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Haider G, Dadey DYA, Rodrigues A, Pollom EL, Adler JR, Veeravagu A. Socio-economic disparities influence likelihood of post-operative radiation to resection cavities of metastatic brain tumors. Acta Neurochir (Wien) 2023; 165:4253-4258. [PMID: 37816918 DOI: 10.1007/s00701-023-05826-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE Irradiating the surgical bed of resected brain metastases improves local and distant disease control. Over time, stereotactic radiosurgery (SRS) has replaced whole brain radiotherapy (WBRT) as the treatment standard of care because it minimizes long-term damage to neuro-cognition. Despite this data and growing adoption, socio-economic disparities in clinical access can result in sub-standard care for some patient populations. We aimed to analyze the clinical and socio-economic characteristics of patients who did not receive radiation after surgical resection of brain metastasis. METHODS Our sample was obtained from Clinformatics® Data Mart Database and included all patients from 2004 to 2021 who did or did not receive radiation treatment within sixty days after resection of tumors metastatic to the brain. Regression analysis was done to identify factors responsible for loss to adjuvant radiation treatment. RESULTS Of 8362 patients identified who had undergone craniotomy for resection of metastatic brain tumors, 3430 (41%) patients did not receive any radiation treatment. Compared to patients who did receive some form of radiation treatment (SRS or WBRT), patients who did not get any form of radiation were more likely to be older (p = 0.0189) and non-white (p = 0.008). Patients with Elixhauser Comorbidity Index ≥3 were less likely to receive radiation treatment (p < 0.01). Fewer patients with household income ≥ $75,000 did not receive radiation treatment (p < 0.01). CONCLUSION Age, race, household income, and comorbidity status were associated with differential likelihood to receive post-operative radiation treatment.
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Affiliation(s)
- Ghani Haider
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA.
| | - David Y A Dadey
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA
| | - Adrian Rodrigues
- School of Medicine, Stanford University, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - John R Adler
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA
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Parmar A, Ghosh S, Sahgal A, Lalani AKA, Hansen AR, Reaume MN, Wood L, Basappa NS, Heng DYC, Graham J, Kollmannsberger C, Soulières D, Breau RH, Tanguay S, Kapoor A, Pouliot F, Bjarnason GA. Evaluating the impact of early identification of asymptomatic brain metastases in metastatic renal cell carcinoma. Cancer Rep (Hoboken) 2023; 6:e1763. [PMID: 36517084 PMCID: PMC10026314 DOI: 10.1002/cnr2.1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 09/14/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Brain metastases (BM) in metastatic renal cell carcinoma (mRCC) have been reported to be present in up to 25% of patients diagnosed with mRCC. There is limited published literature evaluating the role of routine intra-cranial imaging for the screening of asymptomatic BM in mRCC. AIMS To evaluate the potential utility of routine intra-cranial imaging, a retrospective cohort study was conducted to characterize the outcomes of mRCC patients who presented with asymptomatic BM, as compared to symptomatic BM. METHODS AND RESULTS The Canadian Kidney Cancer Information System (CKCis) database was used to identify mRCC patients diagnosed with BM. This cohort was divided into two groups based on the presence or absence of BM symptoms. Details regarding patient demographics, disease characteristics, systemic treatments, BM characteristics and survival outcomes were extracted. Statistical analysis was through chi-square tests, analysis of variance, and Kaplan-Meier method to characterize survival outcomes. A p-value of <0.05 was considered statistically significant for all analyses. A total of 267 mRCC patients with BM were identified of which 106 (40%) presented with asymptomatic disease. The majority of patients presented with multiple (i.e., >1) BM (75%) with no significant differences noted in number of BM or BM-directed therapy received in symptomatic, as compared to asymptomatic BM patients. Median [95% confidence interval (CI)] overall survival (OS) from mRCC diagnosis was 42 months (95% CI: 32-62) for patients with asymptomatic BM, and 39 months (95% CI: 29-48) with symptomatic BM (p = 0.10). OS from time of BM diagnosis was 28 months (95% CI: 18-42) for the asymptomatic BM group, as compared to 13 months (95% CI: 10-21) in the symptomatic BM group (p = 0.04). CONCLUSIONS Given a substantial proportion of patients may present with asymptomatic BM, limiting intra-cranial imaging to patients with symptomatic BM, may be associated with a missed opportunity for timely diagnosis and treatment. The utility of routine intra-cranial imaging in patients with renal cell carcinoma, warrants further prospective evaluation.
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Affiliation(s)
- Ambica Parmar
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Arjun Sahgal
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Aly-Khan A Lalani
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Aaron R Hansen
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - M Neil Reaume
- Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Lori Wood
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Naveen S Basappa
- Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Y C Heng
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Denis Soulières
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | | | | | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Frédéric Pouliot
- Cancer Research Center, Centre Hospitalier Universitaire de Québec - Université Laval, Québec City, QC, Canada
| | - Georg A Bjarnason
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Dogan I, Iribas A, Paksoy N, Vatansever S, Basaran M. Outcomes and prognostic factors in metastatic renal cell carcinoma patients with brain metastases. J Cancer Res Ther 2023; 19:S587-S591. [PMID: 38384023 DOI: 10.4103/jcrt.jcrt_972_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/10/2022] [Indexed: 02/23/2024]
Abstract
BACKGROUND To evaluate the outcomes and prognostic factors in patients with brain metastatic renal cell carcinoma (bmRCC). METHODS The data of 322 patients with metastatic renal cell carcinoma, taken between 2012 and 2020, were retrospectively reviewed. Overall survival (OS) and prognostic factors were evaluated with Kaplan-Meier analysis and Cox regression analysis. RESULTS Forty (12.4%) of the patients had bmRCC. Seventeen (42.5%) of the patients were de novo metastatic, and nine (22.5%) of the patients had brain metastases at presentation. Twenty-four (60%) patients previously had received various therapies (tyrosine kinase inhibitor or checkpoint inhibitors). After brain metastases developed, 35 (87.5%) of the patients received brain radiotherapy (whole-brain radiotherapy or stereotactic radiosurgery), and twenty-five (62.5%) patients received different systemic therapies. Nine patients received sunitinib, nine received pazopanib, five received nivolumab, and two received axitinib. The median OS was 8.8 months (range: 2.9-14.6) for all patients with bmRCC. In univariate analysis, the number of brain metastasis (P = 0.35), the site of brain metastasis (left, right or bilateral) (P = 0.79), the largest size of brain metastasis (P = 0.45), the number of extracranial metastatic sites (P = 0.81), de novo metastatic disease (P = 0.17), primary tumor site (left or right) (P = 0.90), and tumor grade (P = 0.09) were not statistically significant factors on OS. However, age (P = 0.02), a history of nephrectomy (P < 0.001), receiving brain radiotherapy (P = 0.005), and type of systemic treatment (P = 0.04) were statistically significant. Only, the effect of brain radiotherapy on OS (P = 0.01) was confirmed in multivariate analysis. CONCLUSIONS In this study, we observed that the prognosis of patients with bmRCC was poor. Despite a small number of patients, we detected that the effect of tyrosine kinase inhibitors and nivolumab was comparable, and receiving brain radiotherapy was a prognostic factor for OS.
