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Dykstra MP, Regan SN, Yin HM, McLaughlin PW, Boike T, Bhatt A, Zaki M, Kendrick D, Mislmani M, Paluch S, Litzenberg DW, Mietzel MA, Narayana V, Smith A, Heimburger DK, Schipper MJ, Jackson WC, Dess RT. Variation in Androgen Deprivation Therapy Use Among Men With Intermediate-Risk Prostate Cancer: Results From a Statewide Radiation Oncology Quality Consortium. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00689-8. [PMID: 38844140 DOI: 10.1016/j.ijrobp.2024.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/06/2024] [Accepted: 05/24/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE For men with intermediate-risk prostate cancer treated with definitive therapy, the addition of androgen deprivation therapy (ADT) reduces the risk of distant metastasis and cancer-related mortality. However, the absolute benefit of ADT varies by baseline cancer risk. Estimates of prognosis have improved over time, and little is known about ADT decision making in the modern era. We sought to characterize variability and identify factors associated with intended ADT use within the Michigan Radiation Oncology Quality Consoritum (MROQC). MATERIALS AND METHODS Patients with localized prostate cancer undergoing definitive radiation therapy were enrolled from June 9, 2020, to June 26, 2023 (n = 815). Prospective data were collected using standardized patient, physician, and physicist forms. Intended ADT use was prospectively defined and was the primary outcome. Associations with patient, tumor, and practice-related factors were tested with multivariable analyses. Random intercept modeling was used to estimate facility-level variability. RESULTS Five hundred seventy patients across 26 facilities were enrolled with intermediate-risk disease. ADT was intended for 46% of men (n = 262/570), which differed by National Comprehensive Cancer Network favorable intermediate-risk (23.5%, n = 38/172) versus unfavorable intermediate-risk disease (56.3%, n = 224/398; P < .001). After adjusting for the statewide case mix, the predicted probability of intended ADT use varied significantly across facilities, ranging from 15.4% (95% CI, 5.4%-37.0%) to 71.7% (95% CI, 57.0%-82.9%), with P < .01. Multivariable analyses showed that grade group 3 (OR, 4.60 [3.20-6.67]), ≥50% positive cores (OR, 2.15 [1.43-3.25]), and prostate-specific antigen 10 to 20 (OR, 1.87 [1.24-2.84]) were associated with ADT use. Area under the curve was improved when incorporating MRI adverse features (0.76) or radiation treatment variables (0.76), but there remained significant facility-level heterogeneity in all models evaluated (P < .05). CONCLUSIONS Within a state-wide consortium, there is substantial facility-level heterogeneity in intended ADT use for men with intermediate-risk prostate cancer. Future efforts are necessary to identify patients who will benefit most from ADT and to develop strategies to standardize appropriate use.
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Affiliation(s)
- Michael P Dykstra
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Samuel N Regan
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Huiying Maggie Yin
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Patrick William McLaughlin
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiation Oncology, Providence Cancer Center, Novi, Michigan
| | - Thomas Boike
- MHP Radiation Oncology Institute, Farmington Hills, Michigan
| | - Amit Bhatt
- Department of Radiation Oncology, Karmanos Cancer Institute at McLaren, Lansing, Michigan
| | - Mark Zaki
- Department of Radiation Oncology, Covenant Healthcare, Saginaw, Michigan
| | - Danielle Kendrick
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Mazen Mislmani
- Department of Radiation Oncology, West Michigan Cancer Center, Kalamazoo, Michigan
| | - Sarah Paluch
- Department of Radiation Oncology, Covenant Healthcare, Saginaw, Michigan
| | - Dale W Litzenberg
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Melissa A Mietzel
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Vrinda Narayana
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiation Oncology, Providence Cancer Center, Novi, Michigan
| | - Andrea Smith
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - David K Heimburger
- Department of Radiation Oncology, Munson Healthcare, Traverse City, Michigan
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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Sun Y, Saulsberry L, Liao C, Hedeker D, Huo D. Geographic and Physician-Level Variation in the Use of Hypofractionated Radiation Therapy for Breast Cancer in the U.S.: A Cross-Classified Multilevel Analysis. Adv Radiat Oncol 2024; 9:101487. [PMID: 38725638 PMCID: PMC11078635 DOI: 10.1016/j.adro.2024.101487] [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: 10/11/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
Purpose We aimed to assess geographic and physician-level variation for hypofractionated whole-breast irradiation (HF-WBI) use for early-stage breast cancer patients in the United States. We further evaluated the association between HF-WBI use and demographic factors after accounting for these variations. Methods and Materials We performed a retrospective study of early-stage breast cancer patients using private employer-sponsored insurance claims from 2008 to 2017. Patients were clustered according to geographic level and by radiation oncologist. Bayesian cross-classified multilevel logistic models were used to examine the geographic heterogeneity and variation of radiation oncologists simultaneously. Intracluster correlation coefficient (ICC) and median odds ratios (MOR) were calculated to quantify the variation at different levels. We also used the cross-classified model to identify patient demographic factors associated with receiving HF-WBI. Results The study included 79,747 women (74.0%) who received conventionally fractionated whole-breast irradiation (CF-WBI) and 27,999 women (26.0%) who underwent HF-WBI. HF-WBI adoption increased significantly across time (2008-2017). The variation in HF-WBI utilization was attributed mostly to physician-level variability (MOR = 2.59). The variability of HF-WBI utilization across core-based statistical areas (CBSAs) (MOR = 1.55) was found to be the strongest among all geographic classifications. After accounting for variability in both CBSAs and radiation oncologists, age, receiving chemotherapy, and several community-level factors, including distance from home to facility, community education level, and racial composition, were found to be associated with HF-WBI utilization. Conclusion This study demonstrated geographic and physician-level heterogeneity in the use of HF-WBI among early-stage breast cancer patients. HF-WBI utilization was also found to be associated with patient and community-level characteristics. Given observed physician-level variability, intervention through continuing medical education could help doctors to better understand the advantages of HF-WBI and promote the adoption of HF-WBI in the U.S. Influence of physician-level characteristics on HF-WBI utilization merits further study.
