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Nowicka-Matus K, Friborg J, Hansen C, Bernsdorf M, Elstrøm U, Farhadi M, Grau C, Eriksen J, Johansen J, Nielsen M, Holm A, Samsøe E, Sibolt P, Smulders B, Jensen K. Acute toxicities in proton therapy for head and neck cancer - A matched analysis of the DAHANCA 35 feasibility study. Clin Transl Radiat Oncol 2024; 48:100835. [PMID: 39189000 PMCID: PMC11345689 DOI: 10.1016/j.ctro.2024.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/30/2024] [Accepted: 07/30/2024] [Indexed: 08/28/2024] Open
Abstract
Background and purpose As preparation for a national randomized study comparing proton radiotherapy to photon radiotherapy, DAHANCA 35, we performed a non-randomized pilot study to investigate patient selection, logistics, planning, and treatment delivery. With the present study, as a comprehensive safety analysis, we want to compare toxicity during and up to two months after therapy to a historically matched group of patients treated with photon radiotherapy. Materials and methods 62 patients treated with protons were matched to 124 patients who received photon treatment outside a protocol. Available data were retrieved from the DAHANCA database. Patients were matched on treatment centre, concurrent chemotherapy, tumour site, stage, p16 status for oropharynx cancers. Selection of patients for proton therapy was based on comparative treatment plans with a NTCP reduction for dysphagia and xerostomia at six months. Results Baseline characteristics between groups were well balanced, except for the type of drug used concurrently; more photon patients received Carboplatin (21.2 % vs 5.8 %, p = 0.01). Proton therapy was associated with significantly less weight loss at the end of treatment, mean weight loss of 3 % for protons and 5 % for photons (p < 0.001). There were more grade 3 skin reactions and grade 3 mucositis after proton treatment compared with photons at the end of treatment, Risk Ratio (RR) 1.9 (95 % CI: 1.01-3.5, p = 0.04) and RR 1.5 (95 % CI: 1.3-1.7, p < 0.001), respectively. All differences resolved at follow up two months after treatment. There were no significant differences between groups on opioid use, use of feeding tubes, or hospitalization during the observation period. Conclusion Proton treatment resulted in excess objective mucositis and dermatitis, which was transient and did not seem to negatively influence weight or treatment compliance and intensity. Selection bias was likely especially since NTCP models were used for selection of proton treatment and photon treated patients were matched manually. We are currently including patients in a randomized controlled trial.
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Affiliation(s)
- K. Nowicka-Matus
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - J. Friborg
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Rigshospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - C.R. Hansen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - M. Bernsdorf
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Rigshospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - U.V. Elstrøm
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - M. Farhadi
- Dept of Oncology, Zealand University Hospital, Naestved, Denmark
| | - C. Grau
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J.G. Eriksen
- Dept of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J. Johansen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Odense University Hospital, Odense, Denmark
| | - M.S. Nielsen
- Dept of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - A. Holm
- Dept of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - E. Samsøe
- Dept of Oncology, Zealand University Hospital, Naestved, Denmark
| | - P. Sibolt
- Dept of Oncology, Herlev Hospital, Herlev, Denmark
| | - B. Smulders
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Rigshospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - K. Jensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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Vasudevan SS, Deeb H, Katta A, Olinde L, Pang J, Asarkar AA, Katz S, Nathan CAO. Efficacy and safety of proton therapy versus intensity-modulated radiation therapy in the treatment of head and neck tumors: A systematic review and meta-analysis. Head Neck 2024. [PMID: 39007360 DOI: 10.1002/hed.27877] [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: 05/13/2024] [Revised: 06/19/2024] [Accepted: 07/07/2024] [Indexed: 07/16/2024] Open
Abstract
To comprehensively evaluate the therapeutic efficacy and safety when utilizing proton therapy (PT) versus intensity-modulated radiation therapy (IMRT) in head and neck cancer patients. Pubmed, ScienceDirect, Embase, Scopus, and Web of Science were systematically searched for studies on comparative PT and IMRT outcomes. We performed a random effect model meta-analysis to estimate the hazard ratio (HR) and odds ratio (OR) for efficacy and safety outcome variables between PT and IMRT. From 641 identified articles, 11 studies met the inclusion criteria, comprising 3087 patients (606 treated with PT and 2481 with IMRT). On toxicity analysis, PT is associated with decreased acute grade 1 nausea (OR = 0.34, 95% CI: 0.13-0.84, p = 0.02) compared to IMRT. In grade 2 toxicity, PT showed significant advantages over IMRT in mucositis (OR = 0.44, p < 0.0001), dysgeusia (OR = 0.35, p = 0.02), dysphagia (OR = 0.36, p < 0.0001), fatigue (OR = 0.29, p = 0.001), pain (OR = 0.34, p = 0.01), and weight loss (OR = 0.54, p = 0.02). Proton therapy also exhibited increased safety in grade 3 dysphagia incidence (OR = 0.44, p < 0.0001) compared to IMRT. PT demonstrated improved overall survival (OS) compared to IMRT across multiple time points: 1-year OS (HR = 0.43, p = 0.02), 2-year OS (HR = 0.44, p < 0.0001), and 5-year OS (HR = 0.78, p = 0.004). In terms of disease-free survival (DFS), PT also showed improved outcomes at 2-year DFS (HR = 0.65, p = 0.03) and 5-year DFS (HR = 0.81, p = 0.03). Proton therapy demonstrated superior overall survival (OS), disease-free survival (DFS), and better local control rate (LCR) compared to IMRT. The data also showed better safety outcomes in PT patients, particularly when involving grade 2 acute toxicity events.
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Affiliation(s)
- Srivatsa Surya Vasudevan
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Haya Deeb
- Department of Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Anuhya Katta
- Department of Academics, Jonelta Foundation School of Medicine, University of Perpetual Help System Dalta, Las Piñas, Philippines
| | - Lindsay Olinde
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - John Pang
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Ameya A Asarkar
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Sanford Katz
- Department of Radiation Oncology, Willis-Knighton Cancer Center, Shreveport, Louisiana, USA
| | - Cherie-Ann O Nathan
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Surgery, Overton Brooks Veterans Administration Medical Center, Shreveport, Louisiana, USA
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3
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McDonald MW, Bates JE, McCall NS, Goyal S, Liu Y, Rudra S, Remick JS, Tian S, El-Deiry MW, Saba NF, Stokes WA, Swinney E. Insurance Authorization and Access to Proton Therapy for Patients With Head and Neck Cancers. Int J Radiat Oncol Biol Phys 2023; 116:404-412. [PMID: 36889515 DOI: 10.1016/j.ijrobp.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE We evaluated our institutional experience to assess potential racial inequities in insurance coverage for proton therapy in patients with head and neck (HN) cancer. METHODS AND MATERIALS We examined the demographics of 1519 patients with HN cancer seen in consultation at our HN multidisciplinary clinic (HN MDC) and 805 patients for whom a proton insurance authorization was sought (PAS) from January 2020 to June 2022. The prospects for proton therapy insurance authorization were prospectively noted based on each patient's ICD-10 (International Classification of Diseases, 10th Revision) diagnosis code and their specific insurance plan. Proton-unfavorable (PU) insurance were those plans whose policy describes proton beam therapy as "experimental" or "not medically necessary" for the given diagnosis. RESULTS For patients seen in our HN MDC, Black, Indigenous, and people of color (BIPOC) were significantly more likely to have PU insurance than non-Hispanic White (NHW) patients (24.9% vs 18.4%, P = .005). In multivariable analysis including race, average income of residence ZIP code, and Medicare eligibility age, BIPOC patients had an odds ratio of 1.25 for PU insurance (P = .041). In the PAS cohort, while there was no difference in the percentage of patients receiving insurance approval for proton therapy between NHW and BIPOC populations (88% vs 88.2%, P = .80), for patients with PU insurance, the median time to determination was significantly longer (median, 15.5 days), and the median time to start any radiation of any modality was longer (46 vs 35 days, P = .08). Compared with NHW patients, the median time from consultation to start of radiation therapy was longer for BIPOC patients (37 vs 43 days, P = .01). CONCLUSIONS BIPOC patients were significantly more likely to have insurance plans unfavorable to proton therapy coverage. These PU insurance plans were associated with a longer median time to determination, a lower approval rate for proton therapy, and a longer time to start radiation of any modality.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia.
