Similar survival for patients undergoing reduced-intensity total body irradiation (TBI) versus myeloablative TBI as conditioning for allogeneic transplant in acute leukemia

PURPOSE

Hematopoietic stem cell transplantation (HSCT) is the mainstay of treatment for adults with acute leukemia. Total body irradiation (TBI) remains an important part of the conditioning regimen for HCST. For those patients unable to tolerate myeloablative TBI (mTBI), reduced intensity TBI (riTBI) is commonly used. In this study we compared outcomes of patients undergoing mTBI with those of patients undergoing riTBI in our institution.

METHODS AND MATERIALS

We performed a retrospective review of all patients with acute leukemia who underwent TBI-based conditioning, using a prospectively acquired database of HSCT patients treated at our institution. Patient data including details of the transplantation procedure, disease status, Karnofsky performance status (KPS), response rates, toxicity, survival time, and time to progression were extracted. Patient outcomes for various radiation therapy regimens were examined. Descriptive statistical analysis was performed.

RESULTS

Between June 1985 and July 2012, 226 patients with acute leukemia underwent TBI as conditioning for HSCT. Of those patients, 180 had full radiation therapy data available; 83 had acute lymphoblastic leukemia and 94 had acute myelogenous leukemia; 45 patients received riTBI, and 135 received mTBI. Median overall survival (OS) was 13.7 months. Median relapse-free survival (RFS) for all patients was 10.2 months. Controlling for age, sex, KPS, disease status, and diagnosis, there were no significant differences in OS or RFS between patients who underwent riTBI and those who underwent mTBI (P=.402, P=.499, respectively). Median length of hospital stay was shorter for patients who received riTBI than for those who received mTBI (16 days vs 23 days, respectively; P<.001), and intensive care unit admissions were less frequent following riTBI than mTBI (2.22% vs 12.69%, respectively, P=.043). Nonrelapse survival rates were also similar (P=.186).

CONCLUSIONS

No differences in OS or RFS were seen between all patients undergoing riTBI and those undergoing mTBI, despite older age and potential increased comorbidity of riTBI patients. riTBI regimens were associated with shorter length of hospital stay, fewer intensive care unit admissions, and similar rates of nonrelapse survival, which may reflect reduced toxicity. Prospective trials comparing riTBI and mTBI are warranted.

The management of adenocarcinoma of the prostate in rural Georgia: A population-based analysis

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Background: The management of adenocarcinoma of the prostate (ACP) in minority populations and in the rural setting remains understudied. We conducted a population-based analysis exploring the management of ACP in rural Georgia. Methods: All cases of ACP diagnosed from 2001 to 2003 in a rural, 33-county, Southwest Georgia region were included. Data were obtained for all patients through direct medical record abstraction. Patient characteristics were described and associated with three specific outcomes: receipt of therapy, initiation of planned therapy, and completion of radiation therapy (RT) when initiated. Results: One thousand eighty seven patients were available for the analysis; median patient age was 69, and 44% of the patients were African American (AA). A total of 804 patients underwent a course of definitive therapy or elected to pursue regular active surveillance (AS). Of the patients 8.9% underwent radical prostatectomy (RP) alone, 3.1% RP and external beam radiation therapy (EBRT), 30.2 % EBRT alone, 10.8% brachytherapy (BT) alone, and 44.5% combination EBRT and BT; 2.5 % of patients underwent AS. Hormone therapy (HT) was used in 43.8% of all patients available for analysis. In a multivariable analysis conducted for the entire patient cohort, not being married (OR 0.60, 95% CI 0.42-0.85, p=0.004), lack of insurance (OR 0.32, 95% CI 0.16-0.61, p=0.008), and older age (OR 0.93, 95% CI 0.91-0.95, p<0.001) were all independently associated with not receiving definitive therapy. Race was not significantly related to receipt of definitive therapy. The full course of EBRT was successfully completed as planned in 98.4% of patients. Conclusions: Amongst those patients undergoing therapy for ACP in rural Georgia, a combination of BT and EBRT was the most common treatment modality. In contrast to recent studies, we found that race was not a significant predictor of receipt of care in Southwest Georgia. In this rural setting, EBRT was associated with extremely high rates of treatment completion. Despite the geographic and socioeconomic challenges associated with rural residency, our population-based study demonstrates that EBRT is a common treatment modality, with high patient compliance, even when used in a rural setting.

Neoadjuvant Hormonal Therapy is Associated with Comparable Outcomes to Neoadjuvant Chemotherapy in Post-Menopausal Women with Estrogen Receptor-Positive Breast Cancer

Objectives: We compared outcomes in post-menopausal estrogen receptor-positive (ER+) breast cancer patients treated with neoadjuvant hormonal therapy (NAHT) or neoadjuvant chemotherapy (NACT).

Methods: We retrospectively identified post-menopausal women who received either NAHT or NACT for non-metastatic, non-inflammatory, ER+, Her2neu negative breast cancer from 2004 to 2011. We compared long-term rates of locoregional relapse free survival (LRFS), distant metastasis free survival (DMFS), and overall survival (OS) using the Kaplan–Meier method. The Cox proportional hazards model was used to identify patient and disease factors significantly associated with these endpoints.

Results: We identified 99 patients in our study, including 27 who received NAHT and 72 who received NACT. There were no differences in 4-year LRFS, DMFS, or OS between groups. On Cox proportional hazards modeling, the type of systemic therapy (NAHT versus NACT) was not associated with OS. However, patients with progesterone receptor (PR) positive disease had a 92% lower risk of death compared to patients with PR negative disease.