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Affiliation(s)
- Izzet Dogan
- Department of Medical Oncology, Istanbul University Institute of Oncology, Istanbul, Turkey
| | - Ayca Iribas
- Department of Radiation Oncology, Istanbul University Institute of Oncology, Istanbul, Turkey
| | - Nail Paksoy
- Department of Medical Oncology, Istanbul University Institute of Oncology, Istanbul, Turkey
| | - Sezai Vatansever
- Department of Medical Oncology, Istanbul University Institute of Oncology, Istanbul, Turkey
| | - Mert Basaran
- Department of Medical Oncology, Istanbul University Institute of Oncology, Istanbul, Turkey
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Impact of socio-economic factors on radiation treatment after resection of metastatic brain tumors: trends from a private insurance database. J Neurooncol 2022; 158:445-451. [PMID: 35596873 DOI: 10.1007/s11060-022-04031-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/06/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) to the surgical bed of resected brain metastases is now considered the standard of care due to its advantages over whole brain radiation therapy (WBRT). Despite the upward trend in SRS adoption since the 2000s, disparities have been reported suggesting that socio-economic factors can influence SRS utilization. OBJECTIVE To analyze recent trends in SRS use and identify factors that influence treatment. METHODS We conducted a retrospective cohort study with the Optum Commercial Claims and Encounters Database and included all patients from 2004 to 2021 who received SRS or WBRT within 60 days after resection of tumors metastatic to the brain. RESULTS A total of 3495 patients met the inclusion and exclusion criteria. There were 1998 patients in the SRS group and 1497 patients in the WBRT group. SRS use now supersedes WBRT by a wide margin. Lung, breast and colon were the most common sites of primary tumor. Although we found no significant differences based on race among the treatment groups, patients with annual household income greater than $75,000 and those with some college or higher education are significantly more likely to receive SRS (OR 1.44 and 1.30; 95% CI 1.18-1.76 and 1.08-1.56; P = 0.001 and 0.005, respective). Patients with Elixhauser Comorbidity Index of three or more were significantly more likely to receive SRS treatment. CONCLUSION The use of post-surgical SRS for brain metastasis has increased significantly over time, however education and income were associated with differential SRS utilization.
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Beydoun HA, Huang S, Beydoun MA, Eid SM, Zonderman AB. Interrupted Time-Series Analysis of Stereotactic Radiosurgery for Brain Metastases Before and After the Affordable Care Act. Cureus 2022; 14:e21338. [PMID: 35186596 PMCID: PMC8849367 DOI: 10.7759/cureus.21338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
The 2010 Patient Protection and Affordable Care Act was aimed at reducing healthcare costs, improving healthcare quality, and expanding health insurance coverage among uninsured individuals in the United States. We examined trends in the utilization of radiation therapies and stereotactic radiosurgery before and after its implementation among U.S. adults hospitalized with brain metastasis. Interrupted time-series analyses of data on 383,934 Nationwide Inpatient Sample hospitalizations (2005-2010 and 2011-2013) were performed, whereby yearly and quarterly cross-sectional data were evaluated and Affordable Care Act implementation was considered the main exposure variable, stratifying by patient and hospital characteristics. Overall, we observed a declining trend in radiation therapy over time, with an upward shift post-Affordable Care Act. A downward shift in radiation therapy post-Affordable Care Act was observed among Northeastern and rural hospitals, whereas an upward shift was noted among specific patient (females, 18-39 or ≥ 65 years of age, Charlson Comorbidity Index (CCI) ≥10, non-elective admissions, Medicare, self-pay, no pay or other insurance) and hospital (Midwestern, Western, non-teaching urban) subgroups. Stereotactic radiosurgery utilization among recipients of radiation therapy increased over time among Hispanics, elective admissions, and rural hospitals, whereas post-Affordable Care Act was associated with increased stereotactic radiosurgery among African-Americans and non-elective admissions and decreased stereotactic radiosurgery among elective admissions, and rural hospitals. Whereas hospitalized adults in the United States utilized less radiation therapy over the nine-year period, utilization of radiation therapy, in general, and stereotactic radiosurgery, in particular, were not consistent among distinct subgroups defined by patient and hospital characteristics, with some traditionally underserved populations more likely to receive healthcare services post-Affordable Care Act. The Affordable Care Act may be helpful at closing the gap in access to technological advances such as stereotactic radiosurgery for treating brain metastases.
