Require Radiation Therapy Research Articles

The Australian paediatric brachytherapy experience: A pathway to a national programme.

Paediatric cancers are rare, and most children requiring radiation therapy receive external beam radiation (EBRT). Although EBRT may offer organ preservation compared to surgery, it can be associated with significant late effects. Image-guided brachytherapy is a highly specialised technique offering both organ preservation and dose conformity to minimise late toxicity. This is a retrospective mono-institutional review of paediatric brachytherapy in one of the largest paediatric centres in Australia. Outcomes and toxicities are presented as well as brachytherapy versus proton plan comparison in four patients. A total of 14 patients were treated with adjuvant brachytherapy between 2012 and 2022. The predominant histology was rhabdomyosarcoma, and all patients had pelvic tumours. High-dose rate (HDR) brachytherapy was given for 13 patients with one patient receiving low-dose rate (LDR) brachytherapy. Only one grade three late toxicity was reported and two patients developed metastatic disease within one year of completion of treatment. The brachytherapy plan was superior to protons in two of four patients and equivocal in one patient. This is the first Australian publication of a paediatric brachytherapy series from a single institution. This retrospective series demonstrates the feasibility and safety of brachytherapy in paediatric pelvic tumours. The initial work presented here demonstrates the value of a comprehensive radiation plan review in selecting the optimal modality for an individual paediatric patient.

Expanding Geographical Access to Cancer Care in Botswana: Current Status and Future Prospects.

The growing cancer burden in Botswana has been linked to aging, lifestyle factors, and high HIV infection prevalence. The government has designated four geographically distributed hospitals as public oncology centers (POCs). A needs assessment was undertaken to ascertain the characteristics of cancer care at these centers. A multisite cross-sectional survey study of cancer care was conducted with oncology staff at Princess Marina Hospital (PMH), Nyangabgwe Referral Hospital (NRH), Sekgoma Memorial Hospital (SMH), and Letsholathebe II Memorial Hospital (LMH) from February to April 2021. At each POC, a focal person (experienced nurse working in oncology) identified relevant oncology staff and confirmed service availability. Only PMH and NRH had a broad array of diagnostic, surgical, and treatment services. In addition, PMH was the only center with a a dedicated inpatient oncology service, a multidisciplinary committee to review patients, and a palliative care team. To support the only national cancer screening program, for cervical cancer, all POCs offered Pap tests. Mammography, available at PMH and NRH, was used solely for diagnosis. Patients from POCs requiring radiation therapy were referred to Gaborone Private Hospital at government expense. For perceived service availability, 51 staff, mainly oncologists, physicians, and nurses, were surveyed (66% based at PMH). Perceptions of services revealed a few concerns, for example, numerous staff considered hysterectomies for cervical cancer available when they were only performed at PMH. Despite Botswana's efforts to increase the proximity of cancer services to patients, there are marked gaps, particularly at the two district-level POCs, SMH and LMH. In the future, SMH and LMH could provide selected services for specific prevalent cancers on-site, as well as follow-up and palliative care.

Pediatric Solid Pseudopapillary Neoplasm of the Pancreas.

Solid pseudopapillary neoplasm (SPN) of the pancreas in children is a rare tumor with low malignant potential. Some tumors, however, behave aggressively. There is very little literature on managing these variants, especially in children. We share our experience of managing large and recurrent SPN and explore the clinicopathological findings correlating to the risk of recurrence. This is a retrospective study of children treated for SPN between 2012 and 2022 at a tertiary care center in India. The clinicopathological features and management strategies in these children were evaluated. Sixteen children with SPN were treated during this period (88% of girls). The median age of presentation was 12 years (interquartile range [IQR]: 9-14). All children presented with abdominal pain. Computed tomography gave a definitive diagnosis in 81% of cases. The tumor predominantly involved the head of the pancreas (n = 9, 56%). Eight of nine children classified as high-grade (HG) malignant had a benign course. One child had a recurrence of the tumor 4 years after the initial resection and further recurrence on chemotherapy. She required radiation therapy in addition to reoperation following which she was disease free for 77 months. The overall median follow-up was 46 months (IQR: 18-72 months). Complete resection of the tumor provides a cure in most patients with SPN. Recurrent tumors require a multi-modality approach. Long-term survival is good. There is a need for clear definitions of the components within the WHO criteria for HG malignancy.

Paediatric radiation therapy without anaesthesia – Are the children moving?