Conclusion: Our data suggest that outcomes are not adversely affected by NAHT in post-menopausal women with ER+ breast cancer. Therefore, NAHT is a viable and potentially less toxic option than NACT in appropriately selected patients. Furthermore, although PR negative disease appears to be associated with poor prognosis, intensification of systemic treatment with chemotherapy may not be associated with improvement of disease-related outcomes in this patient population.

Residence proximity to benzene release sites is associated with increased incidence of non-Hodgkin lymphoma

BACKGROUND

An increased risk of non-Hodgkin lymphoma (NHL) has been observed among individuals with occupational exposure to benzene, but the risk among those living near benzene release sites has not been well described.

METHODS

To investigate the spatial patterns of NHL incidence and the association between NHL incidence and distance to benzene release sites, the authors linked and geocoded data on benzene release sites in Georgia from 1988 to 1998 using the Environmental Protection Agency's (EPA) Toxics Release Inventory (TRI), census tract level population statistics, and NHL incidence from the Georgia Comprehensive Cancer Registry (GCCR) from 1999 to 2008. Standardized incidence ratios were mapped by census tract, and a Poisson regression was performed on NHL and NHL subtype incidence data using the mean distance between the tract centroids and release sites as markers of exposure. Cluster analyses were conducted at the global, local, and focal levels.

RESULTS

Poisson regression indicated that, for every mile the average distance to benzene release sites increased, there was an expected 0.31% decrease in the risk of NHL. Similar results were observed for all NHL subtypes analyzed. Clusters of NHL were spatially associated with benzene release sites located in metropolitan areas, but not with release sites in other areas of the state.

CONCLUSIONS

NHL incidence was significantly higher in census tracts that were closer, on average, to benzene release sites. Additional studies are needed to examine spatial patterns of NHL incidence in other geographic regions and interactions between benzene and other exposures.

Breast reconstruction and post-mastectomy radiation practice

PURPOSE

The goal of this study was to explore the perspectives and practice of radiation oncologists who treat breast cancer patients who have had breast reconstruction.

METHODS

In 2010, an original electronic survey was sent to all physician members of the American Society of Radiation Oncology, National Cancer Research Institute-Breast Cancer Studies Group in the United Kingdom, Thai Society of Therapeutic Radiology and Oncology, Swiss Society of Radiation Oncology, and Turkish Radiation Oncology Society. We identified factors associated with radiation oncologists who treat breast cancer patients with reconstruction performed prior to radiation and obtained information regarding radiation management of the breast reconstruction.

RESULTS

358 radiation oncologists responded, and 60% of the physicians were from the United States. While 64% of participants agree or strongly agree that breast image affects a woman's quality of life during radiation, 57% feel that reconstruction challenges their ability to deliver effective breast radiation. Compared with other countries, treatment within the United States was associated with a high reconstruction rate (>/= 50% of mastectomy patients) prior to radiation (p < 0.05). Delayed-immediate reconstruction with a temporary tissue expander was more common in the United States than in other countries (52% vs. 23%, p = 0.01). Among physicians who treat patients with tissue expanders, the majority (60%) prefer a moderately inflated implant with 150-250 cc of fluid rather than a completely deflated (13%) or inflated expander (28%) during radiation. Among radiation oncologists who treat reconstructions, 49% never use bolus and 40% never boost a breast reconstruction. United States physicians were more likely than physicians from other countries to boost or bolus the reconstruction irrespective of the type of reconstruction seen in their clinic patients (p < 0.01).

CONCLUSIONS

Great variation in practice is evident from our study of radiation treatment for breast cancer patients with reconstruction. Further research on the impact and delivery of radiation to a reconstructed breast may validate some of the observed practices, highlight the variability in treatment practice, and help create a treatment consensus.

Radiation therapy sequencing for resected pancreatic adenocarcinoma in the National Cancer Data Base: A multi-institutional comparative analysis

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Background: Pancreatic adenocarcinoma (PAC) remains a devastating malignancy and the role for preoperative radiation therapy (prRT) remains uncertain. This analysis used the National Cancer Data Base (NCDB) to report outcomes for the largest known retrospective cohort of patients treated with prRT for resectable PAC to date. Methods: NCDB data were obtained for all patients who underwent resection and RT for PAC from 1998-2002. Patients with metastatic (M1) disease, combined prRT and poRT, missing OS or missing RT variables were excluded. The difference in patients’ characteristics was assessed by a Chi-square test and ANOVA. The Kaplan-Meier method was used to estimate overall survival (OS); survival differences were assessed using a log-rank test. A Cox proportional hazards model was used for unadjusted and multivariable (MV) survival analysis. Two MV logistic regression models also were used to assess for differences in margin status and lymph node (LN) status across treatment groups. Results: 5,414 analyzable patients were identified. 5.1% (277/5,414) received prRT and 94.9% (5,137/5,414) received poRT. All patients underwent resection and prRT or poRT +/- chemotherapy; 92.9% chemo. 793 patients were AJCC 5th edition stage I, 1,002 stage II, 2,990 were stage III, and 522 were stage IVa; 107 patients were M0 with unknown overall stage. There was no significant difference in OS between the two groups on unadjusted Kaplan-Meier analysis. In covariate-adjusted analysis, there was no significant difference in OS in the prRT (HR, 1.20 [95% CI .98-1.48]; p = 0.08) compared with poRT; prRT was associated with lower rates of LN positivity (OR, 0.45 [95% CI 0.31-0.65]; p < 0.001) and higher rates of negative margins (OR 1.71 [95% CI 1.17-2.52]; p = 0.006). Conclusions: In the largest published series of prRT patients to date, prRT was associated with negative margins and LN negativity at resection. There was no significant difference in OS between the groups. Limitations of this study include its retrospective nature, a small prRT cohort and lack of comorbidity data. These data may be useful in generating future prospective studies of prRT for PAC.