Single vs. multiple fraction non-inferiority trial of stereotactic ablative radiotherapy for the comprehensive treatment of oligo-metastases/progression: SIMPLIFY-SABR-COMET

BACKGROUND

Radiotherapy delivery regimens can vary between a single fraction (SF) and multiple fractions (MF) given daily for up to several weeks depending on the location of the cancer or metastases. With limited evidence comparing fractionation regimens for oligometastases, there is support to explore toxicity levels to nearby organs at risk as a primary outcome while using SF and MF stereotactic ablative radiotherapy (SABR) as well as explore differences in patient-reported quality of life and experience.

METHODS

This study will randomize 598 patients in a 1:1 ratio between the standard arm (MF SABR) and the experimental arm (SF SABR). This trial is designed as two randomized controlled trials within one patient population for resource efficiency. The primary objective of the first randomization is to determine if SF SABR is non-inferior to MF SABR, with respect to healthcare provider (HCP)-reported grade 3-5 adverse events (AEs) that are related to SABR. Primary endpoint is toxicity while secondary endpoints include lesional control rate (LCR), and progression-free survival (PFS). The second randomization (BC Cancer sites only) will allocate participants to either complete quality of life (QoL) questionnaires only; or QoL questionnaires and a symptom-specific survey with symptom-guided HCP intervention. The primary objective of the second randomization is to determine if radiation-related symptom questionnaire-guided HCP intervention results in improved reported QoL as measured by the EuroQoL-5-dimensions-5levels (EQ-5D-5L) instrument. The primary endpoint is patient-reported QoL and secondary endpoints include: persistence/resolution of symptom reporting, QoL, intervention cost effectiveness, resource utilization, and overall survival.

DISCUSSION

This study will compare SF and MF SABR in the treatment of oligometastases and oligoprogression to determine if there is non-inferior toxicity for SF SABR in selected participants with 1-5 oligometastatic lesions. This study will also compare patient-reported QoL between participants who receive radiation-related symptom-guided HCP intervention and those who complete questionnaires alone.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05784428. Date of Registration: 23 March 2023.

Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

Anorexia Nervosa in Adolescence: A Comprehensive Study of Multidimensional Factors Associated with Symptom Severity 1 Year Following the Diagnosis

The overarching goal of this study was to examine the unique contribution of psychological, familial, and friendship factors in explaining anorexia nervosa (AN) symptom severity 1 year following diagnosis among a sample of adolescent girls. A second objective was to determine whether friendship factors mediated the association between psychological and/or familial factors and AN symptom severity. This study included 143 adolescent girls under the age of 18 diagnosed with AN (M = 14.84, SD = 1.31). Participants were recruited from specialized eating disorder treatment programs. At admission (T1), participants completed a set of self-report questionnaires measuring psychological, familial, and friendship factors. AN symptom severity was assessed 1 year later (T2). Results of hierarchical regression analysis revealed that greater general psychological maladjustment at T1 (b = .26; se = .03; p = .00) was associated with greater AN symptom severity at T2. Greater alienation from friends at T1 (b = 1.20, se = .53, p = .03) also predicted greater AN symptom severity at T2, above and beyond the influence of adolescent girls' general psychological maladjustment. Finally, the mediating role of alienation from friends in the association between general psychological maladjustment at T1 and AN symptom severity at T2 was also identified. AN is a multidimensional disorder with a prognosis that involves both psychological and social factors. The results stemming from the present study shed light on the role of peer as a mechanism through which general psychological maladjustment is linked to AN symptom severity 1 year following diagnosis.

[An innovative process for sustaining and scaling up a school-based mental health promotion and anxiety prevention programs: The example of the HORS-PISTE program]