PurposeChildren who require radiation therapy (RT) should ideally be treated awake, without anaesthesia, if possible. Audiovisual distraction is a known method to facilitate awake treatment, but its effectiveness at keeping children from moving during treatment is not known. The aim of this study was to evaluate intrafraction movement of children receiving RT while awake. MethodsIn this prospective study, we measured the intrafraction movement of children undergoing treatment with fractionated RT, using pre- and post-RT cone beam CT (CBCT) with image matching on bony anatomy. Study CBCTs were acquired at first fraction, weekly during RT, and at last fraction. The primary endpoint was the magnitude of vector change between the pre- and post-RT scans. Our hypothesis was that 90 % of CBCT acquisitions would have minimal movement, defined as <3 mm for head-and-neck (HN) treatments and <5 mm for non-HN treatments. ResultsA total of 65 children were enrolled and had evaluable data across 302 treatments with CBCT acquisitions. Median age was 11 years (range, 2–18; 1st and 3rd quartiles 7 and 14 years, respectively). Minimal movement was observed in 99.4 % of HN treatments and 97.2 % of non-HN treatments. The study hypothesis of >90 % of evaluations having minimal movement was met. Children who were age >11 years moved less at initial evaluation but tended to move more as a course of radiation progressed, as compared to children who were younger. ConclusionChildren receiving RT with audiovisual distraction while awake had small magnitudes of observed intrafraction movement, with minimal movement in >97 % of observed RT fractions. This study validates methods of anaesthesia avoidance using audiovisual distraction for selected children.

Stereotactic intensity-modulated radiotherapy for skull base meningioma using the HybridArc with Novalis STx system.

Skull base meningiomas are often difficult to remove completely with preserved nerve function and may require radiation therapy. However, the Gamma Knife is unsuitable for large tumor volume or the optic nerve, which is difficult to identify on imaging. We report the results of stereotactic radiotherapy with HybridArc using Novalis STx for skull base meningiomas. We retrospectively examined 28 patients with skull base meningioma who underwent stereotactic radiotherapy (54 Gy/30 fractions) with HybridArc. The 28 patients, nine males and 19 females, were aged 31-83 years (mean 58.4 years), and the tumor volume was 2.6-97.1 mL (mean 29.7 mL). HybridArc irradiation was performed with D95 54 Gy/30 fractions for all patients with a median follow-up period of 36.0 months (range: 12-78 months). Tumor control rates at 1, 2, and 5 years after radiotherapy were 92.6%, 89.1%, and 82.8%, respectively. Only one non-atypical meningioma remained uncontrolled; thus, the tumor control rate for non-atypical meningioma at 1, 2, and 5 years was 94.1%. Tumor control rates for atypical meningioma at 1, 2, and 5 years were 85.7%, 71.4%, and 53.6%, respectively, significantly worse than for non-atypical meningiomas (P = 0.0395). Radiation injury was observed in two cases (7.1%). Visual field defects were observed in 16 patients, and diplopia in 6. Visual field and diplopia improvements were achieved in 5 and 2 patients, respectively (with overlap). Stereotactic radiotherapy (54 Gy/30 fractions) with HybridArc using Novalis STx is a safe and effective approach for relatively large skull base meningiomas.

Targeted Immunotherapy and Checkpoint Blockade in Children, Adolescents, and Young Adults with Lymphoma: Radical Hodgkin Cohort

Background: Significant chronic health conditions continue to increase over time among pediatric, adolescent, and young adult (CAYA) classical Hodgkin lymphoma (cHL) survivors. Targeting the tumor microenvironment (TME) and tumor-specific antigens are emerging as effective and safe treatments for cHL patients which may help reduce toxicity. Recently, we completed a phase 2 trial evaluating the use of an antibody-drug conjugate targeting CD30 (brentuximab vedotin, Bv) and an anti-CD20 antibody targeting regulatory B-cells (rituximab, RTX) added to risk-adapted chemotherapy in newly diagnosed cHL CAYA patients. The combination was safe and resulted in significant reduction to toxic chemotherapy and radiation therapy (RT), while keeping superior outcomes (5-year OS/EFS 100%) [Hochberg/Cairo, JITC 2022]. Adding the checkpoint inhibitor nivolumab to chemoimmunotherapy with RTX + Bv may allow further anthracycline dose reduction and reduce the need for RT in intermediate-/high-risk cHL in CAYA. Methods: This is a multicenter study for patients with intermediate- and high-risk cHL. Intermediate-risk cHL patients receive 2 cycles of Bv, doxorubicin, vinblastine, dacarbazine, and RTX (Bv-AVD-R). Rapid early responders (RER) or slow early responders (SER) by FDG-PET scan receive 2 or 4 cycles of Bv, vinblastine, dacarbazine, nivolumab, and RTX (Bv-NVD-R), respectively without further anthracycline. High-risk cHL patients receive 2 cycles of Bv-AVD-R. RERs by FDG-PET scan receive 4 cycles of Bv-NVD-R; SERs receive 2 cycles of Bv, nivolumab, doxorubicin, vinblastine, dacarbazine and RTX (Bv-NAVD-R), followed by 4 cycles of Bv-NVD-R. RT will only be given to patients not achieving CR at the end of therapy. Results: Nine patients have received at least one dose of nivolumab to date and are included in the safety analysis, including 4 intermediate- and 5 high-risk patients. All 9 of these patients have completed interim FDG-PET following 2 cycles of Bv-AVD-R to evaluate early response status. All intermediate-risk patients and 3 high risk patients evaluated to date have been RER, achieving a complete response (CR) at interim FDG-PET. Two high-risk patients have been SER, with a partial response (PR) at interim FDG-PET. Both SER patients achieved a CR following the 6 additional cycles of chemotherapy as detailed above. No patients have required radiation therapy. Accrual is ongoing. We have completed the planned nivolumab safety run in phase. There have been no unexpected grade III/IV adverse events secondary to nivolumab and no dose-limiting toxicities. Conclusions: Targeting the Hodgkin Reed-Sternberg cell as well as the TME (regulatory B-cells) and PD1/PD-L1 axis is a promising approach in CAYA with cHL. (NCT05253495).