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Neal S McCall
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Subir Goyal
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Soumon Rudra
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jill S Remick
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mark W El-Deiry
- Department of Otolaryngology Head and Neck Surgery, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - William A Stokes
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Erica Swinney
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Yahya N, Manan HA. Quality of Life and Patient-Reported Outcomes Following Proton Therapy for Oropharyngeal Carcinoma: A Systematic Review. Cancers (Basel) 2023; 15:cancers15082252. [PMID: 37190180 DOI: 10.3390/cancers15082252] [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: 12/08/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Complex anatomy surrounding the oropharynx makes proton therapy (PT), especially intensity-modulated PT (IMPT), a potentially attractive option due to its ability to reduce the volume of irradiated healthy tissues. Dosimetric improvement may not translate to clinically relevant benefits. As outcome data are emerging, we aimed to evaluate the evidence of the quality of life (QOL) and patient-reported outcomes (PROs) following PT for oropharyngeal carcinoma (OC). MATERIALS AND METHODS We searched PubMed and Scopus electronic databases (date: 15 February 2023) to identify original studies on QOL and PROs following PT for OC. We employed a fluid strategy in the search strategy by tracking citations of the initially selected studies. Reports were extracted for information on demographics, main results, and clinical and dose factor correlates. Quality assessment was performed using the NIH's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The PRISMA guidelines were followed in the preparation of this report. RESULTS Seven reports were selected, including one from a recently published paper captured from citation tracking. Five compared PT and photon-based therapy, although none were randomized controlled trials. Most endpoints with significant differences favored PT, including xerostomia, cough, need for nutritional supplements, dysgeusia, food taste, appetite, and general symptoms. However, some endpoints favored photon-based therapy (sexual symptoms) or showed no significant difference (e.g., fatigue, pain, sleep, mouth sores). The PROs and QOL improve following PT but do not appear to return to baseline. CONCLUSION Evidence suggests that PT causes less QOL and PRO deterioration than photon-based therapy. Biases due to the non-randomized study design remain obstacles to a firm conclusion. Whether or not PT is cost-effective should be the subject of further investigation.
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Affiliation(s)
- Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, Center for Diagnostic, Therapeutic and Investigative Studies (CODTIS), Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur 56000, Malaysia
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Trotter J, Lin A. Advances in Proton Therapy for the Management of Head and Neck Tumors. Surg Oncol Clin N Am 2023; 32:587-598. [PMID: 37182994 DOI: 10.1016/j.soc.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Proton therapy (PBRT) is a form of external beam radiotherapy with several dosimetric advantages compared with conventional photon (x-ray) radiotherapy. Unlike x-rays, protons deposit most of their dose over a finite range, with no exit dose, in a pattern known as the Bragg peak. Clinically, this can be exploited to optimize dose to tumors while delivering a lower integral dose to normal tissues. However, the optimal role of PBRT is not as well-defined as advanced x-ray-based techniques such as intensity-modulated radiotherapy.
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Hanna GJ, Patel N, Tedla SG, Baugnon KL, Aiken A, Agrawal N. Personalizing Surveillance in Head and Neck Cancer. Am Soc Clin Oncol Educ Book 2023; 43:e389718. [PMID: 37079869 DOI: 10.1200/edbk_389718] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Head and neck squamous cell carcinoma (HNSCC) encompasses a spectrum of heterogeneous diseases originating in the oral cavity, pharynx, and larynx. Within the United States, head and neck cancer (HNC) accounts for 66,470 new cases, or 3% of all malignancies, annually.1 The incidence of HNC is rising, largely driven by increases in oropharyngeal cancer.2-4 Recent molecular and clinical advancements, particularly with regard to molecular and tumor biology, reflect the heterogeneity of the subsites contained within the head and neck. Despite this, existing guidelines for post-treatment surveillance remain broad without much consideration given to different anatomic subsites and etiologic factors (such as human papillomavirus [HPV] status or tobacco exposure).5 Surveillance incorporating the physical examination, imaging, and emerging molecular biomarkers is an essential part of care for patients treated for HNC and allows for the detection of locoregional recurrence, distant metastases, and second primary malignancies aiming for better functional and survival outcomes. Additionally, it allows for evaluation and management of post-treatment complications.
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Affiliation(s)
- Glenn J Hanna
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Nirali Patel
- Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL
| | - Sara G Tedla
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Kristen L Baugnon
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Ashley Aiken
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Nishant Agrawal
- Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL
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Pan-Canadian consensus recommendations for proton beam therapy access in Canada. Radiother Oncol 2022; 176:228-233. [PMID: 36228758 DOI: 10.1016/j.radonc.2022.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/21/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Proton Beam Therapy (PBT)is a treatment option for select cancer patients. It is currently not available in Canada. Assessment and referral processes for out-of-country treatment for eligible patients vary by jurisdiction, leading to variability in access to this treatment for Canadian cancer patients. The purpose of this initiative was to develop a framework document to inform consistent and equitable PBT access for appropriate patients through the creation of pan-Canadian PBT access consensus recommendations. MATERIALS AND METHODS A modified Delphiprocess was used to develop pan-Canadian recommendations with input from 22 PBT clinical and administrative experts across all provinces, external peer-review by provincial cancer and system partners, and feedback from a targeted community consultation. This was conducted by electronic survey and live discussion. Consensus threshold was set at 70% agreement. RESULTS Fourconsensus rounds resulted in a final set of 27 recommendations divided into three categories: patient eligibility (n = 9); program level (n = 10); and system level (n = 8). Patient eligibility included: anatomic site (n = 4), patient characteristics (n = 3), clinical efficacy (n = 2). Program level included: regulatory and staff requirements (n = 5), equipment and technologies (n = 4), quality assurance (n = 1). System level included: referral process (n = 5), costing, budget impact and quality adjusted life years (n = 2), eligible patient estimates (n = 1). Recommendations were released nationally in June 2021 and distributed to all 43 cancer programs in Canada. CONCLUSION A pan-Canadian consensus-building approach was successful in creating an evidence-based, peer-reviewed suite of recommendations thatsupportapplication of consistent clinical criteria to inform treatment options, facility set-up and access to high quality proton therapy.