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Affiliation(s)
- Yijia Sun
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Chuanhong Liao
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Donald Hedeker
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Dezheng Huo
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
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Chitti B, Stefanov DG, Potters L, Andrews J. Radiation Therapy Practice Patterns for Treatment of Curative Breast Cancer in a Large Tertiary Health Care System. Adv Radiat Oncol 2024; 9:101436. [PMID: 38435966 PMCID: PMC10906153 DOI: 10.1016/j.adro.2023.101436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/20/2023] [Indexed: 03/05/2024] Open
Abstract
Purpose Disparities have been reported in women treated for breast cancer (BrCa). This study examines potential disparities in BrCa treatment offered based on race and age from a multicenter radiation department. Methods and Materials We identified 901 patients with early stage BrCa who received curative intent radiation therapy (RT) between 2004 and 2018. Data extracted included age, race, disease stage, treatment technique, treatment dates, and fractionation. Patient race was recorded as Asian, Black, Hispanic, and White. RT technique delivered was classified as a type of external beam radiation therapy or brachytherapy/intraoperative radiation therapy. Fractionation schema were defined as 1) standard fractionation, 1.8-2 Gy; 2) hypofractionation, 2.5-2.67 Gy; 3) accelerated partial breast irradiation (APBI), 3.4 Gy - 4.25 Gy, and 4) intraoperative radiation therapy, single dose of 20 Gy. Stage was recorded using TNM staging. The χ2 test and a multivariable multinomial logistic regression model were used to assess whether patient characteristics, such as age, race, or stage influenced fractionation schemes. Results with 2-sided P values < .05 were considered statistically significant. Results Racial composition of the study was 13.8% Asian, 22% Black, 29%, White, and 35.1% Hispanic. Mean age was 61 and was divided into 4 age range groups: 30 to 49 (n = 160), 50 to 59 (n = 231), 60 to 69 (n = 294), and ≥70 years (n = 216). In addition, 501 patients (56%) received hypofractionation, 342 (38.8%) received standard fractionation, and 58 (7.1%) received APBI, respectively. For all groups, hypofractionation became more common over time. Age ≥70 years was associated with 9 times higher odds of APBI and 14 times higher odds of hypofractionation, compared with age 30 to 49 years. After adjusting for the other predictors in a multivariable multinomial logistic regression model, the race distribution differed among the 3 groups (P = .03), with a smaller percentage of Hispanics and higher percentage of blacks in the standard group. Conclusions This study of a diverse cohort of patients with breast cancer failed to identify treatment differences associated by race. The study found an association between age and hypofractionation.