The management of symptomatic hyperostotic bilateral spheno-orbital meningiomas: patient series.

The occurrence of hyperostotic bilateral spheno-orbital meningiomas (BSOMs) is very rare. Patients present with bilateral symptoms and require bilateral treatment. This series describes 6 patients presenting to 2 UK neurosurgical units and includes a literature review. To the best of the authors' knowledge, this is the largest series documented. This is a retrospective review of patients with BSOMs presenting between 2006 and 2023. Six females, whose mean age was 43 (range: 36-64) years, presented with features of visual disturbance. Bilateral sphen-oorbital meningiomas were identified. All patients underwent bilateral staged resections. The patients had an initial improvement in their symptoms. Extensive genetic testing was performed in 4 patients, with no variants in the NF2, LZTR1, SMARCB1, SMARCE1, and SMARCA4 genes or other variants detected. The mean follow-up was 100.3 (range: 64-186) months. Sixty-seven percent of patients had good long-term visual acuity. The progression rate was 75% and was particularly aggressive in 1 patient. Four patients required radiation therapy, and 2 needed further surgery. Hyperostotic BSOMs are extensive, challenging tumors causing significant disability. They can recur, with significant patient impact. Multidisciplinary management and indefinite long-term follow-up are essential. The biology of these tumors remains unclear. As molecular testing expands, the understanding of BSOM oncogenesis and potential therapeutic targets is likely to improve.

Aspects of hypofractionation in modern radiation oncology

Background. In the modern world, the incidence of cancer diseases is rapidly increasing and is the second most common cause of death. This is preconditioned by the quantitative growth of the senior and elderly population, as well as the growth of the main risk factors for cancer, which is related to the socio-economic development of society. About half of cancer cases require radiation therapy (RT) as a component of multimodal treatment, therefore its improvement, namely the introduction of hypofractionated radiation regimens, is considered today as one of the most effective ways to increase availability of oncological care and optimize the use of health care system resources.&#x0D; Purpose. To find out clinical and medico-social advantages of the hypofractionated approach in radiation oncology in order to optimize the functioning of the health care system by increasing availability of treatment for cancer patients. To highlight the importance of hypofractionated RT in terms of evidence-based medicine for the most common oncological pathology and in neuro-oncology. To demonstrate the influence of the COVID-19 pandemic on the implementation of hypofractionated RT. To present our own experience of using hypofractionated radiation regimens in patients with glioblastoma (GB).&#x0D; Materials and methods. MEDLINE (Pubmed), EMBASE (Ovid), Web of Science (Web of Knowledge) databases were used to search for literature. The search was performed in the English-language sources with the following keywords: «Radiation», «Hypofractionation radiotherapy», «Hypofractionated radiotherapy», «Hypofractionated irradiation»; «Breast cancer»; «Prostate cancer»; «Lung cancer»; «Glioblastoma», COVID-19. Systematic reviews, meta-analyses, randomized controlled trials and retrospective clinical trials were reviewed in full. The primary sources were backreferenced to identify additional relevant studies related to hypofractionated radiation treatment regimens. The last date of the search is 05.25.2023. The authors’ own experience of the hypofractionated approach in the adjuvant radiation treatment of patients with GB is presented briefly, as a reflection of the relevance of the authors’ practical experience to the provisions of the narrative review, based on the results of a retrospective single-center non-randomized study conducted at the State Institution «Romodanov Neurosurgery Institute National Academy of Medical Sciences of Ukraine» in 2014–2020. The oncological results of 110 (69.2%) patients of the hypofractionated RT group (15 fractions, single fraction dose (SFD) 3.5 Gy, total fraction dose (TFD) 52.5 Gy) and 49 (30.8%) patients of the standard RT group (30 fractions, RVD 2.0 Gy, SVD 60.0 Gy) were compared. RT was performed with Trilogy linear accelerator (USA) (6 MeV) using the intensity-modulated radiotherapy method (IMRT). Overall survival (OS) and recurrence-free survival (RFS) in the groups were analyzed.&#x0D; Results and discussion. Hypofractionated approaches, which allow to significantly decrease the duration of radiation treatment, have clinical, medical and social advantages, including: increased comfort for a patient; reduction of the workload on staff and technological equipment of medical facilities; reduction of the cost of treatment. The introduction of hypofractionated RT allows to increase access to cancer care at the global level, reducing disparity in the results of treatment of cancer patients between low- and middle-income countries and the countries with high income level. Hypofractionated radiation regimens are included in the clinical guidelines of professional associations, as for the most common forms of cancer and for malignant brain tumors, and represent the standard of treatment for particular clinical cases. Our experience of using the hypofractionated radiation regimen is based on the adjuvant radiation treatment of 110 patients with GB and in terms of clinical results is a relevant concept presented in a narrative review. The analysis showed no statistical difference between the groups of standard fractionation and hypofractionated RT in OS (Logrank test p = 0.06757) and RFS (Logrank test p = 0.43374). In the hypofractionation group, with an observation time median of 22.3 months, the OS median was 16.5 (95% CI 14.1–18.8) months; median RFS was 9.0 (95% CI 8.0–10.0) months. In the standard radiation regimen group, with a median of observation time of 24.4 months, the median OS was 15.0 (95% CI 14.1–17.1) months; median RFS is 9.0 (95% CI 9.0–10.0) months.&#x0D; Conclusion. Development and implementation of the measures designed to optimize the use of resources of medical facilities of Ukraine is a necessary condition for maintaining high-quality care for cancer patients in the conditions of full-scale military aggression, which has been ongoing since February 24, 2022. Increased application of hypofractionated approaches in radiation oncology can be considered as a potential tool for optimization of the use of resources of the healthcare system of Ukraine and enhancing public health.