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Falek S, Regmi R, Herault J, Dore M, Vela A, Dutheil P, Moignier C, Marcy PY, Drouet J, Beddok A, Letwin NE, Epstein J, Parvathaneni U, Thariat J. Dental management in head and neck cancers: from intensity-modulated radiotherapy with photons to proton therapy. Support Care Cancer 2022; 30:8377-8389. [PMID: 35513755 DOI: 10.1007/s00520-022-07076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 04/18/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite reduction of xerostomia with intensity-modulated compared to conformal X-ray radiotherapy, radiation-induced dental complications continue to occur. Proton therapy is promising in head and neck cancers to further reduce radiation-induced side-effects, but the optimal dental management has not been defined. MATERIAL AND METHODS Dental management before proton therapy was assessed compared to intensity-modulated radiotherapy based on a bicentric experience, a literature review and illustrative cases. RESULTS Preserved teeth frequently contain metallic dental restorations (amalgams, crowns, implants). Metals blur CT images, introducing errors in tumour and organ contour during radiotherapy planning. Due to their physical interactions with matter, protons are more sensitive than photons to tissue composition. The composition of restorative materials is rarely documented during radiotherapy planning, introducing dose errors. Manual artefact recontouring, metal artefact-reduction CT algorithms, dual or multi-energy CT and appropriate dose calculation algorithms insufficiently compensate for contour and dose errors during proton therapy. Physical uncertainties may be associated with lower tumour control probability and more side-effects after proton therapy. Metal-induced errors should be quantified and removal of metal restorations discussed on a case by case basis between dental care specialists, radiation oncologists and physicists. Metallic amalgams can be replaced with water-equivalent materials and crowns temporarily removed depending on rehabilitation potential, dental condition and cost. Implants might contraindicate proton therapy if they are in the proton beam path. CONCLUSION Metallic restorations may more severely affect proton than photon radiotherapy quality. Personalized dental care prior to proton therapy requires multidisciplinary assessment of metal-induced errors before choice of conservation/removal of dental metals and optimal radiotherapy.
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Affiliation(s)
- Sabah Falek
- Department of Oral and Maxillo-Facial Surgery, Francois Baclesse Center, Caen, France
| | - Rajesh Regmi
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Joel Herault
- Institut Méditerranéen de Protonthérapie, Antoine Lacassagne Center, Nice, France
| | - Melanie Dore
- Department of Radiation Oncology, Institut de Cancérologie de L'Ouest, Nantes, France
| | - Anthony Vela
- Department of Medical Physics, François Baclesse Center / Proton Therapy Center, Caen, France
| | - Pauline Dutheil
- Department of Medical Physics, François Baclesse Center / Proton Therapy Center, Caen, France
| | - Cyril Moignier
- Department of Medical Physics, François Baclesse Center / Proton Therapy Center, Caen, France
| | - Pierre-Yves Marcy
- Radiodiagnostics and Interventional Radiology, Polyclinique ELSAN, Ollioules, France
| | - Julien Drouet
- Department of Oral and Maxillo-Facial Surgery, Francois Baclesse Center, Caen, France
| | - Arnaud Beddok
- Department of Radiation Oncology, Curie Institute, Paris, France
| | - Noah E Letwin
- Swedish Medical Center General Practice Residency, Seattle, WA and owner Seattle Special Care Dentistry, Seattle, WA, USA
| | - Joel Epstein
- City of Hope Comprehensive Cancer Center, Duarte CA and Cedars-Sinai Medical System, Los Angeles, CA, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Caen, France.
- Laboratoire de Physique Corpusculaire, IN2P3/ENISAEN-CNRS, Caen, France.
- Normandie Universite, Caen, France.
- SAS Cyclhad, Hérouville-Saint-Clair, France.
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Raghavapudi H, Singroul P, Kohila V. Brain Tumor Causes, Symptoms, Diagnosis and Radiotherapy Treatment. Curr Med Imaging 2021; 17:931-942. [PMID: 33573575 DOI: 10.2174/1573405617666210126160206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 11/22/2022]
Abstract
The strategy used for the treatment of given brain cancer is critical in determining the post effects and survival. An oncological diagnosis of tumor evaluates a range of parameters such as shape, size, volume, location and neurological complexity that define the symptomatic severity. The evaluation determines a suitable treatment approach chosen from a range of options such as surgery, chemotherapy, hormone therapy, radiation therapy and other targeted therapies. Often, a combination of such therapies is applied to achieve superior results. Radiotherapy serves as a better treatment strategy because of a higher survival rate. It offers the flexibility of synergy with other treatment strategies and fewer side effects on organs at risk. This review presents a radiobiological perspective in the treatment of brain tumor. The cause, symptoms, diagnosis, treatment, post-treatment effects and the framework involved in its elimination are summarized.
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Affiliation(s)
- Haarika Raghavapudi
- Department of Biotechnology, National Institute of Technology Warangal, Warangal -506004, Telangana, India
| | - Pankaj Singroul
- Department of Biotechnology, National Institute of Technology Warangal, Warangal -506004, Telangana, India
| | - V Kohila
- Department of Biotechnology, National Institute of Technology Warangal, Warangal -506004, Telangana, India
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10
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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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11
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Huang D, Frank SJ, Verma V, Thaker NG, Brooks ED, Palmer MB, Harrison RF, Deshmukh AA, Ning MS. Cost-Effectiveness Models of Proton Therapy for Head and Neck: Evaluating Quality and Methods to Date. Int J Part Ther 2021; 8:339-353. [PMID: 34285960 PMCID: PMC8270103 DOI: 10.14338/ijpt-20-00058.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/28/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Proton beam therapy (PBT) is associated with less toxicity relative to conventional photon radiotherapy for head-and-neck cancer (HNC). Upfront delivery costs are greater, but PBT can provide superior long-term value by minimizing treatment-related complications. Cost-effectiveness models (CEMs) estimate the relative value of novel technologies (such as PBT) as compared with the established standard of care. However, the uncertainties of CEMs can limit interpretation and applicability. This review serves to (1) assess the methodology and quality of pertinent CEMs in the existing literature, (2) evaluate their suitability for guiding clinical and economic strategies, and (3) discuss areas for improvement among future analyses. MATERIALS AND METHODS PubMed was queried for CEMs specific to PBT for HNC. General characteristics, modeling information, and methodological approaches were extracted for each identified study. Reporting quality was assessed via the Consolidated Health Economic Evaluation Reporting Standards 24-item checklist, whereas methodologic quality was evaluated via the Philips checklist. The Cooper evidence hierarchy scale was employed to analyze parameter inputs referenced within each model. RESULTS At the time of study, only 4 formal CEMs specific to PBT for HNC had been published (2005, 2013, 2018, 2020). The parameter inputs among these various Markov cohort models generally referenced older literature, excluding many clinically relevant complications and applying numerous hypothetical assumptions for toxicity states, incorporating inputs from theoretical complication-probability models because of limited availability of direct clinical evidence. Case numbers among study cohorts were low, and the structural design of some models inadequately reflected the natural history of HNC. Furthermore, cost inputs were incomplete and referenced historic figures. CONCLUSION Contemporary CEMs are needed to incorporate modern estimates for toxicity risks and costs associated with PBT delivery, to provide a more accurate estimate of value, and to improve their clinical applicability with respect to PBT for HNC.
