood to recommend a healthcare provider. Providers should consider the unique needs of socioeconomically disadvantaged individuals.

Advancing Sampling Techniques: Multivariate Ratio Estimation for Variance Vector in Two-Phase Sampling

The problem of variance vector estimation using multi-auxiliary variables is not quite often considered in the literature. In the present study, we propose a multivariate ratio estimation approach for estimating a vector of variances in two-phase sampling using a vector of variables, following the situation if the desired parameters are available only for some of the auxiliary variables. Some special cases of the proposed generalized multivariate variance estimator have also been discussed. Expressions of the bias, and generalized variance has been derived. With the help of real-life data, the applicability of the proposed multivariate variance estimator has been given, and it is shown that the proposed multivariate estimator is more efficient than the modified versions of multivariate variance estimators. A simulation study has also been carried out to show that the proposed estimator surpasses the modified version of multivariate estimators.

Prospective Assessment of Bone Metabolism Biomarkers and Survival in Metastatic Castration-resistant Prostate Cancer Patients Treated with Radium-223: The PRORADIUM Study

BackgroundRadium-223 is an active therapy option for bone metastatic castration-resistant prostate cancer (mCRPC). The lack of adequate biomarkers for patient selection and response assessment are major drawbacks for its use. ObjectiveTo assess the prognostic value of bone metabolism biomarkers (BMBs) in ra-223–treated mCRPC patients. Design, setting, and participantsA prospective cohort study of mCRPC patients treated with Ra-223 (PRORADIUM study: NCT02925702) was conducted. Outcome measurements and statistical analysisThe main objective of the study was to evaluate the association between high (≥median) baseline values in at least three bone formation (bone alkaline phosphatase [BAP] and C-terminal type-I collagen propeptide) and bone resorption (N-terminal telopeptide and pyridinoline) biomarkers, and survival. The independent prognostic value of each BMB was also assessed. The association with time to radiographic, clinical, and prostate-specific antigen (PSA) progression; time to skeletal-related events; and PSA response were secondary objectives. Multivariable (MV) Cox-regression models were evaluated. Results and limitationsA total of 169 patients were included. Of the patients, 70.4% received Ra-223 in second/third line; 144 (85.2%) were Eastern Cooperative Oncology Group 0–1, 126 (74.6%) were in pain, and 80 (47.5%) had more than ten bone metastases. Sixty-seven (39.6%) patients had elevation in at least three BMBs. The median overall survival was 12.1 mo (95% confidence interval [CI]: 10–14.7). No association was observed with other treatment-related secondary outcome parameters. Patients with high values in three or more BMBs had significantly worse survival (9.9 vs 15.2 mo; hazard ratio [HR]: 1.8 [95% CI: 1.3–2.5]; p < 0.001) in the univariate analysis, but not independent in the MV analysis (HR: 1.33; 95% CI: 0.89–2; p = 0.181). High baseline BAP was the only biomarker associated with survival in the MV model (HR: 1.89; 95% CI: 1.28–2.79; p = 0.001). Addition of BAP to the MV clinical model increased the area under the receiver operating characteristic curve 2-yr value from 0.667 to 0.755 (p = 0.003). ConclusionsBiomarkers of bone formation, especially BAP, have prognostic value in mCRPC patients treated with radium-223. Its predictive value remains to be assessed, ideally in prospective, adequately powered, randomised clinical trials. Patient summaryIn this study, we evaluate the role of bone metabolism biomarkers to help improve the use of radium-223 as therapy for advanced prostate cancer. We found that bone alkaline phosphatase may be a suitable tool.

Dose-Escalated Radiation Therapy Is Associated With Improved Outcomes for High-Grade Meningioma

The optimal modern radiation therapy (RT) approach after surgery for atypical and malignant meningioma is unclear. We present results of dose escalation in a single-institution cohort spanning 2000 to 2021. Consecutive patients with histopathologic grade 2 or 3 meningioma treated with RT were reviewed. A dose-escalation cohort (≥66 Gy equivalent dose in 2-Gy fractions using an α/β=10) was compared with a standard-dose cohort (<66 Gy). Outcomes were progression-free survival (PFS), cause-specific survival, overall survival (OS), local failure (LF), and radiation necrosis. One hundred eighteen patients (111 grade 2, 94.1%) were identified; 54 (45.8%) received dose escalation and 64 (54.2%) standard dose. Median follow-up was 45.4 months (IQR, 24.0-80.0 months) and median OS was 9.7 years (Q1: 4.6 years, Q3: not reached). All dose-escalated patients had residual disease versus 65.6% in the standard-dose cohort (P < .001). PFS at 3, 4, and 5 years in the dose-escalated versus standard-dose cohort was 78.9%, 72.2%, and 64.6% versus 57.2%, 49.1%, and 40.8%, respectively, (P=.030). On multivariable analysis, dose escalation (hazard ratio [HR], 0.544; P=.042) was associated with improved PFS, whereas ≥2 surgeries (HR, 1.989; P=.035) and older age (HR, 1.035; P < .001) were associated with worse PFS. The cumulative risk of LF was reduced with dose escalation (P=.016). Multivariable analysis confirmed that dose escalation was protective for LF (HR, 0.483; P=.019), whereas ≥2 surgeries before RT predicted for LF (HR, 2.145; P=.008). A trend was observed for improved cause-specific survival and OS in the dose-escalation cohort (P < .1). Seven patients (5.9%) developed symptomatic radiation necrosis with no significant difference between the 2 cohorts. Dose-escalated RT with ≥66 Gy for high-grade meningioma is associated with improved local control and PFS with an acceptable risk of radiation necrosis.