Abstract P1-10-05: Safety of stereotactic body radiation therapy, stereotactic radiosurgery, and other radiation therapy with use of CDK 4/6 inhibitors for hormone receptor positive (HR+), HER2- metastatic breast cancer: a retrospective cohort study

Abstract Objective Patients with hormone receptor positive (HR+), HER2- metastatic breast cancer frequently require radiation therapy (RT) in addition to systemic therapy for disease control and symptom management. CDK 4/6 inhibitors are increasingly used in the care of hormone positive breast cancers. Stereotactic body radiotherapy (SBRT), a form of very focused high dose radiation, is also increasingly used in the care of metastatic breast cancer. Limited data have reported on the safety of palliative RT with CDK4/6 inhibitors, with some reports demonstrating synergistic effects with potential for increased toxicity. The objective of our study is to assess toxicity among patients who received SBRT, stereotactic radiosurgery (SRS), or other high dose RT along with CDK 4/6 inhibitors for treatment of metastatic breast cancer. Methods Women with metastatic breast cancer who received SBRT, SRS, or other higher dose RT with CDK 4/6 inhibitors at any point in their treatment between 2013 and 2021 were retrospectively identified. Timing of radiation therapy, either before, during, or after CDK 4/6 inhibitor use was assessed, as well as the interval between the two treatments. Treatment sites for radiotherapy included lung/chest, spine, and brain metastases. Physician assessed adverse events were obtained through clinical follow up and graded using CTCAE v5. Local control and OS were reported. Results Twenty patients met study inclusion criteria. Patients received radiation therapy and CDK 4/6 inhibitors concurrently (within 7 days) [n=7, 35%], within 30 days (RT pre-CDK 4/6 inhibitor use) [n=3, 15%], and greater than 30 days (RT pre-CDK 4/6 inhibitor use [n=6, 30%] and RT post-CDK 4/6 inhibitor use [n=4, 20%]). Radiation treatment sites were spine [n=10, 55%], brain [n=6, 30%], and lung/chest wall [n=3, 15%]. Radiation doses were as follows: 60 Gy in 5 fractions [n=1, 5%], 50 Gy in 5 fractions [n=2, 10%], 55 Gy in 20 fractions (chest wall recurrence) [n=1, 5%], 35 Gy in 15 fractions [n=1, 5%], 30 Gy in 10 fractions [n=6, 30%], 30 Gy in 3 fractions [n= 4, 20%], 24 Gy in 1 fraction [n=3, 15%], 20 Gy in 5 fractions [n=2, 10%]. Palbociclib was used in 85% of patients [n=17] and abemaciclib in 15% [n=3]. Median follow up for surviving patients was 4.7 years [IQR: 2.5-6.8 years]. Local control was achieved in 85% of patients [n=17]. Median OS was 2.7 years [IQR: 0.1-6.8 years]. Grade 2 toxicity [n=9, 45%] and grade 3 toxicity [n=3, 15%] was reported across all three treatment areas, with grade 2 or 3 fatigue [n=7, 35%] being the most frequently reported toxicity. In the spine treatment group, 1 patient who had CDK 4/6 inhibitor use within 30 days of radiotherapy experienced a grade 3 vertebral compression fracture as well as grade 3 fatigue. In the lung/chest wall treatment group, the patient treated to 55 Gy in 20 fractions to the chest wall with concurrent use had grade 3 skin/wound toxicity requiring prolonged wound care before healing. In the intra-cranial SRS group, grade 3 fatigue was reported in 1 patient with concurrent use. Conclusion The use of CDK 4/6 inhibitors concurrently with or within 30 days of radiation therapy was generally well tolerated with limited grade 3 toxicity. Two of three reports of grade 3 toxicity occurred with concurrent treatment. Due to the potential radiosensitizing properties of CDK 4/6 inhibitors, it may be prudent to hold combined treatment when clinically feasible. Further study is needed to validate these results. Citation Format: Kiran Chauhan, Roman O. Kowalchuk, Allison E. Garda, Dean A. Shumway, Mark R. Waddle, Robert Mutter, Kimberly Corbin. Safety of stereotactic body radiation therapy, stereotactic radiosurgery, and other radiation therapy with use of CDK 4/6 inhibitors for hormone receptor positive (HR+), HER2- metastatic breast cancer: a retrospective cohort study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-10-05.