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Affiliation(s)
- Danmeng Huang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Steven J. Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eric D. Brooks
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Ross F. Harrison
- Department of Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish A. Deshmukh
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Matthew S. Ning
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Fossati P, Perpar A, Stock M, Georg P, Carlino A, Gora J, Martino G, Hug EB. Carbon Ion Dose Constraints in the Head and Neck and Skull Base: Review of MedAustron Institutional Protocols. Int J Part Ther 2021; 8:25-35. [PMID: 34285933 PMCID: PMC8270085 DOI: 10.14338/ijpt-20-00093.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/16/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Dose constraints are of paramount importance for the outcome of any radiotherapy treatment. In this article, we report dose-volume constraints as well as currently used fractionation schedules for carbon ion radiotherapy as applied in MedAustron (Wiener Neustadt, Austria). MATERIALS AND METHODS For fractionation schedules, both German and Japanese regimes were used. From the clinical experience of National Institute of Radiological Sciences (Chiba, Japan) and Heidelberg Ion Therapy (Heidelberg, Germany; formerly GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany) and the work by colleagues in Centro Nazionale Adroterapia Oncologica (Pavia, Italy) recalculating the dose from the microdosimetric kinetic model to the local effect model, we have set the dose constraints for critical organs of the head and neck area. Where no clinical data was available, an educated guess was made, based on data available from photon and proton series. RESULTS We report the constraints for the optic nerve and chiasm, brainstem, spinal cord, cochlea, brain parenchyma, salivary gland, eye and adnexa, and mandibular/maxillary bone; constraints are grouped based on a fractionation scheme (German versus Japanese) and the risk of toxicity (safe, low to middle, and middle to high). CONCLUSION We think validation of dose constraints should present a relevant part of the activity of any carbon ion radiotherapy facility, and we anticipate future multicentric, joint evaluations.
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Affiliation(s)
- Piero Fossati
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Ana Perpar
- Oncology Institute Ljubljana, Ljubljana, Slovenia
| | - Markus Stock
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Petra Georg
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | | | - Joanna Gora
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | | | - Eugen B. Hug
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
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13
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McDowell L, Gough K, King M, Corry J, Rischin D. Patient-reported quality of life and symptom burden measures in human papillomavirus associated oropharyngeal cancer - A review of the literature and PRO methodology. Oral Oncol 2021; 118:105309. [PMID: 33933778 DOI: 10.1016/j.oraloncology.2021.105309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/13/2021] [Accepted: 04/12/2021] [Indexed: 12/21/2022]
Abstract
The emergence of human papillomavirus-associated oropharyngeal cancer (HPVOPC) has resulted in an explosion of clinical research offering reduced toxicity and improved health-related quality of life (HRQL) through treatment de-escalation. At the heart of this objective are patient-reported outcomes (PROs) which aim to quantify the patient experience, usually through the measurement of HRQL or symptom burden. A number of PRO measures (PROMs) are available to HNC researchers and selection of the optimal instrument relies on a detailed understanding of their content and psychometric properties matched to the clinical endpoint of interest. As PROMs become increasingly favoured as the primary or co-primary endpoints of interest in HNC clinical trials, particularly those focussed on HPVOPC, future treatment paradigms will be determined by these measures and it is imperative that they are applied with sophistication and rigor. This review draws attention to the limitations and challenges our specialty faces in PRO application, analysis and reporting. These shortfalls typically include a reliance on statistical rather than clinically relevant differences, multiple hypothesis testing, a lack of evidence-based minimal clinically important differences for the commonly used tools, as well as variations in PROM selection. The aim of this review is to provide: (1) an overview of PRO/PROM terminology and methodology in the HNC setting; (2) to provide a summary of HRQL and symptom burden reports in the HPVOPC literature; and (3) to draw attention to the unmet research need of refining PROM development, application and interpretation to guide our treatment decisions based on what matters to patients.
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Affiliation(s)
- Lachlan McDowell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; The Sir Peter MacCallum Department of Medical Oncology, The University of Melbourne, Melbourne, Australia.
| | - Karla Gough
- Department of Cancer Experiences, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia; Department of Nursing, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Victoria, Australia
| | - Madeleine King
- The University of Sydney, Faculty of Science, School of Psychology, Sydney Quality of Life Office, Sydney, Australia
| | - June Corry
- GenesisCare Radiation Oncology, Division Radiation Oncology, St. Vincent's Hospital, Melbourne, Victoria Australia; Department of Medicine St Vincent's, The University of Melbourne, Victoria, Australia
| | - Danny Rischin
- The Sir Peter MacCallum Department of Medical Oncology, The University of Melbourne, Melbourne, Australia; Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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14
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Brodin NP, Kabarriti R, Schechter CB, Pankuch M, Gondi V, Kalnicki S, Garg MK, Tomé WA. Individualized quality of life benefit and cost-effectiveness estimates of proton therapy for patients with oropharyngeal cancer. Radiat Oncol 2021; 16:19. [PMID: 33478544 PMCID: PMC7819210 DOI: 10.1186/s13014-021-01745-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background Proton therapy is a promising advancement in radiation oncology especially in terms of reducing normal tissue toxicity, although it is currently expensive and of limited availability. Here we estimated the individual quality of life benefit and cost-effectiveness of proton therapy in patients with oropharyngeal cancer treated with definitive radiation therapy (RT), as a decision-making tool for treatment individualization.
Methods and materials Normal tissue complication probability models were used to estimate the risk of dysphagia, esophagitis, hypothyroidism, xerostomia and oral mucositis for 33 patients, comparing delivered photon intensity-modulated RT (IMRT) plans to intensity-modulated proton therapy (IMPT) plans. Quality-adjusted life years (QALYs) lost were calculated for each complication while accounting for patient-specific conditional survival probability and assigning quality-adjustment factors based on complication severity. Cost-effectiveness was modeled based on upfront costs of IMPT and IMRT, and the cost of acute and/or long-term management of treatment complications. Uncertainties in all model parameters and sensitivity analyses were included through Monte Carlo sampling.
Results The incremental cost-effectiveness ratios (ICERs) showed considerable variability in the cost of QALYs spared between patients, with median $361,405/QALY for all patients, varying from $54,477/QALY to $1,508,845/QALY between individual patients. Proton therapy was more likely to be cost-effective for patients with p16-positive tumors ($234,201/QALY), compared to p16-negative tumors ($516,297/QALY). For patients with p16-positive tumors treated with comprehensive nodal irradiation, proton therapy is estimated to be cost-effective in ≥ 50% of sampled cases for 8/9 patients at $500,000/QALY, compared to 6/24 patients who either have p16-negative tumors or receive unilateral neck irradiation. Conclusions Proton therapy cost-effectiveness varies greatly among oropharyngeal cancer patients, and highlights the importance of individualized decision-making. Although the upfront cost, societal willingness to pay and healthcare administration can vary greatly among different countries, identifying patients for whom proton therapy will have the greatest benefit can optimize resource allocation and inform prospective clinical trial design.