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Affiliation(s)
- Bhargava Chitti
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York
- Donald and Barabar Zucker School of Medicine at Hofstra/Northwell Health, Zucker School of Medicine, Hempstead, New York
| | - Dimitre G. Stefanov
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, New York
| | - Louis Potters
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York
- Donald and Barabar Zucker School of Medicine at Hofstra/Northwell Health, Zucker School of Medicine, Hempstead, New York
| | - Janna Andrews
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York
- Donald and Barabar Zucker School of Medicine at Hofstra/Northwell Health, Zucker School of Medicine, Hempstead, New York
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Yang G, Kim JW, Lee IJ, Jeong J, Ahn SG, Bae SJ, Kim JH, Cho Y. Feasibility of Intraoperative Radiotherapy Tumor Bed Boost in Patients with Breast Cancer after Neoadjuvant Chemotherapy. Yonsei Med J 2024; 65:129-136. [PMID: 38373832 PMCID: PMC10896667 DOI: 10.3349/ymj.2023.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 02/21/2024] Open
Abstract
PURPOSE This study aimed to assess the feasibility and safety of administering intraoperative radiotherapy (IORT) as a boost during breast-conserving surgery (BCS) following neoadjuvant chemotherapy for patients at high risk of breast cancer recurrence. MATERIALS AND METHODS Patients who underwent neoadjuvant chemotherapy received a single 20-Gy dose of IORT during BCS, followed by external beam radiotherapy 4-6 weeks after surgery. RESULTS The median follow-up duration was 31.0 months (range, 18.0-59.0 months). Initial tumor sizes had a median of 2.6 cm (range: 0.8-5.3 cm), reducing to 0.3 cm (range: 0-4.0 cm) after neoadjuvant chemotherapy. The most common neoadjuvant chemotherapy regimen was doxorubicin and cyclophosphamide, followed by paclitaxel (n=42, 73.7%). Among 57 patients who received neoadjuvant chemotherapy before BCS and IORT, 2 patients (3.5%) required secondary surgery to achieve negative resection margins due to initially positive margins. Regional lymph node irradiation was performed in 37 (64.9%) patients. There was no grade 3 or higher adverse events, with 4 patients (7.0%) experiencing grade 2 acute radiation dermatitis and 3 (5.3%) having less than grade 2 breast edema. Binary correlation analysis did not reveal statistically significant associations between applicator size or radiation therapy modality and the risk of treatment-related toxicity. Furthermore, chi-square analysis showed that the grade of treatment-related toxicity was not associated with the fractionated regimen (p=0.375). CONCLUSION Most patients successfully received IORT as a tumor bed boost after neoadjuvant chemotherapy. Thus, IORT may be a safe and feasible option for patients with advanced-stage breast cancer receiving neoadjuvant chemotherapy.
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Affiliation(s)
- Gowoon Yang
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Hung Kim
- Division of Medical Oncology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Allen SG, Dragovic AF, Yin HM, Bryant AK, Paximadis PA, Matuszak MM, Schipper MJ, Dess RT, Hayman JA, Dominello MM, Kestin LL, Movsas B, Jolly S, Bergsma DP. Prospective Evaluation of Limited-Stage Small Cell Lung Cancer Radiotherapy Fractionation Regimen Usage and Acute Toxicity in a Large Statewide Quality Collaborative. Pract Radiat Oncol 2023; 13:444-453. [PMID: 37100388 DOI: 10.1016/j.prro.2023.04.007] [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: 02/20/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE National guidelines on limited-stage small cell lung cancer (LS-SCLC) treatment give preference to a hyperfractionated regimen of 45 Gy in 30 fractions delivered twice daily; however, use of this regimen is uncommon compared with once-daily regimens. The purpose of this study was to characterize the LS-SCLC fractionation regimens used throughout a statewide collaborative, analyze patient and treatment factors associated with these regimens, and describe real-world acute toxicity profiles of once- and twice-daily radiation therapy (RT) regimens. METHODS AND MATERIALS Demographic, clinical, and treatment data along with physician-assessed toxicity and patient-reported outcomes were prospectively collected by 29 institutions within the Michigan Radiation Oncology Quality Consortium between 2012 and 2021 for patients with LS-SCLC. We modeled the influence of RT fractionation and other patient-level variables clustered by treatment site on the odds of a treatment break specifically due to toxicity with multilevel logistic regression. National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0, incident grade 2 or worse toxicity was longitudinally compared between regimens. RESULTS There were 78 patients (15.6% overall) treated with twice-daily RT and 421 patients treated with once-daily RT. Patients receiving twice-daily RT were more likely to be married or living with someone (65% vs 51%; P = .019) and to have no major comorbidities (24% vs 10%; P = .017). Once-daily RT fractionation toxicity peaked during RT, and twice-daily toxicity peaked within 1 month after RT. After stratifying by treatment site and adjusting for patient-level variables, once-daily treated patients had 4.11 (95% confidence interval, 1.31-12.87) higher odds of treatment break specifically due to toxicity than twice-daily treated patients. CONCLUSIONS Hyperfractionation for LS-SCLC remains infrequently prescribed despite the lack of evidence demonstrating superior efficacy or lower toxicity of once-daily RT. With peak acute toxicity after RT and lower likelihood of a treatment break with twice-daily fractionation in real-word practice, providers may start using hyperfractionated RT more frequently.
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Affiliation(s)
- Steven G Allen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Huiying Maggie Yin
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Alex K Bryant
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Peter A Paximadis
- Department of Radiation Oncology, Spectrum Health Lakeland, St. Joseph, Michigan
| | - Martha M Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J Schipper
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michael M Dominello
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Larry L Kestin
- Michigan Healthcare Professionals, 21st Century Oncology, Farmington Hills, Michigan
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Derek P Bergsma
- Department of Radiation Oncology, Mercy Health Saint Mary's, Grand Rapids, Michigan.
