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Loap P, Vu-Bezin J, De Marzi L, Kirova Y. Proton therapy reduces the effective dose to immune cells in breast cancer patients. Strahlenther Onkol 2024:10.1007/s00066-024-02263-1. [PMID: 39060636 DOI: 10.1007/s00066-024-02263-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND The effective dose to circulating immune cells (EDIC) is associated with survival in lung and esophageal cancer patients. This study aimed to evaluate the benefit of intensity-modulated proton therapy (IMPT) for EDIC reduction as compared to volumetric modulated arc therapy (VMAT) in patients with locally advanced breast cancer (BC). MATERIALS AND METHODS Ten BC patients treated with locoregional VMAT after breast-conserving surgery were included. Mean dose to the heart (MHD), lungs (MLD), and liver (MlD), as well as the integral dose to the body (ITD), were retrieved, and we calculated EDIC as 0.12 × MLD + 0.08 × MHD + 0.15 × 0.85 × √(n/45) × MlD + (0.45 + 0.35 × 0.85 × √(n/45)) × ITD/(62 × 103), where n is the number of fractions. EDIC was compared between VMAT and IMPT plans. RESULTS Median EDIC was reduced from 3.37 Gy (range: 2.53-5.99) with VMAT to 2.13 Gy (1.31-3.77) with IMPT (p < 0.01). For left-sided BC patients, EDIC was reduced from 3.15 Gy (2.53-3.78) with VMAT to 1.65 Gy (1.31-3.77) with IMPT (p < 0.01). For right-sided BC patients, EDIC was reduced from 5.60 Gy (5.06-5.99) with VMAT to 3.38 Gy (3.10-3.77) with IMPT (p < 0.01). Right-sided BC patients had a higher EDIC irrespective of the technique. Integral dose reduction was the main driver of EDIC reduction with IMPT and was associated with lung sparing for left-sided BC patients or liver sparing for right-sided BC patients. CONCLUSION IMPT significantly reduced EDIC in BC patients undergoing locoregional adjuvant radiotherapy. Integral total dose reduction, associated with improved lung sparing in left-sided BC patients or liver sparing in right-sided BC patients, mainly drove EDIC reduction with IMPT. The emergence of dynamic models taking into account the circulatory kinetics of immune cells may improve the accuracy of the estimate of the dose received by the immune system compared to calculation of the EDIC, which is based solely on static dosimetric data.
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Affiliation(s)
- Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France.
| | - Jeremi Vu-Bezin
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Ludovic De Marzi
- Department of Radiation Oncology, Institut Curie, Paris, France
- Inserm U1288, Laboratoire d'Imagerie Translationnelle en Oncologie (LITO), Institut Curie, Université Paris-Saclay, 91898, Orsay, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
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2
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Kim DW, Hong CS, Son J, Kim SY, Park YI, Chung M, Chung WK, Han MC, Kim J, Kim H, Kim JS. Dosimetric analysis of six whole-breast irradiation techniques in supine and prone positions. Sci Rep 2024; 14:14347. [PMID: 38907042 PMCID: PMC11192744 DOI: 10.1038/s41598-024-65461-y] [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: 11/27/2023] [Accepted: 06/20/2024] [Indexed: 06/23/2024] Open
Abstract
In breast cancer radiation therapy, minimizing radiation-related risks and toxicity is vital for improving life expectancy. Tailoring radiotherapy techniques and treatment positions can reduce radiation doses to normal organs and mitigate treatment-related toxicity. This study entailed a dosimetric comparison of six different external beam whole-breast irradiation techniques in both supine and prone positions. We selected fourteen breast cancer patients, generating six treatment plans in both positions per patient. We assessed target coverage and organs at risk (OAR) doses to evaluate the impact of treatment techniques and positions. Excess absolute risk was calculated to estimate potential secondary cancer risk in the contralateral breast, ipsilateral lung, and contralateral lung. Additionally, we analyzed the distance between the target volume and OARs (heart and ipsilateral lung) while considering the treatment position. The results indicate that prone positioning lowers lung exposure in X-ray radiotherapy. However, particle beam therapies (PBTs) significantly reduce the dose to the heart and ipsilateral lung regardless of the patient's position. Notably, negligible differences were observed between arc-delivery and static-delivery PBTs in terms of target conformity and OAR sparing. This study provides critical dosimetric evidence to facilitate informed decision-making regarding treatment techniques and positions.
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Affiliation(s)
- Dong Wook Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, South Korea, 03722
| | - Chae-Seon Hong
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, South Korea, 03722.
| | - Junyoung Son
- Department of Radiation Oncology, Yongin Severance Hospital, Yongin, South Korea
| | - Se Young Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Seoul, South Korea
| | - Ye-In Park
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, South Korea, 03722
| | - Mijoo Chung
- Department of Radiation Oncology, Changwon Hanmaeum Hospital, Hanyang University College of Medicine, Changwon, South Korea
| | - Weon Kuu Chung
- Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Min Cheol Han
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, South Korea, 03722
| | - Jihun Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hojin Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, South Korea, 03722
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, South Korea, 03722.
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3
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Howard TP, McClelland S, Jimenez RB. Evolving Role of Proton Radiation Therapy in Clinical Practice. JCO Oncol Pract 2024; 20:771-777. [PMID: 38377440 DOI: 10.1200/op.23.00674] [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: 10/17/2023] [Revised: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 02/22/2024] Open
Abstract
With the expansion of proton radiation therapy centers across the United States and a gradually expanding body of academic evidence supporting its use, more patients are receiving-and asking about-proton therapy than ever before. Here, we outline, for nonradiation oncologists, the theoretical benefits of proton therapy, the clinical evidence to date, the controversies affecting utilization, and the numerous randomized trials currently in progress. We also discuss the challenges of researching and delivering proton therapy, including the cost of constructing and maintaining centers, barriers with insurance approval, clinical situations in which proton therapy may be approached with caution, and the issue of equitable access for all patients. The purpose of this review is to assist practicing oncologists in understanding the evolving role of proton therapy and to help nonradiation oncologists guide patients regarding this technology.
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Affiliation(s)
| | - Shearwood McClelland
- Departments of Radiation Oncology and Neurological Surgery, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
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4
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McCullum LB, Karagoz A, Dede C, Garcia R, Nosrat F, Hemmati M, Hosseinian S, Schaefer AJ, Fuller CD. Markov models for clinical decision-making in radiation oncology: A systematic review. J Med Imaging Radiat Oncol 2024. [PMID: 38766899 DOI: 10.1111/1754-9485.13656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024]
Abstract
The intrinsic stochasticity of patients' response to treatment is a major consideration for clinical decision-making in radiation therapy. Markov models are powerful tools to capture this stochasticity and render effective treatment decisions. This paper provides an overview of the Markov models for clinical decision analysis in radiation oncology. A comprehensive literature search was conducted within MEDLINE using PubMed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies published from 2000 to 2023 were considered. Selected publications were summarized in two categories: (i) studies that compare two (or more) fixed treatment policies using Monte Carlo simulation and (ii) studies that seek an optimal treatment policy through Markov Decision Processes (MDPs). Relevant to the scope of this study, 61 publications were selected for detailed review. The majority of these publications (n = 56) focused on comparative analysis of two or more fixed treatment policies using Monte Carlo simulation. Classifications based on cancer site, utility measures and the type of sensitivity analysis are presented. Five publications considered MDPs with the aim of computing an optimal treatment policy; a detailed statement of the analysis and results is provided for each work. As an extension of Markov model-based simulation analysis, MDP offers a flexible framework to identify an optimal treatment policy among a possibly large set of treatment policies. However, the applications of MDPs to oncological decision-making have been understudied, and the full capacity of this framework to render complex optimal treatment decisions warrants further consideration.
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Affiliation(s)
- Lucas B McCullum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aysenur Karagoz
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Cem Dede
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raul Garcia
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Fatemeh Nosrat
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Mehdi Hemmati
- School of Industrial and Systems Engineering, The University of Oklahoma, Norman, Oklahoma, USA
| | | | - Andrew J Schaefer
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
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5
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Talapatra K, Chitkara G, Murali-Nanavati S, Gupte A, Bardeskar NS, Behal S, Shaikh M, Atluri P. Practice of Tumor Bed Boost in Patients after Oncoplastic Breast-Conserving Surgery. Indian J Surg Oncol 2024; 15:63-70. [PMID: 38511033 PMCID: PMC10948658 DOI: 10.1007/s13193-023-01824-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/26/2023] [Indexed: 03/22/2024] Open
Abstract
The practice of boost to the tumor bed after treatment with oncoplastic breast-conserving surgery (BCS) remains variable. Using a survey, the present study evaluated the current practice of tumor bed boost administered in women after oncoplastic BCS. Actively practicing radiation oncologists across India were sent a questionnaire on the practice of adjuvant whole-breast radiotherapy and tumor bed boost after oncoplastic BCS via email and encouraged to participate. Of the 54 radiation oncologists who participated, most (98.1%) used a linear accelerator for radiotherapy. Hypofractionation was preferred by 59.26%, standard fractionation by 7.41%, and the remaining selected the fractionation strategy based on various patient factors. In addition, 83.33% participants reported that they always planned tumor boost, 51.85% preferred photons for the boost, and 75.93% administered sequential boost. The most common dose for the boost was 12.5 Gy in five fractions (40.74%). Most participants (77.78%) revealed that they used a combination of methods for identifying the tumor bed. With respect to clip placement, most surgeons (96%) at the participants' centers placed ≥ 4 clips at the tumor site, with both the base and margins being preferred by surgeons (81.48%) for placement. Finally, 12.96% participants revealed that the surgeons always involved them during surgical planning, whereas 7.4% participants reported that they always included the surgeons during radiotherapy planning, suggesting that radiation oncologists and oncoplastic surgeons do not involve each other during surgical and radiotherapy planning, possibly leading to suboptimal treatment. This may be attributed to the absence of guidelines regarding boost practices after oncoplastic BCS.