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Affiliation(s)
- N Patrik Brodin
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA. .,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.
| | - Rafi Kabarriti
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Mark Pankuch
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, 60555, USA
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, 60555, USA
| | - Shalom Kalnicki
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Urology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Madhur K Garg
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Urology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Wolfgang A Tomé
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA. .,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA. .,Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
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15
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Cozzi L, Comito T, Loi M, Fogliata A, Franzese C, Franceschini D, Clerici E, Reggiori G, Tomatis S, Scorsetti M. The Potential Role of Intensity-Modulated Proton Therapy in Hepatic Carcinoma in Mitigating the Risk of Dose De-Escalation. Technol Cancer Res Treat 2020; 19:1533033820980412. [PMID: 33287650 PMCID: PMC7727039 DOI: 10.1177/1533033820980412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To investigate the role of intensity-modulated proton therapy (IMPT) for hepatocellular carcinoma (HCC) patients to be treated with stereotactic body radiation therapy (SBRT) in a risk-adapted dose prescription regimen. METHODS A cohort of 30 patients was retrospectively selected as "at-risk" of dose de-escalation due to the proximity of the target volumes to dose-limiting healthy structures. IMPT plans were compared to volumetric modulated arc therapy (VMAT) RapidArc (RA) plans. The maximum dose prescription foreseen was 75 Gy in 3 fractions. The dosimetric analysis was performed on several quantitative metrics on the target volumes and organs at risk to identify the relative improvement of IMPT over VMAT and to determine if IMPT could mitigate the need of dose reduction and quantify the consequent potential patient accrual rate for protons. RESULTS IMPT and VMAT plans resulted in equivalent target dose distributions: both could ensure the required coverage for CTV and PTV. Systematic and significant improvements were observed with IMPT for all organs at risk and metrics. An average gain of 9.0 ± 11.6, 8.5 ± 7.7, 5.9 ± 7.1, 4.2 ± 6.4, 8.9 ± 7.1, 6.7 ± 7.5 Gy was found in the near-to-maximum doses for the ribs, chest wall, heart, duodenum, stomach and bowel bag respectively. Twenty patients violated one or more binding constraints with RA, while only 2 with IMPT. For all these patients, some dose de-intensification would have been required to respect the constraints. For photons, the maximum allowed dose ranged from 15.0 to 20.63 Gy per fraction while for the 2 proton cases it would have been 18.75 or 20.63 Gy. CONCLUSION The results of this in-silico planning study suggests that IMPT might result in advantages compared to photon-based VMAT for HCC patients to be treated with ablative SBRT. In particular, the dosimetric characteristics of protons may avoid the need for dose de-escalation in a risk-adapted prescription regimen for those patients with lesions located in proximity of dose-limiting healthy structures. Depending on the selection thresholds, the number of patients eligible for treatment at the full dose can be significantly increased with protons.
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Affiliation(s)
- Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Tiziana Comito
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Mauro Loi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
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16
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Pedersen J, Liang X, Casares-Magaz O, Bryant C, Mendenhall N, Li Z, Muren LP. Multivariate normal tissue complication probability models for rectal and bladder morbidity in prostate cancer patients treated with proton therapy. Radiother Oncol 2020; 153:279-288. [PMID: 33096166 DOI: 10.1016/j.radonc.2020.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Normal tissue complication probability (NTCP) models applied for model-based patient selection to proton therapy (PT) have usually been derived using dose/volume histogram (DVH) parameters from photon-based radiotherapy. This study aimed to derive PT-specific multivariate NTCP models that also accounted for the spatial dose distribution (rectum only) as well as non-dose/volume related factors. MATERIALS AND METHODS The study included rectum and bladder DVHs, 2D rectal dose maps and relevant patient/treatment characteristics from 1151 prostate cancer cases treated with PT. Prospectively scored Grade 2 late rectal bleeding (CTCAE v3.0, also procedural interventions separately) (n = 156 (15%)) and Grade 3+ GU morbidity (n = 51 (4%)) were entered into a multivariate logistic regression analysis. Model evaluation included assessment of the area under the receiver operating characteristic curve (AUC). RESULTS Anticoagulant use was a dominant predictor, chosen in four of the six rectum models and in the bladder model. Age was a dominant predictor in all procedural only rectum models while prostate volume, bladder D5% and V75Gy were predictors in the bladder model. The selection frequency of the dose/volume predictors varied widely, where the percentage of the anterior rectum surface receiving >=75 Gy was the most robust. AUC values ranged from 0.58 to 0.70 across all models, with no clear difference between the DVH- and spatial-based models for the rectum. CONCLUSION Anticoagulant use and age were the most prominent predictors in the NTCP models. V75Gy of the rectal wall and the bladder was a predictor in the DVH-based models of the rectum and bladder respectively.
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Affiliation(s)
- Jesper Pedersen
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Denmark.
| | - Xiaoying Liang
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Oscar Casares-Magaz
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Denmark
| | - Curtis Bryant
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Nancy Mendenhall
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Zuofeng Li
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Denmark
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17
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Weber DC, Langendijk JA, Grau C, Thariat J. Proton therapy and the European Particle Therapy Network: The past, present and future. Cancer Radiother 2020; 24:687-690. [PMID: 32753239 PMCID: PMC7395642 DOI: 10.1016/j.canrad.2020.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/19/2022]
Abstract
Proton therapy is delivered to selected cancer patients presenting with rare tumours, for which a dose escalation paradigm and/or a reduced dose-bath to the organs at risk is pursued. It is a costly treatment with an additional cost factor of 2–3 when compared to photon radiotherapy. Notwithstanding the 180′000 patients treated with protons, scars robust clinical evidence is available to justify the administration of this treatment modality. The European Particle Therapy Network (EPTN) was created in 2015 to answer the critical European needs for cooperation among protons and carbon ions centres in the framework of clinical research networks. EPTN with other European groups will launch a number of prospective clinical trials that could be practice changing if positive. Alternative way to generate clinical data could be provided by alternative methodologies, such as the Dutch model-based approach, or could be provided by European infrastructure projects.
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Affiliation(s)
- D C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, 144, WPTA, CH-5232 Villigen West Campus, Switzerland; University Hospital Zürich, Zürich, Switzerland; University of Bern, Bern, Switzerland.
| | - J A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - C Grau
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - J Thariat
- Radiation Oncology Department, centre François-Baclesse, 3, avenue General-Harris, 14000 Caen, France
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18
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Jensen SB, Vissink A, Limesand KH, Reyland ME. Salivary Gland Hypofunction and Xerostomia in Head and Neck Radiation Patients. J Natl Cancer Inst Monogr 2020; 2019:5551361. [PMID: 31425600 DOI: 10.1093/jncimonographs/lgz016] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 05/21/2019] [Accepted: 05/26/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The most manifest long-term consequences of radiation therapy in the head and neck cancer patient are salivary gland hypofunction and a sensation of oral dryness (xerostomia). METHODS This critical review addresses the consequences of radiation injury to salivary gland tissue, the clinical management of salivary gland hypofunction and xerostomia, and current and potential strategies to prevent or reduce radiation injury to salivary gland tissue or restore the function of radiation-injured salivary gland tissue. RESULTS Salivary gland hypofunction and xerostomia have severe implications for oral functioning, maintenance of oral and general health, and quality of life. Significant progress has been made to spare salivary gland function chiefly due to advances in radiation techniques. Other strategies have also been developed, e.g., radioprotectors, identification and preservation/expansion of salivary stem cells by stimulation with cholinergic muscarinic agonists, and application of new lubricating or stimulatory agents, surgical transfer of submandibular glands, and acupuncture. CONCLUSION Many advances to manage salivary gland hypofunction and xerostomia induced by radiation therapy still only offer partial protection since they are often of short duration, lack the protective effects of saliva, or potentially have significant adverse effects. Intensity-modulated radiation therapy (IMRT), and its next step, proton therapy, have the greatest potential as a management strategy for permanently preserving salivary gland function in head and neck cancer patients.Presently, gene transfer to supplement fluid formation and stem cell transfer to increase the regenerative potential in radiation-damaged salivary glands are promising approaches for regaining function and/or regeneration of radiation-damaged salivary gland tissue.