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Duggar WN, Roberts PR, Thomas TV, Dulaney C. Building Better Patient Care in Mississippi Radiation Oncology: Why Mississippi Needs a Collaborative Quality Initiative. South Med J 2023; 116:415-418. [PMID: 37137476 DOI: 10.14423/smj.0000000000001549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVES Cancer is an insidious and devastating disease that affects many people. Progress in mortality rate has not been realized universally across the United States, and challenges remain in how to best make up the ground that has been lost in these areas, one of which is Mississippi. Radiation therapy is a significant contributor to cancer control rates and certain challenges exist specifically regarding this treatment modality. METHODS The challenges of radiation oncology in Mississippi have been reviewed and discussed, with the proposal of a potential collaboration between clinical practitioners and payors to provide optimal and cost-effective radiation therapy to patients in Mississippi. RESULTS A similar model to that proposed has been reviewed and evaluated. This model is discussed based on its potential validity and usefulness in Mississippi. CONCLUSIONS Significant barriers exist in the state of Mississippi to patients receiving a consistent standard of care, regardless of their location and socioeconomic status. A collaborative quality initiative has been shown to be a boon to this endeavor elsewhere and stands to have a similar impact in Mississippi.
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Affiliation(s)
- William N Duggar
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Paul R Roberts
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Toms V Thomas
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Caleb Dulaney
- Radiation Oncology, Anderson Regional Medical Center, Meridian, Mississippi
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Alcorn SR, Deville C. Ensuring That Health Inequities and Disparities Are Not Exacerbated in the Evolving Oligometastatic Treatment Paradigm. Int J Radiat Oncol Biol Phys 2022; 114:843-845. [DOI: 10.1016/j.ijrobp.2022.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022]
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Fane L, Biswas T, Jindal C, Choi YM, Efird JT. Breast Cancer Disparities in Asian Women: The Need for Disaggregated Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9790. [PMID: 36011424 PMCID: PMC9408195 DOI: 10.3390/ijerph19169790] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/06/2022] [Accepted: 08/07/2022] [Indexed: 06/15/2023]
Abstract
Asian (AZN) women are a heterogeneous group, comprising a wide array of cultural beliefs, languages, and healthcare needs. Yet, studies of breast cancer (BCa) risks and outcomes predominately consider AZNs in aggregate, assuming that the distinct ethnicities have similar disease profiles and homogeneous responses to treatment. This stereotypical portrayal of AZNs as a homogenous group tends to mask disparities. For example, healthcare-seeking behaviors and attitudes of medical providers toward AZN BCa patients frequently differ within this group and from other races. Misconceptions may arise that significantly influence the prevention, detection, treatment, and post-therapeutic care of AZN women. In addition to low BCa screening rates among AZN women, disparities also exist in various stages of BCa treatment-omission of radiation after breast-conserving surgery, less access to hypofractionation, underutilization of hormonal therapy, and higher-cost treatment owing to high HER2+ incidence. In this perspective, we highlight the need for disaggregated research of BCa among AZN women and advocate for comprehensive, culturally sensitive strategies to address health disparities in this priority population. Improving BCa literacy and awareness, access to care, and equitable recruitment into clinical trials are a few amelioratory goals to consider in the future.
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Affiliation(s)
- Lauren Fane
- MD University Program, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Charulata Jindal
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | | | - Jimmy T. Efird
- VA Cooperative Studies Program Coordinating Center, Boston, MA 02130, USA
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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Chapman CH, Jagsi R, Griffith KA, Moran JM, Vicini F, Walker E, Dominello M, Abu-Isa E, Hayman J, Laucis AM, Mietzel M, Pierce L. Mediators of Racial Disparities in Heart Dose Among Whole Breast Radiotherapy Patients. J Natl Cancer Inst 2022; 114:1646-1655. [PMID: 35916737 PMCID: PMC9949587 DOI: 10.1093/jnci/djac120] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/22/2022] [Accepted: 06/09/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Racial disparities in survival of patients with cancer motivate research to quantify treatment disparities and evaluate multilevel determinants. Previous research has not evaluated cardiac radiation dose in large cohorts of breast cancer patients by race nor examined potential causes or implications of dose disparities. METHODS We used a statewide consortium database to consecutively sample 8750 women who received whole breast radiotherapy between 2012 and 2018. We generated laterality- and fractionation-specific models of mean heart dose. We generated patient- and facility-level models to estimate race-specific cardiac doses. We incorporated our data into models to estimate disparities in ischemic cardiac event development and death. All statistical tests were 2-sided. RESULTS Black and Asian race independently predicted higher mean heart dose for most laterality-fractionation groups, with disparities of up to 0.42 Gy for Black women and 0.32 Gy for Asian women (left-sided disease and conventional fractionation: 2.13 Gy for Black women vs 1.71 Gy for White women, P < .001, 2-sided; left-sided disease and accelerated fractionation: 1.59 Gy for Asian women vs 1.27 Gy for White women, P = .002). Patient clustering within facilities explained 22%-30% of the variability in heart dose. The cardiac dose disparities translated to estimated excesses of up to 2.6 cardiac events and 1.3 deaths per 1000 Black women and 0.7 cardiac events and 0.3 deaths per 1000 Asian women vs White women. CONCLUSIONS Depending on laterality and fractionation, Asian women and Black women experience higher cardiac doses than White women. This may translate into excess radiation-associated ischemic cardiac events and deaths. Solutions include addressing inequities in baseline cardiac risk factors and facility-level availability and use of radiation technologies.