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Affiliation(s)
- Kaustav Talapatra
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Garvit Chitkara
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Sridevi Murali-Nanavati
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Ajinkya Gupte
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Nikhil S. Bardeskar
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Shruti Behal
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Muzammil Shaikh
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Pooja Atluri
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
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6
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Choi S, Dreyfuss I, Taswell CS, Cyriac J, Butkus M, Takita C. Proton Beam Therapy for Breast Cancer. Crit Rev Oncog 2024; 29:67-82. [PMID: 38683154 DOI: 10.1615/critrevoncog.2023050319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Given the radiobiological and physical properties of the proton, proton beam therapy has the potential to be advantageous for many patients compared with conventional radiotherapy by limiting toxicity and improving patient outcomes in specific breast cancer scenarios.
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Affiliation(s)
- Seraphina Choi
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Isabella Dreyfuss
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | | | - Jonathan Cyriac
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Michael Butkus
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
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7
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Wu XY, Chen M, Cao L, Li M, Chen JY. Proton Therapy in Breast Cancer: A Review of Potential Approaches for Patient Selection. Technol Cancer Res Treat 2024; 23:15330338241234788. [PMID: 38389426 PMCID: PMC10894553 DOI: 10.1177/15330338241234788] [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: 09/06/2023] [Revised: 11/25/2023] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
Proton radiotherapy may be a compelling technical option for the treatment of breast cancer due to its unique physical property known as the "Bragg peak." This feature offers distinct advantages, promising superior dose conformity within the tumor area and reduced radiation exposure to surrounding healthy tissues, enhancing the potential for better treatment outcomes. However, proton therapy is accompanied by inherent challenges, primarily higher costs and limited accessibility when compared to well-developed photon irradiation. Thus, in clinical practice, it is important for radiation oncologists to carefully select patients before recommendation of proton therapy to ensure the transformation of dosimetric benefits into tangible clinical benefits. Yet, the optimal indications for proton therapy in breast cancer patients remain uncertain. While there is no widely recognized methodology for patient selection, numerous attempts have been made in this direction. In this review, we intended to present an inspiring summarization and discussion about the current practices and exploration on the approaches of this treatment decision-making process in terms of treatment-related side-effects, tumor control, and cost-efficiency, including the normal tissue complication probability (NTCP) model, the tumor control probability (TCP) model, genomic biomarkers, cost-effectiveness analyses (CEAs), and so on. Additionally, we conducted an evaluation of the eligibility criteria in ongoing randomized controlled trials and analyzed their reference value in patient selection. We evaluated the pros and cons of various potential patient selection approaches and proposed possible directions for further optimization and exploration. In summary, while proton therapy holds significant promise in breast cancer treatment, its integration into clinical practice calls for a thoughtful, evidence-driven strategy. By continuously refining the patient selection criteria, we can harness the full potential of proton radiotherapy while ensuring maximum benefit for breast cancer patients.
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Affiliation(s)
- Xiao-Yu Wu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Mei Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Min Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jia-Yi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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8
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Chakraborty MA, Khan AJ, Cahlon O, Xu AJ, Braunstein LZ, Powell SN, Choi JI. Proton Reirradiation for High-Risk Recurrent or New Primary Breast Cancer. Cancers (Basel) 2023; 15:5722. [PMID: 38136268 PMCID: PMC10742022 DOI: 10.3390/cancers15245722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Radiotherapy is an integral component of multidisciplinary breast cancer care. Given how commonly radiotherapy is used in the treatment of breast cancer, many patients with recurrences have received previous radiotherapy. Patients with new primary breast cancer may also have received previous radiotherapy to the thoracic region. Curative doses and comprehensive field photon reirradiation (reRT) have often been avoided in these patients due to concerns for severe toxicities to organs-at-risk (OARs), such as the heart, lungs, brachial plexus, and soft tissue. However, many patients may benefit from definitive-intent reRT, such as patients with high-risk disease features such as lymph node involvement and dermal/epidermal invasion. Proton therapy is a potentially advantageous treatment option for delivery of reRT due to its lack of exit dose and greater conformality that allow for enhanced non-target tissue sparing of previously irradiated tissues. In this review, we discuss the clinical applications of proton therapy for patients with breast cancer requiring reRT, the currently available literature and how it compares to historical photon reRT outcomes, treatment planning considerations, and questions in this area warranting further study. Given the dosimetric advantages of protons and the data reported to date, proton therapy is a promising option for patients who would benefit from the added locoregional disease control provided by reRT for recurrent or new primary breast cancer.
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Affiliation(s)
- Molly A. Chakraborty
- Rutgers New Jersey Medical School, Newark, NJ 07103, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Atif J. Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Oren Cahlon
- Department of Radiation Oncology, New York University, New York, NY 10016, USA
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- New York Proton Center, New York, NY 10035, USA
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9
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Chaballout BH, Chang EM, Parikh NR, Min Y, Raldow AC. Assessing utilities for muscle-invasive bladder cancer-related health states. Urol Oncol 2023; 41:456.e7-456.e12. [PMID: 37524576 DOI: 10.1016/j.urolonc.2023.07.005] [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: 01/17/2023] [Revised: 06/12/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVES How patients value functional outcomes against oncologic outcomes during decision-making for muscular-invasive bladder cancer (MIBC) remains unclear. We sought to quantify individuals' preferences on a scale of 0 to 1, where 1 represents perfect health and 0 represents death. METHODS Descriptions of 6 hypothetical health states were developed. These included: Neoadjuvant chemotherapy followed by radical cystectomy with ileal conduit (IC) or with neobladder reconstruction (NB), Transurethral resection and chemotherapy/radiation (CRT), CRT requiring salvage cystectomy (SC), Recurrent/metastatic bladder cancer after local therapy (RMBC), and Metastatic bladder cancer (MBC). Descriptions consisted of diagnosis, treatments, adverse effects, follow-up protocol, and prognosis and were reviewed for accuracy by expert panel. Included individuals were asked to evaluate states using the visual analog scale (VAS) and standard gamble (SG) methods. RESULTS Fifty-four individuals were included for analysis. No score differences were observed between IC, NB, and CRT on VAS or SG. On VAS, SC (value = 0.429) was rated as significantly worse (P < 0.001) than NB (value = 0.582) and CRT (value = 0.565). However, this was not the case using the SG method. Both RMBC (VAS value = 0.178, SG value = 0.631) and MBC (VAS value = 0.169, SG value = 0.327) rated as significantly worse (P < 0.001) than the other states using both VAS and SG. CONCLUSIONS Within this sample of the general population, preferences for local treatments including IC, NB, and CRT were not found to be significantly different. These values can be used to calculate quality-adjusted life expectancy in future cost-effectiveness analyses.
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Affiliation(s)
- Basil H Chaballout
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Eric M Chang
- Interstate Radiation Oncology Center, Kaiser Permanente Northwest, Portland, Oregon
| | - Neil R Parikh
- Department of Radiation Oncology, UCLA, Los Angeles, CA
| | - Yugang Min
- Department of Radiation Oncology, UCLA, Los Angeles, CA
| | - Ann C Raldow
- Department of Radiation Oncology, UCLA, Los Angeles, CA.
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10
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Li G, Xia YF, Huang YX, Okat D, Qiu B, Doyen J, Bondiau PY, Benezery K, Gao J, Qian CN. Cost-effectiveness of using protons for breast irradiation aiming at minimizing cardiotoxicity: A risk-stratification analysis. Front Med (Lausanne) 2022; 9:938927. [PMID: 36091675 PMCID: PMC9452743 DOI: 10.3389/fmed.2022.938927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Incidental exposure of the heart to ionizing irradiation is associated with an increased risk of ischemic heart disease and subsequent fatality in patients with breast cancer after radiotherapy. Proton beam therapy can limit the heart dose in breast irradiation to a negligible level. However, compared with conventional photon modality, proton breast irradiation is more expensive. In this study, we performed cost-effectiveness analyses to identify the type of patients who would be more suitable for protons. Methods A Markov decision model was designed to evaluate the cost-effectiveness of protons vs. photons in reducing the risk of irradiation-related ischemic heart disease. A baseline evaluation was performed on a 50-year-old woman patient without the preexisting cardiac risk factor. Furthermore, risk-stratification analyses for photon mean heart dose and preexisting cardiac risk were conducted on 40-, 50-, and 60-year-old women patients under different proton cost and willingness-to-pay (WTP) settings. Results Using the baseline settings, the incremental effectiveness (protons vs. photons) increased from 0.043 quality-adjusted life-year (QALY) to 0.964 QALY when preexisting cardiac risk increased to 10 times its baseline level. At a proton cost of 50,000 US dollars ($), protons could be cost-effective for ≤ 60-year-old patients with diabetes and ≤50-year-old patients with grade II–III hypertension at the WTP of China ($37,653/QALY); for ≤ 60-year-old patients with diabetes and ≤ 50-year-old patients with grade II–III hypertension or ≥ 2 major cardiac risk factors at a WTP of $50,000/QALY; and for ≤ 60-year-old patients with diabetes, grade II–III hypertension or ≥ 2 major cardiac risk factors and ≤ 50-year-old patients with total cholesterol ≥ 240 mg/dL at a WTP of $100,000/QALY. Conclusion Patients' preexisting cardiac risk status was a key factor affecting the cardiac benefits gained from protons and should therefore be a major consideration for the clinical decision of using protons; cost-effective scenarios of protons exist in those patients with high risk of developing cardiac diseases.