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Affiliation(s)
- Siri Beier Jensen
- Department of Dentistry and Oral Health, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center, Groningen, The Netherlands
| | | | - Mary E Reyland
- Department of Craniofacial Biology, School of Dental Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
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19
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Cozzi L, Vanderstraeten R, Fogliata A, Chang FL, Wang PM. The role of a knowledge based dose-volume histogram predictive model in the optimisation of intensity-modulated proton plans for hepatocellular carcinoma patients : Training and validation of a novel commercial system. Strahlenther Onkol 2020; 197:332-342. [PMID: 32676685 DOI: 10.1007/s00066-020-01664-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/29/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE To investigate the performance of a knowledge-based RapidPlan, for optimisation of intensity-modulated proton therapy (IMPT) plans applied to hepatocellular cancer (HCC) patients. METHODS A cohort of 65 patients was retrospectively selected: 50 were used to "train" the model, while the remaining 15 provided independent validation. The performance of the RapidPlan model was benchmarked against manual optimisation and was also compared to volumetric modulated arc therapy (RapidArc) photon plans. A subanalysis appraised the performance of the RapidPlan model applied to patients with lesions ≤300 cm3 or larger. Quantitative assessment was based on several metrics derived from the constraints of the NRG-GI003 clinical trial. RESULTS There was an equivalence between manual plans and RapidPlan-optimised IMPT plans, which outperformed the RapidArc plans. The planning dose-volume objectives were met on average for all structures except for D0.5 cm3 ≤30 Gy in the bowels. Limiting the results to the class-solution proton plans (all values in Gy), the data for manual plans vs RapidPlan-based IMPT plans, respectively, showed the following: D99% to the target of 47.5 ± 1.4 vs 47.2 ± 1.2; for organs at risk, the mean dose to the healthy liver was 6.7 ± 3.6 vs 6.7 ± 3.7; the mean dose to the kidneys was 0.2 ± 0.5 vs 0.1 ± 0.2; D0.5 cm3 for the bowels was 33.4 ± 16.4 vs 30.2 ± 16.0; for the stomach was 17.9 ± 19.9 vs 14.9 ± 18.8; for the oesophagus was 17.9 ± 15.1 vs 14.9 ± 13.9; for the spinal cord was 0.5 ± 1.6 vs 0.2 ± 0.7. The model performed similarly for cases with small or large lesions. CONCLUSION A knowledge-based RapidPlan model was trained and validated for IMPT. The results demonstrate that RapidPlan can be trained adequately for IMPT in HCC. The quality of the RapidPlan-based plans is at least equivalent compared to what is achievable with manual planning. RapidPlan also confirmed the potential to optimise the quality of the proton therapy results, thus reducing the impact of operator planning skills on patient results.
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Affiliation(s)
- Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Via Manzoni 56, 20089, Milan-Rozzano, Italy. .,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy.
| | | | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Via Manzoni 56, 20089, Milan-Rozzano, Italy
| | - Feng-Ling Chang
- Radiation Oncology Department, Asian University Hospital, Taichung, Taiwan, Province of China
| | - Po-Ming Wang
- Radiation Oncology Department, Asian University Hospital, Taichung, Taiwan, Province of China
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20
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Grant SR, Hutcheson KA, Ye R, Garden AS, Morrison WH, Rosenthal DI, Gunn GB, Fuller C, Phan J, Reddy JP, Moreno AC, Lewin JS, Sturgis EM, Ferrarotto R, Frank SJ. Prospective longitudinal patient-reported outcomes of swallowing following intensity modulated proton therapy for oropharyngeal cancer. Radiother Oncol 2020; 148:133-139. [PMID: 32361662 PMCID: PMC9815953 DOI: 10.1016/j.radonc.2020.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE With an enlarging population of long-term oropharyngeal cancer survivors, dysphagia is an increasingly important toxicity following oropharynx cancer treatment. While lower doses to normal surrounding structures may be achieved with intensity modulated proton therapy (IMPT) compared to photon-based radiation, the clinical benefit is uncertain. METHODS AND MATERIALS Seventy-one patients with stage III/IV oropharyngeal cancer (AJCC 7th edition) undergoing definitive IMPT on a longitudinal prospective cohort study who had completed the MD Anderson Dysphagia Inventory (MDADI) at pre-specified time points were included. RESULTS The majority of patients had HPV-positive tumors (85.9%) and received bilateral neck radiation (81.4%) with concurrent systemic therapy (61.8%). Mean composite MDADI scores decreased from 88.2 at baseline to 59.6 at treatment week 6, and then increased to 74.4 by follow up week 10, 77.0 by 6 months follow up, 80.5 by 12 months follow up, and 80.1 by 24 months follow up. At baseline, only 5.6% of patients recording a poor composite score (lower than 60), compared to 61.2% at treatment week 6, 19.1% at follow up week 10, 13.0% at 6 months follow up, 13.5% at 1 year follow up, and 11.1% at 2 years follow up. CONCLUSIONS Patient reported outcomes following IMPT for oropharyngeal cancer demonstrates decreased swallowing function at completion of treatment with relatively rapid recovery by 10 weeks follow up and steady improvement through 2 years. The results are comparable to similar longitudinal studies of photon-based radiotherapy for oropharynx cancer, and suggest that IMPT confers no additional excess toxicity related to swallowing.
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Affiliation(s)
- Stephen R. Grant
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine A. Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rong Ye
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S. Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H. Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I. Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G. Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C.D. Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay P. Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy C. Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan S. Lewin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M. Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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21
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Grégoire V, Guckenberger M, Haustermans K, Lagendijk JJW, Ménard C, Pötter R, Slotman BJ, Tanderup K, Thorwarth D, van Herk M, Zips D. Image guidance in radiation therapy for better cure of cancer. Mol Oncol 2020; 14:1470-1491. [PMID: 32536001 PMCID: PMC7332209 DOI: 10.1002/1878-0261.12751] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
The key goal and main challenge of radiation therapy is the elimination of tumors without any concurring damages of the surrounding healthy tissues and organs. Radiation doses required to achieve sufficient cancer-cell kill exceed in most clinical situations the dose that can be tolerated by the healthy tissues, especially when large parts of the affected organ are irradiated. High-precision radiation oncology aims at optimizing tumor coverage, while sparing normal tissues. Medical imaging during the preparation phase, as well as in the treatment room for localization of the tumor and directing the beam, referred to as image-guided radiotherapy (IGRT), is the cornerstone of precision radiation oncology. Sophisticated high-resolution real-time IGRT using X-rays, computer tomography, magnetic resonance imaging, or ultrasound, enables delivery of high radiation doses to tumors without significant damage of healthy organs. IGRT is the most convincing success story of radiation oncology over the last decades, and it remains a major driving force of innovation, contributing to the development of personalized oncology, for example, through the use of real-time imaging biomarkers for individualized dose delivery.