Predictors of radiation-induced skin reactions in patients with T-cell skin lymphomas after total skin irradiation: retrospective cohort study

INTRODUCTION: Skin reactions negatively affect a patient’s quality of life and may require radiation therapy premature interruption, what impairs illness control. Numerous agents determine tissue radiosensitivity, but demographic and lifestyle factors remain poorly understood. Those kind of patients herapeutic algorithm demands studies.OBJECTIVE: Radiation-induced skin reactions (RISR) formation and severity prognostic factors determination for primary malignant skin lymphomas patients.MATERIALS AND METHODS: 45 patients malignant T-cell skin lymphoma study, aged 38 to 82 years (29 mycosis fungoides patients, 2 lymphomatoid papulosis, 14 patients with primary anaplastic large cell skin lymphoma) received fast electrons total skin irradiation on the basis of the Federal State Institution «Russian Radiology and Surgical Technologies Scientific Center named after Academician A.M.Granov» of the Ministry of Health of the Russian Federation from 2012 to June 2022. Radiation therapy performed in the usual fractionation mode on linear electron accelerators Elekta Precise with 4–6 MeV bremsstrahlung total doses from 14 to 30 Gy (22±2.4 Gy). In order to identify the role of possible prognostic factors of skin toxicity — gender, age, body mass index (BMI), smoking status, lymphoma body surface area (BSA), the presence of concomitant diseases (diabetes mellitus and arterial hypertension) and previous chemotherapy.Statistics: Statistical analysis was performed using the IBM SPSS Statistics v. 26 program (developed by IBM Corporation). The value of p&lt;0.05 was considered statistically significant. Verification of the sample belonging to the normal general population was carried out using the Shapiro–Wilk criterion. Spearman's rank correlation coefficient was used for correlation analysis. The regression parameters were estimated using the least squares method.RESULTS: The analysis revealed positive associations between the severity of RISR and predictor factors: BMI (r=0.799, p&lt;0.01), smoking status (r=0.655, p&lt;0.01), age (r=0.534, p&lt;0.05), presence of diabetes mellitus (r=0.456, p&lt;0.05), arterial hypertension (r=0.227, p&lt;0.05), previous chemotherapy (r=0.422, p&lt;0.01) and lymphoma body surface area (r=0.378, p&lt;0.01). Severity of RISR scale value increase by those parameters. Negative links found between the severity of RISR and the total focal dose (SOD) of the beginning of their formation (r=–0.109, p&lt;0.05).CONCLUSION: Formation and severity prognostic factors for the RCC upon fast electrons total skin exposure for patients with primary malignant T-cell skin lymphomas (mycosis fungoides, lymphomatoid papulosis, primary anaplastic large cell lymphoma of the skin) were identified.