ÜNİVERSİTE ÖĞRENCİLERİNDE KİNDARLIK DUYGUDURUMU İLE YAŞAM DOYUMU ARASINDAKİ İLİŞKİ

The aim of this study is to investigate the relationship between grudge mood in university students and their satisfaction with life. The study group consisted of a total of 520 university students, 320 of whom were female and 200 of whom were male. The study was carried out in two steps. In the first step, a development study was carried out to measure the grudge mood in individuals using the ‘Grudge Mood Scale." For this purpose, a item pool was created with the views of relevant literature and field workers. The created items were appilied to 335 university students and analyzed with Exploratory Factor Analysis. According to the Exploratory Factor Analysis, the scale consists of four sub-dimensions. This four-dimensional structure it was applied to 350 students and analyzed by Confirmatory Factor Analysis. The results of confirmatory factor analysis have shown that the fit indices of the scale indicate a good fit with a four-factor structure. To test the validity and reliability of the developed scale, internal consistency coefficient, split-half reliability, content validity, test-retest reliability, and scale-related validity analyses were conducted. As a result of the analyses, it was concluded that the developed 'Grudge Mood Scale' is a valid and reliable scale.&#x0D; In the second step of the research, the relationship between grudge mood and life satisfaction was examined. Grudge Mood Scale, Life Satisfaction Scale and Personal Information Form were used as data collection tools. After the normality examination of the data, the Pearson Moment Product Correlation and Multivariate Variance Analysis techniques were used. According to the results of the analysis, there is a negative and significant relationship between university students' grudge mood and life satisfaction. Furthermore, the relationship between grudge mood and life satisfaction varies significantly according to the students' genders. The findings obtained from this study were interpreted in the context of the literature and recommendations were made.

Comparing Patient Reported Satisfaction Following Telehealth and In-Person Medical Encounters

Telehealth patient encounters can increase access to healthcare and allow for its provision in a safe manner during pandemics. Telehealth is particularly important for oncology patients who might be at risk of severe infections during potential periodic increases of COVID-19 infections. There is a lack of studies examining the impact of telemedicine on quality of care. Herein, we report our recent institutional experience with patient reported satisfaction and engagement during telehealth encounters. Following each medical encounter in our radiation oncology department, patients are invited to complete a National Research Corporation (NRC) survey rating their satisfaction. We retrospectively analyzed the available survey results for patients who had a medical encounter between March 2020 and January 2022 at any of the four radiation oncology facilities within our institution. We examined patient responses to four questions including "provider would recommend" and "facility would recommend", both rated on a scale of 1-10, with 10 indicating the highest likelihood. The other two questions included "had enough input" into care, and "good communication with staff", both rated on a Likert scale from 1 to 4 (1 as "No", 2 as "Yes, somewhat", 3 as "Yes, mostly", 4 as "Yes, definitely"). We dichotomized the results for each question as favorable or unfavorable, with favorable being a score ≥9 for the first two questions, or ≥3 for the remaining questions. We used univariate (UVA) and multivariable (MVA) logistic regression analyses to compare telehealth and in-person encounters. Odds ratio (OR) were calculated for each question. We collected 5,672 surveys, of which 1,027 (18%) were for telehealth encounters. For all four of the examined categories in the survey, patients reported less satisfaction following telehealth visits compared to in-person visits in UVA and MVA logistic regression analyses. For MVA, we included type of encounter, patient age, patient race, patient sex, facility location, type of insurance, and year of visit. The MVA OR of a patient reporting < 9 for a telehealth compared to an in-person encounter were 1.46 ((95% CI 1.1-1.9, P 0.007) for "had enough input" into care, 1.46 (95% CI 1.1-1.9, P 0.007) for "good communication with staff", 1.43 (95% CI 1.1-1.86, P 0.007) for "facility would recommend", and 1.57 (95% CI 0.92-2.59, P 0.08) for provider would recommend. In this retrospective analysis, we found that patients were less likely to report high satisfaction with telehealth compared to in-person encounters. Further research is needed to address potential limitations of telemedicine encounters to increase access to health, particularly for patients at risk of severe infections, without compromising overall quality of care.

Racial and Ethnic Disparities in Health-Related Quality of Life for Patients with Colorectal Cancer: Analysis of the SEER-MHOS Linked Data Set