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Affiliation(s)
- Guo Li
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, China
| | - Yun-Fei Xia
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yi-Xiang Huang
- Department of Health Management, Public Health Institute of Sun Yat-sen University, Guangzhou, China
| | - Deniz Okat
- Department of Finance, Hong Kong University of Science and Technology, Kowloon, Hong Kong SAR, China
| | - Bo Qiu
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jerome Doyen
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
- Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Pierre-Yves Bondiau
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
- Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Karen Benezery
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
- Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Jin Gao
- Division of Life Sciences and Medicine, Department of Radiation Oncology, The First Affiliated Hospital of University of Science and Technology of China, University of Science and Technology of China, Hefei, China
| | - Chao-Nan Qian
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- *Correspondence: Chao-Nan Qian ;
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11
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Nogueira LM, Jemal A, Yabroff KR, Efstathiou JA. Assessment of Proton Beam Therapy Use Among Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Netw Open 2022; 5:e229025. [PMID: 35476066 PMCID: PMC9047654 DOI: 10.1001/jamanetworkopen.2022.9025] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, those surrounded by sensitive tissues, and childhood cancers. OBJECTIVE To assess patterns of use of PBT according to the present American Society of Radiation Oncology (ASTRO) clinical indications in the US. DESIGN, SETTING, AND PARTICIPANTS Individuals newly diagnosed with cancer between 2004 and 2018 were selected from the National Cancer Database. Data analysis was performed from October 4, 2021, to February 22, 2022. ASTRO's Model Policies (2017) were used to classify patients into group 1, for which health insurance coverage for PBT treatment is recommended, and group 2, for which coverage is recommended only if additional requirements are met. MAIN OUTCOMES AND MEASURES Use of PBT. RESULTS Of the 5 919 368 patients eligible to receive PBT included in the study, 3 206 902 were female (54.2%), and mean (SD) age at diagnosis was 62.6 (12.3) years. Use of PBT in the US increased from 0.4% in 2004 to 1.2% in 2018 (annual percent change [APC], 8.12%; P < .001) due to increases in group 1 from 0.4% in 2010 to 2.2% in 2018 (APC, 21.97; P < .001) and increases in group 2 from 0.03% in 2014 to 0.1% in 2018 (APC, 30.57; P < .001). From 2010 to 2018, among patients in group 2, PBT targeted to the breast increased from 0.0% to 0.9% (APC, 51.95%), and PBT targeted to the lung increased from 0.1% to 0.7% (APC, 28.06%) (P < .001 for both). Use of PBT targeted to the prostate decreased from 1.4% in 2011 to 0.8% in 2014 (APC, -16.48%; P = .03) then increased to 1.3% in 2018 (APC, 12.45; P < .001). Most patients in group 1 treated with PBT had private insurance coverage in 2018 (1039 [55.4%]); Medicare was the most common insurance type among those in group 2 (1973 [52.5%]). CONCLUSIONS AND RELEVANCE The findings of this study show an increase in the use of PBT in the US between 2004 to 2018; prostate was the only cancer site for which PBT use decreased temporarily between 2011 and 2014, increasing again between 2014 and 2018. These findings may be especially relevant for Medicare radiation oncology coverage policies.
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Affiliation(s)
- Leticia M. Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Department of Radiation Oncology, Massachusetts General Hospital, Boston
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12
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Zientara N, Giles E, Le H, Short M. A scoping review of patient selection methods for proton therapy. J Med Radiat Sci 2022; 69:108-121. [PMID: 34476905 PMCID: PMC8892419 DOI: 10.1002/jmrs.540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/08/2021] [Accepted: 08/07/2021] [Indexed: 01/14/2023] Open
Abstract
The aim was to explore various national and international clinical decision-making tools and dose comparison methods used for selecting cancer patients for proton versus X-ray radiation therapy. To address this aim, a literature search using defined scoping review methods was performed in Medline and Embase databases as well as grey literature. Articles published between 1 January 2015 and 4 August 2020 and those that clearly stated methods of proton versus X-ray therapy patient selection and those published in English were eligible for inclusion. In total, 321 studies were identified of which 49 articles met the study's inclusion criteria representing 13 countries. Six different clinical decision-making tools and 14 dose comparison methods were identified, demonstrating variability within countries and internationally. Proton therapy was indicated for all paediatric patients except those with lymphoma and re-irradiation where individualised model-based selection was required. The most commonly reported patient selection tools included the Normal Tissue Complication Probability model, followed by cost-effectiveness modelling and dosimetry comparison. Model-based selection methods were most commonly applied for head and neck clinical indications in adult cohorts (48% of studies). While no 'Gold Standard' currently exists for proton therapy patient selection with variations evidenced globally, some of the patient selection methods identified in this review can be used to inform future practice in Australia. As literature was not identified from all countries where proton therapy centres are available, further research is needed to evaluate patient selection methods in these jurisdictions for a comprehensive overview.
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Affiliation(s)
- Nicole Zientara
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- Liverpool Cancer Therapy CentreLiverpool HospitalSydneyNew South WalesAustralia
| | - Eileen Giles
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Hien Le
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Michala Short
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
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13
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Kowalchuk RO, Corbin KS, Jimenez RB. Particle Therapy for Breast Cancer. Cancers (Basel) 2022; 14:cancers14041066. [PMID: 35205814 PMCID: PMC8870138 DOI: 10.3390/cancers14041066] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 02/05/2023] Open
Abstract
Particle therapy has received increasing attention in the treatment of breast cancer due to its unique physical properties that may enhance patient quality of life and reduce the late effects of therapy. In this review, we will examine the rationale for the use of proton and carbon therapy in the treatment of breast cancer and highlight their potential for sparing normal tissue injury. We will discuss the early dosimetric and clinical studies that have been pursued to date in this domain before focusing on the remaining open questions limiting the widespread adoption of particle therapy.
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Affiliation(s)
- Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Kimberly S. Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Rachel B. Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence:
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14
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Loap P, De Marzi L, Almeida CE, Barcellini A, Bradley J, de Santis MC, Dendale R, Jimenez R, Orlandi E, Kirova Y. Hadrontherapy techniques for breast cancer. Crit Rev Oncol Hematol 2021; 169:103574. [PMID: 34958916 DOI: 10.1016/j.critrevonc.2021.103574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 12/31/2022] Open
Abstract
Radiotherapy plays a key role in breast cancer treatment, and recent technical advances have been made to improve the therapeutic window by limiting the risk of radiation-induced toxicity or by increasing tumor control. Hadrontherapy is a form a radiotherapy relying on particle beams; compared with photon beams, particle beams have specific physical, radiobiological and immunological properties, which can be valuable in diverse clinical situations. To date, available hadrontherapy techniques for breast cancer irradiation include proton therapy, carbon ion radiation therapy, fast neutron therapy and boron neutron capture therapy. This review analyzes the current rationale and level of evidence for each hadrontherapy technique for breast cancer.
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Affiliation(s)
- Pierre Loap
- Proton Therapy Center, Institut Curie, Orsay, France.
| | | | - Carlos Eduardo Almeida
- Department of Radiological Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - Julie Bradley
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | | | - Remi Dendale
- Proton Therapy Center, Institut Curie, Orsay, France
| | - Rachel Jimenez
- Massachusetts General Hospital, Boston, MA, United States
| | - Ester Orlandi
- National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Youlia Kirova
- Proton Therapy Center, Institut Curie, Orsay, France
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15
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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16
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Vega RBM, Mohammadi H, Patel SH, Md ALH, Lockney NA, Lynch JW, Bansal MM, Liang X, Slayton WB, Parsons SK, Hoppe BS, Mendenhall NP. Establishing cost-effective allocation of proton therapy for patients with mediastinal Hodgkin lymphoma. Int J Radiat Oncol Biol Phys 2021; 112:158-166. [PMID: 34348176 DOI: 10.1016/j.ijrobp.2021.07.1711] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE For curative treatment of Hodgkin lymphoma, radiotherapy benefit must be weighed against toxicity. Although more costly, proton radiotherapy reduces dose to healthy tissue, potentially improving the therapeutic ratio compared to photons. We sought to determine the cost-effectiveness of proton versus photon therapy for mediastinal Hodgkin lymphoma (MHL) based on reduced heart disease. METHODS Our model approach was two-fold: (1) Utilize patient-level dosimetric information for a cost-effectiveness analysis using a Markov cohort model. (2) Utilize population-based data to develop guidelines for policy-makers to determine thresholds of proton therapy favorability for a given photon dose. The HD14 trial informed relapse risk; coronary heart disease risk was informed by the Framingham risk calculator modified by the mean heart dose (MHD) from radiation. Sensitivity analyses assessed model robustness and identified the most influential model assumptions. A 30-year-old adult with MHL was the base case using 30.6-Gy proton therapy versus photon intensity-modulated radiotherapy. RESULTS Proton therapy was not cost-effective in the base case for male ($129K/QALY) or female patients ($196/QALY). A 5-Gy MHD decrease was associated with proton therapy incremental cost-effectiveness ratio<$100K/QALY in 40% of scenarios. The hazard ratio associating MHD and heart disease was the most influential clinical parameter. CONCLUSION Proton therapy may be cost-effective a select minority of patients with MHLbased on age, sex, and MHD reduction. We present guidance for clinicians utilizing MHD to aid decision-making for radiotherapy modality.
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Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA.
| | - Homan Mohammadi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Samir H Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Adam L Holtzman Md
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Natalie A Lockney
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - James W Lynch
- Department of Medicine, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Manisha M Bansal
- Department of Pediatrics, Nemours Children's Hospital, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - William B Slayton
- Department of Pediatrics, Nemours Children's Hospital, Jacksonville, FL, USA
| | - Susan K Parsons
- Department of Medicine, Tufts University College of Medicine, Boston, MA, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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17
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Kim KS, Wu HG. Who Will Benefit from Charged-Particle Therapy? Cancer Res Treat 2021; 53:621-634. [PMID: 34176253 PMCID: PMC8291184 DOI: 10.4143/crt.2021.299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/14/2021] [Indexed: 02/07/2023] Open
Abstract
Charged-particle therapy (CPT) such as proton beam therapy (PBT) and carbon-ion radiotherapy (CIRT) exhibit substantial physical and biological advantages compared to conventional photon radiotherapy. As it can reduce the amount of radiation irradiated in the normal organ, CPT has been mainly applied to pediatric cancer and radioresistent tumors in the eloquent area. Although there is a possibility of greater benefits, high set-up cost and dearth of high level of clinical evidence hinder wide applications of CPT. This review aims to present recent clinical results of PBT and CIRT in selected diseases focusing on possible indications of CPT. We also discussed how clinical studies are conducted to increase the number of patients who can benefit from CPT despite its high cost.