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Affiliation(s)
- Christina Hunter Chapman
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Kent A Griffith
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Jean M Moran
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Eyad Abu-Isa
- Ascension Providence Hospital, Southfield, MI, USA
| | - James Hayman
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Anna M Laucis
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Melissa Mietzel
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Lori Pierce
- Correspondence to: Lori J. Pierce, MD, University of Michigan Rogel Comprehensive Cancer Center, Rm 4308, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA (e-mail: )
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Jagsi R, Griffith KA, Vicini F, Boike T, Dominello M, Gustafson G, Hayman JA, Moran JM, Radawski JD, Walker E, Pierce L. Identifying Patients Whose Symptoms Are Underrecognized During Treatment With Breast Radiotherapy. JAMA Oncol 2022; 8:887-894. [PMID: 35446337 PMCID: PMC9026246 DOI: 10.1001/jamaoncol.2022.0114] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Understanding whether physicians accurately detect symptoms in patients with breast cancer is important because recognition of symptoms facilitates supportive care, and clinical trials often rely on physician assessments using Common Toxicity Criteria for Adverse Events (CTCAE). Objective To compare the patient-reported outcomes (PROs) of patients with breast cancer who received radiotherapy from January 1, 2012, to March 31, 2020, with physicians' CTCAE assessments to assess underrecognition of symptoms. Design, Setting, and Participants This cohort study included a total of 29 practices enrolled in the Michigan Radiation Oncology Quality Consortium quality initiative. Of 13 725 patients with breast cancer who received treatment with radiotherapy after undergoing lumpectomy, 9941 patients (72.4%) completed at least 1 PRO questionnaire during treatment with radiotherapy and were evaluated for the study. Of these, 9868 patients (99.3%) were matched to physician CTCAE assessments that were completed within 3 days of the PRO questionnaires. Exposures Patient and physician ratings of 4 symptoms (pain, pruritus, edema, and fatigue) were compared. Main Outcomes and Measures We used multilevel multivariable logistic regression to evaluate factors associated with symptom underrecognition, hypothesizing that it would be more common in racial and ethnic minority groups. Results Of 9941 patients, all were female, 1655 (16.6%) were Black, 7925 (79.7%) were White, and 361 (3.6%) had Other race and ethnicity (including American Indian/Alaska Native, Arab/Middle Eastern, and Asian), either as self-reported or as indicated in the electronic medical record. A total of 1595 (16.0%) were younger than 50 years, 2874 (28.9%) were age 50 to 59 years, 3353 (33.7%) were age 60 to 69 years, and 2119 (21.3%) were 70 years or older. Underrecognition of symptoms existed in 2094 of 6781 (30.9%) observations of patient-reported moderate/severe pain, 748 of 2039 observations (36.7%) of patient-reported frequent pruritus, 2309 of 4492 observations (51.4%) of patient-reported frequent edema, and 390 of 2079 observations (18.8%) of patient-reported substantial fatigue. Underrecognition of at least 1 symptom occurred at least once for 2933 of 5510 (53.2%) of those who reported at least 1 substantial symptom. Factors independently associated with underrecognition were younger age (younger than 50 years compared with 60-69 years: odds ratio [OR], 1.35; 95% CI, 1.14-1.59; P < .001; age 50-59 years compared with 60-69 years: OR, 1.19; 95% CI, 1.03-1.37; P = .02), race (Black individuals compared with White individuals: OR, 1.56; 95% CI 1.30-1.88; P < .001; individuals with Other race or ethnicity compared with White individuals: OR, 1.52; 95% CI, 1.12-2.07; P = .01), conventional fractionation (OR, 1.26; 95% CI, 1.10-1.45; P = .002), male physician sex (OR, 1.54; 95% CI, 1.20-1.99; P = .002), and 2-field radiotherapy (without a supraclavicular field) (OR, 0.80; 95% CI, 0.67-0.97; P = .02). Conclusions and Relevance The results of this cohort study suggest that PRO collection may be essential for trials because relying on the CTCAE to detect adverse events may miss important symptoms. Moreover, since physicians in this study systematically missed substantial symptoms in certain patients, including younger patients and Black individuals or those of Other race and ethnicity, improving symptom detection may be a targetable mechanism to reduce disparities.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
| | | | | | | | | | | | - James A Hayman
- Radiation Oncology Clinical Division, University of Michigan, Ann Arbor.,Michigan Radiation Oncology Quality Consortium
| | - Jean M Moran
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Eleanor Walker
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Lori Pierce
- Michigan Radiation Oncology Quality Consortium.,Department of Radiation Oncology, University of Michigan, Ann Arbor
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11