We hypothesized that racial and ethnic disparities exist in health-related quality of life (HRQOL) among older adults with colorectal cancer, both before and after diagnosis. The Surveillance, Epidemiology, and End Results and Medicare Health Outcomes Survey (SEER-MHOS) linked data set was used to identify patients 65 years old and above who were diagnosed with colorectal cancer between 1996 and 2015. Self-reported race/ethnicity, the predictor of interest, was categorized as White (W), Asian/Pacific Islander (API), Black/African American (B), or Hispanic (H). HRQOL data from the 36-Item Short Form Survey and Veterans RAND 12-Item Health Survey were extracted within 24 months pre- and post-diagnosis. HRQOL was measured using the Physical Component Summary (PCS), Mental Component Summary (MCS), and Total Component Summary (TCS, a summation of PCS and MCS), which were the response variables. Associations were assessed via univariable (UVA) and multivariable (MVA) linear regression analysis, adjusting for age, sex, region, marital status, education, income, number of comorbidities, limitations in activities of daily living, stage, and histology. Pairwise comparisons were performed between all racial and ethnic groups. We identified a total of 1,204 evaluable patients, with 815 in the pre-diagnosis cohort and 562 in the post-diagnosis cohort, including 173 patients in both. With unadjusted p-values, pre-diagnosis UVA revealed a higher mean PCS in API patients compared to W, B, and H patients (p<0.001, p<0.001, p = 0.02) as well as in W compared to H patients (p = 0.002); a higher mean MCS in W and API patients compared to B (p<0.001, p = 0.002) and H patients (p<0.001, p = 0.002); and a higher mean TCS in API compared to W, B, and H patients (p = 0.027, p<0.001, p<0.001) as well as in W compared to B and H patients (p<0.001, p = 0.012). Pre-diagnosis MVA revealed a higher mean PCS in API compared to B patients (p = 0.028) and a higher mean MCS in W and B compared to H patients (p = 0.022, p = 0.021). Post-diagnosis UVA showed a higher mean MCS in W compared to B and H patients (p<0.001 for both) as well as in API compared to H patients (p = 0.002), and a higher mean TCS in W and API patients compared to B (p<0.001, p = 0.045) and H patients (p<0.001, p = 0.007). Post-diagnosis MVA showed a higher mean MCS in API compared to H patients (p = 0.035). Compared to pre-diagnosis, post-diagnosis mean TCS was numerically lower for all groups. Among older adults with colorectal cancer, there appear to be racial and ethnic disparities in HRQOL. Before the cancer diagnosis, API patients had better physical HRQOL than B patients, while W and B patients had better mental HRQOL than H patients. After diagnosis, API patients had better mental HRQOL than H patients. For all groups, the cancer diagnosis seemed to have a negative impact on overall HRQOL.

Disease Characteristics, Treatment and Survival for Oropharyngeal Squamous Cell Carcinoma of Elderly

Incidence of oropharyngeal cancers (OP) has been increasing over the past few decades, mainly driven by human papilloma virus (HPV) associated cancers in younger men. However, a large number of OP patients in recent years are ≥65 years of age. We wanted to determine if there is a difference in outcomes in elderly patients with OP as compared to younger patients. We queried our institutional prospectively maintained head and neck cancer database for patients with non-metastatic OP treated between 1/2009-6/2020. We excluded patients who did not receive any definitive treatment. We analyzed clinicopathological and treatment characteristics for elderly (age at diagnosis ≥65 years) compared to young (<65 years) across HPV subtypes. We also studied survival endpoints among age groups using Kaplan-Meier curves and log-rank test. Independent predictors were estimated using multivariate (MVA) Cox regression models for each HPV subtype. We identified 340 patients who met our inclusion criteria: elderly 123 (36%) and young 213 (64%). The proportion of elderly HPV+ve patients showed an increasing trend over the years studied. Median age was 70 years (range 65-91) in elderly and 56 years (38-64) in young (p<0.001); and HPV+ve/-ve were 73.2/26.8% vs 74.6/25.3% for both age groups respectively (p = 0.86). Elderly patients had higher Charlson Comorbidity Index (CCI) and included more divorcees (p<0.05). There were more elderly current/former smokers (97% vs 82%; p = 0.007) within HPV-ve cases. Definitive radiotherapy (RT) +/- systemic therapy (CRT) was utilized in 73.2% (n = 249), while the remainder had surgery +/- adjuvant RT/CRT. There was no difference with age for OP subsite, 8th edition AJCC stage and treatment received except for more use of cetuximab (22.5% vs 10.2%; p<0.001) and weekly cisplatin (32.4% vs 25.8%; p<0.001) among elderly patients. After a median follow up of 5.24 years (IQR: 3.53), 3-year overall (OS) (HPV+ve: 85 vs 81%; HPV-ve: 39 vs 52%), locoregional free (LRFS) (HPV+ve: 86 vs 90%; HPV-ve: 67 vs 69%) and distant metastasis free (DMFS) survival (HPV+ve: 91 vs 90%; HPV-ve: 79 vs 81%) were all non-significant for elderly vs young respectively. On MVA, CCI and AJCC stage for HPV+ve; and smoking, T-stage and lymphovascular space invasion for HPV- were associated with OS. For HPV+ve, AJCC stage, adjuvant vs definitive RT and treatment in later years were predictive of better LRFS, whereas smoking index and extracapsular space invasion were deterministic for DMFS. Interestingly, outcomes among those who received cetuximab was similar to those who received concurrent cisplatin for all endpoints. We did not note any significant difference in outcomes among elderly patients treated for OP when compared to the younger patients when multi-disciplinary head and neck cancer care is provided. This was noted even though a significantly larger proportion of elderly patients received cetuximab concurrent with RT as opposed to standard of care cisplatin.

