Use Of Trimodality Therapy Research Articles

Outcomes from a single institution cohort of 248 patients with stage I–III esophageal cancer treated with radiotherapy: Comparison of younger and older populations

Outcomes for patients receiving radiotherapy (RT) for non-metastatic esophageal cancer at a single institution were assessed, as well as the impact of factors including age and intensity modulated RT (IMRT) planning on patient outcomes. A retrospective cohort of patients treated with RT for stage I-III esophageal cancer between 2010 and 2018 was identified. Among 248 identified patients, 28 % identified as older (≥75 years of age). Other than histology, there were no other statistically significant differences in patient and tumour characteristics between the younger and older populations. Treatments varied between the two age groups, with significantly less older patients completing trimodality treatments (17 % vs 58 %). Median overall survival (M−OS) and progression-free survival (M−PFS) were 20 months and 12 months for all patients and 40 months and 26 months for trimodality patients, respectively. In the older patients, the M−OS improved from 13 months for all to 34 months for trimodality patients; and M−PFS from 10 months to 16 months. On multivariate analysis, the use of trimodality therapy showed improved OS (HR 0.26, p < 0.001). In the non-surgical older patient group, significantly better survival was seen in patients who had a heart V30Gy under 46 %. There was no significant difference in M−OS in patients planned with IMRT compared with 3D-conformal RT. Clinical outcomes in the treatment of esophageal cancer vary significantly by treatment approach, with the most favourable results in those receiving trimodality therapy. Among older patients deemed fit after assessment by the multidisciplinary team for trimodality treatments, the M−OS is comparable to the younger patient group.

Treatment Patterns and Outcomes of Elderly Patients With Potentially Curable Esophageal Cancer.

ObjectivesThe proportion of elderly patients with esophageal cancer (EC) is increasing due to prolonged life expectancy and aging process. The aim of the study is to explore the optimal treatment strategy for elderly patients (aged ≥70 years) with locally advanced EC.MethodsEligible patients with cT2-4aNxM0 EC were identified in the Surveillance, Epidemiology, and End Results database from 2010 to 2016. Treatment patterns were divided into six groups: surgical resection (S), chemoradiotherapy (CRT), trimodality therapy (CRT+S), radiotherapy (RT), chemotherapy (CT), or observation with no treatment (Obs). Survival between groups was compared using the log-rank test, and the Cox proportional hazards model was used to identify factors associated with overall survival (OS).ResultsA total of 2917 patients with potentially curable EC were identified. Of all the patients included, 6.7%, 51.8%, 18.0%, 9.4% and 3.6%received S, CRT, CRT+S, RT, and CT, respectively, whereas 10.6% underwent Obs. The 3-year OS estimates were 30.2% (95% confidence interval [CI]: 23.5–38.9%), 25.4% (95% CI: 22.8–28.3%),44.3% (95% CI: 39.3–49.9%), 11.4% (95% CI: 7.7–17.0%), 16.1% (95% CI: 9.1–28.3%), and 5.6% (95% CI: 3.2–9.8%) for S, CRT, CRT+S RT, CT, and Obs (p<0.001), respectively. Overall, patents underwent CRT+S had the longest OS, compared to other treatment patterns, and the survival difference was not significant between patients receiving CRT and S (p=0.12) in the elderly population. However, the survival benefits of trimodality therapy over CRT gradually weakened with the increase in age, and became statistically non-significant for EC patients aged ≥80 years (p=0.35). Multivariate analysis showed that treatment patterns, age, sex, tumor grade, T stage, N stage, and marital status were significantly associated with OS.ConclusionGenerally, the use of trimodality therapy was associated with the longest OS, the survival benefits were comparable between CRT and S alone, and CRT was superior to RT or CT alone in elderly patients with curable EC. For patients intolerable to surgery or aged ≥80 years, definitive CRT should be considered as a preferable option.

Targeting barriers to wider use of trimodality therapy in localized muscle invasive bladder cancer.