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Hypofractionated Radiation Therapy for Breast Cancer: Financial Risk and Expenditures in the United States, 2008 to 2017. Int J Radiat Oncol Biol Phys 2022; 112:654-662. [PMID: 34637883 PMCID: PMC9212189 DOI: 10.1016/j.ijrobp.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/02/2021] [Accepted: 10/05/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Rising cancer care expenditures and technological advancement of shorter radiation therapy regimens have drawn significant attention to the use of hypofractionated radiation therapy in clinical care. We examine the costs of hypofractionated whole breast irradiation (HF-WBI) compared with conventional whole breast irradiation (CF-WBI) in the United States and investigate the influences of patient characteristics and commercial insurance on HF-WBI use. METHODS AND MATERIALS In a retrospective study using private employer-sponsored insurance claims, a pooled cross-sectional evaluation of radiation therapy in patients with commercial insurance was performed from 2008 to 2017. The study population included female patients with early-stage breast cancer treated with lumpectomy and whole breast irradiation. RESULTS A total of 15,869 women received HF-WBI, and 59,328 received CF-WBI. HF-WBI use increased from 2008 to 2017. Community-level factors such as a higher proportion of college graduates and greater mixed racial composition were associated with increased HF-WBI use. Mean insurer-paid radiation therapy expenditures were significantly lower for HF-WBI versus CF-WBI (adjusted difference, $6375; 95% confidence interval, $6147-$6603). Mean patient out-of-pocket expenditure for HF-WBI was $139 less than that for CF-WBI. Geographic variation existed across the United States in HF-WBI use (range, 9.6%-36.2%), with no consistent relationship between HF-WBI use and corresponding average cost differences between HF-WBI and CF-WBI. CONCLUSIONS If trends continue, HF-WBI will soon become the dominant form of radiation treatment in the United States. Although HF-WBI represents significant savings to the health care system and individual patients, no evidence indicated that a financial disincentive had slowed adoption of HF-WBI. Therefore, multilevel approaches, including individuals, the community, and health policy, should be used to promote cost-effective cancer care. Innovations to policies on cost-effective radiation therapy treatment might consider non-financial incentives to promote HF-WBI use.
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12
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Herr DJ, Hochstedler KA, Yin H, Dess RT, Matuszak M, Grubb M, Dominello M, Movsas B, Kestin LL, Bergsma D, Dragovic AF, Grills IS, Hayman JA, Paximadis P, Schipper M, Jolly S. Effect of education and standardization of cardiac dose constraints on heart dose in lung cancer patients receiving definitive radiation therapy across a statewide consortium. Pract Radiat Oncol 2022; 12:e376-e381. [PMID: 35121192 DOI: 10.1016/j.prro.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE/OBJECTIVES Cardiac radiation exposure is associated with an increased rate of adverse cardiac events in patients receiving radiation therapy for locally advanced non-small cell lung carcinoma (NSCLC). Previous analysis of practice patterns within XXXX revealed 1 in 4 patients received a mean heart dose >20 Gy and significant heterogeneity existed among treatment centers in using cardiac dose constraints. The purpose of this study is to analyze the effect of education and initiation of standardized cardiac dose constraints on heart dose across a statewide consortium. MATERIALS/METHODS From 2012 to 2020, 1681 patients from 27 academic and community centers who received radiation therapy for locally advanced NSCLC were included in this analysis. Dosimetric endpoints including mean heart dose (MHD), mean lung dose, and mean esophagus dose were calculated using data from dose-volume histograms. These dose metrics were grouped by year of treatment initiation for all patients. Education regarding data for cardiac dose constraints first occurred in small lung cancer working group meetings and then consortium-wide starting in 2016. In 2018, a quality metric requiring mean heart dose <20 Gy while maintaining dose coverage (D95) to the target was implemented. Dose metrics were compared before (2012-2016) versus after (2017-2020) initiation of interventions targeting cardiac constraints. Statistical analysis was performed using the Wilcoxon Rank Sum test. RESULTS Following education and implementation of the heart dose performance metric, mean MHD declined from an average of 12.2 Gy pre-intervention to 10.4 Gy post-intervention (p < 0.0001), and the percentage of patients receiving MHD >20 Gy reduced from 21.1% to 10.3% (p < 0.0001). Mean lung dose and mean esophagus dose did not increase, and target coverage remained unchanged. CONCLUSIONS Education and implementation of a standardized cardiac dose quality measure across a statewide consortium was associated with a reduction of mean heart dose in patients receiving radiation therapy for locally advanced NSCLC. These dose reductions were achieved without sacrificing target coverage, increasing mean lung dose, or increasing mean esophagus dose. Analysis of the clinical ramifications of the reduction in cardiac doses is ongoing.