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Affiliation(s)
- Hind A Beydoun
- Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, USA
| | - Shuyan Huang
- Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, USA
| | - May A Beydoun
- Intramural Research Program, National Institute on Aging, Baltimore, USA
| | - Shaker M Eid
- Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Alan B Zonderman
- Intramural Research Program, National Institute on Aging, Baltimore, USA
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Global management of brain metastasis from renal cell carcinoma. Crit Rev Oncol Hematol 2022; 171:103600. [DOI: 10.1016/j.critrevonc.2022.103600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 11/20/2022] Open
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Vogelbaum MA, Brown PD, Messersmith H, Brastianos PK, Burri S, Cahill D, Dunn IF, Gaspar LE, Gatson NTN, Gondi V, Jordan JT, Lassman AB, Maues J, Mohile N, Redjal N, Stevens G, Sulman E, van den Bent M, Wallace HJ, Weinberg JS, Zadeh G, Schiff D. Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline. J Clin Oncol 2021; 40:492-516. [PMID: 34932393 DOI: 10.1200/jco.21.02314] [Citation(s) in RCA: 268] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To provide guidance to clinicians regarding therapy for patients with brain metastases from solid tumors. METHODS ASCO convened an Expert Panel and conducted a systematic review of the literature. RESULTS Thirty-two randomized trials published in 2008 or later met eligibility criteria and form the primary evidentiary base. RECOMMENDATIONS Surgery is a reasonable option for patients with brain metastases. Patients with large tumors with mass effect are more likely to benefit than those with multiple brain metastases and/or uncontrolled systemic disease. Patients with symptomatic brain metastases should receive local therapy regardless of the systemic therapy used. For patients with asymptomatic brain metastases, local therapy should not be deferred unless deferral is specifically recommended in this guideline. The decision to defer local therapy should be based on a multidisciplinary discussion of the potential benefits and harms that the patient may experience. Several regimens were recommended for non-small-cell lung cancer, breast cancer, and melanoma. For patients with asymptomatic brain metastases and no systemic therapy options, stereotactic radiosurgery (SRS) alone should be offered to patients with one to four unresected brain metastases, excluding small-cell lung carcinoma. SRS alone to the surgical cavity should be offered to patients with one to two resected brain metastases. SRS, whole brain radiation therapy, or their combination are reasonable options for other patients. Memantine and hippocampal avoidance should be offered to patients who receive whole brain radiation therapy and have no hippocampal lesions and 4 months or more expected survival. Patients with asymptomatic brain metastases with either Karnofsky Performance Status ≤ 50 or Karnofsky Performance Status < 70 with no systemic therapy options do not derive benefit from radiation therapy.Additional information is available at www.asco.org/neurooncology-guidelines.
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Affiliation(s)
| | | | | | | | - Stuart Burri
- Levine Cancer Institute at Atrium Health, Charlotte, NC
| | - Dan Cahill
- Massachusetts General Hospital, Boston, MA
| | - Ian F Dunn
- Stephenson Cancer Center at the University of Oklahoma, Oklahoma City, OK
| | - Laurie E Gaspar
- University of Colorado School of Medicine, Aurora, CO.,University of Texas MD Anderson Cancer Center Northern Colorado, Greeley, CO
| | - Na Tosha N Gatson
- Banner MD Anderson Cancer Center, Phoenix, AZ.,Geisinger Neuroscience Institute. Danville, PA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL
| | | | | | - Julia Maues
- Georgetown Breast Cancer Advocates, Washington, DC
| | - Nimish Mohile
- University of Rochester Medical Center, Rochester, NY
| | - Navid Redjal
- Capital Health Medical Center - Hopewell Campus, Princeton, NJ
| | | | | | - Martin van den Bent
- Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | | | - David Schiff
- University of Virginia Medical Center, Charlottesville, VA
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Hospitalization outcomes among brain metastasis patients receiving radiation therapy with or without stereotactic radiosurgery from the 2005-2014 Nationwide Inpatient Sample. Sci Rep 2021; 11:19209. [PMID: 34584139 PMCID: PMC8478906 DOI: 10.1038/s41598-021-98563-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/08/2021] [Indexed: 11/09/2022] Open
Abstract
The purpose of this study was to compare hospitalization outcomes among US inpatients with brain metastases who received stereotactic radiosurgery (SRS) and/or non-SRS radiation therapies without neurosurgical intervention. A cross-sectional study was conducted whereby existing data on 35,199 hospitalization records (non-SRS alone: 32,981; SRS alone: 1035; SRS + non-SRS: 1183) from 2005 to 2014 Nationwide Inpatient Sample were analyzed. Targeted maximum likelihood estimation and Super Learner algorithms were applied to estimate average treatment effects (ATE), marginal odds ratios (MOR) and causal risk ratio (CRR) for three distinct types of radiation therapy in relation to hospitalization outcomes, including length of stay (' ≥ 7 days' vs. ' < 7 days') and discharge destination ('non-routine' vs. 'routine'), controlling for patient and hospital characteristics. Recipients of SRS alone (ATE = - 0.071, CRR = 0.88, MOR = 0.75) or SRS + non-SRS (ATE = - 0.17, CRR = 0.70, MOR = 0.50) had shorter hospitalizations as compared to recipients of non-SRS alone. Recipients of SRS alone (ATE = - 0.13, CRR = 0.78, MOR = 0.59) or SRS + non-SRS (ATE = - 0.17, CRR = 0.72, MOR = 0.51) had reduced risks of non-routine discharge as compared to recipients of non-SRS alone. Similar analyses suggested recipients of SRS alone had shorter hospitalizations and similar risk of non-routine discharge when compared to recipients of SRS + non-SRS radiation therapies. SRS alone or in combination with non-SRS therapies may reduce the risks of prolonged hospitalization and non-routine discharge among hospitalized US patients with brain metastases who underwent radiation therapy without neurosurgical intervention.
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Stereotactic Body Radiotherapy in Contralateral Kidney Oligometastasis From Renal Cell Carcinoma in a Nephrectomized Patient. Ochsner J 2021; 21:296-300. [PMID: 34566513 PMCID: PMC8442205 DOI: 10.31486/toj.20.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Renal cell carcinoma (RCC) frequently metastasizes to distal organs such as the lungs, abdomen, bones, and brain. Although rare cases of adrenal gland metastasis from RCC have been described, to our knowledge, no cases have reported the use of stereotactic body radiotherapy (SBRT) in contralateral kidney oligometastasis in a nephrectomized patient with RCC. Case Report: We report a rare case of single contralateral renal metastasis from RCC in a 65-year-old female that occurred 1 year after right radical nephrectomy. At diagnosis of relapse, the patient received targeted therapy with sunitinib for 9 consecutive months, resulting in a partial regression of renal metastasis. To preserve the organ and consolidate response, SBRT was administered to the residual mass. Targeted therapy was temporarily discontinued 15 days before and after SBRT. Total SBRT dose was 40 Gy in 5 daily fractions given with volumetric modulated arc and image-guided technique. Three months later, magnetic resonance imaging documented a complete regression of disease, a result that persisted at the last follow-up 19 months after SBRT. Conclusion: The combination of sequential targeted therapy and SBRT provided an excellent outcome in a patient with a solitary kidney who experienced contralateral kidney metastasis from RCC. This treatment approach was well tolerated and controlled the disease.