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Affiliation(s)
- Kyung Su Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul,
Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University Hospital, Seoul,
Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul,
Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul,
Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul,
Korea
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18
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Lin A, Chang JHC, Grover RS, Hoebers FJP, Parvathaneni U, Patel SH, Thariat J, Thomson DJ, Langendijk JA, Frank SJ. PTCOG Head and Neck Subcommittee Consensus Guidelines on Particle Therapy for the Management of Head and Neck Tumors. Int J Part Ther 2021; 8:84-94. [PMID: 34285938 PMCID: PMC8270078 DOI: 10.14338/ijpt-20-00071.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/30/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Radiation therapy is a standard modality in the treatment for cancers of the head and neck, but is associated with significant short- and long-term side effects. Proton therapy, with its unique physical characteristics, can deliver less dose to normal tissues, resulting in fewer side effects. Proton therapy is currently being used for the treatment of head and neck cancer, with increasing clinical evidence supporting its use. However, barriers to wider adoption include access, cost, and the need for higher-level evidence. Methods The clinical evidence for the use of proton therapy in the treatment of head and neck cancer are reviewed here, including indications, advantages, and challenges. Results The Particle Therapy Cooperative Group Head and Neck Subcommittee task group provides consensus guidelines for the use of proton therapy for head and neck cancer. Conclusion This report can be used as a guide for clinical use, to understand clinical trials, and to inform future research efforts.
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Affiliation(s)
| | | | - Ryan S Grover
- University of California-San Diego, San Diego, CA, USA
| | - Frank J P Hoebers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Juliette Thariat
- Radiation Oncology Department, François Baclesse Center/ARCHADE, Normandy University, Caen, France
| | - David J Thomson
- The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J Frank
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Mizumoto M, Fuji H, Miyachi M, Soejima T, Yamamoto T, Aibe N, Demizu Y, Iwata H, Hashimoto T, Motegi A, Kawamura A, Terashima K, Fukushima T, Nakao T, Takada A, Sumi M, Oshima J, Moriwaki K, Nozaki M, Ishida Y, Kosaka Y, Ae K, Hosono A, Harada H, Ogo E, Akimoto T, Saito T, Fukushima H, Suzuki R, Takahashi M, Matsuo T, Matsumura A, Masaki H, Hosoi H, Shigematsu N, Sakurai H. Proton beam therapy for children and adolescents and young adults (AYAs): JASTRO and JSPHO Guidelines. Cancer Treat Rev 2021; 98:102209. [PMID: 33984606 DOI: 10.1016/j.ctrv.2021.102209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
Children and adolescents and young adults (AYAs) with cancer are often treated with a multidisciplinary approach. This includes use of radiotherapy, which is important for local control, but may also cause adverse events in the long term, including second cancer. The risks for limited growth and development, endocrine dysfunction, reduced fertility and second cancer in children and AYAs are reduced by proton beam therapy (PBT), which has a dose distribution that decreases irradiation of normal organs while still targeting the tumor. To define the outcomes and characteristics of PBT in cancer treatment in pediatric and AYA patients, this document was developed by the Japanese Society for Radiation Oncology (JASTRO) and the Japanese Society of Pediatric Hematology/Oncology (JSPHO).
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Affiliation(s)
- Masashi Mizumoto
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology and National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Miyachi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Toshinori Soejima
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Takayuki Hashimoto
- Department of Radiation Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsushi Motegi
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Atsufumi Kawamura
- Department of Neurosurgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keita Terashima
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Fukushima
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomohei Nakao
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akinori Takada
- Department of Radiology, Mie University Hospital, Tsu-shi, Mie, Japan
| | - Minako Sumi
- Department of Radiation Oncology and Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Radiation Oncology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | | | - Kensuke Moriwaki
- Department of Medical Statistics, Kobe Pharmaceutical University, Kobe, Hyogo, Japan
| | - Miwako Nozaki
- Department of Radiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yuji Ishida
- Department of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keisuke Ae
- Department of Orthopaedic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ako Hosono
- Department of Pediatric Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Etsuyo Ogo
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Saito
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroko Fukushima
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryoko Suzuki
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuru Takahashi
- Department of Orthopaedic Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Akira Matsumura
- Departments of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hidekazu Masaki
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Sakurai
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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20
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Ko H, Chang JS, Moon JY, Lee WH, Shah C, Shim JSA, Han MC, Baek JG, Park RH, Kim YB, Kim JS. Dosimetric Comparison of Radiation Techniques for Comprehensive Regional Nodal Radiation Therapy for Left-Sided Breast Cancer: A Treatment Planning Study. Front Oncol 2021; 11:645328. [PMID: 33912459 PMCID: PMC8072050 DOI: 10.3389/fonc.2021.645328] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/17/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose How modern cardiac sparing techniques and beam delivery systems using advanced x-ray and proton beam therapy (PBT) can reduce incidental radiation exposure doses to cardiac and pulmonary organs individually or in any combination is poorly investigated. Methods Among 15 patients with left-sided breast cancer, partial wide tangential 3D-conformal radiotherapy (3DCRT) delivered in conventional fractionation (CF) or hypofractionated (HF) schedules; PBT delivered in a CF schedule; and volumetric modulated arc therapy (VMAT) delivered in an HF schedule, each under continuous positive airway pressure (CPAP) and free-breathing (FB) conditions, were examined. Target volume coverage and doses to organs-at-risk (OARs) were calculated for each technique. Outcomes were compared with one-way analysis of variance and the Bonferroni test, with p-values <0.05 considered significant. Results Target volume coverage was within acceptable levels in all interventions, except for the internal mammary lymph node D95 (99% in PBT, 90% in VMAT-CPAP, 84% in VMAT-FB, and 74% in 3DCRT). The mean heart dose (MHD) was the lowest in PBT (<1 Gy) and VMAT-CPAP (2.2 Gy) and the highest in 3DCRT with CF/FB (7.8 Gy), respectively. The mean lung dose (MLD) was the highest in 3DCRT-CF-FB (20 Gy) and the lowest in both VMAT-HF-CPAP and PBT (approximately 5-6 Gy). VMAT-HF-CPAP and PBT delivered a comparable maximum dose to the left ascending artery (7.2 and 6.13 Gy, respectively). Conclusions Both proton and VMAT in combination with CPAP can minimize the radiation exposure to heart and lung with optimal target coverage in regional RT for left-sided breast cancer. The clinical relevance of these differences is yet to be elucidated. Continued efforts are needed to minimize radiation exposures during RT treatment to maximize its therapeutic index.
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Affiliation(s)
- Heejoo Ko
- College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Young Moon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Won Hee Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - Min Cheol Han
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Geol Baek
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Ryeong Hwang Park
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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21
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Loap P, Beddok A, Cao KI, Goudjil F, Fourquet A, Dendale R, Kirova Y. Clinical practice of breast cancer protontherapy: A single-centre experience from selection to treatment. Cancer Radiother 2021; 25:358-365. [PMID: 33676830 DOI: 10.1016/j.canrad.2021.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Breast protontherapy efficiently limits cardiac, lung and contralateral breast exposure, which may clinically translate into better late tolerance profile compared with classic photon techniques. While breast protontherapy is already implemented in the United States and in some European countries, clinical experience of breast cancer protontherapy is currently limited in France. The aim of this study is to evaluate the clinical practice of breast cancer protontherapy at the Institut Curie in order to implement this technique at a larger scale. MATERIALS AND METHODS Data from all breast cancer patients that have been addressed to the protontherapy centre of Orsay (CPO, Institut Curie) for adjuvant breast protontherapy were retrieved. We analysed why these patients were ultimately treated with protontherapy or not. RESULTS Between November 2019 and November 2020, eleven breast cancer patients have been evaluated for adjuvant protontherapy at the CPO. Two of them were ultimately treated with proton beams; adjuvant breast protontherapy therapy was well tolerated. The nine other patients were not treated with protontherapy due to lack of availability of protontherapy treatment rooms in acceptable time limits, at the time of patient evaluation. CONCLUSION Despite dosimetric advantages and excellent clinical tolerance, lack of availability of protontherapy machines currently limits wider implementation of breast protontherapy.
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Affiliation(s)
- P Loap
- Department of radiation oncology, Institut Curie, Paris, France
| | - A Beddok
- Department of radiation oncology, Institut Curie, Paris, France
| | - K I Cao
- Department of radiation oncology, Institut Curie, Paris, France
| | - F Goudjil
- Department of radiation oncology, Institut Curie, Paris, France
| | - A Fourquet
- Department of radiation oncology, Institut Curie, Paris, France
| | - R Dendale
- Department of radiation oncology, Institut Curie, Paris, France
| | - Y Kirova
- Department of radiation oncology, Institut Curie, Paris, France.
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22
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Austin AM, Douglass MJ, Nguyen GT, Cunningham L, Le H, Hu Y, Penfold SN. Individualised selection of left-sided breast cancer patients for proton therapy based on cost-effectiveness. J Med Radiat Sci 2021; 68:44-51. [PMID: 32638527 PMCID: PMC7890920 DOI: 10.1002/jmrs.416] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 05/13/2020] [Accepted: 06/11/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The significantly greater cost of proton therapy compared with X-ray therapy is frequently justified by the expected reduction in normal tissue toxicity. This is often true for indications such as paediatric and skull base cancers. However, the benefit is less clear for other more common indications such as breast cancer, and it is possible that the degree of benefit may vary widely between these patients. The aim of this work was to demonstrate a method of individualised selection of left-sided breast cancer patients for proton therapy based on cost-effectiveness of treatment. METHODS 16 left-sided breast cancer patients had a treatment plan generated for the delivery of intensity-modulated proton therapy (IMPT) and of intensity-modulated photon therapy (IMRT) with the deep inspiration breath-hold (DIBH) technique. The resulting dosimetric data was used to predict probabilities of tumour control and toxicities for each patient. These probabilities were used in a Markov model to predict costs and the number of quality-adjusted life years expected as a result of each of the two treatments. RESULTS IMPT was not cost-effective for the majority of patients but was cost-effective where there was a greater risk reduction of second malignancies with IMPT. CONCLUSION The Markov model predicted that IMPT with DIBH was only cost-effective for selected left-sided breast cancer patients where IMRT resulted in a significantly greater dose to normal tissue. The presented model may serve as a means of evaluating the cost-effectiveness of IMPT on an individual patient basis.