Non-Operative Management of Rectal or Anal Canal Adenocarcinoma: National Cancer Database Analysis of the Impact of Disease, Treatment, and Social Determinants of Health on Overall Survival

For select patients with rectal or anal canal adenocarcinoma (RA-ACA), a non-operative management (NOM) strategy utilizing definitive radiotherapy (RT) has emerged as an option with the goal to improve quality of life compared with surgical management while maintaining similar oncologic outcomes. Disease and treatment characteristics as well as social determinants of health have been associated with access to care and health outcomes, and we hypothesized that such factors would impact overall survival (OS) amongst patients who received a NOM approach. The purpose of this study was to explore the influence of patient demographics, disease characteristics, and social determinants of health on OS amongst those receiving NOM utilizing the National Cancer Database (NCDB). We identified patients at least 18 of years of age diagnosed with clinical stage 1-3 RA-ACA from 2004-2018. The NOM cohort included patients who received RT and either refused surgery or surgery was not recommended in their treatment. Patients were excluded if receipt of chemotherapy or RT were unknown, received RT to a site outside of the pelvis, or received palliative-intent treatment. OS was estimated using the Kaplan-Meier method. Univariable and multivariable (MVA) Cox proportional hazards model was used to assess characteristics associated with OS. Analyses were performed using STATA (version 17, College Station, TX). A p<0.05 was considered statistically significant. A total of 12,409 patients were identified as the NOM cohort. The median OS was 48.8 months (95% CI: 46.8-50.6). On MVA, variables associated with poorer OS included age ≥ 70 vs 50-69, male sex, Charlson-Deyo Score ≥ 1 vs 0, insurance status (no insurance, Medicaid or Medicare vs. private), geographical region (South, Midwest or West vs. Northeast), rural urban density vs metro/urban, treatment in a community facility vs academic, year of diagnosis (2004-2011 vs. 2012-2018), clinical T4 vs T1, clinical N1 or N2 vs N0, and grade 3 vs 1 (all p<0.05). Treatment with a RT dose < 45 Gy vs. 45-54 Gy (HR: 2.24, 95% CI: 2.07-2.44), but not > 55 Gy vs. 45-54 Gy, and omission of chemotherapy (HR: 1.28, 95% CI: 1.16-1.43) were associated with poorer OS. Patient, disease, treatment, and social determinants of health may influence OS amongst patients with RA-ACA who receive a NOM approach. Further work is needed to determine if the influence on OS can be explained, in part, by patients' lack of access to the intense surveillance necessary and/or the potential need for subsequent surgical management. Heightened awareness of these differential outcomes is needed to assist in patient selection and to successfully address barriers in access to optimize outcomes for patients who receive NOM.

The Effect of Package Time on Locally Advanced Oral Cavity Cancer Outcomes

Oral cavity cancer (OCC) with adverse pathologic features is treated with adjuvant radiation (RT) following definitive surgical resection. The 5-year overall survival (OS) in locally advanced OCC patients receiving adjuvant RT has remained stagnant at 60% for over 30 years. Although pathologic risk factors are well-established, the effect of clinical variables such as treatment package time (TPT) in the modern era of radiation and systemic agents is unclear. Examining a large, homogenous cohort of OCC patients, we hypothesized that TPT can predict OS and event free survival (EFS). A retrospective review of 359 adult patients with OCC treated with surgery and adjuvant RT with or without concurrent chemotherapy from 2012-2022 was performed at a single, high-volume center. Those without definitive surgery, treated to <50 Gy, or with a history of prior RT were excluded. TPT was defined as time from surgery to completion of RT. Other variables considered were sex, race, smoking status, AJCC 8 pathologic stage, perineural invasion (PNI), lymphovascular invasion (LVI), margin positivity, extranodal extension (ENE), and hospitalization between surgery and RT. Log rank tests were performed for OS and EFS where TPT was dichotomized into short (<97.5 days) and long (>97.5 days) groups based on the median TPT of the cohort. Univariate (UVA) and multivariate (MVA) cox regression analyses were performed for OS and EFS. A total of 234 patients met inclusion criteria. Median OS was 81.6 months. Median EFS was 50.0 months. Median OS was 51.1 months in the longer TPT group and was not reached in the shorter TPT group. Median EFS was greater with shorter TPT (72.6 vs 31.3 months). The longer TPT group had worse OS and EFS probabilities than the shorter TPT group (p = 0.006 and p = 0.059, respectively). On UVA, factors significantly associated with OS were TPT (p = 0.006), former/current smoker status (p = 0.003 and p = 0.011, respectively), pathologic stage IV (p<0.001), positive PNI (p<0.001) or LVI (p = 0.005), and ENE (p<0.001). On MVA for OS, shorter TPT (p = 0.026), former smoker status (p = 0.009), pathologic stage IV (p = 0.026), positive PNI (p = 0.009), and ENE (p = 0.05), remained significant. On UVA, factors significantly associated with EFS were former/current smoker status (p = 0.01/p = 0.04), pathologic stage IV (p<0.001), pT1/T2 (p = 0.018), positive PNI (p = 0.011) or ENE (p<0.001), and concurrent chemotherapy (p = 0.001). On MVA, former smoker status (p = 0.035) and positive PNI (p = 0.018) remained significant. Notably, of the 130 patients requiring hospitalization between surgery and radiation, 101 (78%) were prior/current smokers. In this large cohort of locally advanced OCC patients, TPT <97.5 days is associated with improved OS and EFS. Smoking history should be further explored for its potential contribution to treatment delay. Multidisciplinary coordination should be encouraged to minimize TPT.