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Affiliation(s)
- Daniel J Herr
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Huiying Yin
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Martha Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Margaret Grubb
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Michael Dominello
- Department of Radiation Oncology, Karmanos Cancer Institute, Detroit, MI
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI
| | - Larry L Kestin
- MHP Radiation Oncology Institute/GenesisCare USA, Farmington Hills, MI
| | - Derek Bergsma
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; St. Mary's Hospital, Lacks Cancer Center, Grand Rapids, MI
| | - Aleksandar F Dragovic
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Department of Radiation Oncology, Brighton Center for Specialty Care, Brighton, MI
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Peter Paximadis
- Department of Radiation Oncology, Spectrum Health Lakeland, St. Joseph, MI
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI.
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13
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Meattini I, Becherini C, Boersma L, Kaidar-Person O, Marta GN, Montero A, Offersen BV, Aznar MC, Belka C, Brunt AM, Dicuonzo S, Franco P, Krause M, MacKenzie M, Marinko T, Marrazzo L, Ratosa I, Scholten A, Senkus E, Stobart H, Poortmans P, Coles CE. European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice consensus recommendations on patient selection and dose and fractionation for external beam radiotherapy in early breast cancer. Lancet Oncol 2022; 23:e21-e31. [PMID: 34973228 DOI: 10.1016/s1470-2045(21)00539-8] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 12/17/2022]
Abstract
High-quality randomised clinical trials testing moderately fractionated breast radiotherapy have clearly shown that local control and survival is at least as effective as with 2 Gy daily fractions with similar or reduced normal tissue toxicity. Fewer treatment visits are welcomed by patients and their families, and reduced fractions produce substantial savings for health-care systems. Implementation of hypofractionation, however, has moved at a slow pace. The oncology community have now reached an inflection point created by new evidence from the FAST-Forward five-fraction randomised trial and catalysed by the need for the global radiation oncology community to unite during the COVID-19 pandemic and rapidly rethink hypofractionation implementation. The aim of this paper is to support equity of access for all patients to receive evidence-based breast external beam radiotherapy and to facilitate the translation of new evidence into routine daily practice. The results from this European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice consensus state that moderately hypofractionated radiotherapy can be offered to any patient for whole breast, chest wall (with or without reconstruction), and nodal volumes. Ultrafractionation (five fractions) can also be offered for non-nodal breast or chest wall (without reconstruction) radiotherapy either as standard of care or within a randomised trial or prospective cohort. The consensus is timely; not only is it a pragmatic framework for radiation oncologists, but it provides a measured proposal for the path forward to influence policy makers and empower patients to ensure equity of access to evidence-based radiotherapy.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences M Serio, University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Carlotta Becherini
- Department of Experimental and Clinical Biomedical Sciences M Serio, University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Orit Kaidar-Person
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands; Sheba Medical Center, Ramat Gan and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gustavo Nader Marta
- Department of Radiation Oncology-Hospital Sírio-Libanês, São Paulo, Brazil; Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| | - Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - Claus Belka
- Department of Radiation Oncology, LMU Klinikum, Ludwig-Maximilians University Munich, Munich, Germany
| | - Adrian Murray Brunt
- School of Medicine, University of Keele, Keele, UK; Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy; Department of Radiation Oncology, Maggiore della Carità University Hospital, Novara, Italy
| | - Mechthild Krause
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; National Center for Tumor Diseases, Partner Site Dresden, German Cancer Research Center, Heidelberg, Germany; German Cancer Research Center, Heidelberg and German Cancer Consortium, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany
| | | | - Tanja Marinko
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Livia Marrazzo
- Medical Physics Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Astrid Scholten
- Department of Radiotherapy, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Elżbieta Senkus
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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14
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Erfani P, Figueroa JF, Lam MB. Reforms to the Radiation Oncology Model: Prioritizing Health Equity. Int J Radiat Oncol Biol Phys 2021; 110:328-330. [PMID: 33989572 DOI: 10.1016/j.ijrobp.2021.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
| | - Jose F Figueroa
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Miranda B Lam
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts.