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Haque W, Verma V, Adeberg S, Rustomily R, Lo S, Butler EB, Teh BS. Outcomes following stereotactic radiosurgery or whole brain radiation therapy by molecular subtype of metastatic breast cancer. ACTA ACUST UNITED AC 2021; 26:341-351. [PMID: 34277087 PMCID: PMC8281912 DOI: 10.5603/rpor.a2021.0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
Background This study quantified clinical outcomes by molecular subtype of metastatic breast cancer (BC) following whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS). Doing so is important for patient counseling and to assess the potential benefit of combining targeted therapy and brain radiotherapy for certain molecular subtypes in ongoing trials. Materials and methods The National Cancer Database was queried for BC (invasive ductal carcinoma) cases receiving brain radiotherapy (divided into WBRT and SRS ). Statistics included multivariable logistic regression to determine factors associated with SRS delivery, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling. Results Of 1,112 patients, 186 (16.7%) received SRS and 926 (83.3%) underwent WBRT. Altogether, 410 (36.9%), 195 (17.5%), 162 (14.6%), and 345 (31.0%) were ER+/HER2−, ER+/HER2+, ER−/HER2+, and ER−/HER2−, respectively. In the respective molecular subtypes, the proportion of subjects who underwent SRS was 13.4%, 19.4%, 24.1%, and 15.7%. Respective OS for WBRT patients were 12.9, 22.8, 10.6, and 5.8 months; corresponding figures for the SRS cohort were 28.3, 40.7, 15.0, and 12.9 months (p < 0.05 for both). When comparing OS between treatment different histologic subtypes, patients with ER−/HER2+ and ER−/HER2− disease had worse OS than patients with ER+/HER2− disease, for both patients treated with SRS and for patients treated with WBRT. Conclusions Molecular subtype may be a useful prognostic marker to quantify survival following SRS/WBRT for metastatic BC. Patients with HER 2-enriched and triple-negative disease had the poorest survival following brain irradiation, lending credence to ongoing studies testing the addition of targeted therapies for these subtypes.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, United States
| | - Sebastian Adeberg
- Deparemnt of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Robert Rustomily
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, United States
| | - Simon Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
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Stenman M, Benmakhlouf H, Wersäll P, Johnstone P, Hatiboglu MA, Mayer-da-Silva J, Harmenberg U, Lindskog M, Sinclair G. Metastatic renal cell carcinoma to the brain: optimizing patient selection for gamma knife radiosurgery. Acta Neurochir (Wien) 2021; 163:333-342. [PMID: 32902689 DOI: 10.1007/s00701-020-04537-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/11/2020] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The effects of single-fraction gamma knife radiosurgery (sf-GKRS) on patients with renal cell carcinoma (RCC) brain metastases (BM) in the era of targeted agents (TA) and immune checkpoint inhibitors (ICI) are insufficiently studied. METHODS AND MATERIALS Clear cell metastatic RCC patients treated with sf-GKRS due to BM in 2005-2014 at three European centres were retrospectively analysed (n = 43). Median follow-up was 56 months. Ninety-five percent had prior nephrectomy, 53% synchronous metastasis and 86% extracranial disease at first sf-GKRS. Karnofsky performance status (KPS) ranged from 60 to 100%. Outcome measures were overall survival (OS), local control (LC) and adverse radiation effects (ARE). RESULTS One hundred and ninety-four targets were irradiated. The median number of targets at first sf-GKRS was two. The median prescription dose was 22.0 Gy. Thirty-seven percent had repeated sf-GKRS. Eighty-eight percent received TA. LC rates at 12 and 18 months were 97% and 90%. Median OS from the first sf-GKRS was 15.7 months. Low serum albumin (HR for death 5.3), corticosteroid use pre-sf-GKRS (HR for death 5.8) and KPS < 80 (HR for death 9.1) were independently associated with worse OS. No further prognostic information was gleaned from MSKCC risk group, synchronous metastasis, age, number of BM or extracranial metastases. Other prognostic scores for BM radiosurgery, including DS-GPA, renal-GPA, LLV-SIR and CITV-SIR, again, did not add further prognostic value. ARE were seldom symptomatic and were associated with tumour volume, 10-Gy volume and pre-treatment perifocal oedema. ARE were less common among patients treated with TA within 1 month of sf-GKRS. CONCLUSIONS We identified albumin, corticosteroid use and KPS as independent prognostic factors for sf-GKRS of clear cell RCC BM. Studies focusing on the prognostic significance of albumin in sf-GKRS are rare. Further studies with a larger number of patients are warranted to confirm the above analytical outcome. Also, in keeping with previous studies, our data showed optimal rates of local tumour control and limited toxicity post radiosurgery, rendering GKRS the tool of choice in the management of RCC BM.
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Affiliation(s)
- M Stenman
- Department of Immunology, Genetics, and Pathology, Experimental and Clinical Oncology, Uppsala University, Uppsala, Sweden
| | - H Benmakhlouf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - P Wersäll
- Department of Oncology-Pathology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - P Johnstone
- Department of Oncology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - M A Hatiboglu
- Department of Neurosurgery, Bezmialem Vakif University Medical School, Istanbul, Turkey
| | - J Mayer-da-Silva
- Centro Gamma Knife, CUF Infante Santo Hospital, Lisbon, Portugal
| | - U Harmenberg
- Department of Oncology-Pathology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - M Lindskog
- Department of Immunology, Genetics, and Pathology, Experimental and Clinical Oncology, Uppsala University, Uppsala, Sweden
| | - G Sinclair
- Department of Neurosurgery, Bezmialem Vakif University Medical School, Istanbul, Turkey.
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
- Department of Oncology, North Middlesex University Hospital NHS Trust, London, UK.