Radical cystectomy with bilateral pelvic lymphadenectomy and trimodality bladder-sparing therapy or TMT, are both curative options for patients with nonmetastatic muscle invasive bladder cancer. Patients should be afforded the opportunity for a multidisciplinary evaluation with equipoise in discussing these options for eligible patients. We discuss the barriers to broader acceptance and utilization of TMT and encourage support of clinical trials of TMT.

PD55-03 COST-EFFECTIVENESS OF RADICAL CYSTECTOMY VS. TRIMODALITY THERAPY FOR MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Invasive V (PD55)1 Apr 2020PD55-03 COST-EFFECTIVENESS OF RADICAL CYSTECTOMY VS. TRIMODALITY THERAPY FOR MUSCLE INVASIVE BLADDER CANCER Nathan Suskovic*, Ann Raldow, Trevor Royce, and Angela Smith Nathan Suskovic*Nathan Suskovic* More articles by this author , Ann RaldowAnn Raldow More articles by this author , Trevor RoyceTrevor Royce More articles by this author , and Angela SmithAngela Smith More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000965.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Muscle invasive bladder cancer (MIBC) comprises 25% of all bladder cancers at the time of diagnosis. Radical Cystectomy (RC) has traditionally been the gold standard curative treatment for MIBC. Trimodality therapy (TMT) with maximal transurethral resection of bladder tumor, chemotherapy, and radiation is a treatment alternative and Category 1 recommendation by the NCCN. TMT has shown equivalent survival for carefully selected patients. However, the comparative cost effectiveness between RC and TMT is unknown. Therefore, the purpose of this study was to compare the cost-effectiveness of RC versus TMT for MIBC. METHODS: We developed a Markov model using TreeAge software to simulate a 5-year outcome for one million 65-year old hypothetical patients with MIBC undergoing either RC or TMT (Figure 1). Hypothetical patients in the RC treatment pathway would have an adverse event, no adverse event, or immediate death after surgery. After RC, patients either would have no evidence of disease or transition to locoregional recurrence, metastatic recurrence, or death. Hypothetical patients in the TMT treatment pathway would either have an adverse event or no adverse from treatment. After TMT, patients either would have disease-free bladder intact survival or transition to locoregional failure, metastatic recurrence, or death. Patients with locoregional failure from TMT transition into non-salvageable disease or salvageable disease. Patients with salvageable disease prompted a salvage cystectomy. Model probabilities and utilities were extracted from the literature. Costs were derived from 2019 National Medicare Fee Schedule. RESULTS: RC and TMT were associated with quality adjusted life years (QALY) of 2.88 and 3.38 respectively (incremental QALYs of 0.5 favoring TMT). The mean costs of RC and TMT were $37,107 and $23,916 respectively. TMT was less expensive with an incremental cost of $13,191. CONCLUSIONS: In patients aged 65 and older with MIBC, TMT was the dominant strategy as compared to RC, as it was both cheaper and associated with increased QALYs based upon model assumptions. The results of this study are the first to evaluate the cost effectiveness of RC and TMT and can inform the ongoing discussion regarding the use of TMT and RC in MIBC. Source of Funding: Office of Research at the University of North Carolina at Chapel Hill © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1182-e1183 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Suskovic* More articles by this author Ann Raldow More articles by this author Trevor Royce More articles by this author Angela Smith More articles by this author Expand All Advertisement PDF downloadLoading ...

Trimodality Therapy for Muscle-Invasive Bladder Cancer: Recent Advances and Unanswered Questions.

Bladder-sparing trimodality therapy (TMT) has become an accepted alternative to cystectomy for selected muscle invasive bladder cancer (MIBC) patients unfit for cystectomy or opting for bladder preservation. This review will summarize recent advances in TMT for MIBC. A growing body of literature has emerged which supports the use of TMT. However, its delivery is yet to be standardized. The role of chemotherapy and predictive biomarkers remain to be elucidated. Novel bladder-sparing approaches, drug combinations including immunotherapy and targeted therapies are under investigation in clinical trials, with the goal of ultimately enhancing survival and quality of life outcomes. Recent advances in TMT have made bladder preservation possible for MIBC patients seeking an alternative local therapy to cystectomy. With careful patient selection, TMT offers comparable survival outcomes to cystectomy, and improved quality of life as patients are able to successfully retain their bladder.