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Affiliation(s)
| | - Michael J.J. Douglass
- Department of PhysicsUniversity of AdelaideAdelaideSAAustralia
- Department of Medical PhysicsRoyal Adelaide HospitalAdelaideSAAustralia
| | - Giang T. Nguyen
- School of Mathematical SciencesUniversity of AdelaideAdelaideSAAustralia
| | - Lisa Cunningham
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSAAustralia
| | - Hien Le
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSAAustralia
| | - Yvonne Hu
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSAAustralia
| | - Scott N. Penfold
- Department of PhysicsUniversity of AdelaideAdelaideSAAustralia
- Department of Medical PhysicsRoyal Adelaide HospitalAdelaideSAAustralia
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23
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Bartolucci L, Adrien C, Goudjil F, Amessis M, El Amine W, Fourquet A, Mazal A, Kirova Y. Dosimetric comparison of four high performance techniques for irradiation of breast cancer patients. Cancer Radiother 2021; 25:254-258. [PMID: 33402289 DOI: 10.1016/j.canrad.2020.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE The use of IMRT for the treatment of breast cancer has been growing considerably in our institution since 2009. Alternatively, helical tomotherapy (HT) using a field width of 2.5 and 5cm (HT_FW_5), volumetric-modulated arc therapy (VMAT), or proton therapy with pencil-beam scanning (PT-PBS) have also been used to reduce treatment duration or optimize organ-at-risk (OAR) sparing. The purpose of this study was to compare the 4 treatment modalities available at our site. PATIENTS AND METHODS We studied 10 patients treated for breast cancer with lymph node involvement. The prescribed dose was 51.8Gy to the breast with a simultaneous integrated boost up to 63Gy, and 50.4Gy to lymph nodes in 28 fractions. The CTV was delineated according to ESTRO Guidelines. Dosimetric planning in routine clinical practice was performed using HT_FW_2.5. The approved clinical plan was compared to the 3 other plans. Dosimetric goals for PTV coverage were D95%≥95% and D2%≤107% of the prescribed dose. Mean and maximum doses to OAR were recorded. RESULTS HT_FW_5 and VMAT plans ensure equivalent or even better PTV coverage compared to the initial clinically approved plan but at the cost of poorer OAR sparing. PT_PBS plans showed that an excellent PTV coverage can be maintained with significantly lower doses to OAR. CONCLUSION HT_FW_5 and VMAT plans allow a significant reduction of treatment duration and can be a good alternative to HT_FW_2.5 for specific populations. HT_FW_2.5 could be chosen for patients at higher risk of side effects. In addition, PT_PBS should be considered in the near future as it has been shown to have a major potential benefit to lower the risk of side effects with the same level of PTV coverage.
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Affiliation(s)
- L Bartolucci
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - C Adrien
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - F Goudjil
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - M Amessis
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - W El Amine
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - A Fourquet
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - A Mazal
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - Y Kirova
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France.
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24
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Hernandez M, Lee JJ, Yeap BY, Ye R, Foote RL, Busse P, Patel SH, Dagan R, Snider J, Mohammed N, Lin A, Blanchard P, Cantor SB, Teferra MY, Hutcheson K, Yepes P, Mohan R, Liao Z, DeLaney TF, Frank SJ. The Reality of Randomized Controlled Trials for Assessing the Benefit of Proton Therapy: Critically Examining the Intent-to-Treat Principle in the Presence of Insurance Denial. Adv Radiat Oncol 2020; 6:100635. [PMID: 33732960 PMCID: PMC7940795 DOI: 10.1016/j.adro.2020.100635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 11/04/2020] [Accepted: 11/17/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose This study hypothesized that insurance denial would lead to bias and loss of statistical power when evaluating the results from an intent-to-treat (ITT), per-protocol, and as-treated analyses using a simulated randomized clinical trial comparing proton therapy to intensity modulated radiation therapy where patients incurred increasing rates of insurance denial. Methods and Materials Simulations used a binary endpoint to assess differences between treatment arms after applying ITT, per-protocol, and as-treated analyses. Two scenarios were developed: 1 with clinical success independent of age and another assuming dependence on age. Insurance denial was assumed possible for patients <65 years. All scenarios considered an age distribution with mean ± standard deviation: 55 ± 15 years, rates of insurance denial ranging from 0%-40%, and a sample of N = 300 patients (150 per arm). Clinical success rates were defined as 70% for proton therapy and 50% for intensity modulated radiation therapy. The average treatment effect, bias, and power were compared after applying 5000 simulations. Results Increasing rates of insurance denial demonstrated inherent weaknesses among all 3 analytical approaches. With clinical success independent of age, a per-protocol analysis demonstrated the least bias and loss of power. When clinical success was dependent on age, the per-protocol and ITT analyses resulted in a similar trend with respect to bias and loss of power, with both outperforming the as-treated analysis. Conclusions Insurance denial leads to misclassification bias in the ITT analysis, a missing data problem in the per-protocol analysis, and covariate imbalance between treatment arms in the as-treated analysis. Moreover, insurance denial forces the critical appraisal of patient features (eg, age) affected by the denial and potentially influencing clinical success. In the presence of insurance denial, our study suggests cautious reporting of ITT and as-treated analyses, and placing primary emphasis on the results of the per-protocol analysis.
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Affiliation(s)
- Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rong Ye
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Paul Busse
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida Health, Gainesville, Florida
| | - James Snider
- Department of Radiation Oncology, University of Maryland Medical System, Baltimore, Maryland
| | - Nasiruddin Mohammed
- Department of Radiation Oncology, Northwestern Medicine, Warrenville, Illinois
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Menna Y Teferra
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kate Hutcheson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pablo Yepes
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Physics and Astronomy, Rice University, Houston, Texas
| | - Radhe Mohan
- Department of Physics and Astronomy, Rice University, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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25
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Xie Y, Guo B, Zhang R. Cost-effectiveness analysis of advanced radiotherapy techniques for post-mastectomy breast cancer patients. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:26. [PMID: 32774176 PMCID: PMC7398314 DOI: 10.1186/s12962-020-00222-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/30/2020] [Indexed: 11/21/2022] Open
Abstract
Background Prior cost-effectiveness studies of post-mastectomy radiotherapy (PMRT) only compared conventional radiotherapy versus no radiotherapy and only considered tumor control. The goal of this study was to perform cost-effectiveness analyses of standard of care (SOC) and advanced PMRT techniques including intensity-modulated radiotherapy (IMRT), standard volumetric modulated arc therapy (STD-VMAT), non-coplanar VMAT (NC-VMAT), multiple arc VMAT (MA-VMAT), Tomotherapy (TOMO), mixed beam therapy (MIXED), and intensity-modulated proton therapy (IMPT). Methods Using a Markov model, we estimated the cost-effectiveness of various techniques over 15 years. A cohort of women (55-year-old) was simulated in the model, and radiogenic side effects were considered. Transition probabilities, utilities, and costs for each health state were obtained from literature and Medicare data. Model outcomes include quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER). Results For the patient cohort, STD-VMAT has an ICER of $32,617/QALY relative to SOC; TOMO is dominated by STD-VMAT; IMRT has an ICER of $19,081/QALY relative to STD-VMAT; NC-VMAT, MA-VMAT, MIXED are dominated by IMRT; IMPT has an ICER of $151,741/QALY relative to IMRT. One-way analysis shows that the probability of cardiac toxicity has the most significant impact on the model outcomes. The probability sensitivity analyses show that all advanced PMRT techniques are more cost-effective than SOC at a willingness-to-pay (WTP) threshold of $100,000/QALY, while almost none of the advanced techniques is more cost-effective than SOC at a WTP threshold of $50,000/QALY. Conclusion Advanced PMRT techniques are more cost-effective for breast cancer patients at a WTP threshold of $100,000/QALY, and IMRT might be a cost-effective option for PMRT patients.
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Affiliation(s)
- Yibo Xie
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA USA
| | - Beibei Guo
- Department of Experimental Statistics, Louisiana State University, Baton Rouge, LA USA
| | - Rui Zhang
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA USA.,Department of Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, LA USA
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26
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Li G, Qiu B, Huang YX, Doyen J, Bondiau PY, Benezery K, Xia YF, Qian CN. Cost-effectiveness analysis of proton beam therapy for treatment decision making in paranasal sinus and nasal cavity cancers in China. BMC Cancer 2020; 20:599. [PMID: 32590957 PMCID: PMC7320568 DOI: 10.1186/s12885-020-07083-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/16/2020] [Indexed: 02/03/2023] Open
Abstract
Background Cost-effectiveness is a pivotal consideration for clinical decision making of high-tech cancer treatment in developing countries. Intensity-modulated proton radiation therapy (IMPT, the advanced form of proton beam therapy) has been found to improve the prognosis of the patients with paranasal sinus and nasal cavity cancers compared with intensity-modulated photon-radiation therapy (IMRT). However, the cost-effectiveness of IMPT has not yet been fully evaluated. This study aimed at evaluating the cost-effectiveness of IMPT versus IMRT for treatment decision making of paranasal sinus and nasal cavity cancers in Chinese settings. Methods A 3-state Markov model was designed for cost-effectiveness analysis. A base case evaluation was performed on a patient of 47-year-old (median age of patients with paranasal sinus and nasal cavity cancers in China). Model robustness was examined by probabilistic sensitivity analysis, Markov cohort analysis and Tornado diagram. Cost-effective scenarios of IMPT were further identified by one-way sensitivity analyses and stratified analyses were performed for different age levels. The outcome measure of the model was the incremental cost-effectiveness ratio (ICER). A strategy was defined as cost-effective if the ICER was below the societal willingness-to-pay (WTP) threshold of China (30,828 US dollars ($) / quality-adjusted life year (QALY)). Results IMPT was identified as being cost-effective for the base case at the WTP of China, providing an extra 1.65 QALYs at an additional cost of $38,928.7 compared with IMRT, and had an ICER of $23,611.2 / QALY. Of note, cost-effective scenarios of IMPT only existed in the following independent conditions: probability of IMPT eradicating cancer ≥0.867; probability of IMRT eradicating cancer ≤0.764; or cost of IMPT ≤ $52,163.9. Stratified analyses for different age levels demonstrated that IMPT was more cost-effective in younger patients than older patients, and was cost-effective only in patients ≤56-year-old. Conclusions Despite initially regarded as bearing high treatment cost, IMPT could still be cost-effective for patients with paranasal sinus and nasal cavity cancers in China. The tumor control superiority of IMPT over IMRT and the patient’s age should be the principal considerations for clinical decision of prescribing this new irradiation technique.