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15
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Ong WL, Khor R, Chao M, Milne RL, Millar J, Foroudi F. Choosing Wisely in radiation therapy for breast cancer: Time lag in adoption of hypofractionated radiation therapy in Victoria. J Med Imaging Radiat Oncol 2021; 65:224-232. [PMID: 33591610 DOI: 10.1111/1754-9485.13155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/07/2021] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION To evaluate the adoption of hypofractionated radiotherapy (HFRT) for breast cancer (BC) in Victoria, Australia. METHODS This is a population-based cohort of women with BC who had breast RT as captured in the Victorian Radiotherapy Minimum Data Set between 2012 and 2017. We defined HFRT as < 25 fractions of RT. The pattern of HFRT use over time was evaluated with the Cochrane-Armitage test for trend. Factors associated with HFRT were identified using multivariable logistic regression. RESULTS 12,717 women were included in the study. Overall, 6,653 (52%) patients had HFRT. HFRT use increased from 35% in 2012 to 66% in 2017 (P-trend < 0.001). Older women were more likely to have HFRT (74% for women aged ≥ 70 years vs. 27% for women aged < 50 years; P < 0.001). Women who had nodal irradiation were less likely to have HFRT compared with those who did not (13% vs. 57%; P < 0.001). HFRT use was more common in public than private institutions (57% vs. 46%, P < 0.001), and in metropolitan than regional centres (54% vs. 46%, P < 0.001). In multivariable analyses, the progressive increase in HFRT use over time was independent of other covariates - women treated in 2017 were 7.3 times (95% CI = 6.3-8.6, P < 0.001) more likely to be treated with HFRT than in 2012. Age at RT, nodal irradiation, area of residence and institutional type and locations were all independently associated with HFRT use. CONCLUSION This large Australian contemporary population-based study demonstrates increasing use of HFRT for BC. However, large sociodemographic and institutional provider-related variations in practice still exist.
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Affiliation(s)
- Wee Loon Ong
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.,Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Chao
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia.,Genesis Cancer Care, Ringwood, Victoria, Australia
| | - Roger L Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Precision Medicine, School of Clinical Science, Monash Health, Melbourne, Victoria, Australia
| | - Jeremy Millar
- Alfred Health Radiation Oncology Services, Prahran, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
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16
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Jagsi R, Griffith KA, Vicini F, Boike T, Burmeister J, Dominello MM, Grills I, Hayman JA, Moran JM, Paximadis P, Radawski JD, Walker EM, Pierce LJ. Toward Improving Patients' Experiences of Acute Toxicity From Breast Radiotherapy: Insights From the Analysis of Patient-Reported Outcomes in a Large Multicenter Cohort. J Clin Oncol 2020; 38:4019-4029. [PMID: 32986529 PMCID: PMC9798927 DOI: 10.1200/jco.20.01703] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Understanding acute toxicities after whole-breast radiotherapy is important to inform patients, guide treatment decisions, and target supportive care. We evaluated patient-reported outcomes prospectively collected from a cohort of patients with breast cancer. METHODS We describe the maximal toxicity reported by 8,711 patients treated between 2012 and 2019 at 27 practices. Multivariable models identified characteristics associated with (1) breast pain, (2) bother from itching, stinging/burning, swelling, or hurting of the treated breast, and (3) fatigue within 7 days of completing whole-breast radiotherapy. RESULTS Moderate or severe breast pain was reported by 3,233 (37.1%): 1,282 (28.9%) of those receiving hypofractionation and 1,951 (45.7%) of those receiving conventional fractionation. Frequent bother from at least one breast symptom was reported by 4,424 (50.8%): 1,833 (41.3%) after hypofractionation and 2,591 (60.7%) after conventional fractionation. Severe fatigue was reported by 2,008 (23.1%): 843 (19.0%) after hypofractionation and 1,165 (27.3%) after conventional fractionation. Among patients receiving hypofractionated radiotherapy, younger age (P < .001), higher body mass index (BMI; P < .001), Black (P < .001) or other race (P = .002), smoking status (P < .001), larger breast volume (P = .002), lack of chemotherapy receipt (P = .004), receipt of boost treatment (P < .001), and treatment at a nonteaching center predicted breast pain. Among patients receiving conventionally fractionated radiotherapy, younger age (P < .001), higher BMI (P = .003), Black (P < .001) or other race (P = .002), diabetes (P = .001), smoking status (P < .001), and larger breast volume (P < .001) predicted breast pain. CONCLUSION In this large observational data set, substantial differences existed according to radiotherapy dose fractionation. Race-related differences in pain existed despite controlling for multiple other factors; additional research is needed to understand what drives these differences to target potentially modifiable factors. Intensifying supportive care may be appropriate for subgroups identified as being vulnerable to greater toxicity.
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Affiliation(s)
- Reshma Jagsi
- University of Michigan, Ann Arbor, MI,Reshma Jagsi, MD, DPhil, Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Dr, Ann Arbor, MI 48109-5010; e-mail:
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