Trends in Racial and Ethnicity Disparities in the Health-Related Quality of Life in Older Adults with Breast Cancer: A SEER-MHOS National Database Study

To examine racial and ethnic disparities in Health-Related Quality of Life (HRQOL) in older adults with breast cancer, both pre- and post-diagnosis. Using the Surveillance, Epidemiology and End Results-Medicare Health Outcomes Survey (SEER-MHOS) database, we included patients > 65 years old with breast cancer diagnosed from 1998-2019, who had completed the Health Outcomes Survey within 24 months pre- and post-diagnosis, and who had a reported ethnicity of non-Hispanic White (W), non-Hispanic Asian or Pacific Islander (API), non-Hispanic Black or African American (B), or Hispanic (H). HRQOL data was measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the Medical Outcomes Study Short Form-36 and the Veterans RAND 12-Item Health Survey instruments. Univariable (UVA) and multivariable (MVA) linear regression models were fitted for MCS, PCS, and TCS (composite MCS and PCS) as response variables to assess for potential disparities between races and ethnicities. MVA models were adjusted for sex, age, marital status, education, income, number of comorbidities, limitations in activities of daily living, national region, histology, and treatment type (in post-diagnosis cohort only). We identified 1,008 in the pre-diagnosis cohort (56.6% stage I, 29.8% stage II, 9.3% stage III, and 4.3% stage IV) and 991 patients in the post-diagnosis cohort (58.3% stage I, 28.6% stage II, 9.3% stage III, 3.8% stage IV). On UVA, differences in mean scores of TCS, PCS, and MCS, respectively, were found among W, API, B, and H patients in both pre-diagnosis and post-diagnosis cohorts (pre-diagnosis - TCS: 93.4, 93.0, 87.0, 86.3; PCS: 40.3, 40.0, 37.0, 37.5; MCS: 53.1, 52.9, 50.0, 48.7; post-diagnosis - TCS: 90.8, 90.3, 84.3, 83.5; PCS: 38.5, 39.2, 36.8, 34.5; MCS: 52.3, 51.1, 49.8, 46.8; all p < .001). A drop in PCS, MCS, and TCS scores numerically was observed for all groups. Among patients in the pre-diagnosis cohort who would be diagnosed with stage IV breast cancer, race was found to be a predictor of PCS with overall significance (p = 0.04) within MVA linear regression. Specifically, on the local test, compared to B, W had higher pre-diagnosis PCS scores (+13.32, p = 0.03). Race was not found to be a predictor in PCS, MCS, or TCS scores otherwise. Among older patients who would be diagnosed with stage IV breast cancer, W had better physical HRQOL as compared to B patients' pre-diagnosis. The decrease in numerical HRQOL scores of the physical domain in all groups post-diagnosis highlights the potential negative physical impact breast cancer has on patients, demonstrating the need for determining the proper resources and support to improve physical HRQOL following diagnosis.

Outcomes Following Dose Escalated Radiotherapy for High Grade Meningioma

Conventionally fractionated radiotherapy (RT) is a defined treatment following surgery for atypical and malignant meningioma. However, the optimal radiotherapeutic approach is not well defined. We present the results of our dose-escalation strategy. Consecutive patients with a histopathologic grade 2 or 3 meningioma treated with RT were retrospectively reviewed. The primary outcome was progression-free survival (PFS), and secondary outcomes included cause-specific survival (CSS), overall survival (OS), local failure and incidence of radiation necrosis. We specifically compared the dose-escalation cohort, defined as those treated with ≥66 Gy EQD2 (equivalent dose in 2 Gy fractions, a/b = 10), to the standard dose cohort receiving <66 Gy EQD2. We defined adjuvant as RT delivered within 6 months of surgery otherwise the treatment was salvage. A total of 118 patients with Grade 2 (111/118) or 3 (7/118) meningioma were identified. 54/118 (45.8%) received dose-escalation and 64/118 (54.2%) standard dosing. 34/54 (63.0%) dose-escalated and 45/64 (70.3%) standardly dosed were treated adjuvantly. The median follow-up was 45.4 months (IQR: 24.0-80.0 months) and median OS was 9.7 years. Post-operative residual disease was present in all dose-escalated patients, as compared to 65.6% in the standard dose cohort. PFS at 3-, 4- and 5-years in the dose-escalated vs. standard dose cohort were 78.9%, 72.2% and 64.6% vs. 57.2%, 49.1% and 40.8%, respectively, (p = 0.030). On multivariable (MVA) analysis, dose-escalation (HR: 0.544, 95% CI: 0.303-0.977, p = 0.042) was associated with improved PFS, whereas ≥2 surgeries (HR: 1.989, 95% CI: 1.049-3.773, p = 0.035) and older age (HR: 1.035, 95% CI:1.015-1.056, p<0.001) associated with worse PFS. The cumulative risk of local failure at 3-, 4- and 5-years in the dose-escalated vs. standard dose cohort were 16.9%, 23.8% and 31.8% vs. 39.6%, 45.6% and 53.9%, respectively, favoring dose-escalation (p = 0.016). MVA confirmed dose-escalation as predictive of a lower risk of LF (HR: 0.483, 95% CI: 0.263-0.887, p = 0.019), while ≥2 surgeries prior to RT predicted for greater LF rates (HR:2.145, 95% CI:1.220-3.771, p = 0.008). A trend was observed for prolonged CSS and OS in the dose escalation cohort (p = <0.1). Seven patients (5.9%) developed symptomatic radiation necrosis (RN) with no significant difference between the two cohorts. Dose-escalated radiotherapy for high grade meningioma to at least 66 Gy is associated with significantly improved rates of local control and PFS with an acceptable risk of RN.