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Affiliation(s)
- Guo Li
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, Guangdong, 510095, P. R. China
| | - Bo Qiu
- State Key Laboratory of Oncology in South China, 651 Dongfeng East Road, Guangzhou, Guangdong, 510060, P. R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China
| | - Yi-Xiang Huang
- Department of Health Management, Public Health Institute of Sun Yat-sen University, Guangzhou, Guangdong, 510000, P. R. China
| | - Jerome Doyen
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, 06189, Nice, France.,Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, 06200, Nice, France
| | - Pierre-Yves Bondiau
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, 06189, Nice, France.,Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, 06200, Nice, France
| | - Karen Benezery
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, 06189, Nice, France.,Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, 06200, Nice, France
| | - Yun-Fei Xia
- State Key Laboratory of Oncology in South China, 651 Dongfeng East Road, Guangzhou, Guangdong, 510060, P. R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China
| | - Chao-Nan Qian
- State Key Laboratory of Oncology in South China, 651 Dongfeng East Road, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, Guangdong, 510045, P. R. China.
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27
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Lee HL, Lim LH, Master Z, Wong SMM. The role of breath hold intensity modulated proton therapy for a case of left-sided breast cancer with IMN involvement. How protons compare with other conformal techniques? Tech Innov Patient Support Radiat Oncol 2020; 15:1-5. [PMID: 32490219 PMCID: PMC7256639 DOI: 10.1016/j.tipsro.2020.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose To evaluate the dosimetric impact of four different radiotherapy techniques for a case of left-sided breast cancer with Internal Mammary lymph Nodes (IMN) involvement. Materials and methods To identify the best radiotherapy technique for this patient, four methods were compared: 3D Conformal Radiotherapy (3D-CRT), Volumetric Modulated Arc Therapy (VMAT), Tomotherapy (TOMO) and Intensity Modulated Proton Therapy (IMPT). Patient was treated using deep inspiration breath-hold (DIBH) technique. Prescribed dose was 40.05y in 15 fractions. Plan evaluation was performed on target coverage and dose to the organs-at-risk (OARs) using 3D-CRT as a baseline. Results TOMO has the most ideal Conformity Index (CI) at 1.139, followed by IMPT at 1.158, VMAT at 0.765, and 3D-CRT at 0.685. Using 3D-CRT as a baseline, VMAT, TOMO and IMPT all showed improved dose coverage. IMPT has the best dose coverage. TOMO has the most ideal homogeneity index (HI) and Conformity Number (CN). Mean heart dose (MHD) is lowest for IMPT at 0.55 Gy and highest for VMAT at 4.79 Gy. V20Gy of left lung is the lowest for IMPT at 11.11%, compared to 17.53% for TOMO, 18.19% for VMAT and 33.33% for 3D-CRT. V5Gy for the contralateral breast ranges from 0.01% in IMPT to 72.32% in TOMO. Conclusion 3D-CRT compromising target coverage but achieving good OAR sparing for the contralateral right breast, left lung and right lung. Overall, IMPT performed best in terms of target coverage and OAR-sparing. Protons delivered superior target dose coverage and sparing of normal structures for this patient. As dose value parameters are expected to correlate with acute and chronic toxicities, proton therapy should be given due consideration as the preferred technique for the treatment of left-sided breast cancers with IMN involvement. Further studies with more patients can be done to evaluate the effectiveness of proton therapy on acute and chronic toxicities.
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Affiliation(s)
- H L Lee
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore
| | - L H Lim
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Zubin Master
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Sharon M M Wong
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore.,Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,College of Allied Health, SingHealth Academy, Singapore
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28
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Thorpe CS, Niska JR, Anderson JD, Girardo ME, McGee LA, Hartsell WF, Larson GL, Tsai HK, Rossi CJ, Rosen LR, Vargas CE. Acute toxicities after proton beam therapy following breast-conserving surgery for breast cancer: Multi-institutional prospective PCG registry analysis. Breast J 2020; 26:1760-1764. [PMID: 32297453 DOI: 10.1111/tbj.13812] [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: 12/27/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/29/2022]
Abstract
We investigated adverse events (AEs) and clinical outcomes for proton beam therapy (PBT) after breast-conserving surgery (BCS) for breast cancer. From 2012 to 2016, 82 patients received PBT in the prospective multi-institutional Proton Collaborative Group registry. AEs were recorded prospectively at each institution. Median follow-up was 8.1 months. Median dose was 50.4 Gy in 28 fractions. Most patients received a lumpectomy bed boost (90%) and regional nodal irradiation (RNI)(83%). Six patients (7.3%) experienced grade 3 AEs (5 with dermatitis, 5 with breast pain). Body mass index (BMI) was associated with grade 3 dermatitis (P = .015). Fifty-eight patients (70.7%) experienced grade ≥2 dermatitis. PBT including RNI after BCS is well-tolerated. Elevated BMI is associated with grade 3 dermatitis.
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Affiliation(s)
| | - Joshua R Niska
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Marlene E Girardo
- Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Gary L Larson
- ProCure Proton Therapy Center, Oklahoma City, Oklahoma
| | - Henry K Tsai
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Carl J Rossi
- Scripps Proton Therapy Center, San Diego, California
| | - Lane R Rosen
- Willis-Knighton Proton Therapy Center, Shreveport, Louisiana
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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29
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Isobe T, Mori Y, Takei H, Sato E, Sakae T. [14. Biological Dose and Effects of Neutrons in Proton Beam Therapy]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2020; 76:863-869. [PMID: 32814743 DOI: 10.6009/jjrt.2020_jsrt_76.8.863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
| | | | | | - Eisuke Sato
- Faculty of Health Science, Juntendo University
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30
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Jones DA, Smith J, Mei XW, Hawkins MA, Maughan T, van den Heuvel F, Mee T, Kirkby K, Kirkby N, Gray A. A systematic review of health economic evaluations of proton beam therapy for adult cancer: Appraising methodology and quality. Clin Transl Radiat Oncol 2020; 20:19-26. [PMID: 31754652 PMCID: PMC6854069 DOI: 10.1016/j.ctro.2019.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE With high treatment costs and limited capacity, decisions on which adult patients to treat with proton beam therapy (PBT) must be based on the relative value compared to the current standard of care. Cost-utility analyses (CUAs) are the gold-standard method for doing this. We aimed to appraise the methodology and quality of CUAs in this area. MATERIALS AND METHODS We performed a systematic review of the literature to identify CUA studies of PBT in adult disease using MEDLINE, EMBASE, EconLIT, NHS Economic Evaluation Database (NHS EED), Web of Science, and the Tufts Medical Center Cost-Effectiveness Analysis Registry from 1st January 2010 up to 6th June 2018. General characteristics, information relating to modelling approaches, and methodological quality were extracted and synthesized narratively. RESULTS Seven PBT CUA studies in adult disease were identified. Without randomised controlled trials to inform the comparative effectiveness of PBT, studies used either results from one-armed studies, or dose-response models derived from radiobiological and epidemiological studies of PBT. Costing methods varied widely. The assessment of model quality highlighted a lack of transparency in the identification of model parameters, and absence of external validation of model outcomes. Furthermore, appropriate assessment of uncertainty was often deficient. CONCLUSION In order to foster credibility, future CUA studies must be more systematic in their approach to evidence synthesis and expansive in their consideration of uncertainties in light of the lack of clinical evidence.
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Affiliation(s)
- David A. Jones
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Joel Smith
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Xue W. Mei
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | | | - Tim Maughan
- CRUK/MRC Oxford Institute for Radiation Oncology, Oxford, UK
| | - Frank van den Heuvel
- CRUK/MRC Oxford Institute for Radiation Oncology, Oxford, UK
- Department of Haematology/Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thomas Mee
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Karen Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Norman Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Mutter RW, Jethwa KR, Gonuguntla K, Remmes NB, Whitaker TJ, Hieken TJ, Ruddy KJ, McGee LA, Corbin KS, Park SS. 3 fraction pencil-beam scanning proton accelerated partial breast irradiation: early provider and patient reported outcomes of a novel regimen. Radiat Oncol 2019; 14:211. [PMID: 31752934 PMCID: PMC6873533 DOI: 10.1186/s13014-019-1417-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 11/07/2019] [Indexed: 12/19/2022] Open
Abstract
Background and purpose To report dosimetry and early adverse effects, aesthetic, and patient-reported outcomes of a prospective study of 3-fraction pencil-beam scanning (PBS) proton accelerated partial irradiation (APBI). Materials and methods Eligibility included women age ≥ 50 years with estrogen receptor positive (ER+), sentinel lymph node negative invasive or in-situ breast cancer measuring ≤2.5 cm. The prescription was 21.9 Gy (RBE 1.1) in 3 daily fractions to the post-operative tumor bed with a 1 cm expansion. Toxicities were collected using Common Terminology Criteria for Adverse Events (CTCAE) version 4.0, 10-point Linear Analog Scale Assessment, Patient-Reported Outcomes Version of the CTCAE, and the Harvard Breast Cosmesis Scale. Results Seventy-six women were treated between 2015 and 2017. The median breast volume receiving 50% of prescription or more was 28%. Median mean heart, mean ipsilateral lung, and maximum skin dose were 0 Gy, 0.1 Gy, and 20.6 Gy, respectively. With a median follow-up of 12 months, no treatment-related toxicity grade ≥ 2 has been observed. Most common grade 1 adverse events were dermatitis (68%) and skin hyperpigmentation (18%). At 12 months, the only persistent toxicities were one patient with grade 1 breast edema and one patient with a grade 1 seroma. 90% of patients reported quality of life as ≥7 out of 10 (0 indicating “as bad as it can be” and 10 indicating “as good as it can be”) and 98% of patients reported excellent or good cosmesis. Conclusion 3-fraction PBS proton APBI is well tolerated with low rates of physician and patient reported early adverse effects. Follow-up is ongoing to assess late toxicities and disease control outcomes. Further investigation of this novel adjuvant treatment strategy is warranted.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Karthik Gonuguntla
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Nicholas B Remmes
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Thomas J Whitaker
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Karasawa K, Omatsu T, Arakawa A, Yamamoto N, Ishikawa T, Saito M, Fukuda S, Kamada T. A Phase I clinical trial of carbon ion radiotherapy for Stage I breast cancer: clinical and pathological evaluation. JOURNAL OF RADIATION RESEARCH 2019; 60:342-347. [PMID: 30805611 PMCID: PMC6530622 DOI: 10.1093/jrr/rry113] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/21/2018] [Indexed: 06/09/2023]
Abstract
Even with its high RBE and >20 years history, there had been no breast cancer clinical trial using carbon-ion radiotherapy. We started a Phase I trial of carbon ion radiotherapy for Stage I breast cancer in 2013. This article describes the clinical and pathological evaluation of this study. Patients with low-risk Stage I breast cancer were eligible. A dose escalation study was designed, with dose levels of 48.0, 52.8 or 60.0 Gy relative biological effectiveness (RBE) administered in four fractions within 1 week. Three months after radiotherapy, the patients underwent tumor excision for pathological evaluation. Between April 2013 and December 2014, three cases receiving 48 Gy (RBE), three cases receiving 52.8 Gy (RBE) and one case receiving 60 Gy (RBE) underwent this protocol. No adverse effects were observed except for Grade 1 acute skin reaction in four cases. Pathological evaluation revealed that all four cases with doses of 52.8 Gy (RBE) and 60.0 Gy (RBE) achieved Grade 2b or more, but only two cases reached Grade 3. At the end of 2017, all cases were alive without recurrence or late had not caused any late adverse reaction. Carbon ion radiotherapy for Stage I breast cancer seems to be safe, and we found that it did not reach enough treatment effect 3 months after the treatment.