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Haque W, Verma V, Barber S, Tremont IW, Brian Butler E, Teh BS. Management, outcomes, and prognostic factors of adult primary spinal cord gliomas. J Clin Neurosci 2020; 84:8-14. [PMID: 33485604 DOI: 10.1016/j.jocn.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/27/2020] [Accepted: 12/10/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE Primary spinal cord tumors are rare, particularly in the adult population, and national guidelines remain ambiguous with regard to management approaches. To address this knowledge gap, we evaluated management, outcomes, and prognostic factors of these neoplasms. METHODS The National Cancer Database was queried (2004-2016) for newly-diagnosed, histologically-confirmed WHO grades I-III astrocytomas and glioblastoma. Statistics included Kaplan-Meier overall survival (OS) analysis, along with Cox proportional hazards modeling. RESULTS Of 1,033 subjects, 196 (19%) were pilocytic astrocytomas (PAs), 539 (52%) were grade II/III astrocytomas, and 298 (29%) were glioblastomas (GBMs). Respectively, 11%, 30%, and 27% did not undergo resection (biopsy only). RT was delivered to 27%, 54%, and 73%; chemotherapy was given to 5%, 21%, and 37%, respectively. The median OS was not reached for PAs, but was 101.2 months for grade II/III astrocytomas, and 23.9 months for GBMs (p < 0.001). Neither chemotherapy nor RT (or dose thereof) was associated with increased OS for grade II/III astrocytomas (p > 0.05 for all), though there was a trend toward improved OS with the use of chemotherapy for patients with GBM. Surgical resection was associated with improved OS for grade II/III astrocytomas and GBM (p < 0.05). Independent prognostic factors for survival in this cohort included histologic classification and resection (compared to biopsy only) (p < 0.05 for both). CONCLUSIONS This study sheds light onto the management of these rare tumors; surgery was associated with OS benefit for patients with GBM and Grade II/III astrocytomas. Neither RT nor chemotherapy were associated with OS benefit. Although not implying causation, these data can be used to guide patient counseling and therapeutic approaches.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States.
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, United States
| | - Sean Barber
- Department of Radiation Neurosurgery, Houston Methodist Hospital, Houston, TX, United States
| | - Ivo W Tremont
- Department of Nuerooncology, Houston Methodist Hospital, TX, United States
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
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13
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Chin AL, Li G, Gephart MH, Sandhu N, Nagpal S, Soltys SG, Pollom EL. Stereotactic Radiosurgery After Resection of Brain Metastases: Changing Patterns of Care in the United States. World Neurosurg 2020; 144:e797-e806. [PMID: 32971279 DOI: 10.1016/j.wneu.2020.09.085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Management of symptomatic brain metastases often includes surgical resection with postoperative radiotherapy. Postoperative whole-brain radiotherapy (WBRT) improves intracranial control but detrimentally impacts quality of life and neurocognition. We sought to characterize the use in the United States of postoperative stereotactic radiosurgery (SRS), an evolving standard-of-care associated with reduced cognitive effects. METHODS With the MarketScan Commercial Claims and Encounters Database from 2007 to 2015, we identified patients aged 18-65 years treated with resection of a brain metastasis followed by SRS or WBRT within 60 days of surgery. Logistic regression estimated associations between co-variables (treatment year, age, sex, geographic region, place of service, insurance type, disease histology, comorbidity score, and median area household income and educational attainment) and SRS receipt. RESULTS Of 4007 patients included, 1506 (37.6%) received SRS and 2501 (62.4%) received WBRT. Postoperative SRS increased from 16.5% (2007-2008) to 56.8% (2014-2015). Patients residing in areas with a median household income or an educational attainment below 50th percentile were significantly less likely to receive SRS after controlling for treatment year and other demographic characteristics (P < 0.01). Factors associated with greater odds of receiving SRS included younger age, female sex, melanoma histology, Western region location, hospital-based facility, and high-deductible health plan enrollment (P < 0.05 for each). CONCLUSIONS Postoperative SRS for brain metastases has increased from 2007 to 2015, with the majority of patients now receiving SRS over WBRT. Patients in areas of lower socioeconomic class were less likely to receive SRS, warranting further investigation of barriers to SRS adoption.
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Affiliation(s)
- Alexander L Chin
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Melanie Hayden Gephart
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Navjot Sandhu
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Seema Nagpal
- Division of Neuro-Oncology, Department of Neurology, Stanford Cancer Institute, Stanford, California, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA.
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14
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Wilhelm ML, Chan MKH, Abel B, Cremers F, Siebert FA, Wurster S, Krug D, Wolff R, Dunst J, Hildebrandt G, Schweikard A, Rades D, Ernst F, Blanck O. Tumor-dose-rate variations during robotic radiosurgery of oligo and multiple brain metastases. Strahlenther Onkol 2020; 197:581-591. [PMID: 32588102 PMCID: PMC8219559 DOI: 10.1007/s00066-020-01652-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 06/02/2020] [Indexed: 12/31/2022]
Abstract
Purpose For step-and-shoot robotic stereotactic radiosurgery (SRS) the dose delivered over time, called local tumor-dose-rate (TDR), may strongly vary during treatment of multiple lesions. The authors sought to evaluate technical parameters influencing TDR and correlate TDR to clinical outcome. Material and methods A total of 23 patients with 162 oligo (1–3) and multiple (>3) brain metastases (OBM/MBM) treated in 33 SRS sessions were retrospectively analyzed. Median PTV were 0.11 cc (0.01–6.36 cc) and 0.50 cc (0.12–3.68 cc) for OBM and MBM, respectively. Prescription dose ranged from 16 to 20 Gy prescribed to the median 70% isodose line. The maximum dose-rate for planning target volume (PTV) percentage p in time span s during treatment (TDRs,p) was calculated for various p and s based on treatment log files and in-house software. Results TDR60min,98% was 0.30 Gy/min (0.23–0.87 Gy/min) for OBM and 0.22 Gy/min (0.12–0.63 Gy/min) for MBM, respectively, and increased by 0.03 Gy/min per prescribed Gy. TDR60min,98% strongly correlated with treatment time (ρ = −0.717, p < 0.001), monitor units (MU) (ρ = −0.767, p < 0.001), number of beams (ρ = −0.755, p < 0.001) and beam directions (ρ = −0.685, p < 0.001) as well as lesions treated per collimator (ρ = −0.708, P < 0.001). Median overall survival (OS) was 20 months and 1‑ and 2‑year local control (LC) was 98.8% and 90.3%, respectively. LC did not correlate with any TDR, but tumor response (partial response [PR] or complete response [CR]) correlated with all TDR in univariate analysis (e.g., TDR60min,98%: hazard ration [HR] = 0.974, confidence interval [CI] = 0.952–0.996, p = 0.019). In multivariate analysis only concomitant targeted therapy or immunotherapy and breast cancer tumor histology remained a significant factor for tumor response. Local grade ≥2 radiation-induced tissue reactions were noted in 26.3% (OBM) and 5.2% (MBM), respectively, mainly influenced by tumor volume (p < 0.001). Conclusions Large TDR variations are noted during MBM-SRS which mainly arise from prolonged treatment times. Clinically, low TDR corresponded with decreased local tumor responses, although the main influencing factor was concomitant medication.