Racial Difference in Outcomes in Breast Cancer Patients with Residual Nodal Disease after Neoadjuvant Chemotherapy

African Americans (AA) requiring neoadjuvant chemotherapy (NAC) have been associated with worse outcomes. Residual nodal disease (ypN+) after NAC represents a highly unfavorable risk factor. We hypothesized that even within this unfavorable subgroup, that racial differences in outcome would persist. An IRB-approved retrospective review of breast cancer (BC) patients in a multi-institutional study was performed between 2005-2018 to identify ypN+ patients (excluding metastatic or inflammatory BC). Clinico-pathologic parameters stratified by race were collected and analyzed. For molecular subtype analyses, patients were stratified into triple negative (TN), hormone receptor (HR)+/HER2-, and HR+/HER2+, and HR-/HER2+ subtypes. Overall survival (OS), disease free survival (DFS) and recurrence outcomes were obtained, and univariate and multivariate (MVA) logistic regression models were constructed and analyzed. Among 404 ypN+ patients, 107 (26%) were AA, and 297 (74%) were non-AA. Median follow-up for the non-AA group was 3.8 years (y) (IQR 2.4-6.3) and 3.5y (IQR 2.0-6.2) for the AA group. Clinical and pathologic patient characteristics (age, molecular subtypes, BRCA status, histology, grade, smoking status, primary surgery type, axillary/reconstruction surgery rates, margin status, stage) were without significant statistical differences between the non-AA and AA group, except the non-AA group had proportionally more cN3 disease (10.5% vs. 5.1%; p = .01). Despite this, AA demonstrated worse OS and DFS outcomes (Table). AA also had significantly worse local (15% vs. 6.7%, p = .02), regional (11.2% vs. 5.1%, p = .05) and distant recurrences (32.7% vs. 22.6%, p = .05) compared to non-AA. On MVA for OS and DFS, HR+ status, clinical stage, and AA race (HR 2.1 (CI 1.3-3.4), p = .004 and HR 1.7 (CI 1.1-2.6), p = .01 respectively) remained significant. Molecular subtype analysis demonstrated that AA with HR+/HER2- but not the TN subtypes demonstrated significantly worse outcomes (Table). Utilization of endocrine therapy was not different between AA and non-AA patients (94% vs. 97%, p = 0.3) to explain this discrepancy. Worse outcomes in HER2 subtype for AA group was suggested but could not be statistically verified due to insufficient sample size. There was no discernible difference in chemotherapy and radiation therapy regimen or compliance between the AA and non-AA groups. AA patients who fail to achieve nodal clearance with NAC had higher local, regional and distant recurrence, and worse survival compared to non-AA, particularly those with non-TN status. These differences could not be readily explained by therapeutic disparity, or compliance. These hypothesis generating findings suggest need to explore biological implications, and alternative therapeutic strategies for this unfavorable subgroup.

Clinical outcomes following observation, post-operative radiation therapy, or post-operative chemoradiation for HPV-associated oropharyngeal squamous cell carcinomas

BackgroundIntermediate and high-risk features (IRFs/HRFs) for locoregional recurrence following initial surgery for oropharyngeal SCCs (OP-SCCs) were defined prior to the known association of HPV with OP-SCC. There are limited reports on practice patterns and outcomes associated with post-operative radiation therapy (PORT) or chemoradiation (POCRT) for HPV-associated OP-SCCs. Materials/Methods:The National Cancer Database was queried for patients with HPV-associated OP-SCCs managed initially with surgery with IRFs or HRFs. IRFs were defined as pT3/T4 disease, pN1-3 disease, and lymphovascular space invasion, and HRFs as positive margins and extranodal extension (ENE). Patients were stratified into no adjuvant therapy, PORT, or POCRT arms. Kaplan-Meier analysis was utilized for comparison of overall survival (OS) between treatment arms followed by a Cox multivariate (MVA) proportional-hazards model and propensity score analyses with inverse probability treatment weighting (IPTW). ResultsWe identified 6,301 patients; 51.2% had IRFs only and 48.8% had HRFs. Regarding treatment, 25.5%, 38.2%, and 36.3% of patients received no RT, PORT, and POCRT, respectively. Patients with IRFs who did not receive RT or CRT had inferior 8-year OS (81.1% vs. 87.8%; p < 0.001) that remained significant on IPTW MVA (hazard ratio (HR) = 1.69 (95% CI: 1.27–2.24; p < 0.001). Among patients with HRFs, 8-year OS was not significantly different between patients receiving PORT vs. POCRT (77.3% vs. 79.2%; p = 0.22) that remained insignificant on IPTW MVA (HR = 0.91(0.72–1.17); p = 0.48). ConclusionA significant proportion of HPV-associated OP-SCC patients with IRFs or HRFs did not receive PORT, which was associated with inferior OS. We did not demonstrate with statistical power that POCRT vs. PORT was associated with superior OS in patients with HRFs, though prospective studies are warranted.

Relationship between vertical facial morphology and dental arch measurements in class II malocclusion: a retrospective study.