Context Anxiety disorders are among the most prevalent psychopathologies for children and adolescents in Quebec. The prevalence of anxiety disorders is very high and has been affecting a growing number of young people for the past 10 years. It is possible to observe an increased number of anxiety prevention programs for young people around the world. However, some authors point out that they are rarely faithfully implemented, sustained, and scaled up in several schools. Based on implementation science, this HORS-PISTE program was developed to address these important issues by preventing anxiety in Quebec high school students. Implemented in more than 100 schools, the program is now part of Action 4.3 (Promote the deployment of the HORS-PISTE program) of the new interdepartmental Action Plan on Mental Health of the Government of Quebec (2022). Purpose This article aims to describe how the Knowledge-to-Action (KTA) framework, derived of implementation science, was used to design, implement, sustain, evaluate, and scale up the HORS-PISTE program. This framework proposes a cyclical process in seven phases. Method A multi-method and multi-stakeholder approach was conducted with a grant from the Public Health Agency of Canada's Mental Health Promotion Innovation Fund, which has been supporting 20 innovative projects across Canada since 2019. It includes a pre-post evaluation protocol consisting of validated questionnaires, surveys (administered to students, parents, and teachers), semi-structured logbooks completed by program facilitators and implementation review meetings in each school. The different cycles of the program development, implementation and evaluation are discussed through the KTA framework phases. Results From 2017 to 2021, this methodology made it possible to evaluate and readjust the program each year to promote its adaptation and prepare its scaling up. This article highlights the data collected and analyzed in relation to the seven phases of the KTA framework. Conclusion This article demonstrates how implementation science can support designers of anxiety prevention programs who are concerned by scaling up and sustaining their programs. Issues in combining the scientific rigor of evaluation with the reality of the field are also raised.

Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2/3 trial

BACKGROUND

Conventional external beam radiotherapy is the standard palliative treatment for spinal metastases; however, complete response rates for pain are as low as 10-20%. Stereotactic body radiotherapy delivers high-dose, ablative radiotherapy. We aimed to compare complete response rates for pain after stereotactic body radiotherapy or conventional external beam radiotherapy in patients with painful spinal metastasis.

METHODS

This open-label, multicentre, randomised, controlled, phase 2/3 trial was done at 13 hospitals in Canada and five hospitals in Australia. Patients were eligible if they were aged 18 years and older, and had painful (defined as ≥2 points with the Brief Pain Inventory) MRI-confirmed spinal metastasis, no more than three consecutive vertebral segments to be included in the treatment volume, an Eastern Cooperative Oncology Group performance status of 0-2, a Spinal Instability Neoplasia Score of less than 12, and no neurologically symptomatic spinal cord or cauda equina compression. Patients were randomly assigned (1:1) with a web-based, computer-generated allocation sequence to receive either stereotactic body radiotherapy at a dose of 24 Gy in two daily fractions or conventional external beam radiotherapy at a dose of 20 Gy in five daily fractions using standard techniques. Treatment assignment was done centrally by use of a minimisation method to achieve balance for the stratification factors of radiosensitivity, the presence or absence of mass-type tumour (extraosseous or epidural disease extension, or both) on imaging, and centre. The primary endpoint was the proportion of patients with a complete response for pain at 3 months after radiotherapy. The primary endpoint was analysed in the intention-to-treat population and all safety and quality assurance analyses were done in the as-treated population (ie, all patients who received at least one fraction of radiotherapy). The trial is registered with ClinicalTrials.gov, NCT02512965.

FINDINGS

Between Jan 4, 2016, and Sept 27, 2019, 229 patients were enrolled and randomly assigned to receive conventional external beam radiotherapy (n=115) or stereotactic body radiotherapy (n=114). All 229 patients were included in the intention-to-treat analysis. The median follow-up was 6·7 months (IQR 6·3-6·9). At 3 months, 40 (35%) of 114 patients in the stereotactic body radiotherapy group, and 16 (14%) of 115 patients in the conventional external beam radiotherapy group had a complete response for pain (risk ratio 1·33, 95% CI 1·14-1·55; p=0·0002). This significant difference was maintained in multivariable-adjusted analyses (odds ratio 3·47, 95% CI 1·77-6·80; p=0·0003). The most common grade 3-4 adverse event was grade 3 pain (five [4%] of 115 patients in the conventional external beam radiotherapy group vs five (5%) of 110 patients in the stereotactic body radiotherapy group). No treatment-related deaths were observed.

INTERPRETATION

Stereotactic body radiotherapy at a dose of 24 Gy in two daily fractions was superior to conventional external beam radiotherapy at a dose of 20 Gy in five daily fractions in improving the complete response rate for pain. These results suggest that use of conformal, image-guided, stereotactically dose-escalated radiotherapy is appropriate in the palliative setting for symptom control for selected patients with painful spinal metastases, and an increased awareness of the need for specialised and multidisciplinary involvement in the delivery of end-of-life care is needed.