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Affiliation(s)
- Maria-Lisa Wilhelm
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany.,Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.,Strahlenklinik, University Hospital Essen, Hufelandstr. 55, Essen, Germany
| | - Benedikt Abel
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Florian Cremers
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Frank-Andre Siebert
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | - David Krug
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany. .,Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.
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15
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Miccio JA, Oladeru OT, Jun Ma S, Johung KL. Radiation Therapy for Patients with Advanced Renal Cell Carcinoma. Urol Clin North Am 2020; 47:399-411. [PMID: 32600541 DOI: 10.1016/j.ucl.2020.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stereotactic radiosurgery and stereotactic body radiation therapy (SBRT) have led to a resurgence of the use of radiotherapy in the management of advanced renal cell carcinoma (RCC). These techniques provide excellent local control and palliation of metastatic sites of disease with minimal toxicity. Additionally, SBRT to the primary tumor may be efficacious and well tolerated in select patients that are not surgical candidates. Emerging data suggest that SBRT may potentiate the immune response, and current and future study will evaluate if SBRT can improve survival outcomes in patients with metastatic RCC.
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Affiliation(s)
- Joseph A Miccio
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA
| | | | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA.
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16
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Wright JM, Ascha M, Wright CH, Smith G, Lagman C, Patel M, Elder TA, Kruchko C, Barnholtz-Sloan JS, Sloan AE. Geographic and temporal variations in the utilization of stereotactic radiosurgery for treatment of non-small cell lung cancer brain metastases from 2010 to 2015: An analysis of the national cancer database. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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17
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Haque W, Thong Y, Verma V, Rostomily R, Brian Butler E, Teh BS. Patterns of management and outcomes of unifocal versus multifocal glioblastoma. J Clin Neurosci 2020; 74:155-159. [PMID: 32089384 DOI: 10.1016/j.jocn.2020.01.086] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/27/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Glioblastoma (GBM) presents as a solitary lesion (unifocal), or as multiple discrete lesions (multifocal). Multifocal GBM may have a worse prognosis as compared to unifocal GBM, but existing data are limited to small institutional series. The purpose of the present study was to evaluate demographic and clinical characteristics of patients with unifocal versus multifocal GBM to highlight demographic differences and clinical outcomes for two groups of patients. METHODS The National Cancer Database (NCDB) was queried (2004-2016) for patients newly diagnosed with either unifocal or multifocal GBM. Statistics included Kaplan-Meier overall survival (OS) analysis, along with Cox proportional hazards modeling. RESULTS Of 45,268 total patients, 37,483 (82.8%) had unifocal GBM and 7,785 (17.2%) had multifocal GBM. Patients with unifocal GBM more frequently received gross total resection (GTR) (41.2% versus 25.8%, p < 0.001) and conventionally fractionated radiation therapy (RT) (48.2% versus 42.7%, p < 0.001). Patients with multifocal GBM had a higher rate of surgery with biopsy only (34.0% compared to 24.1%, p < 0.001). Median OS was 12.8 months versus 8.3 months (p < 0.001) for patients with unifocal GBM or multifocal GBM, respectively. On multivariate analysis, factors associated with improved OS included unifocal disease, MGMT methylation, RT use, and chemotherapy use. CONCLUSIONS This is the largest study to date describing outcomes for patients with multifocal GBM, and it shows that multifocal GBM is associated with a decreased use both of GTR and conventionally fractionated RT, as well as worse median OS. Further research is needed to improve clinical outcomes for patients with multifocal GBM.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA.
| | - Yvonne Thong
- Department of Psychology, University of Texas at Dallas, Richardson, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Health, Pittsburgh, PA, USA
| | - Robert Rostomily
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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18
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Kondo T, Ishihara H. Unique behavior of brain metastases during the treatment of nivolumab for metastatic renal cell carcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:S267. [PMID: 32015986 DOI: 10.21037/atm.2019.12.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan.,Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroki Ishihara
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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19
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Ascha MS, Funk K, Sloan AE, Kruchko C, Barnholtz-Sloan JS. Disparities in the use of stereotactic radiosurgery for the treatment of lung cancer brain metastases: a SEER-Medicare study. Clin Exp Metastasis 2020; 37:85-93. [PMID: 31705229 DOI: 10.1007/s10585-019-10005-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 11/03/2019] [Indexed: 12/21/2022]
Abstract
Stereotactic radiosurgery (SRS) is a costly procedure used to irradiate disease tissue while sparing healthy tissue, ideally limiting the side effects of treatment. SRS is frequently used in the setting of lung cancer, which is associated with greater rates of BM, though its cost may lead to potentially inequitable use across patient populations. This study investigates potential disparities in the use of SRS to treat Medicare patients. Surveillance, Epidemiology, and End-Results cancer registry data for patients diagnosed between the years 2010 and 2012 were examined to identify lung cancer patients diagnosed with BM at the same time as their primary cancer (SBM). Medicare claims for SRS were identified; the odds of having SRS claims and hazards of mortality associated with those odds were examined with respect to various clinical and demographic characteristics. Of 74,142 Medicare-enrolled patients diagnosed with lung cancer, 9192 were diagnosed with SBM and 3259 of those patients received SRS. Adjusting for clinical and demographic characteristics, males with SBM had 0.85 times the odds of SRS compared to females with SBM. Black patients and those of other race had significantly lower odds of evidence of SRS compared to WNH patients. SRS may not be delivered equitably among Medicare patients. Males and minority patients may have decreased odds of SRS and worse survival compared to female and WNH patients, respectively.