To evaluate the relationship between dental arch measurements and the vertical facial pattern determined in skeletal Class II untreated patients. Lateral cephalograms and plaster models were obtained from 124 untreated female adults (average age: 17.6 ± 3.8 years). Class I (CI), Class II Division 1 (CII/1) and Class II Division 2 (CII/2) malocclusions were divided into three subgroups according to their vertical morphology as hypodivergent, normodivergent and hyperdivergent. The multivariate variance analysis (MANOVA) method was used in the comparison of measurement values according to vertical and sagittal morphology. The relationship between both A point-Nasion-B point (ANB) and Frankfurt-mandibular plane (FMA) angles and dental arch measurements was examined by Pearson correlation analysis. The significance level was received as p < 0.05. While vertical morphology has a statistically significant effect on mandibular arch length, sagittal morphology affects maxillary arch depth. The parameters influenced by both morphologies are maxillary and mandibular arch length, as well as maxillary intermolar width. The mandibular arch length was significantly shorter in hyperdivergent-CII-2 malocclusion (50.5 ± 7.4 mm). Larger values were obtained in both mandibular arch length and maxillary arch depth measurements in CII-1 malocclusion compared to CII-2 malocclusion. The maxillary intermolar width was significantly shorter in hypodivergent-CII-1 malocclusion (46.8 ± 3.4 mm), while it was higher in hypodivergent-CI malocclusion (51.1 ± 3.4 mm). The maxillary arch length was the lowest in hyperdivergent-CI malocclusion (63.1 ± 13.3 mm) and the highest in hypodivergent-CI malocclusion (72.8 ± 7.6 mm). Additionally, a positive but weak correlation was found between ANB and FMA angles. Dental arch measurements have been found to be affected by both vertical facial morphology and skeletal sagittal relationship. A positive correlation was found between ANB and FMA angles.

Investigation on the performance of wire electrical discharge machining (WEDM) using aluminium matrix composites (AMCs) micro-channel

This study focuses on microchannel fabrication of Al-10% SiC composite using Wire-EDM process with the applications of single variable and multi variable, optimization. This work was targeted keeping in considerations the wider scope of microchannel applications in the fields such as medical, aerospace, automobile, etc. In this research work, the experiment was conducted to achieve high precision and quality surface finish in terms of minimum surface roughness (SR), high material removal rate (MRR), low tool wear rate (TWR) and optimum spark gap (SG). The used experiments were design on the basis of Taguchi design of experiment approach. Four input process parameters were considered namely, pulse on time (Ton), sparking voltage (SV), wire tension (WT), and wire feed rate (WFR). For the experimentation task, the workpeice (Aluminum and silicon carbide (10% Wt SiCmicro)) material, in a desired shape was fabricated through stir casting process. The tool electrode applied for the experiment purpose had specification as, 0.25 mm diameter brass alloy wire (copper 63 percent and zinc 37 percent). For single variable optimization ANOVA (analysis of variance) was applied while as, for multi variables optimization, grey relational analysis (GRA) was applied. The results of the study indicated that, on the basis of single variable optimization, the highest contribution of Ton resulted in case of the performance measures, MRR and SR while as, for TWR and SG, the highest contribution of sparking voltage, observed. Furthermore, the findings of the study indicated that, on the basis of multi variables optimization, the optimal combination of input process parameters is, pulse on time 125 μs, sparking voltage 10 volt, wire tension 12 kgf, and wire feed rate 4 m min−1. These results also get support from the previous research works. The findings of this study be useful for microchannel manufacturing and other related industrial applications.

Risk Factors and Survival Impact Associated With Documentation of Radiation Therapy Refusal in Patients With Gynecologic Cancer

Radiation therapy (RT) refusal is known to have deleterious effects on survival for multiple cancer types. Factors associated with RT refusal by patients with gynecologic malignancies have not been well described. This study aimed to examine factors associated with and the survival impact of documented RT refusal among patients with gynecologic cancers. This study analyzed data from the National Cancer Database (NCDB) of patients with gynecologic cancers diagnosed between 2004 and 2020. Patients were included if they had complete survival data and a documented RT recommendation by their treating physician in the NCDB. Patients coded as received RT were compared with those coded as refused RT in the NCDB using a multivariate log binomial regression with robust variance to yield incidence rate ratios (IRR). Overall survival was analyzed using a multivariate (MV) Cox proportional hazards model to yield hazard ratios. This study identified 209,976 patients. A total of 5.75% (n=12,081) patients were coded as refusing RT. Multivariable IRR showed that documentation of RT refusal was positively associated with older age (MV IRR, 1.04; 95% CI, 1.041-1.045), Native Hawaiian Pacific Islander race (1.72 [1.27-2.32]), and increased morbidity (score=1: 1.06 [1.02-1.11]; score=2: 1.20 [1.12-1.29]; score ≥3: 1.26 [1.14-1.38]). Negative associations were seen with Hispanic ethnicity (0.74 [0.67-0.80]), having insurance (0.58 [0.53-0.63]), and annual income >$74,063 (0.85 [0.81-0.90]). During the 16-year period, a statistically significant test for trend (P=.001) for increasing RT refusal was noted. RT refusal was associated with a significantly higher risk of death (MV hazard ratio, 1.59 [1.55-1.63]). For patients with gynecologic malignancies diagnosed from 2004 to 2020, an increase in documented RT refusal is associated with decreased overall survival in all disease types. Targeted interventions aimed at mitigating potential sociodemographic barriers to receipt of RT are warranted.

Prediction based fusion estimator-controller for an event-triggered multi-sensor cyber-physical systems

This article focusses on development of centralized fusion estimator-controller for event-triggered multi-variable(MV) multi-sensors(MS) cyber–physical systems. The unified mathematical model is developed, which is able to take care of simultaneous occurrences of packet loss in S-E and C-A channels and event-triggered conditions. The model uses current measurements and state predictions to handle communication flaws and untriggered sensor measurements. The centralized fusion estimator is developed using orthogonal projections for augmented MV-MS system, offering a globally optimal solution. The proposed fusion estimator possesses linear minimum variance property and it is unbiased. Feedback control is designed and it ensures mean square stability. Zero estimate error concept is introduced to reduce the computation burden, network congestion and energy utilization. The novel residual-based cyber-attack detection algorithm is developed. The proposed method is validated for cruise control system and performance is compared with other popular works.