Trimodality therapy for bladder cancer: modern management and future directions.

This review examines both trimodality therapy (TMT) in the definitive management of bladder cancer as well as the use of adjuvant radiotherapy for bladder cancer with a specific focus on publications from the last 2 years. TMT is an effective management strategy for muscle invasive bladder cancer with outcomes similar to radical cystectomy. Effectiveness of this strategy exists in variant histologies and can be personalized with use of biomarkers. There is a role for adjuvant radiotherapy in locally advanced bladder cancer, especially in the age of improved imaging and modern radiotherapy techniques. This review should provide the reader data necessary to support use of TMT and adjuvant radiation therapy in their clinic.

Bladder Preserving Trimodality Therapy for Muscle-Invasive Bladder Cancer.

Here, we will review and summarize the current status and emerging data supporting the use of trimodality therapy as an alternative to cystectomy for patients with muscle-invasive bladder cancer. There are no randomized-controlled data comparing radical cystectomy with bladder preserving trimodality therapy available for comparison. However, observational data suggests acceptable bladder preservation and functional outcomes in patients receiving bladder preserving trimodality therapy as well as similar oncologic outcomes in select patients compared to radical cystectomy. Future trials are focusing on new techniques and novel therapeutics in patients with bladder cancer. Bladder preserving trimodality therapy results in satisfactory quality of life and comparable disease outcomes for select patients with muscle-invasive urothelial carcinoma of the bladder compared to cystectomy.

Genomic profiling of muscle invasive bladder cancer to predict response to bladder-sparing trimodality therapy.

513 Background: Trimodality therapy with TURBT followed by chemoradiation is an acceptable alternative to cystectomy for muscle invasive bladder cancer (MIBC). Genomic profiling has demonstrated MIBC can be divided into molecular subtypes with differing responses to chemotherapy. We explored the utility of genomic data to select patients for bladder-sparing trimodality therapy. Methods: Transcriptome wide gene expression profiles were generated for 189 MIBC TURBT samples from patients treated with trimodality therapy at a single institution. Of these, 103 passed microarray QC. Molecular subtype and expression of bladder cancer genes were assessed for association with overall and disease-specific survival. Transcriptome wide differential expression analysis was used to explore gene set enrichment in trimodality therapy response groups. Results: The chemoradiation cohort (n = 103) had a median followup of 6.9 years for alive patients, and was classified into four subtypes: basal (n = 44), basal claudin-low (n = 12), infiltrated luminal (n = 17) and luminal tumors (n = 30). There was no significant difference in overall or disease-specific survival by subtype. However, higher expression of the luminal-associated PPARG was correlated with increased survival after adjusting for subtype and clinical factors (HR = 0.52, p = 0.002). In contrast, a p53 signature predicted worse survival after adjusting for clinical factors (HR = 1.92, p = 0.022). Elevated mRNA expression of the DNA damage repair gene MRE11 was associated with improved survival in the trimodality cohort (HR = 0.69, P = 0.031), consistent with its potential role as a predictive biomarker for radiation response. Gene set enrichment revealed differential regulation of immune pathways in trimodality therapy responders relative to non-responders, including enrichment of interferon gamma signaling (p = 0.01) and CXCL9 (p = 0.031), suggestive of an interplay between tumor immunologic microenvironment and response to chemoradiation. Conclusions: Transcriptional profiling of MIBC revealed gene signatures correlated with response to chemoradiation, suggesting the potential of genomics to guide use of trimodality therapy.

Comparison of bimodality versus trimodality therapy for esophageal or gastroesophageal junction (GEJ) cancer: Experience from the Princess Margaret Cancer Centre.