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Affiliation(s)
- Mustafa S Ascha
- Department of Population and Quantitative Health Sciences, Center for Clinical Investigation, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kaitlyn Funk
- Case Western Reserve University, Cleveland, OH, USA
| | - Andrew E Sloan
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Jill S Barnholtz-Sloan
- Department of Population and Quantitative Health Sciences, Case Comprehensive Cancer Center, Institute for Computational Biology, Case Western Reserve University School of Medicine, 2-526 Wolstein Research Bldg, 2103 Cornell Rd, Cleveland, OH, 44106-7295, USA.
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20
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Patterns of Care and Outcomes of Elderly Esophageal Cancer Patients Not Meeting Age-based Criteria of the CROSS Trial. Am J Clin Oncol 2019; 42:67-74. [PMID: 30216194 DOI: 10.1097/coc.0000000000000481] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The CROSS trial established neoadjuvant chemoradiation followed by surgery (nCRT-S) as superior to surgery alone (S) for locally advanced esophageal cancer (EC). However, because patients above 75 years of age were excluded, this comparison cannot be extrapolated to older patients. This study of a large, contemporary national database evaluated practice patterns in elderly patients ineligible for CROSS, and analyzed overall survival (OS) between nCRT+S, S, and definitive CRT (dCRT). MATERIALS AND METHODS The National Cancer Data Base was queried for EC patients with cT1N1M0/T2-3N0-1M0 EC (per the CROSS trial) but 76 years and above of age. Multivariable logistic regression ascertained factors associated with nCRT+S (vs. S). Kaplan-Meier analysis evaluated OS; Cox multivariate analysis determined variables associated with OS. Propensity matching aimed to address group imbalances and indication biases. RESULTS Of 4099 total patients, 594 (14%) underwent nCRT+S, 494 (12%) underwent S, and 3011 (73%) underwent dCRT. Since 2010, trimodality management has risen, corresponding to declines in S and dCRT. Median OS in the respective groups were 26.7, 20.3, and 17.8 months (P<0.05). Following propensity matching, there was a trend towards higher OS with nCRT-S over S (P=0.077); dCRT showed poorer OS than nCRT-S (P<0.001) but was equivalent to S (P=0.669). Before and following matching, nCRT-S experienced equivalent 30- and 90-day mortality as S (P>0.05), with lower 30-day readmission and postoperative hospital stay (P<0.05). CONCLUSIONS Although most older patients not meeting CROSS criteria undergo dCRT, utilization of trimodality therapy is rising. Despite the trend towards higher OS with trimodality therapy without poorer postoperative outcomes, careful patient selection continues to be essential in this population.
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21
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Parmar A, Soliman H, Sahgal A, Bjarnason GA. Impact of Systemic Therapy in Metastatic Renal-Cell Carcinoma Patients With Synchronous and Metachronous Brain Metastases. Clin Genitourin Cancer 2019; 18:e224-e232. [PMID: 32139300 DOI: 10.1016/j.clgc.2019.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Modern radiation techniques have led to significant improvements in intracranial disease control and overall survival (OS) for metastatic renal-cell carcinoma (mRCC) patients diagnosed with brain metastases (BM). The impact of systemic therapy in patients developing mRCC BM remains undercharacterized. PATIENTS AND METHODS We performed a retrospective cohort study of mRCC patients diagnosed with BM. Patients were grouped as having either metachronous BM (ie, ≥ 3 months from mRCC diagnosis) or synchronous BM (ie, < 3 months from mRCC diagnosis). Details of patient demographics, BM, systemic therapy, and outcomes were extracted. Statistical analysis comprised chi-square tests, analysis of variance, and Kaplan-Meier method to characterize survival outcomes. RESULTS Seventy-four patients were identified (40 at ≥ 3 months from mRCC diagnosis and 34 at < 3 months from mRCC diagnosis) of which 72 (97%) received local therapy for their BM. Median (interquartile range [IQR]) duration while first line treatment was longer at 7.8 (3.6-17.0) versus 5.1 (3.3-12.6) in patients with metachronous BM versus patients with synchronous BM (P = 0.6), respectively. After BM diagnosis, the metachronous BM cohort continued to receive the same systemic therapy for a median (IQR) duration of 1.9 (0.4-5.5) months, with eventual change most commonly the result of extracranial disease progression. Median (IQR) OS from mRCC diagnosis favored metachronous BM patients versus synchronous BM patients, at 64.2 (31.4-not yet reached) versus 22.4 (9.7-34.1) months (P = .003), respectively. However, this was not significantly different from the time of BM diagnosis, with median (IQR) survival of 20.6 (9.2-31.2) versus 15.7 (11.6-not yet reached) months (P = .95), respectively. CONCLUSION Prolonged OS was found for mRCC patients with BM that presented either metachronously or synchronously. For patients diagnosed with metachronous BM, the development of BM may be an early sign of systemic therapy failure.