Quality Assurance in Clinical Trials Requiring Radiation Therapy in Sub-Saharan Africa

Given the increasing availability of radiation therapy in sub-Saharan Africa, clinical trials that include radiation therapy are likely to grow. Ensuring appropriate delivery of radiation therapy through rigorous quality assurance is an important component of clinical trial execution. We reviewed the process for credentialing radiation therapy sites and radiation therapy quality assurance through the Imaging and Radiation Oncology Core (IROC) Houston Quality Assurance Center for AIDS Malignancy Consortium (AMC)-081, a multicenter study of cisplatin and radiation therapy for women with locally advanced cervical cancer living with HIV, conducted by the AIDS Malignancy Consortium at 2 sites in South Africa and Zimbabwe. Women living with HIV with newly diagnosed stage IB2, IIA (>4 cm), IIB-IVA cervical carcinoma (per the 2009 International Federation of Gynecology and Obstetrics [FIGO] staging classifications) were enrolled in AMC-081. They received 3-dimensional conformal external beam radiation therapy (EBRT) to the pelvis (41.4-45 Gy) using a linear accelerator, high-dose-rate brachytherapy (6-9 Gy to point A with each fraction and up to 4 fractions), and concurrent weekly cisplatin (40 mg/m2). IROC reviewed EBRT and brachytherapy quality assurance records after treatment. All of the 38 women enrolled in AMC-081 received ±5% of the protocol-specified prescribed dose of EBRT. Geometry of brachytherapy applicator placement was scored as per protocol in all implants. Doses to points A and B, International Commission on Radiation Units and Measurements (ICRU) bladder, or ICRU rectum required correction by IROC in >50% of the implants. In the final evaluation, 58% of participants (n=22) were treated per protocol, 40% (n=15) had minor protocol deviations, and 3% (n=1) had major protocol deviations. No records were received within 60 days of treatment completion as requested in the protocol. Major radiation therapy deviations were low, but timely submission of radiation therapy data did not occur. Future studies, especially those that include specialized radiation therapy techniques such as stereotactic or intensity-modulated radiation therapy, will require pathways to ensure timely and adequate quality assurance.

Biofeedback Enabled CALM (BeCALM)—the feasibility of biofeedback on procedural anxiety during radiation therapy: study protocol for a pilot randomised controlled trial

IntroductionPatients undergoing treatment for cancer who require radiation therapy (RT) report anxiety specifically relating to the RT procedure. Procedural anxiety can be detrimental to treatment delivery, causing disruptions to treatment...

Functional Outcomes after Radiation Therapy or Radical Prostatectomy with Postoperative Radiation Therapy for High-Risk Prostate Cancer

<h3>Purpose/Objective(s)</h3> The use of radical prostatectomy (RP) for men with high-risk prostate cancer (PC) is increasing. RP is often utilized as a component of multi-modality therapy, as a method to intensify treatment. Many patients who undergo RP will subsequently require radiation therapy (RT), exposing patients to side effects from both treatments. While the side effects of RT and RP have been directly compared in previous studies, there is limited data comparing side effects of primary RT with those of patients undergoing RP and RT (RP/RT). We hypothesize that patients undergoing RP/RT for high-risk PC will experience significantly higher side effects than those undergoing primary RT. <h3>Materials/Methods</h3> We used the Surveillance Epidemiology and End Results (SEER) database with Medicare insurance claims to identify patients 66 years or older with primary high-risk PC who underwent RP, RT, or both between January 1, 2004 and December 31, 2013. High-risk PC was defined as disease meeting one or more of the following criteria: stage ≥ T3a, grade group ≥ 4, PSA >20. Outcomes of interest included treatment for urinary incontinence, urethral stricture, erectile dysfunction (ED), proctitis and cystitis at least 1 year after completion of primary prostate cancer treatment, which were captured using diagnosis and procedure codes. Rates of these endpoints were compared using cumulative incidence functions as well as cox proportional hazard models. Patients who were lost to follow up or died were censored at the time of their last encounter. <h3>Results</h3> The cohort included 17,649 patients, of which 15,399 were treated with primary RT (87.25%) and 2,250 were treated with RP/RT (12.75%). On multivariable analysis, compared to primary RT, RP/RT was associated with an increased risk of incontinence therapy [HR 1.907 (1.679-2.166)], stricture therapy [HR 1.865 (95% CI: 1.589-2.190)] and ED therapy [HR 2.869 (95% CI: 2.046-4.023)] after treatment for prostate cancer. Rates of therapy for cystitis or proctitis were not significantly different between these two groups. <h3>Conclusion</h3> For men with high-risk PC, treatment with RP/RT was associated with increased utilization of incontinence therapy, stricture therapy, and ED therapy after completion of prostate cancer treatment. With multiple curative treatment options and long duration of survival after treatment, the side effect profile of treatment is a major factor in determining the most appropriate course of treatment for an individual patient. Patients considering primary RP as a component of multimodality therapy for high-risk PC should be informed about the increased risk of side effects. Clinical trials are required to better evaluate this treatment paradigm.