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Affiliation(s)
- Vincent Grégoire
- Department of Radiation OncologyLéon Bérard Cancer CenterLyonFrance
| | - Matthias Guckenberger
- Department for Radiation OncologyUniversity Hospital ZurichUniversity of ZurichSwitzerland
| | - Karin Haustermans
- Department of Radiation OncologyLeuven Cancer InstituteUniversity Hospital GasthuisbergLeuvenBelgium
| | | | | | - Richard Pötter
- Department of Radiation OncologyMedical UniversityGeneral Hospital of ViennaAustria
| | - Ben J. Slotman
- Department of Radiation OncologyAmsterdam University Medical CentersThe Netherlands
| | - Kari Tanderup
- Department of OncologyAarhus University HospitalDenmark
| | - Daniela Thorwarth
- Section for Biomedical PhysicsDepartment of Radiation OncologyUniversity of TübingenGermany
| | - Marcel van Herk
- Department of Biomedical Engineering and PhysicsCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamThe Netherlands
- Institute of Cancer SciencesUniversity of ManchesterUK
- Department of Radiotherapy Related ResearchThe Christie NHS Foundation TrustManchesterUK
| | - Daniel Zips
- Department of Radiation OncologyUniversity of TübingenGermany
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22
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Grau C, Durante M, Georg D, Langendijk JA, Weber DC. Particle therapy in Europe. Mol Oncol 2020; 14:1492-1499. [PMID: 32223048 PMCID: PMC7332216 DOI: 10.1002/1878-0261.12677] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/17/2019] [Accepted: 03/22/2020] [Indexed: 12/16/2022] Open
Abstract
Particle therapy using protons or heavier ions is currently the most advanced form of radiotherapy and offers new opportunities for improving cancer care and research. Ions deposit the dose with a sharp maximum – the Bragg peak – and normal tissue receives a much lower dose than what is delivered by X‐ray therapy. Particle therapy has also biological advantages due to the high linear energy transfer of the charged particles around the Bragg peak. The introduction of particle therapy has been slow in Europe, but within the last decade, more than 20 clinical facilities have opened and facilitated access to this frontline therapy. In this review article, the basic concepts of particle therapy are reviewed along with a presentation of the current clinical indications, the European clinical research, and the established networks.
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Affiliation(s)
- Cai Grau
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Marco Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany.,Institut für Festkörperphysik, Technische Universität Darmstadt, Germany
| | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna/AKH Wien, Vienna, Austria
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Centrum Groningen, Groningen, The Netherlands
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23
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Proton therapy for head and neck squamous cell carcinomas: A review of the physical and clinical challenges. Radiother Oncol 2020; 147:30-39. [PMID: 32224315 DOI: 10.1016/j.radonc.2020.03.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022]
Abstract
The quality of radiation therapy has been shown to significantly influence the outcomes for head and neck squamous cell carcinoma (HNSCC) patients. The results of dosimetric studies suggest that intensity-modulated proton therapy (IMPT) could be of added value for HNSCC by being more effective than intensity-modulated (photon) radiation therapy (IMRT) for reducing side effects of radiation therapy. However, the physical properties of protons make IMPT more sensitive than photons to planning uncertainties. This could potentially have a negative effect on the quality of IMPT planning and delivery. For this review, the three French proton therapy centers collaborated to evaluate the differences between IMRT and IMPT. The review explored the effects of these uncertainties and their management for developing a robust and optimized IMPT treatment delivery plan to achieve clinical outcomes that are superior to those for IMRT. We also provide practical suggestions for the management of HNSCC carcinoma with IMPT. Because metallic dental implants can increase range uncertainties (3-10%), patient preparation for IMPT may require more systematic removal of in-field alien material than is done for IMRT. Multi-energy CT may be an alternative to calculate more accurately the dose distribution. The practical aspects that we describe are essential to guarantee optimal quality in radiation therapy in both model-based and randomized clinical trials.
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24
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Price J, Hall E, West C, Thomson D. TORPEdO - A Phase III Trial of Intensity-modulated Proton Beam Therapy Versus Intensity-modulated Radiotherapy for Multi-toxicity Reduction in Oropharyngeal Cancer. Clin Oncol (R Coll Radiol) 2020; 32:84-88. [PMID: 31604604 DOI: 10.1016/j.clon.2019.09.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/14/2019] [Indexed: 11/26/2022]
Affiliation(s)
- J Price
- The Christie NHS Foundation Trust, Manchester, UK
| | - E Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - C West
- Division of Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - D Thomson
- The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
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25
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Meijer TWH, Scandurra D, Langendijk JA. Reduced radiation-induced toxicity by using proton therapy for the treatment of oropharyngeal cancer. Br J Radiol 2020; 93:20190955. [PMID: 31971818 DOI: 10.1259/bjr.20190955] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Patients with squamous cell carcinoma of the oropharynx are generally treated with (chemo) radiation. Patients with oropharyngeal cancer have better survival than patients with squamous cell carcinoma of other head and neck subsites, especially when related to human papillomavirus. However, radiotherapy results in a substantial percentage of survivors suffering from significant treatment-related side-effects. Late radiation-induced side-effects are mostly irreversible and may even be progressive, and particularly xerostomia and dysphagia affect health-related quality of life. As the risk of radiation-induced side-effects highly depends on dose to healthy normal tissues, prevention of radiation-induced xerostomia and dysphagia and subsequent improvement of health-relatedquality of life can be obtained by applying proton therapy, which offers the opportunity to reduce the dose to both the salivary glands and anatomic structures involved in swallowing.This review describes the results of the first cohort studies demonstrating that proton therapy results in lower dose levels in multiple organs at risk, which translates into reduced acute toxicity (i.e. up to 3 months after radiotherapy), while preserving tumour control. Next to reducing mucositis, tube feeding, xerostomia and distortion of the sense of taste, protons can improve general well-being by decreasing fatigue and nausea. Proton therapy results in decreased rates of tube feeding dependency and severe weight loss up to 1 year after radiotherapy, and may decrease the risk of radionecrosis of the mandible. Also, the model-based approach for selecting patients for proton therapy in the Netherlands is described in this review and future perspectives are discussed.