FUNDING

Canadian Cancer Society and the Australian National Health and Medical Research Council.

Assessing Functionality and Benefits of Comprehensive Dose Volume Prescriptions: An International, Multi-Institutional, Treatment Planning Study in Spine Stereotactic Body Radiation Therapy

PURPOSE

This study aimed to assess the effectiveness of multiple dose-volume specifications in minimizing interinstitutional, target-prescribed, dose variations for spine stereotactic body radiation therapy (SBRT).

METHODS AND MATERIALS

Seven institutions with a total of 10 treatment apparatuses participated in this study. SBRT plans for 3 representative spinal metastases were generated using 2 different protocols (Protocols 1 and 2) for target dose. While using just 2 target dose objectives (doses delivered to 95% and maximum point dose) in Protocol 1, 3 target dose constraints (doses delivered to 95% and 50% and maximum point dose) were defined in Protocol 2 with the intent to decrease target dose variation. A dose-volume histogram analysis was performed for the evaluated planning target volume (PTV_evl) and critical neural structures such as the spinal cord and cauda equina.

RESULTS

Doses to the organs at risk were all maintained at the maximal tolerance in both protocols; however, the interinstitutional variation of the PTV_evl dose-volume histograms was significantly decreased with Protocol 2. Furthermore, the mean PTV_evl covered by the prescription dose was increased from 73.0% in Protocol 1 to 85.8% in Protocol 2. There were no differences in the mean values of the nearly maximum dose of the critical neural structures between 2 protocols.

CONCLUSIONS

In spine SBRT with the emphasis on preservation of critical neural structures, the target prescribed dose should be defined by using multiple dose-volume objectives to minimize user and apparatus-dependent dose variabilities for the spinal metastases that are adjacent to the critical neural structures.

Adolescents' perceptions of the quality of interpersonal relationships and eating disorder symptom severity: The mediating role of low self-esteem and negative mood

Few studies have examined how the perceived quality of multiple interpersonal relationships is related to eating disorder (ED) symptom severity in adolescents and how psychological variables might influence these associations. The aim of this study is to determine whether the perceived level of trust, communication, and alienation in the relationship with one's mother, father, and peers are predictive of ED severity in adolescent females and to test the mediating effects of low self-esteem and negative mood on these associations. Adolescent females aged 12 to 18 (N = 186) with a diagnosis of Anorexia Nervosa (Restrictive; AN-R or Binge/Purge; AN-B/P) completed self-report measures evaluating the perceived quality of interpersonal relationships, ED symptom severity, low self-esteem, and negative mood. Multiple regressions revealed that the level of perceived alienation in the relationship with one's mother and peers was positively associated with ED symptom severity. Low self-esteem and negative mood acted as mediators of these associations. Considering that a high level of perceived alienation in the relationship with one's mother and peers appears to be associated with more severe ED symptoms through its impact on self-esteem and mood, improvements in the quality of these interactions are likely to be an effective target of intervention among adolescents.

[What Are the Individual, Family, and Social Characteristics Differentiating Prepubertal from Pubertal Anorexia Nervosa?]

Prepubertal anorexia nervosa may entail multiple physical effects. When the onset occurs before puberty, the disorder might be associated with a poorer prognosis and a greater resistance to treatment. Until now, prepubertal anorexia nervosa studies have mostly dealt with symptomatology, but rarely with associated factors.

OBJECTIVE:

This study aims to differentiate prepubescent from pubescent anorexia nervosa regarding individual, family and social characteristics.

METHOD:

At admission in programs specialized in eating disorders, female patients (n = 19 prepubertal and 126 pubertal) and their parents filled in questionnaires (EDI-3, BDI II, IPPA, FACES IV, IDPESQ) on key individual, family and social characteristics associated with anorexia nervosa. Prepubertal and pubertal patient results were compared for each measured variable. Pubertal development and anorexia presence were assessed by a paediatrician in all patients.

RESULTS:

Prepubertal patients account for 13.8% of all cases and have a lower percentile rank than pubertal patients. The many questionnaire results showed little or no difficulty at personal, family or social level and no difference with older patients.