Gallbladder Wall Thickening as a Non-Invasive Screening Parameter for Esophageal Varices Compared to Upper GI Endoscopy

Abstract Background Variceal hemorrhage is considered a life threatening complication of esophageal varices (EV).The main cause of esophageal varices is liver Cirrhosis and subsequent Portal hypertension. Current Guidelines recommend screening via Upper GI Endoscopy which is an invasive procedure which has its own hazards, complications and disadvantages. Gallbladder wall thickening is an early finding in patients with liver cirrhosis that occurs even before other manifestations of portal hypertension. In this study, the utility and efficiency of sonographic measurement of gallbladder wall thickness will be analyzed as a non-invasive screening alternative for upper endoscopy for assessment of EV. Objective To assess possibility of using the Gallbladder wall thickness as a non invasive screening parameter for esophageal varices in cirrhotic patients. Patients and Methods 150 patients were enrolled in this study. The laboratory tests, sonographic and endoscopy findings of 150 CLD patients to assess their correlation to esophageal varices. The Patients were classified into two groups according to the presence of varices and ascites into EV Group of 75 cirrhotic patients with esophageal varices regardless of ascites, and Non EV: Group of 75 patients with chronic liver disease and no ascites on sonography as a control group. The esophageal varices group were further subclassified into 3 groups according to the grade of varices present. Patients with grade I varices were assigned to Group (EV 1). Patients with grade II varices (EV 2). Patients with grade III varices were included in (EV 3) group. Results On Comparison of the lab finding, Sonography, and Child score of the EV and Non EV group, it was found a statistical significance in most variables. On using the multi variate assessment, the following parameters were significant as independent predictors for varices being, platelet count, AFP, Liver Span, and GBWT. The platelet levels seem to be of statistical significance with a mean of 109 with an interquartile range of 79 to 146 in the EV group. while the Non EV group, the median is 195 with IQR from 178 to 234. Alpha feto protein shows statistical significance with a median of 4.5 with IQR of 2.7 to 6.7 in the EV group, and median of 2.1 with an IQR of 1.5 to 4.9 in the Non EV group. The mean liver span in the EV group is 127.56 ± 16.19 with values ranging from 84 to 175. While the mean liver span in the Non EV group in 146.88 ± 14.47 with values ranging from 114 to 184.The mean spleen diameter in the EV group was 161.18±20.73 with values ranging from 118 to 213. The mean splenic diameter in the Non EV group is 141.84±12.34 with measurements ranging from 114 to 167. AUROC curve was drawn with a best cutoff value at 3.8 mm with AUC of 0.810 showing a sensitivity of 76%, specificity at 76 %, PPV at 76 % and NPV of 76%. At a cut off value of 4 mm sensitivity was at 62% specificity 81.3%, PPV 77% and a NPV 68%. PC/ SD was assessed with AUROC with a cutoff of 1006.29 with AUC of 0.879 with a sensitivity of 76%, specificity of 96 %, PPV of 95% and NPV of 80%.Noteworthy that GBWT showed statistical significance between grades of varices with a P-value of 0.003 and mean thickness in EV1, EV2, and EV 3 as follows 4.04 ± 0.8, 4.46 ± 0.68, and 5.27 ± 1.75. Conclusion GBWT seems to be a good predictor of varices which could be used as a screening modality for varices.

The Impact of Prophylactic Cranial Irradiation and Consolidative Thoracic Radiation Therapy for Extensive Stage Small-Cell Lung Cancer in the Transition to the Chemo-Immunotherapy Era: A Single Institution Series

IntroductionExtensive-stage small-cell lung cancer (ES-SCLC) continues to have poor survival due to its aggressive behavior, despite improvements with incorporation of immunotherapy with standard chemotherapy. Controversy exists regarding the role of consolidative thoracic radiation therapy (TRT) and prophylactic cranial irradiation (PCI) in ES-SCLC due to high recurrence rates. We report our institutional result of the benefit of PCI and TRT in ES-SCLC. MethodsPatients with ES-SCLC without intracranial metastasis at diagnosis (N = 163) were included. All patients completed systemic therapy with or without immunotherapy based on time of standard of care. Cohorts were divided by systemic therapy use and further subdivided by treatment with PCI and TRT. Overall survival (OS) and progression-free survival (PFS) were estimated by the Kaplan-Meier method with log-rank test for comparison. The effects of TRT and PCI were estimated by multivariable (MVA) Cox regression. ResultsSeventy-four patients (45.4%) received TRT, and 33.1% (n = 54) received PCI. The median follow-up was 11 months (3-85 months). PCI improved median OS to 15 months from 10 months, P = .02) and median PFS to 8.5 months from 5 months (P = .02) which remained significant on MVA, P = .02 and P = .02, respectively. TRT improved OS on UVA (P = 0.002) but was not significant on MVA. TRT did not improve PFS. ConclusionThis study including chemotherapy and chemo-immunotherapy suggests improved outcomes with addition of PCI in patients with ES-SCLC while TRT did not show benefit to either OS or PFS. A future trial is needed to evaluate the role of TRT and PCI in the era of chemo-immunotherapy.