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Affiliation(s)
- Ambica Parmar
- Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hany Soliman
- Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Arjun Sahgal
- Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Georg A Bjarnason
- Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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22
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Haque W, Verma V, Suzanne Klimberg V, Nangia J, Schwartz M, Brian Butler E, Teh BS. Clinical presentation, national practice patterns, and outcomes of breast adenomyoepithelioma. Breast J 2019; 26:653-660. [DOI: 10.1111/tbj.13638] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/06/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology Houston Methodist Hospital Houston TX USA
| | - Vivek Verma
- Department of Radiation Oncology Allegheny General Hospital Pittsburgh PA USA
| | | | - Julie Nangia
- Department of Medical Oncology Baylor College of Medicine Houston TX USA
| | - Mary Schwartz
- Department of Pathology Houston Methodist Hospital Houston TX USA
| | | | - Bin S. Teh
- Department of Radiation Oncology Houston Methodist Hospital Houston TX USA
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23
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Jiang W, Haque W, Verma V, Butler B, Teh BS. Stereotactic radiosurgery for brain metastases from newly diagnosed small cell lung cancer: practice patterns and outcomes. Acta Oncol 2019; 58:491-498. [PMID: 30676131 DOI: 10.1080/0284186x.2018.1562207] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Up-front stereotactic radiosurgery (SRS) has been historically thought of as inadequate for brain metastases (BM) from newly diagnosed small cell lung cancer (SCLC). This study evaluates national practice patterns and clinical outcomes for BM from SCLC. MATERIAL AND METHODS The National Cancer Database was queried (2004-2013) for patients with newly diagnosed metastatic SCLC receiving intracranial radiotherapy. Patients were grouped into three categories: upfront SRS, whole-brain radiotherapy (WBRT) alone, or WBRT with boost (SRS or fractionated radiotherapy). Statistics included temporal trend assessment by annual percent change (APC), logistic regression, exploratory Kaplan-Meier overall survival (OS) analysis without and with propensity matching, and Cox proportional hazards modeling. RESULTS A total of 14,722 patients met selection criteria, of whom 487 (3.3%), 13,657 (92.8%), and 578 (3.9%) received upfront SRS, WBRT and WBRT with boost, respectively. Utilization of SRS showed a slight increasing trend from 2004 to 2013 (2.7-4.3%). In addition to socioeconomic factors, other variables associated with SRS use included diagnosis after 2010, treatment at academic centers, and residing in higher-educated regions. SRS was less often delivered to patients with node-positive disease (p < .05). On exploratory analysis, SRS cohort was observed to have a higher overall survival (OS) than WBRT-based groups (p < .001), namely in patients without extracranial metastases. CONCLUSIONS Utilization of up-front SRS for SCLC BM has been increasing over time but is driven by socioeconomic disparities. Although there are likely numerous biases associated with the OS findings herein, further research is needed to validate this finding as well as the role of SRS on patients with brain metastases due to SCLC.
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Affiliation(s)
- Wei Jiang
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital & Shenzhen Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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24
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Haque W, Verma V, Butler EB, Teh BS, Rusthoven CG. Post-treatment mortality after definitive chemoradiotherapy versus trimodality therapy for locally advanced non-small cell lung cancer. Lung Cancer 2018; 127:76-83. [PMID: 30642556 DOI: 10.1016/j.lungcan.2018.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Locally advanced non-small cell lung cancer (NSCLC) is commonly managed with either definitive chemoradiation (dCRT) or neoadjuvant chemoradiation followed by surgery (nCRT + S). This study sought to compare 30- and 90-day mortality between nCRT + S and dCRT for these patients. METHODS The National Cancer Database was queried (2004-2014) for clinicall staged T1-3N2 or T3-4N0-1 (except T3N0) NSCLC that received nCRT + S or dCRT. Statistics included cumulative incidence analysis of 30- and 90-day mortality (before and following propensity score matching) and Cox proportional hazards regressions. RESULTS Of 28,379 patients, 4063 (14.3%) underwent nCRT-S, and 24,316 (85.6%) dCRT. Of the trimodality patients, 79.2% received lobectomy, 8.2% sublobar resection, and 12.5% pneumonectomy. Trimodality therapy and age, in addition to several soceiodempographic and oncologic variables, were associated with 30- and 90-day mortality. Short-term mortality was significantly higher with nCRT + S compared to dCRT at both 30 (3.4% vs. 0.8%, p < 0.001) and 90days (7.5% vs. 6.6%, p = 0.017), which persisted following propensity matching (3.4% vs. 0.4% and 7.5% vs. 5.3% respectively, both p < 0.001). At both 30 and 90 days, pneumonectomy was associated with higher mortality than lobectomy (6.1% vs. 2.9% and 11.1% vs. 6.9% respectively, both p < 0.001). CONCLUSIONS Treatment with nCRT + S was associated with greater 30- and 90- day post-treatment mortality when compared to treatment with dCRT, with larger differences in observed in 30-day post-treatment mortality. These data may inform shared-decsion making among patients eligible for both aproaches.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA.
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Wardak Z, Christie A, Bowman A, Stojadinovic S, Nedzi L, Barnett S, Patel T, Mickey B, Whitworth T, Hannan R, Brugarolas J, Timmerman R. Stereotactic Radiosurgery for Multiple Brain Metastases From Renal-Cell Carcinoma. Clin Genitourin Cancer 2018; 17:e273-e280. [PMID: 30595522 DOI: 10.1016/j.clgc.2018.11.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Brain metastases (BM) pose a significant problem in patients with metastatic renal-cell carcinoma (mRCC). Local and systemic therapies including stereotactic radiosurgery (SRS) are rapidly evolving, necessitating reassessments of outcomes for modern patient management. PATIENTS AND METHODS The mRCC patients with BM treated with SRS were reviewed. Patient demographics, clinical history, and SRS treatment parameters were identified. RESULTS Among 268 patients with mRCC treated between 2006 and 2015, 38 patients were identified with BM. A total of 243 BM were treated with SRS with 1 to 26 BMs treated per SRS session (median, 2 BMs). The median (range) BM size was 0.6 (0.2-3.1) cm and median (range) SRS treatment dose was 18 (12-24) Gy. Treated BM local control rates at 1 and 2 years were 91.8% (95% confidence interval, 85.7-95.4) and 86.1% (95% confidence interval, 77.1-91.7), respectively. BM control declined for larger tumors. Survival after 1-year was 57.5% (95% CI 40.2-71.4) for all patients. Survival was not statistically different between patients with < 5 BM versus ≥ 5 BM. Survival was prognostic based on International Metastatic Renal Cell Carcinoma Database (IMDC) risk groups in patients with < 5 BM. Two patients experienced grade 3 radiation necrosis requiring surgical intervention. CONCLUSION SRS is effective in controlling BM in patients with mRCC. Over half of treated patients survive past a year, and no differences in survival were noted in patients with > 5 metastases. Prognostic risk categories based on systemic disease (IMDC) are predictive of survival in this BM population, with limited rates of symptomatic radiation necrosis.
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Affiliation(s)
- Zabi Wardak
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX.
| | - Alana Christie
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Alex Bowman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | | | - Lucien Nedzi
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Sam Barnett
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Toral Patel
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Bruce Mickey
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Tony Whitworth
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Raquibul Hannan
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - James Brugarolas
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Robert Timmerman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX; Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
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