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Affiliation(s)
- Kumiko Karasawa
- National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1, Anagawa, Inage-ku, Chiba-city, Japan
- Department of Radiation Oncology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Tokuhiki Omatsu
- National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1, Anagawa, Inage-ku, Chiba-city, Japan
| | - Atsushi Arakawa
- Department of Pathology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Naohito Yamamoto
- Department of Breast Surgery, Chiba Cancer Center,666-2, Nitonacho, Chuo-ku, Chiba-city, Japan
| | - Takashi Ishikawa
- Department of Breast Surgery, Tokyo Medical University, 6-1-1, Shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Mitsue Saito
- Department of Breast Surgery, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Shigekazu Fukuda
- National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1, Anagawa, Inage-ku, Chiba-city, Japan
| | - Tadashi Kamada
- National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1, Anagawa, Inage-ku, Chiba-city, Japan
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Yu AF, Ho AY, Braunstein LZ, Thor ME, Lee Chuy K, Eaton A, Mara E, Cahlon O, Dang CT, Oeffinger KC, Steingart RM, Liu JE. Assessment of Early Radiation-Induced Changes in Left Ventricular Function by Myocardial Strain Imaging After Breast Radiation Therapy. J Am Soc Echocardiogr 2019; 32:521-528. [PMID: 30826225 DOI: 10.1016/j.echo.2018.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Radiation therapy (RT)-induced cardiotoxicity is among the concerning sequelae of breast cancer (BCA) treatment, particularly in HER2-positive BCA patients who receive anthracyclines and trastuzumab-based therapy. The aim of this study was to assess for early RT-induced changes in echocardiographic and circulating biomarkers of left ventricular (LV) function and evaluate their association with radiation dose to the heart among patients with HER2-positive BCA treated with contemporary RT. METHODS A total of 47 women with HER2-positive BCA who were treated with an anthracycline, trastuzumab, and RT to the breast and/or chest wall ± regional lymph nodes were included in this study. Two-dimensional echocardiography with speckle-tracking imaging was performed at baseline (prechemotherapy), prior to and after RT (pre-RT and post-RT), and 6 months post-RT. High-sensitivity troponin I (hsTnI) was measured pre-RT and post-RT. Associations between mean heart dose (MHD) and changes in LV function after RT were examined in multivariable linear regression models. RESULTS The MHD was 1.8 ± 1.5 Gy for patients receiving left-sided RT (n = 26) and 1.1 ± 1.3 Gy for patients receiving right-sided RT (n = 21). Pre-RT, post-RT, and 6-month post-RT echocardiograms were performed at median (interquartile range) of 49 days (27, 77) before and 54 days (25, 78) and 195 days (175, 226) after RT, respectively. Compared with pre-RT, a minimal decrease in LV ejection fraction was observed post-RT (61% ± 7% vs 59% ± 8%; P = .003) without any significant change in global longitudinal, circumferential, or radial strain or diastolic indices at the post-RT timepoint. Median (interquartile range) concentrations of hsTnI decreased from 5.7 pg/mL (3.0, 8.7) pre-RT to 3.7 pg/mL (2.0, 5.9) post-RT. There was no significant change in systolic or diastolic indices of LV function at 6 months post-RT compared with pre-RT. MHD was not associated with changes in echocardiographic parameters of LV function after RT. CONCLUSIONS Breast RT using contemporary techniques can be delivered without evidence of early subclinical LV dysfunction or injury as measured by echocardiography and hsTnI in patients treated with anthracyclines and trastuzumab. Future studies should focus on identifying alternative biomarkers to elucidate early RT-induced cardiovascular effects and further characterizing long-term cardiovascular outcomes associated with contemporary breast RT.
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Affiliation(s)
- Anthony F Yu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria E Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine Lee Chuy
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Eaton
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Elton Mara
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chau T Dang
- Weill Cornell Medical College, New York, New York; Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Richard M Steingart
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Jennifer E Liu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
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Chowdhary M, Lee A, Gao S, Wang D, Barry PN, Diaz R, Bagadiya NR, Park HS, Yu JB, Wilson LD, Moran MS, Higgins SA, Knowlton CA, Patel KR. Is Proton Therapy a "Pro" for Breast Cancer? A Comparison of Proton vs. Non-proton Radiotherapy Using the National Cancer Database. Front Oncol 2019; 8:678. [PMID: 30693271 PMCID: PMC6339938 DOI: 10.3389/fonc.2018.00678] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/21/2018] [Indexed: 12/25/2022] Open
Abstract
Background: Limited data exists demonstrating the clinical benefit of proton radiotherapy (PRT) in breast cancer. Using the National Cancer Database, we evaluated predictors associated with PRT use for patients with breast cancer. An exploratory analysis also investigates the impact of PRT on overall survival (OS). Methods: Patients with non-metastatic breast cancer treated with adjuvant radiotherapy from 2004 to 2014 were identified. Patients were stratified based on receipt of PRT or non-PRT (i.e., photons ± electrons). A logistic regression model was used to determine predictors for PRT utilization. For OS, Multivariable analysis (MVA) was performed using Cox proportional hazard model. Results: A total of 724,492 patients were identified: 871 received PRT and 723,621 received non-PRT. 58.3% of the PRT patients were group stage 0–1. Median follow-up time was 62.2 months. On multivariate logistic analysis, the following factors were found to be significant for receipt of PRT (all p < 0.05): academic facility (odds ratio [OR] = 2.50), South (OR = 2.01) and West location (OR = 12.43), left-sided (OR = 1.21), ER-positive (OR = 1.59), and mastectomy (OR = 1.47); pT2-T4 disease predicted for decrease use (OR = 0.79). PRT was not associated with OS on MVA for all patients: Hazard Ratio: 0.85, p = 0.168. PRT remained not significant on MVA after stratifying for subsets likely associated with higher heart radiation doses, including: left-sided (p = 0.140), inner-quadrant (p = 0.173), mastectomy (p = 0.095), node positivity (p = 0.680), N2-N3 disease (p = 0.880), and lymph node irradiation (LNI) (p = 0.767). Conclusions: Receipt of PRT was associated with left-sided, ER+ tumors, mastectomy, South and West location, and academic facilities, but not higher group stages or LNI. PRT was not associated with OS, including in subsets likely at risk for higher heart doses. Further studies are required to determine non-OS benefits of PRT. In the interim, given the high cost of protons, only well-selected patients should receive PRT unless enrolled on a clinical trial.
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Affiliation(s)
- Mudit Chowdhary
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, United States
| | - Anna Lee
- Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY, United States
| | - Sarah Gao
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, United States
| | - Parul N Barry
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, United States
| | - Roberto Diaz
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Neeti R Bagadiya
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Henry S Park
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - James B Yu
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Lynn D Wilson
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Meena S Moran
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Susan A Higgins
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Christin A Knowlton
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
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Smith WL, Smith CD, Patel S, Eisenstat DD, Quirk S, Mackenzie M, Olivotto IA. What Conditions Make Proton Beam Therapy Financially Viable in Western Canada? Cureus 2018; 10:e3644. [PMID: 30723643 PMCID: PMC6351082 DOI: 10.7759/cureus.3644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Proton beam therapy (PBT) is available in many western and Asian countries, but there is no clinical, gantry-based PBT facility in Canada. Methods A cost analysis was conducted from the Alberta Ministry of Health perspective with a 15-year horizon. Estimated costs were: PBT unit, facility development as part of an ongoing capital project, electricity, maintenance contract, and staffing. Revenues were: savings from stopping USA referrals, avoiding the costs of standard radiation therapy (RT) for Albertans receiving PBT instead, and cost-recovery charges for out-of-province patients. Results The Ministry of Health funded 15 Albertans for PBT in the USA in the 2014/15 fiscal year (mean CAD$ 237,348/patient). A single-vault, compact PBT unit operating 10 hours/day could treat 250 patients annually. A 100 Albertans, with accepted indications, such as the curative-intent treatment of chordomas, ocular melanomas, and selected pediatric cancers, would likely benefit annually from PBT’s improved conformality and/or reduced integral dose compared to RT. The estimated capital cost was $40 million for a single beamline built within an ongoing capital project. Operating costs were $4.8 million/year at capacity. With 50% capacity reserved for non-Albertans at a cost recovery of $45,000/patient, a Western Canadian PBT facility would achieve net positive cash flow by year eight of clinical operations, assuming Alberta-to-USA referrals reach 21 patients/year by 2024 and increase at 3%/year thereafter. Sensitivity analysis indicates the lifetime net savings is robust to the assumptions made. Conclusion This business case, based on Canadian costing data and estimates, demonstrates the potential for a financially viable PBT facility in Western Canada.