122 Background: There are no phase 3 trials comparing definitive chemoradiation (bimodality) versus. perioperative chemoradiation (trimodality) for locoregional esophageal/GEJ cancer. Methods: A retrospective analysis (2011-2015) compared bimodality and trimodality therapy in patients (pts) with locoregional esophageal/GEJ cancer treated with curative intent. Overall survival (OS) and disease-free survival (DFS) were calculated from the date of diagnosis. Uni- and multivariable Cox proportional hazards regression adjusted for patient and disease factors. Results: Of 108 patients, 82 (76%) were male. Mean ages were 69.5 ± 11.0 years (bimodality; N = 41) and 60.5 ± 11.1 years (trimodality; N = 67). For bimodality pts, 37% had adenocarcinoma and 63% had squamous cell carcinoma (SCC). For trimodality pts, 79% had adenocarcinoma and 21% had SCC (p &lt; 0.0001). Bimodality pts received a higher radiation dose compared to trimodality pts (50.1 ± 6.7 vs. 45.2 ± 6.4 Gy). Median follow-up was 49.3 months. We found no significant OS difference between bimodality (27.0 months) and trimodality therapy (29.8 months) in the overall cohort (p = 0.57) (4 year OS rate: 42% vs. 38%). In the subgroup with adenocarcinoma histology, trimodality therapy significantly improved OS and DFS compared to bimodality (OS: 31.8 vs. 10.4 months, hazard ratio (HR) 0.34, 95% confidence interval (CI) 0.18-0.66, p = 0.001; DFS: 15.0 vs. 6.7 months; HR 0.39, 95%CI 0.21-0.73, p = 0.003). In the SCC subgroup, median OS and DFS were similar (OS: not reached vs. 29.2 months, p = 0.48; DFS: 27.0 vs. 24.0, p = 0.96). Using multivariable regression with AIC backward selection, the only retained prognostic factors were treatment modality (p = 0.06) and histology (p = 0.01). Conclusions: Our findings support preferential use of trimodality therapy for pts with adenocarcinoma histology given superior OS and DFS, whereas bimodality and trimodality therapy appeared comparable in pts with SCC histology. Pending confirmation in a larger series with longer follow-up, these findings suggest differential treatment algorithms for locoregional esophageal and GEJ cancer based on tumor histology.

Assessment of treatment approach and survival outcomes in a modern cohort of patients with primary gliosarcoma using the national cancer database

// Lu Deng 1 , Allison Cheung 2 , Harrison X. Bai 3 , Xuejun Li 4 , Weihua Liao 5 , Ya Cao 6 , Giorgos Karakousis 7 , Paul J. Zhang 8 , Bo Xiao 9 and Li Yang 1 1 Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China 2 Department of Molecular, Cellular and Developmental Biology, Yale University, New Haven, Connecticut, 06511, United States 3 Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States 4 Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China 5 Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China 6 Cancer Research Institute, School of Basic Medicine, Central South University, Changsha, Hunan, 410078, China 7 Department of Surgery, Hospital of the University of Pennsylvania, Silverstein, Philadelphia, Pennsylvania, 19104, United States 8 Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States 9 Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China Correspondence to: Li Yang, email: yangli762@csu.edu.cn Bo Xiao, email: Xiaobo_xy@126.com Keywords: age, gliosarcoma, national cancer database, survival, trimodality therapy Received: April 11, 2017&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Accepted: August 26, 2017&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Published: January 12, 2018 ABSTRACT Background: Primary gliosarcoma is a rare malignant brain tumor with dismal prognosis. Previous reports are limited to case reports and small retrospective case series. Objective: To evaluate treatment and survival outcomes in a large cohort of primary gliosarcoma patients treated in the United States. Results: 1622 patients met the inclusion criterion. Median age was 63 years. The 3-year OS rate for the entire cohort was 11.9%. Patients aged 18 to 60 years were significantly more likely to receive trimodality therapy (defined as the use of surgery, radiotherapy [RT] and chemotherapy [CT]) than patients older than 60 (68.1% vs. 56.7%, p &lt; 0.001). The utilization of trimodality therapy significantly increased during the study period (57.5% in 2004&ndash;2008 vs. 65.1% in 2009&ndash;2013; p = 0.002). On multivariate Cox regression analysis, GTR, surgery followed by RT and the use of trimodality therapy were associated with longer OS, while older age, Charlson-Deyo score &ge; 1 and multi-focal tumor were associated with shorter OS. The use of trimodality therapy was consistently associated with longer OS in subgroup analyses based on age and extent of resection. Materials and Methods: The National Cancer Database was used to identify all primary gliosarcoma patients aged 18 to 90 years who were diagnosed between 2004 and 2013. Overall survival (OS) was evaluated by Kaplan-Meir analysis, univariate and multivariate Cox proportional hazard regression analysis. Conclusions: The use of trimodality therapy significantly increased during the study period and was associated with improved outcomes regardless of age and extent of resection.