CONCLUSIONS:

These results contribute to challenge our current understanding of prepubertal anorexia nervosa and the prepubescent patient capacity to report their difficulties, which highlights the importance of using several respondents when defining clinical profiles.

Identification des pratiques prometteuses dans le traitement de l’anorexie mentale

L’anorexie mentale inquiète, d’une part, car elle est associée à de nombreuses complications médicales et, d’autre part, car elle est liée à un mauvais pronostic. Face à ces constats, il est impératif que les traitements les plus efficaces soient offerts aux personnes présentant une anorexie mentale. Cet article vise à présenter une revue systématique de la littérature portant sur les modalités thérapeutiques prometteuses dans le domaine de l’anorexie mentale. Parmi celles-ci, notons le traitement ambulatoire, l’importance d’une équipe multidisciplinaire ainsi que différentes approches psychothérapeutiques, dont l’approche familiale.

[Identification of promising practices in the treatment of anorexia nervosa]

Anorexia nervosa concerned, firstly, because this disorder is associated with many medical complications and secondly, because it is linked with a poor prognosis. Given these facts, it is imperative that effective treatments be available for anorexia nervosa. This article aims to present a systematic review of the literature on the best therapeutic modalities in the field of anorexia nervosa. Among these, we find outpatient treatment, importance of multidisciplinary team and various therapeutic approachs, like familial therapy.

Response assessment after stereotactic body radiotherapy for spinal metastasis: a report from the SPIne response assessment in Neuro-Oncology (SPINO) group

The SPine response assessment In Neuro-Oncology (SPINO) group is a committee of the Response Assessment in Neuro-Oncology working group and comprises a panel of international experts in spine stereotactic body radiotherapy (SBRT). Here, we present the group's first report on the challenges in standardising imaging-based assessment of local control and pain for spinal metastases. We review current imaging modalities used in SBRT treatment planning and tumour assessment and review the criteria for pain and local control in registered clinical trials specific to spine SBRT. We summarise the results of an international survey of the panel to establish the range of current practices in assessing tumour response to spine SBRT. The ultimate goal of the SPINO group is to report consensus criteria for tumour imaging, clinical assessment, and symptom-based response criteria to help standardise future clinical trials.

Patterns of epidural progression following postoperative spine stereotactic body radiotherapy: implications for clinical target volume delineation

OBJECT

The authors performed a pattern-of-failure analysis, with a focus on epidural disease progression, in patients treated with postoperative spine stereotactic body radiotherapy (SBRT).

METHODS

Of the 70 patients with 75 spinal metastases (cases) treated with postoperative spine SBRT, there were 26 cases of local disease recurrence and 25 cases with a component of epidural disease progression. Twenty-four of the 25 cases had preoperative epidural disease with subsequent epidural disease progression, and this cohort was the focus of this epidural-specific pattern-of-failure investigation. Preoperative, postoperative, and follow-up MRI scans were reviewed, and epidural disease was characterized based on location according to a system in which the vertebral anatomy is divided into 6 sectors, with the anterior compartment comprising Sectors 1, 2, and 6, and the posterior compartment comprising Sectors 3, 4, and 5.

RESULTS

Patterns of epidural progression are reported specifically for the 24 cases with preoperative epidural disease and subsequent epidural progression. Epidural disease progression within the posterior compartment was observed to be significantly lower in those with preoperative epidural disease confined to the anterior compartment than in those with preoperative epidural disease involving both anterior and posterior compartments (56% vs. 93%, respectively; p = 0.047). In a high proportion of patients with epidural disease progression, treatment failure was found in the anterior compartment, including both those with preoperative epidural disease confined to the anterior compartment and those with preoperative epidural disease involving both anterior and posterior compartments (100% vs. 73%, respectively). When epidural disease was confined to the anterior compartment on the preoperative and postoperative MRIs, no epidural disease progression was observed in Sector 4, which is the most posterior sector. Postoperative epidural disease characteristics alone were not predictive of the pattern of epidural treatment failure.

CONCLUSIONS

Reviewing the extent of epidural disease on preoperative MRI is imperative when planning postoperative SBRT. When epidural disease is confined to the anterior epidural sectors pre- and postoperatively, covering the entire epidural space circumferentially with a prophylactic "donut" distribution may not be needed.