Role of Stereotactic Radiation Therapy in Operable and Inoperable Early-Stage Non-small Cell Lung Cancer.

Radiation therapy is becoming an increasingly important part of non-small cell lung cancer (NSCLC) management. Approximately 60% of all cancer patients require radiation therapy (RT) as part of their treatment. For lung cancer, this number is even higher, reaching approximately 77% of all patients, from radical to palliative modalities of RT. This percentage may even be underestimated, as it may not account for the more recent use of RT in oligometastatic lung cancer patients. Thus, we can estimate that each year there will be approximately 21,890 new lung cancer patients in the USA requiring RT. These numbers are expected to continue to rise, as lung cancer radiation techniques continue to improve. There is growing interest in determining the best treatment options for early-stage NSCLC patients. There is well-established data showing the benefit of RT for inoperable patients, and more recent encouraging data even in operable patients.

Hearing Loss in Cancer Patients with Skull Base Tumors Undergoing Pencil Beam Scanning Proton Therapy: A Retrospective Cohort Study.

Simple SummaryMost patients with skull base tumors require radiation therapy as part of their overall treatment, preferably with protons. However, vital and healthy organs, such as the cochlea, are often located in the immediate anatomical vicinity of the tumor. Despite the high precision of the proton beam, irradiating the cochlea is often unavoidable, resulting in an increased risk of hearing loss. To assess the frequency and severity of changes in hearing after proton therapy, we performed a retrospective study in a cohort of 51 patients undergoing proton therapy for skull base tumors. We observed that a hearing threshold shift correlates to the applied radiation dose intensity to the cochlea. In addition, advancing age, hearing sensitivity before proton therapy, and the time elapsed after the end of proton therapy are independently associated with the deterioration of the hearing threshold after proton therapy. These results are essential to adequately inform patients about the treatment’s impact and side effects.To assess the incidence and severity of changes in hearing threshold in patients undergoing high-dose pencil-beam-scanning proton therapy (PBS-PT). This retrospective cohort study included fifty-one patients (median 50 years (range, 13–68)) treated with PBS-PT for skull base tumors. No chemotherapy was delivered. Pure tone averages (PTAs)were determined before (baseline) and after PBS-PT as the average hearing thresholds at frequencies of 0.5, 1, 2, and 4 kHz. Hearing changes were calculated as PTA differences between pre-and post-PBS-PT. A linear mixed-effects model was used to assess the relationship between the PTA at the follow-up and the baseline, the cochlea radiation dose intensity, the increased age, and the years after PBS-PT. Included patients were treated for chordoma (n = 24), chondrosarcoma (n = 9), head and neck tumors (n = 9), or meningioma (n = 3), with a mean tumor dose of 71.1 Gy (RBE) (range, 52.0–77.8), and a mean dose of 37 Gy (RBE) (range, 0.0–72.7) was delivered to the cochleas. The median time to the first follow-up was 11 months (IQR, 5.5–33.7). The PTA increased from a median of 15 dB (IQR 10.0–25) at the baseline to 23.8 (IQR 11.3–46.3) at the first follow-up. In the linear mixed-effect model, the baseline PTA (estimate 0.80, 95%CI 0.64 to 0.96, p ≤ 0.001), patient’s age (0.30, 0.03 to 0.57, p = 0.029), follow-up time (2.07, 0.92 to 3.23, p ≤ 0.001), and mean cochlear dose in Gy (RBE) (0.34, 0.21 to 0.46, p ≤ 0.001) were all significantly associated with an increase in PTA at follow-up. The applied cochlear dose and baseline PTA, age, and time after treatment were significantly associated with hearing loss after proton therapy.

Preoperative spinal angiography decreases risk of spinal ischemia in pediatric posterior thoracic tumor resection.

Resection of pediatric posterior thoracic tumors (PTTs) can be complicated by Artery of Adamkiewicz (AKA) injury. Post-op spinal ischemia occurs in approx. 3.2% of patients, typically due to iatrogenic vascular injury. Pre-op angiography (PSA) may help to avoid this complication. Herein, we aim to evaluate outcomes after initiation of routine PSA prior to PTT resection. A single-institution retrospective review identified 25 children (< 18years) treated for PTTs from 2009 to 2021. PTTs included: posterior mediastinum, paraspinal thorax and posterior chest wall tumors. PSA patients were compared to those without pre-operative angiography (NA). Demographics, perioperative and long-term outcomes and event-free survival (EFS) were assessed. Prior to 2012, eleven patients were treated without PSA. However, the last developed post-operative paraplegia secondary to spinal ischemia. Since this event, PSA has become routine for all PTTs (n = 14) identifying six AKAs and nine accessory spinal arteries. Resection was performed in ten (90.1%) NA patients and eight (57.1%) PSA patients. Based on PSA findings, resection was not offered to six patients and planned partial resection was performed in three patients. Five PSA patients required radiation therapy for local control vs two NA patients. There were no differences in recurrence or overall EFS. PSA aids in identifying patients with high-risk thoracic vascular anatomy and may prevent risk of post-operative paraplegia associated with PTT resection.