Androgen Deprivation Therapy (ADT) and Radiation Therapy (RT) Alone As Compared With Trimodality Therapy With ADT, RT, and Surgery in Men With High Risk, Nonmetastatic Adenocarcinoma of the Prostate

Radiation therapy (RT) combined with long-term androgen deprivation therapy (ADT) represents a current standard of care for high risk prostate cancer patients. Despite this, men with high risk prostate cancer often undergo surgical resection before RT and ADT. It remains unknown if the addition of surgery to RT and ADT improves outcomes for men with high risk disease. Given the added cost and morbidity associated with the addition of surgical resection, the potential benefits of surgery seem prudent to explore. We conducted an analysis of men with high risk prostate cancer intended to examine the benefit, if any, to trimodality therapy consisting of surgery, RT, and ADT in high risk patients. The National Cancer Database was queried for men with adenocarcinoma of the prostate, treated from the years of 2004 to 2010, with one high risk feature (PSA>20, >=T3a, or Gleason score of 8-10). Patients were included if they received dose escalated RT (>=75.6 Gy) with ADT, or trimodality therapy consisting of surgery, RT, and ADT. Propensity scores were determined for patients receiving RT and ADT, and patients receiving surgery, RT and ADT. Patient characteristics were compared using t-tests, Wilcoxon Rank-Sum test, and Chi-square tests. Propensity score matching was used to balance between baseline characteristics. Overall survival (OS) was measured beginning at a landmark time of 10 months from diagnosis. OS was assessed with multivariable proportional hazards regression, propensity weighted for average treatment effect for the treated. A total of 25,035 patients met inclusion criteria for this analysis. A total of 24,062 men were treated with RT and ADT alone, and 973 men were treated with surgery, RT, and ADT. The mean age was 69.8 years in the whole cohort. Patients who received trimodality therapy, including RT, ADT, and surgical resection, were more likely to be younger (mean age of 61.5 years in the ADT, RT and Surgery groups versus 70.2 years in ADT and RT alone cohort, P <0.001). On propensity weighted multivariate analysis non-white race, increasing age, higher Charlson-Deyo comorbidity index, and increasing PSA were all associated with worse overall survival. As compared with a reference group of dose escalated RT and ADT, the patients treated with surgery, RT and ADT had no statistically significant improvement in OS, HR 0.866 (95% CI, 0.743 – 1.009, P = 0.066). No statistically significant OS benefit was seen for the use of trimodality therapy including surgery, RT and ADT when compared with dose escalated RT and ADT alone in men with high risk prostate cancer. It remains unknown if more narrowly defined subsets of high risk patients selectively benefit from trimodality therapy. Given the added cost and morbidity of surgery, men who are likely to require RT and ADT after surgery may be best suited by treatment with dose escalated RT and ADT alone.

A curative intent trimodality approach for advanced isolated abdominal nodal metastasis in metastatic colorectal cancer: Update of a single-institutional experience.