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Affiliation(s)
- Wendy L Smith
- Medical Physics, University of Calgary, Calgary, CAN
| | | | - S Patel
- Radiation Oncology, University of Alberta, Alberta, CAN
| | | | - Sarah Quirk
- Medical Physics, University of Calgary, Calgary, CAN
| | | | - Ivo A Olivotto
- Oncology, University of Calgary/Tom Baker Cancer Center, Calgary, CAN
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Bekelman JE, Denicoff A, Buchsbaum J. Randomized Trials of Proton Therapy: Why They Are at Risk, Proposed Solutions, and Implications for Evaluating Advanced Technologies to Diagnose and Treat Cancer. J Clin Oncol 2018; 36:2461-2464. [PMID: 29985746 PMCID: PMC6366815 DOI: 10.1200/jco.2018.77.7078] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Justin E. Bekelman
- Justin E. Bekelman, University of Pennsylvania, Philadelphia, PA; Andrea Denicoff, National Cancer Institute, Bethesda, MD; and Jeffrey Buchsbaum, National Cancer Institute, Bethesda, MD
| | - Andrea Denicoff
- Justin E. Bekelman, University of Pennsylvania, Philadelphia, PA; Andrea Denicoff, National Cancer Institute, Bethesda, MD; and Jeffrey Buchsbaum, National Cancer Institute, Bethesda, MD
| | - Jeffrey Buchsbaum
- Justin E. Bekelman, University of Pennsylvania, Philadelphia, PA; Andrea Denicoff, National Cancer Institute, Bethesda, MD; and Jeffrey Buchsbaum, National Cancer Institute, Bethesda, MD
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Thariat J, Habrand JL, Lesueur P, Chaikh A, Kammerer E, Lecomte D, Batalla A, Balosso J, Tessonnier T. Apports de la protonthérapie à la radiothérapie d’aujourd’hui, pourquoi, comment ? Bull Cancer 2018; 105:315-326. [DOI: 10.1016/j.bulcan.2017.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/07/2017] [Accepted: 12/12/2017] [Indexed: 01/06/2023]
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Les big data , généralités et intégration en radiothérapie. Cancer Radiother 2018; 22:73-84. [DOI: 10.1016/j.canrad.2017.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 04/11/2017] [Accepted: 04/19/2017] [Indexed: 12/25/2022]
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Monten C, Veldeman L, Verhaeghe N, Lievens Y. A systematic review of health economic evaluation in adjuvant breast radiotherapy: Quality counted by numbers. Radiother Oncol 2017; 125:186-192. [PMID: 28923574 DOI: 10.1016/j.radonc.2017.08.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Evolving practice in adjuvant breast radiotherapy inevitably impacts healthcare budgets. This is reflected in a rise of health economic evaluations (HEE) in this domain. The available HEE literature was analysed qualitatively and quantitatively, using available instruments. METHODS HEEs published between 1/1/2000 and 31/10/2016 were retrieved through a systematic search in Medline, Cochrane and Embase. A quality-assessment using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) was translated into a quantitative score and compared with Tufts Medical Centre CEA registry and Quality of Health Economic Studies (QHES) results. RESULTS Twenty cost-effectiveness analyses (CEA) and thirteen cost comparisons (CC) were analysed. In qualitative evaluation, valuation or justification of data sources, population heterogeneity and discussion on generalizability, in addition to declaration on funding, were often absent or incomplete. After quantification, the average CHEERS-scores were 74% (CI 66.9-81.1%) and 75.6% (CI 70.7-80.5%) for CEAs and CCs respectively. CEA-scores did not differ significantly from Tufts and QHES-scores. CONCLUSION Quantitative CHEERS evaluation is feasible and yields comparable results to validated instruments. HEE in adjuvant breast radiotherapy is of acceptable quality, however, further efforts are needed to improve comprehensive reporting of all data, indispensable for assessing relevance, reliability and generalizability of results.
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Affiliation(s)
- Chris Monten
- Ghent University Hospital, Radiation Oncology Department, Belgium.
| | - Liv Veldeman
- Ghent University Hospital, Radiation Oncology Department, Belgium
| | | | - Yolande Lievens
- Ghent University Hospital, Radiation Oncology Department, Belgium
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Tommasino F, Durante M, D'Avino V, Liuzzi R, Conson M, Farace P, Palma G, Schwarz M, Cella L, Pacelli R. Model-based approach for quantitative estimates of skin, heart, and lung toxicity risk for left-side photon and proton irradiation after breast-conserving surgery. Acta Oncol 2017; 56:730-736. [PMID: 28281862 DOI: 10.1080/0284186x.2017.1299218] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton beam therapy represents a promising modality for left-side breast cancer (BC) treatment, but concerns have been raised about skin toxicity and poor cosmesis. The aim of this study is to apply skin normal tissue complication probability (NTCP) model for intensity modulated proton therapy (IMPT) optimization in left-side BC. MATERIAL AND METHODS Ten left-side BC patients undergoing photon irradiation after breast-conserving surgery were randomly selected from our clinical database. Intensity modulated photon (IMRT) and IMPT plans were calculated with iso-tumor-coverage criteria and according to RTOG 1005 guidelines. Proton plans were computed with and without skin optimization. Published NTCP models were employed to estimate the risk of different toxicity endpoints for skin, lung, heart and its substructures. RESULTS Acute skin NTCP evaluation suggests a lower toxicity level with IMPT compared to IMRT when the skin is included in proton optimization strategy (0.1% versus 1.7%, p < 0.001). Dosimetric results show that, with the same level of tumor coverage, IMPT attains significant heart and lung dose sparing compared with IMRT. By NTCP model-based analysis, an overall reduction in the cardiopulmonary toxicity risk prediction can be observed for all IMPT compared to IMRT plans: the relative risk reduction from protons varies between 0.1 and 0.7 depending on the considered toxicity endpoint. CONCLUSIONS Our analysis suggests that IMPT might be safely applied without increasing the risk of severe acute radiation induced skin toxicity. The quantitative risk estimates also support the potential clinical benefits of IMPT for left-side BC irradiation due to lower risk of cardiac and pulmonary morbidity. The applied approach might be relevant on the long term for the setup of cost-effectiveness evaluation strategies based on NTCP predictions.
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Affiliation(s)
- Francesco Tommasino
- Department of Physics, University of Trento, Povo, Italy
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
| | - Marco Durante
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
| | - Vittoria D'Avino
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- Department of Naples, National Institute for Nuclear physics (INFN), Naples, Italy
| | - Raffaele Liuzzi
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Paolo Farace
- Department of Protontherapy, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- Department of Naples, National Institute for Nuclear physics (INFN), Naples, Italy
| | - Marco Schwarz
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
- Department of Protontherapy, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- Department of Naples, National Institute for Nuclear physics (INFN), Naples, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
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Durante M, Orecchia R, Loeffler JS. Charged-particle therapy in cancer: clinical uses and future perspectives. Nat Rev Clin Oncol 2017; 14:483-495. [DOI: 10.1038/nrclinonc.2017.30] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Stick LB, Yu J, Maraldo MV, Aznar MC, Pedersen AN, Bentzen SM, Vogelius IR. Joint Estimation of Cardiac Toxicity and Recurrence Risks After Comprehensive Nodal Photon Versus Proton Therapy for Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 97:754-761. [PMID: 28244411 DOI: 10.1016/j.ijrobp.2016.12.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/22/2016] [Accepted: 12/02/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE The study aims to perform joint estimation of the risk of recurrence caused by inadequate radiation dose coverage of lymph node targets and the risk of cardiac toxicity caused by radiation exposure to the heart. Delivered photon plans are compared with realistic proton plans, thereby providing evidence-based estimates of the heterogeneity of treatment effects in consecutive cases for the 2 radiation treatment modalities. METHODS AND MATERIALS Forty-one patients referred for postlumpectomy comprehensive nodal photon irradiation for left-sided breast cancer were included. Comparative proton plans were optimized by a spot scanning technique with single-field optimization from 2 en face beams. Cardiotoxicity risk was estimated with the model of Darby et al, and risk of recurrence following a compromise of lymph node coverage was estimated by a linear dose-response model fitted to the recurrence data from the recently published EORTC (European Organisation for Research and Treatment of Cancer) 22922/10925 and NCIC-CTG (National Cancer Institute of Canada Clinical Trials Group) MA.20 randomized controlled trials. RESULTS Excess absolute risk of cardiac morbidity was small with photon therapy at an attained age of 80 years, with median values of 1.0% (range, 0.2%-2.9%) and 0.5% (range, 0.03%-1.0%) with and without cardiac risk factors, respectively, but even lower with proton therapy (0.13% [range, 0.02%-0.5%] and 0.06% [range, 0.004%-0.3%], respectively). The median estimated excess absolute risk of breast cancer recurrence after 10 years was 0.10% (range, 0.0%-0.9%) with photons and 0.02% (range, 0.0%-0.07%) with protons. The association between age of the patient and benefit from proton therapy was weak, almost non-existing (Spearman rank correlations of -0.15 and -0.30 with and without cardiac risk factors, respectively). CONCLUSIONS Modern photon therapy yields limited risk of cardiac toxicity in most patients, but proton therapy can reduce the predicted risk of cardiac toxicity by up to 2.9% and the risk of breast cancer recurrence by 0.9% in individual patients. Predicted benefit correlates weakly with age. Combined assessment of the risk from cardiac exposure and inadequate target coverage is desirable for rational consideration of competing photon and proton therapy plans.
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Affiliation(s)
- Line B Stick
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.
| | - Jen Yu
- Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Maja V Maraldo
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marianne C Aznar
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anders N Pedersen
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren M Bentzen
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland; Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ivan R Vogelius
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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