The Impact of SARS-CoV-2 Pandemic on Patients Undergoing Radiation Therapy for Advanced Cervical Cancer at a Romanian Academic Center: A Four-Year Retrospective Analysis.

Background and Objectives: Throughout the COVID-19 pandemic, health systems worldwide adapted to support COVID-19 patients while continuing to provide assistance to patients with other potentially fatal illnesses. While patients with cancer may be at an elevated risk of severe COVID-19-related complications, their oncologic therapies generally cannot be postponed indefinitely without a negative effect on outcomes. Taking this into account, a thorough examination of the therapy management of various cancers is necessary, such as cervical cancer. Therefore, we aimed to develop a retrospective cohort study to measure the impact of the COVID-19 pandemic on the delivery of cancer care services for women diagnosed with cervical cancer staged IB2-IVA, necessitating chemo- and radiotherapy in Romania, as well as determine the difference in cervical cancer staging between the pandemic and pre-pandemic period. Materials and Methods: Using a multicentric hospital database, we designed a retrospective study to compare the last 24 months of the pre-pandemic period to the first 24 months of the SARS-CoV-2 pandemic to evaluate the variation in the proportion of women diagnosed with cervical cancer and the percentage of inoperable cases requiring chemotherapy and radiotherapy, as well as to detail their clinical presentation and other findings. Results: We observed that the likelihood of cervical cancer patients requiring radiation therapy at a later stage than before the pandemic increased by about 20% during the COVID-19 pandemic. Patients at an advanced FIGO stage of cervical cancer had a 3.39 higher likelihood of disease progression after radiotherapy (CI [2.06–4.21], p-value < 0.001), followed by tumor size at diagnosis with a hazard ratio (HR) of 3.12 (CI [2.24–4.00], p-value < 0.001). The factors related to the COVID-19 pandemic, postponed treatment and missed appointments, were also identified as significant risk factors for cervical cancer progression (HR = 2.51 and HR = 2.24, respectively). Conclusions We predict that there will be a considerable rise in cervical cancer cases over the next several years based on existing data and that expanding screening and treatment capacity will attenuate this with a minimal increase in morbidity and fatality.

Bringing Care Closer to Home: The Completion of Alberta's Radiation Therapy Corridor Project

Aim: In 2007 the Alberta government, with support from Health Canada, announced an initiative to improve access and decrease waiting times for health services in Alberta. This led to the initiation of a project termed the “Radiation Therapy Corridor (RTC)” with a goal to implement RT facilities in Lethbridge (JACC), Red Deer (CACC), and Grande Prairie (GPCC). The vision of the RTC is to “provide all Albertans requiring radiation therapy services for cancer and other diseases with integrated, high-quality, and safe care”.

ASO Author Reflections: Deeper Understanding of Patient-Reported Outcomes in Breast Reconstruction Patients Not Requiring Radiation Therapy: Harnessing Propensity Matching Methodology.

ASO Author Reflections: Deeper Understanding of Patient-Reported Outcomes in Breast Reconstruction Patients Not Requiring Radiation Therapy: Harnessing Propensity Matching Methodology.

Patient-Reported Outcomes Measurement in Radiation Oncology: Interpretation of Individual Scores and Change over Time in Clinical Practice.

Tools for measuring patients’ perceived health and quality of life, such as patient-reported outcome measures (PROMs), inform clinical decisions for patients requiring radiation therapy. However, there may be inconsistencies in how patients interpret and respond to PROMs due to cultural, environmental, personal, or experiential factors. Differential item functioning (DIF) and response shift (RS) refer to differences in the meaning of PROMs between patients or over time (respectively). DIF and RS can threaten the accurate interpretation and use of PROMs, potentially resulting in erroneous conclusions about effectiveness, and flawed individual-level clinical decision-making. Given the empirical evidence of DIF and RS, we aim to review clinical implications and solutions for addressing DIF and RS by providing vignettes from collaborative examinations with workshop participants, as well as the literature. By making these methodological concepts accessible and relevant, for practice, clinicians may feel more confident to ask clarifying questions of patients when PROM scores and the contextual patient information do not align. PROM scores need to be interpreted via dialogue with the patient to avoid misinterpretation due to DIF and RS, which could diminish patient–clinician communication and impede shared decision-making. This work is part of an interdisciplinary knowledge translation initiative focused on the interpretation of PROM scores by clinically-oriented audiences.