3556 Background: To define and update survival rates and relapse patterns in patients (pts) with isolated advanced abdominal nodal metastasis secondary to colorectal cancer (CRC), treated with curative intent using aggressive trimodality therapy. Methods: Fifty-seven pts with isolated advanced abdominal lymph node metastasis (retroperitoneal and mesenteric) secondary to colorectal cancer received trimodality therapy defined as chemotherapy delivered in conjunction with external beam radiotherapy (EBRT) followed by lymphadenectomy and intraoperative radiotherapy (IORT). Infusional 5-FU was the most common radiosensitizer used (66%, 38 pts). The median dose of EBRT was 50 Gy &amp; the median dose of intraoperative radiotherapy was 12.5 Gy. End points included distant metastasis, toxicities, local failure within EBRT field, recurrence within the intraoperative radiotherapy field, and survival. Results: 49% of pts were male, median age 50.5 yrs. All patients had ECOG ≤ 1. 27 pts had primary right sided colon cancer, 16 left sided colon cancer and 14 rectal primaries. Median time from initial CRC diagnosis to development of abdominal lymph node metastatic disease was 24 months (95% CI, 23.5-45.1 months). 84% (48 pts) had paraaortic nodal metastases, 12% (7 pts) had mesenteric nodal metastases, and 3% (2 pts) had both. With a median follow up of 89.4 months, the median overall survival and 5-year estimated survival rate were 53.2 months (95% CI, 46.4-78.8 months) and 42%, respectively. Median progression free survival was 19.3 months (95% CI, 15.6-32.8 months). 21 (37%) pts never developed distant disease. Outcome was not affected by disease sidedness, rectal primary, or mutational profile. Treatment was well tolerated without any grade 3/4 toxicities. Conclusions: The use of trimodality therapy including EBRT with radiosensitizing chemotherapy, lymphadenectomy and IORT produces sustainable long-term survival in selected metastatic CRC pts presenting with isolated retroperitoneal/mesenteric nodal relapse.

Assessment of the treatment approach and survival outcomes in a modern cohort of patients with atypical teratoid rhabdoid tumors using the National Cancer Database.

Atypical teratoid rhabdoid tumors (ATRTs) are rare brain tumors that occur primarily in children under the age of 3 years. This report evaluates the treatment approach and survival outcomes in a large cohort of patients treated in the United States. Using the National Cancer Database, the analysis included all ATRT patients aged 0 to 18 years who were diagnosed between 2004 and 2012 and had complete treatment data. Three hundred sixty-one ATRT patients were evaluated. The 5-year overall survival (OS) rate was 29.9%, and it was significantly lower for children who were less than 3 years old (5-year OS, 27.7%) versus those who were 3 years old or older (5-year OS, 37.5%; P < .001). The best outcome was seen for patients with localized disease who received trimodality therapy (surgery, chemotherapy, and radiation therapy [RT]) with a 5-year OS rate of 46.8%. The utilization of trimodality therapy significantly increased during the study period (27.7% in 2004-2008 vs 45.1% in 2009-2012; P < .01), largely because of the increased use of RT. In a multivariate analysis, treatment that did not utilize trimodality therapy was associated with significantly worse OS (hazard ratio, 2.52; 95% confidence interval (1.82-3.51). Children aged 0 to 2 years were significantly less likely to receive trimodality therapy because of decreased utilization of RT in this age group. The use of trimodality therapy significantly increased during the study period and was associated with improved outcomes. For patients with localized disease who received trimodality therapy, the OS rate at 5 years approached 50%. However, further research into the optimal management of children less than 3 years old is needed because of their significantly worse OS in comparison with older children. Cancer 2017;123:682-687. © 2016 American Cancer Society.

Trimodality therapy for bladder preservation in the elderly population with invasive bladder cancer.

Bladder cancer is considered as primarily a disease of the elderly, typically aged in their 70s or 80s and often with associated medical comorbidities. Unfortunately, fewer elderly patients receive radical treatment for muscle-invasive bladder cancer (MIBC) that their younger counterparts. Over the last decades, several studies have shown that the use of trimodality therapy consisting of transurethral bladder resection followed by concomitant chemotherapy and radiation therapy results in comparable outcomes to radical cystectomy, considered the gold standard for this disease. In this review, we revised the literature on bladder-preservation treatments using the trimodality approach in the elderly population with MIBC.