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Affiliation(s)
- Tineke W H Meijer
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Dan Scandurra
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
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26
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Intensity modulated proton therapy compared to volumetric modulated arc therapy in the irradiation of young female patients with hodgkin's lymphoma. Assessment of risk of toxicity and secondary cancer induction. Radiat Oncol 2020; 15:12. [PMID: 31931861 PMCID: PMC6958567 DOI: 10.1186/s13014-020-1462-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/07/2020] [Indexed: 12/20/2022] Open
Abstract
Background To investigate the role of intensity modulated proton therapy (IMPT) compared to volumetric modulated arc therapy (VMAT) for advanced supradiaphragmatic Hodgkin’s lymphoma (HL) in young female patients by assessing dosimetric features and modelling the risk of treatment related complications and radiation-induced secondary malignancies. Methods A group of 20 cases (planned according to the involved-site approach) were retrospectively investigated in a comparative planning study. Intensity modulated proton plans (IMPT) were compared to VMAT RapidArc plans (RA). Estimates of toxicity were derived from normal tissue complication probability (NTCP) calculations with either the Lyman or the Poisson models for a number of endpoints. Estimates of the risk of secondary cancer induction were determined for lungs, breasts, esophagus and thyroid. A simple model-based selection strategy was considered as a feasibility proof for the individualized selection of patients suitable for proton therapy. Results IMPT and VMAT plans resulted equivalent in terms of target dose distributions, both were capable to ensure high coverage and homogeneity. In terms of conformality, IMPT resulted ~ 10% better than RA plans. Concerning organs at risk, IMPT data presented a systematic improvement (highly significant) over RA for all organs, particularly in the dose range up to 20Gy. This lead to a composite average reduction of NTCP of 2.90 ± 2.24 and a reduction of 0.26 ± 0.22 in the relative risk of cardiac failures. The excess absolute risk per 10,000 patients-years of secondary cancer induction was reduced, with IMPT, of 9.1 ± 3.2, 7.2 ± 3.7 for breast and lung compared to RA. The gain in EAR for thyroid and esophagus was lower than 1. Depending on the arbitrary thresholds applied, the selection rate for proton treatment would have ranged from 5 to 75%. Conclusion In relation to young female patients with advanced supradiaphragmatic HL, IMPT can in general offer improved dose-volume sparing of organs at risk leading to an anticipated lower risk of early or late treatment related toxicities. This would reflect also in significantly lower risk of secondary malignancies induction compared to advanced photon based techniques. Depending on the selection thresholds and with all the limits of a non-validated and very basic model, it can be anticipated that a significant fraction of patients might be suitable for proton treatments if all the risk factors would be accounted for.
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27
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Ricardi U, Maraldo MV, Levis M, Parikh RR. Proton Therapy For Lymphomas: Current State Of The Art. Onco Targets Ther 2019; 12:8033-8046. [PMID: 31632057 PMCID: PMC6781741 DOI: 10.2147/ott.s220730] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/13/2019] [Indexed: 12/19/2022] Open
Abstract
The combination of brief chemo-radiotherapy provides high cure rates and represents the first line of treatment for many lymphoma patients. As a result, a high proportion of long-term survivors may experience treatment-related toxic events many years later. Excess and unintended radiation dose to organs at risk (particularly heart, lungs and breasts) may translate in an increased risk of cardiovascular events and second cancers after a few decades. Minimizing dose to organs at risk is thus pivotal to restrain the risk of long-term complications. Proton therapy, with its peculiar physic properties, may help to better spare organs at risk and consequently to reduce toxicities especially in patients receiving mediastinal radiotherapy. Herein, we review the physical basis of proton therapy and the rationale for its implementation in lymphoma patients, with a detailed description of the clinical data. We also discuss the potential disadvantages and uncertainties of protons that may limit their application and critically review the dosimetric studies comparing the risk of late complications between proton and photon radiotherapy.
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Affiliation(s)
| | - Maja V Maraldo
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mario Levis
- Department of Oncology, University of Torino, Torino, Italy
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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28
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Beddok A, Vela A, Calugaru V, Tessonnier T, Kubes J, Dutheil P, Gérard A, Vidal M, Goudjil F, Florescu C, Kammerer E, Bénézery K, Hérault J, Bourhis J, Thariat J. [Proton therapy for head and neck squamous cell carcinomas: From physics to clinic]. Cancer Radiother 2019; 23:439-448. [PMID: 31358445 DOI: 10.1016/j.canrad.2019.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/09/2019] [Accepted: 05/16/2019] [Indexed: 11/17/2022]
Abstract
Intensity-modulated radiation therapy (IMRT) is presently the recommended technique for the treatment of locally advanced head and neck carcinomas. Proton therapy would allow to reduce the volume of irradiated normal tissue and, thus, to decrease the risk of late dysphagia, xerostomia, dysgeusia and hypothyroidism. An exhaustive research was performed with the search engine PubMed by focusing on the papers about the physical difficulties that slow down use of proton therapy for head and neck carcinomas. Range uncertainties in proton therapy (±3 %) paradoxically limit the use of the steep dose gradient in distality. Calibration uncertainties can be important in the treatment of head and neck cancer in the presence of materials of uncertain stoichiometric composition (such as with metal implants, dental filling, etc.) and complex heterogeneities. Dental management for example may be different with IMRT or proton therapy. Some uncertainties can be somewhat minimized at the time of optimization. Inter- and intrafractional variations and uncertainties in Hounsfield units/stopping power can be integrated in a robust optimization process. Additional changes in patient's anatomy (tumour shrinkage, changes in skin folds in the beam patch, large weight loss or gain) require rescanning. Dosimetric and small clinical studies comparing photon and proton therapy have well shown the interest of proton therapy for head and neck cancers. Intensity-modulated proton therapy is a promising treatment as it can reduce the substantial toxicity burden of patients with head and neck squamous cell carcinoma compared to IMRT. Robust optimization will allow to perform an optimal treatment and to use proton therapy in current clinical practice.
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Affiliation(s)
- A Beddok
- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - A Vela
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - V Calugaru
- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - T Tessonnier
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - J Kubes
- Proton Therapy Centre Czech, Prague, République tchèque
| | - P Dutheil
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - A Gérard
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - M Vidal
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - F Goudjil
- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - C Florescu
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - E Kammerer
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - K Bénézery
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - J Hérault
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - J Bourhis
- Département d'oncologie-radiothérapie, centre hospitalier universitaire vaudois, Lausanne, Suisse
| | - J Thariat
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France; Laboratoire de physique corpusculaire IN2P3/Ensicaen - UMR6534, Unicaen - Normandie Université, 14000 Caen, France.
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- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France; Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Proton Therapy Centre Czech, Prague, République tchèque; Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France; Département d'oncologie-radiothérapie, centre hospitalier universitaire vaudois, Lausanne, Suisse; Laboratoire de physique corpusculaire IN2P3/Ensicaen - UMR6534, Unicaen - Normandie Université, 14000 Caen, France
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Lester-Coll NH, Margalit DN. Modeling the Potential Benefits of Proton Therapy for Patients With Oropharyngeal Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2019; 104:563-566. [DOI: 10.1016/j.ijrobp.2019.03.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/24/2019] [Accepted: 03/26/2019] [Indexed: 12/25/2022]
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30
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Head and Neck Cancer Adaptive Radiation Therapy (ART): Conceptual Considerations for the Informed Clinician. Semin Radiat Oncol 2019; 29:258-273. [PMID: 31027643 DOI: 10.1016/j.semradonc.2019.02.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For nearly 2 decades, adaptive radiation therapy (ART) has been proposed as a method to account for changes in head and neck tumor and normal tissue to enhance therapeutic ratios. While technical advances in imaging, planning and delivery have allowed greater capacity for ART delivery, and a series of dosimetric explorations have consistently shown capacity for improvement, there remains a paucity of clinical trials demonstrating the utility of ART. Furthermore, while ad hoc implementation of head and neck ART is reported, systematic full-scale head and neck ART remains an as yet unreached reality. To some degree, this lack of scalability may be related to not only the complexity of ART, but also variability in the nomenclature and descriptions of what is encompassed by ART. Consequently, we present an overview of the history, current status, and recommendations for the future of ART, with an eye toward improving the clarity and description of head and neck ART for interested clinicians, noting practical considerations for implementation of an ART program or clinical trial. Process level considerations for ART are noted, reminding the reader that, paraphrasing the writer Elbert Hubbard, "Art is not a thing, it is a way."
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