Underuse of trimodality treatment affects survival for patients with inflammatory breast cancer: an analysis of treatment and survival trends from the National Cancer Database.

To analyze factors that predict the use of trimodality treatment (chemotherapy, surgery, and radiation therapy [RT]) and evaluate the impact that trimodality treatment use has on survival for patients with inflammatory breast cancer (IBC). Using the National Cancer Data Base, patients who underwent surgical treatment of nonmetastatic IBC from 1998 to 2010 were identified. We collected demographic, tumor, and treatment data and analyzed treatment and survival trends over time. Logistic regression and Cox proportional hazard models were used to examine factors predicting treatment and survival. We identified 10,197 patients who fulfilled study criteria. The use of trimodality therapy fluctuated annually (58.4% to 73.4%). Patients who were older, diagnosed earlier in the study period, lived in regions of the country outside of the Midwest, had lower incomes or public insurance, and had a higher comorbid score were significantly less likely to receive trimodality therapy (all P < .05). Five- and 10-year survival rates were highest among patients receiving trimodality treatment (55.4% and 37.3%, respectively) compared with patients who received the combination of surgery plus chemotherapy, surgery plus RT, or surgery alone. After adjusting for potential confounding variables, use of trimodality therapy remained a significant independent predictor of survival. Underutilization of trimodality therapy negatively impacted survival for patients with IBC. The use of trimodality therapy increased marginally with time, but there remain significant factors associated with differences in use of trimodality treatment. We have identified specific barriers to care that may be targeted to improve treatment delivery and potentially improve patient outcomes.

Pancoast tumor

Pancoast tumors, also known as superior sulcus tumors, to this day remain a complex and challenging condition. This review will explore the evolution of the treatment of these tumors over the better part of a century. It will illustrate how with a multidisciplinary approach and the use of trimodality therapy this entity has evolved from a universally fatal disease to one that is treatable with outcomes similar to those of other stage-matched nonsmall cell lung cancers. The Southwest Oncology Group 9416 Intergroup 0160 trial reported in 2007 By Rusch et al. culminated years of research showing that trimodality therapy with chemotherapy, radiation and surgery provided optimal outcomes. Since that time, there have been studies corroborating these outcomes and utilization of novel surgical approaches including Video-assisted thoracoscopic surgery; however, no change in survival has been reported. The treatment of tumors of the superior sulcus has evolved over the years, so that outcomes approach those of other stage-matched nonsmall cell carcinomas. In the future, new approaches, perhaps the detailed genetic analysis of tumors and guided treatments, will have a positive impact on nonsmall cell carcinomas. The tumors of the superior sulcus will hopefully follow suit in their improved outcomes.

Nomograms Predicting Response to Therapy and Outcomes After Bladder-Preserving Trimodality Therapy for Muscle-Invasive Bladder Cancer

Selective bladder preservation by use of trimodality therapy is an established management strategy for muscle-invasive bladder cancer. Individual disease features have been associated with response to therapy, likelihood of bladder preservation, and disease-free survival. We developed prognostic nomograms to predict the complete response rate, disease-specific survival, and likelihood of remaining free of recurrent bladder cancer or cystectomy. From 1986 to 2009, 325 patients were managed with selective bladder preservation at Massachusetts General Hospital (MGH) and had complete data adequate for nomogram development. Treatment consisted of a transurethral resection of bladder tumor followed by split-course chemoradiation. Patients with a complete response at midtreatment cystoscopic assessment completed radiation, whereas those with a lesser response underwent a prompt cystectomy. Prognostic nomograms were constructed predicting complete response (CR), disease-specific survival (DSS), and bladder-intact disease-free survival (BI-DFS). BI-DFS was defined as the absence of local invasive or regional recurrence, distant metastasis, bladder cancer-related death, or radical cystectomy. The final nomograms included information on clinical T stage, presence of hydronephrosis, whether a visibly complete transurethral resection of bladder tumor was performed, age, sex, and tumor grade. The predictive accuracy of these nomograms was assessed. For complete response, the area under the receiving operating characteristic curve was 0.69. The Harrell concordance index was 0.61 for both DSS and BI-DFS. Our nomograms allow individualized estimates of complete response, DSS, and BI-DFS. They may assist patients and clinicians making important treatment decisions.

Radiation Therapy for Rectal Cancer: Current Status and Future Directions

Treatment for rectal cancer has evolved over the past 70 years from surgery alone to the selective use of trimodality therapy for high-risk patients. Radiotherapy (RT) has improved the potential for tumor downstaging, thus enhancing sphincter preservation and local control. This article reviews the evolution of strategies that incorporate pelvic RT, intraoperative RT, and high-dose-rate endorectal brachytherapy (HDRBT). By tracing the arc of the pendulum that has swung from postoperative RT to preoperative RT, we address the current standard of care and explore the potential of novel radiation techniques and radiosensitizing agents to improve outcomes. With randomized trial data confirming that preoperative RT in addition to chemotherapy improves local control and decreases acute and late morbidity, neoadjuvant programs have now demonstrated the prognostic significance of downstaging as well. Patients with tumors that have a good response to preoperative treatment have superior survival. Future studies will determine the optimal regimen to enhance the pathologic complete or near complete response rates for locally advanced disease. Advances in radiation technology are being investigated to determine whether efficacy can be increased and toxicity decreased so that more aggressive chemotherapeutic agents can be combined. With the growing improvements in combined modality therapy, a future of better rectal cancer outcomes looms brighter than ever before.

Phase III Trial of Trimodality Therapy With Cisplatin, Fluorouracil, Radiotherapy, and Surgery Compared With Surgery Alone for Esophageal Cancer: CALGB 9781

The primary treatment modality for patients with carcinoma of the esophagus or gastroesophageal junction has been surgery, although primary radiation therapy with concurrent chemotherapy produces similar results. As both have curative potential, there has been great interest in the use of trimodality therapy. To this end, we compared survival, response, and patterns of failure of trimodality therapy to esophagectomy alone in patients with nonmetastatic esophageal cancer. Four hundred seventy-five eligible patients were planned for enrollment. Patients were randomly assigned to either esophagectomy with node dissection alone or cisplatin 100 mg/m(2) and fluorouracil 1,000 mg/m(2)/d for 4 days on weeks 1 and 5 concurrent with radiation therapy (50.4 Gy total: 1.8 Gy/fraction over 5.6 weeks) followed by esophagectomy with node dissection. Fifty-six patients were enrolled between October 1997 and March 2000, when the trial was closed due to poor accrual. Thirty patients were randomly assigned to trimodality therapy and 26 were assigned to surgery alone. Patient and tumor characteristics were similar between groups. Treatment was generally well tolerated. Median follow-up was 6 years. An intent-to-treat analysis showed a median survival of 4.48 v 1.79 years in favor of trimodality therapy (exact stratified log-rank, P = .002). Five-year survival was 39% (95% CI, 21% to 57%) v 16% (95% CI, 5% to 33%) in favor of trimodality therapy. The results from this trial reflect a long-term survival advantage with the use of chemoradiotherapy followed by surgery in the treatment of esophageal cancer, and support trimodality therapy as a standard of care for patients with this disease.

The national practice for patients receiving radiation therapy (RT) for carcinoma of the rectum (RC): Comparative analysis of outcome from the 1992–1994 and 1988–1989 patterns of care studies by academic (AC) vs. non-academic (NAC) centers

The national practice for patients receiving radiation therapy (RT) for carcinoma of the rectum (RC): Comparative analysis of outcome from the 1992–1994 and 1988–1989 patterns of care studies by academic (AC) vs. non-academic (NAC) centers